Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. FA The staffing policy is the foundation for work planning. Staffing levels were reviewed for anticipated workloads, identified numbers and appropriate skill mix, or as required due to changes in the services provided and the number of patients. Rosters sighted reflected staffing levels that met patient acuity and bed occupancy. Staff are replaced when on leave as documented in rosters reviewed. The service employs registered nurses with a general practitioner providing clinical oversight of the service. The general practitioner also has a private medical practice on site with locums and PRIME nurses providing cover when the general practitioner is on leave. There are 39 staff providing registered nurse, the management team (general manager, clinical nurse manager and registered nurse rest home), caregivers, allied health staff. Staff in the rest home are predominantly designated to that area with the registered nurse rest home providing 20 hours a week support. There is an activities assistant who works in the rest home and with inpatient and hospital residents. Patients/residents, family members and confirm that staffing is adequate to meet the patients’ needs. Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. FA The service retained relevant and appropriate information to identify patients and track records. This included information gathered, at admission, with the involvement of the family. There was sufficient detail in resident/patient files to identify resident/patients' on-going care history and activities. Resident/patient files in use were appropriate to the service. are policies and procedures in place for privacy and confidentiality. Staff could describe the procedures for maintaining confidentiality of patient records. Files and relevant patient care and support information could be accessed in a timely manner. Entries are legible, dates and signed by the relevant staff member including designation. Patient files were protected from unauthorised access by being locked away in offices. Individual patient files demonstratde service integration. Medication charts were in a separate folder and this is appropriate to the service.
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.10.4 The service is able to demonstrate that written consent is obtained where required. PA Low Six of nine files reviewed had informed consent for outings documented and signed. Three of the nine files reviewed had consent for information sharing. Six of the nine files had consent for use of photographs in place. Not all files included consent for outings, information sharing and use of photographs. Ensue that consent is documented for treatment, information sharing, transportation e.g. for outings and use of photographs. 180 days Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Nineteen incident forms in total were reviewed in the rest home, hospital and inpatient area. Five of the nine incident forms reviewed in the rest home and all incident forms in the inpatient and hospital included documentation that Four of the incident forms in the rest home did not include documentation that family had been notified and progress notes did not evidence this. Ensure that documentation is completed confirming that family have been notified in a timely manner after an incident has occurred.
Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in to comply with legislation, protocols, and guidelines. PA Low Medicines management was implemented to manage the safe and appropriate prescribing, dispensing, administration, storage, disposal, and medicine reconciliation however this did not include six monthly reviews of controlled drugs by the pharmacist. Six monthly reviews and stocktake of the controlled drug register by a pharmacist was not completed. The pharmacist to complete six monthly stock reviews of controlled drugs. 30 days Criterion 1.3.12.5 The facilitation of safe self-administration of medicines by consumers where appropriate. PA Moderate The service had two residents who self-administer medicines. The medicines that were self-administered by the residents were an inhaler and Panadol for use when needed. The resident’s files were reviewed for competency assessments and sign off by the GP, monitoring and documentation of medicines administration and storage of the medicines. The RN’s complete competency assessments on the residents who are considered able to medicines however the GP was not signing off the assessments. Registered nurses were not checking with the residents who medicines that they have taken all medicines on each shift and the residents did not have secure storage for their medicines. Residents who medicines to have their competency assessments signed off by the GP, RN’s to complete checks to ensure the residents have taken their medicines on each shift and the residents to have locked storage for their medicines. 30 days Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. PA Low Handover records were requested for review to verify continuity of care through the handover process for the residents who had an in-depth review of care completed on their files. Interview with the registered nurses confirmed that handover notes were destroyed after use and Continuity of care through handover could not be verified. Continuity of care through handover to be demonstrated in written records. 30 days