Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity Some standards applicable to this service partially attained and of low risk A number of shortfalls that require specific action to address Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk Major shortfalls, significant action is needed to achieve the required levels of performance Some standards applicable to this service unattained and of moderate or high risk Consumer Rights as at 19 November 2013 Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Standards applicable to this service fully attained. Organisational Management as at 19 November 2013 Includes 9 standards that support an outcome consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Some standards applicable to this service partially attained and of low risk. Continuum of Service Delivery as at 19 November 2013 Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Safe and Appropriate Environment as at 19 November 2013 Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Standards applicable to this service attained. Restraint Minimisation and Safe Practice as at 19 November 2013
Audit Team Lead Auditor XXXXX Hours on site 14 Hours off site 6 Other Auditors XXXXX Total hours on site 14 Total hours off site 5 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXX Hours 1 Sample Totals Total audit hours on site 28 audit hours off site 12 audit hours 40 Number of residents interviewed 11 Number of staff interviewed 23 Number of managers interviewed 6 Number of residents’ records reviewed 9 Number of staff records reviewed 8 number of managers (headcount) 3 Number of medication records reviewed 18 Total number of staff (headcount) 155 Number of relatives interviewed 3 Number of residents’ records reviewed using tracer methodology 3 Number of GPs interviewed 1
All meetings held includes discussion on infection control. Internal audits are completed. Infections are benchmarked across the organisation. There is an improvement required around follow through of meeting minutes. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 12 0 3 3 0 0 Criteria 0 38 0 3 3 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 32 Criteria 0 0 0 0 0 0 0 57 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. PA Low HDS(C)S.2008 Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low A review of incident stats across 2013 identified that pressure areas were high for April (7) May (6) and June (6) in the hospital. No corrective actions were established. Incident and accident analysis has been completed monthly but Ensure analysis of incidents includes documented/implemented corrective actions at a facility level to minimise further incidents 60
lacks detail/trends and corrective actions. However, improvements to incident and accident analysis were noted from August 2013. HDS(C)S.2008 Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. PA Moderate HDS(C)S.2008 Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Moderate (i)Six of nine care plans sampled do not have interventions relating to all areas of need. Examples include MRSA, falls risk management, pressure area risk management and weight loss. (ii) One resident in the dementia unit who has a possible delirium and one resident in the hospital with reddened areas in the groin requiring creams do not have short term care plans relating to these needs. Ensure that all areas of identified need have related interventions in care plans. (ii) Ensure that short term care plans are used to address short term needs. 30 HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Moderate HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate (i)One resident in the hospital has her only functioning hand bandaged to prevent her removing her naso gastric tube. has (i) Ensure that all residents using restraint have a documented assessment and plan around this. (ii) Ensure weight loss is appropriately managed 30
(g) The impact the restraint had on the consumer; (h) Whether appropriate advocacy/support was provided or facilitated; (i) Whether the observations and monitoring were adequate and maintained the safety of the consumer; (j) Whether the service's policies and procedures were followed; (k) Any suggested changes or additions required to the restraint education for service providers. HDS(IPC)S.2008 Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. PA Low HDS(IPC)S.2008 Criterion 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner. PA Low The service was to have two outbreaks this year. From 4 – 15 February a GI outbreak in the rest home resulted in 19 residents and six staff affected. From 4 – 21 July and 31 July – 19 August a GI outbreaks resulted in 22 residents in the rest home affected and 11 residents in the dementia unit. Outbreak summary reports and outbreak management meetings were held. Meeting minutes Ensure meeting minutes identify follow through, actions taken, sign off and outcome. 90