Summary of attainment The following table summarises the number of standards and criteria audited and the ratings they were awarded. Attainment Rating Continuous Improvement (CI) Fully Attained (FA) Partially Attained Negligible Risk (PA Negligible) Partially Attained Low Risk (PA Low) Partially Attained Moderate Risk (PA Moderate) Partially Attained High Risk (PA High) Partially Attained Critical Risk (PA Critical) Standards 0 7 0 7 1 0 0 Criteria 0 23 0 11 1 0 0 Attainment Rating Unattained Negligible Risk (UA Negligible) Unattained Low Risk (UA Low) Unattained Moderate Risk (UA Moderate) Unattained High Risk (UA High) Unattained Critical Risk (UA Critical) Standards 0 0 0 0 0 Criteria 0 0 0 0 0
Standard 1.4.8: Natural Light, Ventilation, And Heating Consumers are provided with adequate natural safe ventilation, and an environment that is maintained at a safe and comfortable temperature. FA General living areas and resident rooms are appropriately heated and ventilated. Resident’s rooms are heated via under floor heating; communal living areas are heated and cooled via ceiling heating/cooling systems. General living areas and resident rooms are appropriately heated and ventilated. All rooms have external windows with plenty of natural sunlight. All windows are double-glazed and all areas have good lighting. Standard 3.1: Infection control management There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service. FA There are comprehensive infection control policies that meet the Infection Control Standard SNZ HB 8134.3.1.2008. There are policies including (but not limited to); a) Infection control coordination, b) hand hygiene, c) surveillance, d) standard precautions, e) additional precautions, f) standard definitions of infections. The infection control team will include an IC officer (registered nurse), nurse manager and various care staff. There are clear lines of accountability to report to the IC team on any infection control issues including a reporting and notification to nurse manager. There are documented IC responsibilities that include reporting processes and an IC officer’s job description. Infection control will be an agenda item on meetings and quality meetings. Annual review of the infection control programme will be conducted. Monthly benchmarking of infections is conducted for all Summerset facilities.
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 their 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 1.2.1.3 The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services. PA The appointed nurse manager (who is yet to commence) is an overseas registered nurse who has obtained New Zealand registration. She has significant experience and postgraduate qualifications in dementia care and mental health. She completed one year working in a care home (aged care) environment in 2006 and 2007 in England. The village manager does not have a health background and does not provide clinical support. The appointed nurse manager does not have recent experience in providing rest home and hospital level care. Ensure that clinical aspects of the service are managed by a person with appropriate qualifications and experience in aged care. to occupancy days Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers PA Low All new staff are required to complete an induction and orientation. The organisation has an induction/orientation programme, which includes packages specifically tailored to the position such as Orientation for staff is yet to be provided. Advised, that the newly employed staff commencing, will all receive one-week orientation/training at the facility prior to opening (two weeks for Ensure that all new staff are provided with a complete orientation programme.