Infection prevention and control Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. Standards applicable to this service fully attained. The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control co-ordinator (registered is responsible for coordinating education and training for staff. The infection control co-ordinator has attended external training. The infection control programme has been reviewed annually. There are policies and guidelines in place that reflect good practice. The infection control co-ordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility. 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 40 0 3 2 0 0 Criteria 0 88 0 3 2 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
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 Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality data including infection control, health and safety, education, concerns/complaints and enablers/restraint is discussed at meetings as sighted in the meeting minutes. Staff confirm discussion is held around quality data. Annual staff and resident/relative satisfaction surveys have been completed annually. Internal audits have been completed as per schedule and include environmental and clinical audits. Corrective action plans were raised for identified deficits. There is no documented evidence of the outcomes of internal audits discussed at meetings. The results of surveys have not been collated, feedback to participants or discussed at meetings. Ensure staff are aware of the outcomes of internal audits. Collate survey results and ensure outcomes are feedback to staff and participants. 90 days Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct PA Moderate The manager is aware of essential notification to the DHB for outbreaks, emergency facility events, coroner enquiry and change of manager etc. There was no evidence of DHB notification following an absconding incident involving a police search. Ensure the DHB is notified for all essential notifications under Section 31. 30 days