Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 42 0 3 0 0 0 Criteria 0 90 0 3 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 5 0 0 Criteria 0 0 0 0 0 8 0 0 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 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 (i)Incident form didn’t identify neuro obs. Completed when the resident had a head injury; (ii) one resident file identified a sacral pressure injury, no incident form was completed; (iii) one incident form reviewed did not identify the incident in the progress notes. (i)Ensure neuro obs are documented where the resident has a head injury; (ii) Ensure incident forms are completed for pressure injuries; (iii) Ensure incidents and follow up/assessment are also completed in the progress notes. 60 HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. PA Low
surveys received YTD identified all spoke positively about their experience. Four rest home family members interviewed spoke very positively about the care provided and were well informed and supported. Six rest home residents and two hospital residents spoke positively about the care and the changes made since change of owner. D1.3 all approved service standards are adhered to. D17.7c There are implemented competencies for all staff including caregivers, and registered nurses. There are clear ethical and professional standards and boundaries within job descriptions. The following improvements have been made to the service since change of owner in June 2013. 1. Painting and carpeting of whole facility 2. Installation of kitchenettes in two lounges 3. Change over to DCNZ Quality System. 4. Participation in DCNZ Organisational IC, H&S and Restraint meetings occur six monthly and we have representatives from Leighton House at each meeting. 5. Hazard Register is now reviewed three monthly. 6. Implementation of an incident management database. 7. Implementation of a Complaints, Staff Accident and Quality Improvement Database 8. Implementation of Internal Benchmarking for both levels of care. 9. Infection control surveillance system 10. Inter cultural Awareness programme for staff 11. Diversional therapy team are supported by an Organisational Diversional Therapy Coordinator who is available to all facilities. 12. Provision of supervision training and supervision of all RNs 13. Transition of East Wing into a hospital level wing. 14. Best Friends Approach to Care education programme for staff 15. Staff support provided by Vitae Services Criterion 1.1.8.1 (HDS(C)S.2008:1.1.8.1) The service provides an environment that encourages good practice, should include evidence-based practice. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.)
Standard 1.1.12: Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12) Consumers are able to maintain links with their family/whānau and their community. ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f Attainment and Risk: FA Evidence: D3.1h; Discussion with four family members confirmed that they are encouraged to be involved with the service and care of the residents. Visiting is actively encouraged. Relatives interviewed stated they could visit at any time. The service has open visiting hours. D3.1.e Interviews with activity staff and caregivers described how residents are supported and encouraged to remain involved in the community and external groups. The facility activity programme encourages links with the community. Activities programmes include opportunities to attend events outside of the facility including activities of daily living e.g. shopping. Entertainers are included in the activities programme. The activities coordinators described how outings in the van are tailored to meet the interests of the residents. Residents are encouraged to maintain outside interests as appropriate. Assistance with transport is provided as required. Criterion 1.1.12.1 (HDS(C)S.2008:1.1.12.1) Consumers have access to visitors of their choice. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.1.12.2 (HDS(C)S.2008:1.1.12.2) Consumers are supported to access services within the community when appropriate. Attainment and Risk: FA Evidence: Finding:
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Outcome 1.4: Safe and Appropriate Environment Services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensures 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. Standard 1.4.1: Management Of Waste And Hazardous Substances (HDS(C)S.2008:1.4.1) Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. ARC D19.3c.v; ARHSS D19.3c.v Attainment and Risk: FA Evidence: Organisational polices of Management of Waste and Hazardous Materials policy and relevant procedures to support the safe disposal of waste and hazardous substances are in place. These include, but are not limited to: a) sharps procedure and b) cleaning/chemicals procedures and c) exposure to blood or other body fluid contamination policy. There is an incident reporting system that includes investigation of these types of incidents. Chemicals are labelled correctly and stored safely throughout the facility. There is appropriate protective equipment and clothing for staff. Staff attended chemical safety training in Jan-13 and chemical safety competencies have been completed. They are medical data safety sheets displayed. Staff interviewed were able to describe waste management and chemical safety procedures. Criterion 1.4.1.1 (HDS(C)S.2008:1.4.1.1) Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements. Attainment and Risk: FA Evidence: Finding: