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 45 0 3 2 0 0 Criteria 0 98 0 3 3 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
Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. reviewed. The long-term care plans in place reflected the outcome of the assessments. Cultural, sexuality and intimacy needs have been identified for the residents. Registered nurses are competent in the assessment of acute clinical needs of residents to be able to safely deliver care for residents under medical services. Maternity service The LMC midwives that have access to Waihi maternity provide care for women from the booking date at the start of the pregnancy. During the antenatal period, there are extensive assessments of needs, goals and continued planning with all aspects of the maternity experience. There is a Waihi maternity booking form which provides comprehensive entry information for the service. Once the client enters the facility for the labour birth experience or the postnatal period these previous plans form the basis of the care provided while within the facility. All files reviewed confirm the continuum of provision of care with daily assessments, timely interventions, and achievement of planned goals. The tracer file shows needs and daily goals being met in a timely manner. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. PA Moderate Rest home and hospital: Resident files include all required documentation. The long-term care plan records the resident’s problem/need and objectives. Not all resident files sampled had documented interventions to address the residents’ needs. Care plans are evaluated for identified issues and were completed six monthly, or in some files as condition changed. Short-term care plans are in use for short-term needs and changes in health status. Resident files reviewed identified that family were involved in the care plan development and ongoing care needs of the resident. Families interviewed confirmed their involvement in the care planning process. Maternity service Continuity of care is provided to the clients by their LMC who visits daily and by the facility HCAs. Inpatient orientation to the facility and its services are identified within the daily entries in the facility files while the client is an inpatient. Handover of information between the LMCs and HCAs were evidenced in the five of five files reviewed and show a team approach to the inpatient care. Clients’ delivery plans displayed evidence of required support or interventions that were identified as part of the daily ongoing assessment process. Some summary’s, topics and updates within the care plans and file were absent. One Waihi maternity client phone interview discussed how she felt that having the
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 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low An education and training programme is established and reviewed annually. Since the previous audit, staff have attended a range of training including (but not limited to) open disclosure, complaints management and food safety (kitchen staff). Individual staff attendance records are maintained. The education and training hours available to staff exceeds eight hours per annum. Only one RN is trained in InterRAI due to staff turnover and the lack of availability of InterRAI training courses. Online in-service training was initiated in 2016. completion rates for mandatory topics are below acceptable limits. A corrective action plan has been developed around this with a goal of achieving 80% attendance in 2017. Other gaps in i) On-line training has not been embedded into practice with low attendance rates. ii) The designated health and safety officer has not attended any formal health and safety training. iii) Cultural training has not been provided for staff. iv) InterRAI assessments are behind schedule due to a lack of RN accessibility to InterRAI training. i) Ensure staff complete all online education and training topics that are required. ii) Ensure the health and safety officer attends external health and safety training. iii) Ensure cultural training is included in the annual education and training plan. iv) Ensure there are adequate numbers of InterRAI trained RNs.
and management of weight loss in three of six files reviewed. Maternity Five client were reviewed. All files evidenced that daily updates to postnatal care plan and labour/birth infant summary were not completed. (a-b) Ensure all documentation meets facility and legal requirements. Include dietary requirements to the postnatal care plan. 30 days Criterion 1.3.8.2 Evaluations are documented, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Low Care staff document in progress notes on every shift. Care plan evaluations are conducted six monthly. Short-term care plans have been developed. Two of six short-term care plans from the sample group evidenced evaluation of progress towards the desired goals and were signed off by a registered nurse when the issues were resolved. Two of four short-term care plans reviewed did not document evaluation of progress towards the desired goal and two had not been signed off when resolved. Ensure short-term care plans are evaluated to monitor progress towards the desired goal and are signed off by a registered nurse when resolved. 90 days