Safe and appropriate environment 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 fully attained. A current building warrant of fitness is posted in a visible location. Restraint minimisation and safe practice Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Restraint minimisation and safe practice policies and procedures are in place. On the day of the audit there were six residents using restraint and six residents using bedrails as an enabler. Infection prevention and control
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 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low The facility’s quality plan 2015 is linked to the Terence Kennedy Quality and Safety Policy and Plan 2014-2016. The quality and risk management programme includes data collection and an internal audit programme although there was no evidence of data being collated and analysed. The manager reports that data collection was taking place electronically but that this information has been corrupted due to a computer virus and is no longer retrievable. The staff meeting minutes template includes space to inform staff about the number of adverse events but this section of the meeting template has been left blank. Staff are kept There is a lack of documented evidence to reflect quality and risk data is being collected, analysed and results provided to staff in staff meeting. Note: this finding does not include the infection control surveillance programme or complaints received. Ensure that quality data is collected, analysed and shared with in staff meetings. 90 days
to the manager when completed. These were missing in a sample of staff files selected for review. (Note: four of five staff files selected for review were employed over the past year). Job descriptions were missing in a selection of staff files. were missing in three of five staff files reviewed. evidenced in the staff file. Ensure evidence of completed orientation programmes are held in staff files. 90 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 in place for staff. Education was not provided during the first half of the year but has totalled more than eight hours during the second half of 2015. Staff attendance is less than 50%. in-service attendance rates have fallen below 50%. Ensure staff attend education and training, meeting contractual requirements. Training on restraint minimisation and safe practice is overdue. 90 days Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate Registered nurses are responsible for administration of medications. None of the registered nurses employed have completed a medication competency since July 2014. Six of the registered nurses have a current syringe driver competency. No staff medication competencies have been completed in 2015. Staff who administer medication are required to have their medication competency checked annually 30 days Criterion 2.1.1.4 The use of enablers shall be voluntary and the least restrictive option to meet the needs of the PA Low Three residents’ files whereby enablers (bedrails) were in place were reviewed. In one residents’ file, the assessment for the use of An assessment for one resident with enabler use was completed 30 days Ensure residents undergo an assessment for
consumer with the intention of promoting or maintaining consumer independence and safety. bedrails was completed within the required timeframe. Signed consents were sighted in all three of the residents’ files. after the bedrails had been put into place. enabler use prior to using the enabler. 90 days Criterion 2.2.3.4 Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided or facilitated; (d) The outcome of the restraint; (e) Any injury to any person as a result of the use of restraint; (f) Observations and monitoring of the consumer during the restraint; (g) Comments resulting from the evaluation of the restraint. PA Moderate Residents using bedrails as restraint are being monitored two hourly as per their restraint assessment. Two residents are using lap belts as restraint. One resident who uses a lap belt infrequently was selected for review. Monitoring forms are not being completed in a consistent manner when restraint is in use. Monitoring of a resident wearing a lap belt was not completed as per the frequency determined on the restraint assessment form. Ensure that restraint monitoring forms are completed as per the frequency determined on the resident’s restraint assessment form. 60 days