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
events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. assess and monitor all adverse events that result in an injury to the resident. The two residents whose files were selected for tracer reviews both had unwitnessed falls resulting in injuries. One of these residents had lacerations to their face, however neurological observations were not undertaken (see link 1.3.3.) they have a fall that could result in a possible head injury. they have a fall that could result in a possible head injury. 30 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 Moderate Inservice education calendars for 2014 and 2015 are reviewed and indicate education is provided at least monthly via an on-line learning programme. learning is supplemented by other education sessions provided by specialist educators. Education attendance records are maintained and with the exception reported below, staff have received education in the core topics. staff have first aid certificates that expired in September 2013. A qualified first aid trainer is employed at a sister facility and is scheduled to provide first aid training for some of the staff on 3 December and 4 December 2014 so that there is at least one person on each shift with a current first aid certificate. The general manager and facility manager advised they plan to ensure that all staff have current first aid certificates. At one staff member with a current first aid certificate is not available on each shift. Provide evidence that there is at least one staff member on each shift who has a current first aid certificate. 30 days Criterion 1.3.1.4 Entry criteria, assessment, and entry screening PA Low The service has revised the admission agreement to include dementia level of care service; however the information The documentation provided to new residents and their family does not include all of the Provide evidence that admission information provided to new residents and their family includes
processes are documented and clearly communicated to consumers, their family/whānau of choice where appropriate, local communities, and referral agencies. available to the public and prospective new residents is not currently fully meeting the requirements stated in the contract with the District Health Board. requirements identified in the funding contract with the District Health Board. (E4.1b) all relevant information as identified in the funding contract. 90 days Criterion 1.3.3.3 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Moderate Three residents receiving dementia level of care had their personal files reviewed during the on-site audit. Two of the three residents did not have 24 hour challenging behaviour management plans to guide staff in the management of challenging behaviour, on record. Not all residents receiving dementia level of care have 24 hour challenging behaviour management plans on record. All residents who receive dementia level of care to have 24 hour challenging behaviour management plans in place to help guide service providers in service delivery when residents present with challenging behaviour. 90 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low An electronic database is used to record maintenance requests. The general manager is interviewed and advised the maintenance person checks this electronic database each day. The electronic maintenance register was reviewed and maintenance requests are not marked as being completed. Some of the maintenance requests on this register were reviewed and maintenance has been completed. Electrical items sighted have electrical test tags with the next test date recorded as due by 24 May 2014. Biomedical equipment and scales have current performance verification stickers in place. (i)Electrical equipment is not displaying current electrical safety testing tags; and (ii) the electronic maintenance register is not updated to reflect the status of the maintenance request. Provide documented evidence that (i) testing and tagging of electrical items is current; and (ii) the electronic maintenance register is updated as maintenance requests are actioned. 60 days