zilongwang/ReadingBank huggingface dataset:
disposal comply with current legislation, and guidelines. ensure that this is maintained. 60 days Criterion 1.3.3.1 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. PA Moderate The registered nurses write in separate progress notes to the caregivers. Caregiver’s progress notes were brief and documented every shift. Registered nursing progress notes were detailed and described specific interventions or encounters. Registered nurses progress notes contained gaps of up to two months where no nursing interventions/reviews had been documented. Seven of seven resident files sampled did not contain documented evidence of regular review by registered nurses. Progress notes had periods ranging from one to two months where no nursing interventions or assessments were documented. Ensure that interventions, assessments and reviews by registered nurses are completed and documented regularly. 60 days Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low Each of the seven files sampled contained an initial assessment, an initial care plan, interRAI assessments and long term care plans. All files contained a current interRAI assessment where this was required (the younger resident did not require an interRAI assessment). Until recently only one of the two registered nurses was trained in interRAI assessments, due to difficulty accessing training and contractual timeframes were not always met. The second registered nurse completed interRAI training three months ago and since this time all timeframes have been met and all interRAI assessments have been bought up to date. As the issue has been addressed no finding has been made in relation to this. However other contractual timeframes were not always met. All residents who were under the care of the house GP had contractual timeframes in relation to admission assessments met. Faxes sighted provided evidence that the doctors had been notified for residents who had chosen to retain their (i) Two of the seven resident files sampled had not had the initial assessment completed within 24 hours of admission (noting that all were completed within 72 hours of admission). (ii) Two of seven resident files sampled were not reviewed by a GP within two working days of admission where this was required. Ensure that contractual timeframes around resident assessments are met. 90 days
Organisational management A well-developed planning process is based around the statutory requirements and adapted to meet the needs of the Whanganui region’s people. Values have been updated and are well embedded in the organisation. The current management and leadership structure is effective with an experienced and stable executive management team. The quality and risk framework is well established, led by the General Manager of Patient Safety and Service Quality and supported by a well-qualified team. Connections to national projects and a strong culture of quality improvement are strengths of the organisation, as is the focus on inclusion of whanau/family in quality activities. Staff are involved at all levels with improvement activities, in particular, the ‘Releasing time to care’ programme, and are familiar with audit, data analysis and continuous improvement methodology. Effective systems are in place to integrate the various components of quality and risk management. Data is widely available and well used to monitor patient safety, support projects, make improvements, monitor trends and address issues where they arise. Adverse events, including those of a more serious nature, are being managed as required. Consumer and family involvement within the mental health services is well developed, with involvement of appointed roles at both a strategic and operational level. resources systems are based on best practice. The developments in the orientation process support integration of the values across the organisation. Staff are well supported with training and education opportunities, with improvements to the recording of training evident. The organisation continues to seek ways to further enhance training, using on line and shared resources with other DHBs in the region and nationally. Staff numbers and skill mix are clearly defined and based on accurate information. There is a multi-pronged approach to ensuring staff are utilised in the most efficient way to meet changing patient demands. Clinical records, in general, are well completed, tracking the patient’s care. Records are stored securely and easily retrievable. Privacy of information is maintained.
Specific results for criterion where corrective actions are required 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 Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low Overall care plans described the individual support and interventions required to meet the resident goals, however four resident files reviewed did not include all interventions to support current needs. Four resident files reviewed (two rest home residents, one rest home respite care and one hospital respite level of care resident) did not all include interventions to support current needs. 1) The hospital level respite care resident was assessed at medium risk of falls, had swallowing difficulties and on a soft diet. There were no documented interventions to manage the falls risk and dietary requirements/swallowing difficulties. No weight had been recorded on admission. 2) There were no documented signs/symptoms treatment and management for hypoglycaemia episodes as per discharge summary. 3) One rest home resident has been diagnosed with a new medical condition with associated pain as per GP notes. There were no documented interventions for the newly diagnosed condition or pain management plan in place. 4) One other rest home resident had no documented interventions for a medication that requires close monitoring (as per GP notes). Ensure resident current health are documented to guide staff in the delivery of care and to meet the resident needs. 90 days
Call bells alert staff to residents requiring assistance. At night, to reduce the sound level for the residents, one switch in the building is turned off, however the sound remains able to be heard by staff. Residents reported staff respond promptly to call bells. Security systems in place include staff checking that doors and windows are closed after dark. Staff and residents interviewed confirmed they feel safe at all times. Last year Methven House did have a breach in security where an unknown person came on site and scammed a resident. They took this very seriously and carried out a full investigation which then went to the management board. The family and resident were happy with the process. Police were notified and a section 31 was provided to the Ministry of Health and the local District Health Board (DHB). Standard 1.4.8: Natural Light, Ventilation, And Heating Consumers are provided with adequate natural light, safe ventilation, and an environment that is maintained at a safe and comfortable temperature. FA All residents’ rooms and communal areas are heated and ventilated appropriately. Rooms have natural light and opening external windows. All communal areas have heat pumps, which on the day of audit were on, and the facility was warm. Standard 3.1: Infection control management There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service. FA The service provides a managed environment that minimises the risk of infection to residents, staff and visitors by the implementation of an appropriate infection prevention and control (IPC) programme. Infection control management is guided by a comprehensive and current infection control manual, with input from the NM and Infection Prevention and Control Officer (IPC). The infection control programme and manual are reviewed annually. A registered nurse is the designated IPC coordinator, whose role and responsibilities are defined in a job description. Infection control matters, including surveillance results, are reported monthly to the NM, tabled at the monthly staff meetings and reported at the regular board meetings. Signage at the main entrance to the facility requests anyone who is unwell, or has been unwell in the past 48 hours, not to enter the facility. The infection control manual provides guidance for staff about how long they must stay away from work if they have been unwell. Staff interviewed understood these related responsibilities.
Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA Policies and procedures meet the requirements of the restraint minimisation and safe practice standards and provide guidance on the safe use of both restraints and enablers. The clinical manager is the restraint coordinator and provides relevant education and information when this is required. During the she demonstrated a sound understanding of the organisation’s policies, procedures and practice and was familiar with her responsibilities. There were no residents using an enabler or a restraint on the two days of audit and there is no evidence of the use of a restraint, or an enabler since the last audit. Restraint would reportedly only be used as a last resort when all alternatives had been explored. It is maintained as a topic on the quality and risk meeting agenda to ensure it is not overlooked.
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) 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 0 0 0 0 Criteria 0 93 0 0 0 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
Standard 1.4.1: Management Of Waste And Hazardous Substances Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. FA There are implemented policies in place to guide staff in waste management. Staff interviewed were aware of practices outlined in relevant policy. Gloves, aprons and goggles are available and staff were observed wearing personal protective clothing while carrying out their duties. Infection prevention and control policies state specific tasks and duties for which protective equipment is to be worn. Chemicals sighted were labelled correctly and were all stored safely throughout the facility. Safety data sheets are available. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. FA The facility has a current building warrant of fitness expires 1 July 2017. The service is meeting the relevant requirements as identified by relevant legislation and standards. The physical environment allows easy access, movement for the residents and promotes independence for residents with mobility aids. There is a dining area, separate lounge area and smaller seating areas for more private conversation. The owner is the maintenance person who carries out daily maintenance requests and records corrective actions in the maintenance book. There are monthly internal building and external building maintenance schedules in place. Water temperature monitoring of different rooms is carried out each month (sighted) and complies with regulations. The grounds are tidy, well maintained and able to be accessed safely. There are outdoor ramps with handrails, outdoor seating, shaded areas and raised garden beds. Standard 1.4.3: Toilet, Shower, And Bathing Facilities Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements. FA There are an adequate number of toilet and showering facilities. Privacy locks are in place. Vacant/in use signage is on the toilet/shower rooms. All residents interviewed confirmed their privacy was maintained while attending to personal hygiene cares. Standard 1.4.4: Personal Space/Bed Areas Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. FA All resident’s rooms are of an appropriate size to allow care to be provided and for the safe use and manoeuvring of mobility aids. There are four double rooms which at present have single occupancy. Residents are encouraged to personalise their bedrooms.
Infection control management systems and policies and procedures are in place to minimise the risk of infection to residents, service providers and visitors. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner. Summary of attainment The following 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 14 0 1 1 0 0 Criteria 1 38 0 1 1 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
facility. A six-monthly review is completed. The infection control nurse is supported by the clinical manager and the organization national clinical manager and the clinical director. There has been one suspected outbreak (unconfirmed) which was communicated to the public health unit. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA The service has documented systems in to ensure the use of restraint is actively minimised. There were no residents being restrained and one resident using an enabler (bedrails) during the audit. Enabler use was voluntary and risks were well assessed and documented in the care plan. A number of interventions had been implemented to reduce the need for the enabler but the resident continued to feel more comfortable with the enabler in place. Staff interviews and staff records evidenced guidance has been given on restraint minimisation and safe practice (RMSP), enabler usage, challenging behaviours and de-escalation techniques including activities.
Infection prevention and control Infection control management systems are in to minimise the risk of infection to consumers, service providers and visitors. The infection control (IC) programme is implemented. The IC programme meets the needs of the organisation and provides information and resources to inform the service providers. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and the ongoing in-service education programme. There have been no outbreaks since previous audit. 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 13 0 5 1 0 0 Criteria 0 30 0 8 1 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
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
service providers and, where appropriate, consumers. staff meetings. The collated information is not consistently trended and analysed to identify opportunities for improvement. trended and analysed to identify opportunities for improvement. results communicated to staff and residents where appropriate. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low The service captures quality improvement data (clinical indicators, health and safety, infection control, accidents and incidents and complaints). The service participates in an external benchmarking initiative with four facilities in Northland. The benchmarking group meet quarterly to discuss the collated data set. Where the internal and external quality data is identifying opportunities for improvement at the service, corrective action plans are not consistently being documented. Where corrective action plans have been developed, these are not consistently evaluated and signed out. i) Corrective action plans are not consistently documented where opportunities for improvements are identified. ii) Not all corrective action plans are evaluated and signed off when completed. i-ii) Ensure that corrective actions plans are documented where opportunities for improvement are noted and the corrective action plans are then implemented, reviewed and signed off once completed. 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 As part of the quality management programme, an annual education plan has been documented. The education plan for 2016 was not fully implemented and the education plan for 2017 year to date has not yet been fully implemented. However, staff have been provided with eight hours of professional development annually which covers the training requirements of the Health and Disability Sector Standards. Staff have completed the required competencies in relation to manual handling, health and safety, infection control, medication management and food safety. One of six registered nurses have completed their interRAI training. The organisational policy requires all staff to have a performance review within three months of commencing work and then at least annually. Not all staff have completed the required performance reviews. i)The education plan for 2016 and the education plan 2017 (year to date) have not been fully implemented. ii) Three of six files sampled (cleaner, registered nurse and clinical manager) could not evidence that the required performance reviews had been completed. i) Ensure the annual education plan is fully implemented. ii) Ensure that all staff complete the required performance reviews. 90 days
Team Lead Auditor XXXXXXX Hours on site 4 Hours off site 3 Other Auditors Total hours on site Total hours off site Technical Experts hours on site hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXXXX Hours 1 Sample Totals Total audit hours on site 4 Total audit hours off site 4 Total audit hours 8 Number of residents interviewed Number of staff interviewed Number of managers interviewed 3 Number of residents’ records reviewed Number of staff records reviewed number of managers (headcount) 3 Number of medication records reviewed 12 Total number of staff (headcount) 77 Number of relatives interviewed Number of residents’ records reviewed using tracer methodology Number of GPs interviewed
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) 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 20 0 1 0 0 0 Criteria 1 43 0 1 0 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
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
Corrective actions are established, implemented and are signed off when completed. Health and safety goals are established and regularly reviewed. Health and safety policies are implemented and monitored by the Health and Safety Committee. The health and safety officer was interviewed about the health and safety programme. Risk management, hazard control and emergency policies and procedures are being implemented. Hazard identification forms and a hazard register are in place. There are procedures to guide staff in managing clinical and non-clinical emergencies. All new staff and contractors undergo a health and safety orientation programme. An employee health and safety programme (Bfit) is in place, which is linked to the overarching Bupa National Health and Safety Plan. The resident satisfaction survey for 2016 improved to 95% overall satisfaction from 91% overall satisfaction in 2015. Falls prevention strategies include the analysis of falls events and the identification of interventions on a case-by-case basis to minimise future falls. Falls prevention equipment includes sensor mats and chair alarms. 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. FA Individual reports are completed for each incident/accident with immediate action noted and any follow-up action(s) required. Fourteen accident/incident forms were reviewed. Each event involving a resident reflected a clinical assessment and follow up by a registered nurse. Neurological observations are conducted for unwitnessed falls. Data collected on incident and accident forms are linked to the quality management system. The care home manager and clinical manager are aware of their requirement to notify relevant authorities in relation to essential notifications. Standard 1.2.7: Human Resource Management resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. FA Human resources policies include recruitment, selection, orientation and staff training and development. Eight staff files reviewed (one clinical manager, two RNs, three caregivers, one diversional therapist and one health and safety officer) included a recruitment process (interview process, reference checking and police check), signed employment contracts, job descriptions and completed orientation programmes. A register of registered nursing staff and other health practitioner practising certificates is maintained. The orientation programme provides new staff with relevant information for safe work practice. There is an implemented annual education and training plan that exceeds eight hours annually. There is an attendance register for each training session and an individual staff member record of training. Staff are required to
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 officer (registered is responsible for coordinating/providing education and training for staff. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. The infection control officer uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking with other Bupa facilities. Staff receive ongoing training in infection control. 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 1 40 0 4 0 0 0 Criteria 1 88 0 4 0 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
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) 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 44 0 2 4 0 0 Criteria 0 95 0 2 4 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
are within acceptable parameters to ensure resident safety. 90 days Criterion 2.2.2.1 In assessing whether restraint will be used, appropriate factors are taken into consideration by a suitably skilled service provider. This shall include but is not limited to: (a) Any risks related to the use of restraint; (b) Any underlying causes for the relevant behaviour or condition if known; (c) Existing advance directives the consumer may have made; (d) Whether the consumer has been restrained in the past and, if so, an evaluation of these episodes; (e) Any history of trauma or abuse, which may have involved the consumer being held against their will; (f) Maintaining culturally safe practice; (g) Desired outcome and criteria for ending restraint (which should be made explicit and, as much as practicable, made clear to the consumer); (h) Possible alternative intervention/strategies. PA Two residents using enablers and two residents using restraints’ clinical files were reviewed for safe and appropriate enabler and restraint use. Restraint assessments, consent, risks, monitoring, review and long-term care plans are not consistently completed for all residents using enablers/restraint. i) One of two enabler assessments and consents were not completed. ii) Two of two enabler risks were not identified during assessment. iii) Two of two enabler risks and two of two restraint risks were not reflected in the long-term care plan. iv) Two of two restraint monitoring were not completed. v) Two of two enablers have not been reviewed for appropriateness of current use. All enabler and restraint use to be aligned with requirements and good practice. 90 days
HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan addressing requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low The internal audit schedule is implemented. The internal audits completed between March to August 2014 were reviewed, and audit summaries and action plans are completed where a noncompliance is identified. In two occasions, corrective action plan identified required actions but they were not documented as completed. Clinical file audit completed in May 2014 showed 89% compliance, and audit summary identified issues around The required corrective action plan was to re-audit in two months which was not completed. A care plan audit was completed in May 2014 and identified 90.5% compliance. Required action plan was identified as “one month follow up” but this has not been documented as actioned. Interview with the clinical manager also confirmed that required actions have not yet been implemented. Ensure that required corrective action plans resulting from internal audit activity is implemented. 180 HDS(C)S.2008 Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. PA Moderate
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) 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 1 49 0 0 0 0 0 Criteria 2 99 0 0 0 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
commenced on fluid balance recordings. Antibiotics were only requested for residents with four or more UTI symptoms and where a UTI had been confirmed by the laboratory. The result of this initiative saw the rate of antibiotic therapy use for suspected UTI with no infection confirmed by MSU testing, drop from five in February 2016 to zero by June 2016. The overall confirmed UTI rate also decreased from nine in May 2016 to one per from June 2016. Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. CI Data are collected in relation to a variety of quality activities and an internal schedule has been completed. Areas of identified through quality activities are actioned for improvement. The service has conducted a number of quality improvement projects a review process has occurred, including analysis and reporting of findings. There is evidence of action taken based on findings that has made improvements to service provision. The projects include reviewing if the improvements have had positive impacts on resident safety. Example: The Bainlea House introduced a project to more effectively manage challenging behaviour, which could potentially impact on other residents and families’ well-being. A number of different strategies were implemented, monitored and updated where needed. Ongoing statistical evidence / trends was gathered each month and reported back to staff team at monthly staff meeting. The evaluation identified a reduction in sundowning behaviours. The programme continues to be evaluated. End of the report.
achievement towards the desired goal or outcome. Progress notes were completed on the computer and reflected response to interventions and treatments. Changes to care were documented. Documentation of GP visits evidence that reviews were occurring at least three-monthly. Short-term care plans were in use for short-term issues and evidenced signed off once completed. Standard 1.3.9: Referral To Health And Disability Services (Internal And External) Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs. FA The service facilitates access to other services (medical and non-medical) and where access occurs, referral documentation is maintained. Residents' and/or their family/whānau are involved as appropriate when referral to another service occurs. Registered nurses interviewed described the referral process should they require assistance from specialist practitioners. The review of resident files included evidence of recent referrals. Standard 1.4.1: Management Of Waste And Hazardous Substances Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. FA There are policies and procedures that guide the safe and appropriate storage, transport and disposal of waste and hazardous substances. Waste is appropriately managed. Chemicals are secured in designated locked cupboards. Chemicals are labelled and safety datasheets were available throughout the facility and accessible to staff. Chemicals were observed to be secured safely. Safe chemical handling training has been provided. Personal protective equipment/clothing is freely available. Staff interviewed demonstrated knowledge of handling chemicals. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for purpose. FA Brittany House is currently refurbishing and upgrading the facility. The building has two storeys. The ground floor has two wings; Pampuri wing has twelve bedrooms with two resident bathrooms requiring repair. The other wing has nine bedrooms. The ground floor has one room under refurbishment (currently suitable for a rest home resident) that was not in use. The first-floor level has four wings. St Anne’s wing has four single rooms, one double room and two three bedded rooms and Our Lady wing has seven single rooms and one resident bathroom. St Peters wing has eight single rooms and St John’s wing has six single rooms, one double room and two three-bedded rooms.
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
the function for each stage they manage. Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines. PA Low All medication files sampled contained accurate and legible prescribing information, demographic details and current photographs. Not all files had allergies documented. of sixteen medication files sampled did not have allergies, or allergy status documented. Ensure all medication charts have the allergy status documented. 30 days Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low All resident files sampled had current interRAI and care plans documented and reviewed. Not all documentation was completed within expected timeframes. InterRAI contractual requirements had not previously been met as the service had no interRAI trained RN’s. This issue has now been addressed and all residents now have current interRAI assessments Four of eight files sampled (two hospital and two psychogeriatric) did not have a long-term care plan completed within three weeks of admission. Two of four files sampled under the ARHSS contract did not have contractual timeframes around interRAI met. One hospital file sampled had a period of 11 months between evaluations. Ensure all assessment, care plan and evaluation requirements are completed within contractual timeframes. 90 days Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the PA Low All care plans requiring evaluation had current documentation, however the documentation did not always include progress against the goals. Five of eight care plans sampled (two psychogeriatric including one on a long-term support chronic health condition contract and three hospital including one on an ACC contract) did not Ensure evaluations document progress toward desired outcomes. 90 days
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. All standards applicable to this service fully attained with some standards exceeded. Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Results of surveillance are acted-upon, evaluated and reported to relevant personnel in a timely manner. 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 2 47 0 1 0 0 0 Criteria 2 98 0 1 0 0 0
Attainment against the Health and Disability Services Standards The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit. Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section. For more information on the standards, please click here. For more information on the different types of audits and what they cover please click here. Standard with desired outcome Attainment Rating Audit Evidence Standard 1.1.13: Complaints Management The of the consumer to make a complaint is understood, respected, and upheld. FA The organisation’s complaints policy and procedure is in line with Right 10 of the Health and Disability Commissioner’s Code of Health and Disability Consumer’s Rights (the Code) and includes periods for responding to a complaint. The complaint forms are available at the entrance to the facility. A complaints register is in place and includes: the date the complaint was received; the source of the complaint; a description of the complaint; and the date the complaint was resolved. Evidence relating to each lodged complaint is held in the complaints folder. One complaint had been received in 2017 and this was reviewed. On review of the complaint, evidence demonstrated it was investigated promptly with the issues resolved in a timely manner. Residents and family members interviewed stated they would feel comfortable complaining. The business and care manager confirmed there had been no complaints with the Health and Disability Commission since the previous audit or with other authorities. Standard 1.1.9: Communication FA Policies and procedures, such as accidents/incidents, complaints and open disclosure, guide staff on the process of open disclosure of information.
A comprehensive quality and risk management programme is in place. Corrective actions are implemented and evaluated where opportunities for improvements are identified. The risk management programme includes managing adverse events and health and safety processes. Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice. A comprehensive orientation programme is in place for new staff. Ongoing education and training for staff includes in-service education and competency assessments. Registered nursing cover is provided seven days a week, twenty-four hours a day. Residents and families report that staffing levels are adequate to meet the needs of the residents. The integrated residents’ are appropriate to the service type. Continuum of service delivery Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Standards applicable to this service fully attained. There is a comprehensive information package for residents/relatives on admission to the service. Assessments, risk assessments, care plans, interventions and evaluations are completed by the registered nurses. Care plans demonstrate service integration. Residents and family interviewed confirmed they are involved in the care plan and review processes. The general practitioner completes an admission visit and reviews the residents at least three-monthly. The activity team provide an activities programme that is varied and interesting for each resident The activity programme meets the abilities and recreational needs of the group of residents, including outings and entertainment.
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 0 0 0 0 Criteria 0 93 0 0 0 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
Standards 3 47 0 0 0 0 0 Criteria 4 97 0 0 0 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
are practical, safe, and appropriate/suitable for the type of service provided. Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers. FA The IC coordinator is responsible for coordinating/providing education and training to staff. The orientation package includes specific training around hand washing and standard precautions. IC training was last provided July 2015. The IC coordinator has received education by an external provider to enhance her skills and knowledge. The IC coordinator has access to the Bupa intranet with resources, guidelines best practice and benchmarking. A number of toolbox have been provided including (but not limited to) managing and preventing respiratory infections. Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. CI The surveillance policy describes and outlines the purpose and methodology for the surveillance of infections. The IC coordinator uses the information obtained through surveillance to determine IC activities, resources and education within the facility. Internal IC audits also assist the service in evaluating infection control needs. There is close liaison with the general practitioners and community laboratory that advise and provide feedback/information to the service. Systems in place are appropriate to the size and complexity of the facility. Effective monitoring is the responsibility of the IC coordinator. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. Surveillance data is available to all Infections statistics are included for benchmarking. Corrective actions are established where infections are above the benchmark. There has been a significant reduction in the number of urinary tract infections. All infections are documented monthly in an infection control register is now electronic (from August 2017). Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA The service has documented systems in place to ensure the use of restraint is actively minimised. There were eleven hospital level residents with restraints and two residents using an enabler. Staff interviews and staff records evidenced guidance has been given on restraint minimisation and safe practice (RMSP), enabler usage and prevention and/or techniques. Policies and procedures include definitions of restraint and
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) 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 17 0 0 0 0 0 Criteria 0 40 0 0 0 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