Major shortfalls, significant action is needed to achieve the required levels of performance Some standards applicable to this service unattained and of moderate or high risk Consumer Rights as at 25 November 2013 Includes 13 standards that support an outcome consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Some standards applicable to this service partially attained and of low risk. Organisational Management as at 25 November 2013 Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Some standards applicable to this service partially attained and of low risk. Continuum of Service Delivery as at 25 November 2013 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. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Safe and Appropriate Environment as at 25 November 2013 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. Restraint Minimisation and Safe Practice as at 25 November 2013 Includes 3 standards that support outcomes consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service fully attained. Infection Prevention and Control as at 25 November 2013
Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.10: Informed Consent Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. PA Low HDS(C)S.2008 Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. PA Low of four not for resuscitation plans that had been determined by the GP with family input as the resident is not capable have not been reviewed in the past year. Ensure not for resuscitation are reviewed annually. 180 HDS(C)S.2008 Standard 1.2.7: Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low HDS(C)S.2008 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 In the past four weeks, there have been eight PM shifts without a staff member with a first aid certificate. The operational manager states that she always endeavours to have one staff with a first aid certificate on duty after hours, however when casual staff cover for staff absences at short notice or staff change Ensure that each shift has a staff member with a first aid certificate. 90
resident is receiving the Ensure. (ii) The same resident had a fall in October 2013 resulting in a knock to the head. . The resident was observed for signs of concussion and staff contacted the manager on call. However, a full set of neurological observations were not completed The manager reports that this is because caregivers are not trained to complete full neurological observations. HDS(C)S.2008 Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Moderate HDS(C)S.2008 Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in to comply with legislation, protocols, and guidelines. PA Moderate (i)Controlled drug checks have not occurred weekly. (ii) PRN medications do not document an indication for use on seven of eight medication charts sampled. (iii) Five of eight medication charts sampled have regular medications prescribed that have not always been signed as administered. (iv) There are two open bottles of saline eye drops that had (i)Ensure controlled drug checks occur weekly. (ii) Ensure all PRN medications document an indication for use. (iii) Ensure medications are administered as prescribed. (iv) Ensure all eye drops are dated when they are opened. 90
not been dated when they were opened. HDS(C)S.2008 Criterion 1.3.12.5 The facilitation of safe of medicines by consumers appropriate. PA Low There is one residents who self-administers inhalers and does not have a competency assessment Ensure all residents who self-administer medicines have a current competency assessment. 180 Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards Outcome 1.1: Consumer Rights Consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3) Consumers are treated with respect and receive services in a manner that has regard for dignity, privacy, and independence. ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4 Attainment and Risk: FA Evidence: Staff had training around abuse and neglect in June 2013. Staff have also completed a questionnaire around abuse and neglect. Three of three caregivers confirm knowledge of the procedure to notify the operational manager and/or nurse manager of any abuse and to document an incident form. administration