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. Some standards applicable to this service partially attained and of low risk. The infection control programme is updated annually. The programme is overseen by senior nursing staff. A recently appointed infection control nurse is supported by experienced staff with access to expertise at from DHB IP&C nurse specialist. Policy guidance is sufficient for the programme. Education is appropriate to the service. An active audit programme is undertaken including surveillance of infections. Policy includes guidance and audit requirements for antimicrobial prescribing, however no evidence was provided at audit of antimicrobial monitoring. This is an area for improvement. 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 41 0 7 3 0 0 Criteria 0 92 0 7 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
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 is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Citerion with desired outcome Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.4 There is a document control system to manage the policies and procedures. This system shall ensure documents are approved, up to date, available to service providers and managed to preclude the use of obsolete documents. PA Policies and procedures are available for staff in both hard copy and electronically on the ‘share file’. The review and updating responsibilities are designated. Some of the policies sighted were current and clearly detail staff responsibilities. However there are a number of policy/procedure documents that have not been developed as yet, or were overdue for review. Examples include: The electronic emergency management policy in the share file is not the current version (dated 2012/2013). The intravenous therapy manual on the file is dated 2009 (due for review in 2011). While there are procedures to guide admission processes this does not include clear criteria regarding the decision making process for There are examples of policies and procedural manuals in use which are overdue for review. Some updated policies have not yet replaced the previous version of the PDF policy located on the share file and accessible by staff. are multiple versions of maternity policies available for staff. There are insufficient policy and procedures available that detail the organisation’s expectations related to some aspects of practice. The Ensure policies are procedures are sufficiently detailed to guide staff practice and document control processes consistently implemented. 90 days
The medication policy does not include stocktake requirements for controlled drugs. The restraint policy does not include the full definition of restraints and enablers; or processes required in the event restraint is used. This includes the ongoing monitoring requirements for the client. Criterion 1.2.7.3 The appointment of appropriate service providers to safely meet the of consumers. PA Low Policies detail the process that is required related to human resources practices. The policy aligns with current accepted practice and includes staff completing an application form, interviews, verifying qualifications and experience, conducting police and reference checks. However records are not consistently available to evidence that reference checks and interviews are conducted. These documents are missing in the four staff files sampled where the employee was employed between October 2010 and May 2015. Three of the staff whose files were reviewed were employed since June 2014. Completed police checks were present in the sampled files. Records to evidence that reference checks or interviews are conducted are not present in all staff files sampled. This included the three staff employed since June 2014. Ensure records are maintained to demonstrate that the recruitment process has been followed. 180 days Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Nurses interviewed, including a midwife who no longer holds a practising certificate, have variable to no previous experience in maternity services. Nurses and managers interviewed and clinical records reviewed show that orientation and training for care in the maternity setting relates predominantly to breastfeeding and resuscitation. The RNs advised they have not received orientation and training for their responsibilities for evaluation and other aspects of maternity care. Staff interviewed advised that, with this exception, the orientation programme is comprehensive. Staff complete the generic orientation to Hokianga Health. Department/role specific orientation is While staff confirm a detailed orientation is provided relevant to the staff role and responsibilities, records are not present in some staff files reviewed to demonstrate that the service/department specific component has been completed. For example, the workbooks that are to be completed by medical and nursing staff. The orientation/ongoing education programme is not Ensure records are available to verify that staff have completed any department/role specific orientation in a timely manner. Ensure the orientation and ongoing programme is sufficiently
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 order to comply with legislation, protocols, and guidelines. PA All medicines are stored in lockable storage including controlled drugs, however, the door to the room in the medical unit in which medication is stored is observed to be open and unattended on multiple occasions during audit. The medication trolley has liquid medications on the bottom shelf, including paracetamol elixir. There is a sign on the door reminding staff to shut it. The manager states correct closure of the door is an ongoing issue. Given the presence of clients with impaired mental functioning, paediatric clients and visiting children continued vigilance is required to ensure medication is secure. There is no facility for ambient temperature monitoring of stored medication. The manager states ambient temperatures for stored medications are not monitored. Review of medication charts shows group bracketing of dates of prescriptions, dates of discontinuation of medication is not recorded, recording of dose limits and indications for PRN medications, prescribing of Vitamin K and syntocinon administered in maternity care. Staff ate interview note variable compliance with these requirements. Weekly stocktakes are not reliably recorded including the measurement of liquids where the measuring device on the bottle does not provide an accurate measure. It is recommended that ward stocks of controlled drugs are used rather than clients own supply following admission. In maternity verbal orders from GPs are used for narcotic pain relief. Medicines reconciliation is not competed in three of four clinical records on admission. The door to treatment room in which medication is stored is repeatedly left open during the audit and is reported by staff as an ongoing problem, The ambient temperature of medication storage is not monitored. Medication prescribing is of an appropriate standards with some exceptions which are areas for improvement including: - bracketing of dates of prescriptions - of discontinuation of medication is not recorded - recording of dose limits and indications for PRN medications - prescribing of Vitamin K and syntocinon administered in maternity care. Controlled drug - weekly stocktakes are not reliably recorded including the measurement of liquids where the measuring device on the bottle does not provide an accurate measure. Medicines reconciliation is not reliably completed on Ensure all aspects of medicines management meet the requirements of best practice and legislation. 90 days