Summary of attainment The following 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 38 0 6 6 0 0 Criteria 0 86 0 9 6 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
and were noted to have decreased in 2014, bruises remained above the benchmark Jan2014 – July 2014. The service has a number of meetings including monthly registered nurse meetings. While meeting minutes identify discussions of quality data collected, there is lack of documented evidence that issues were followed through and evaluated. While quality goals are well documented and regularly evaluated through meetings, other clinical indicator analysis is limited. Where QI – corrective actions have been established following benchmarking outcomes there is a little documented evidence that these have been implemented. Criterion 1.2.3.9 Actual and potential risks are identified, documented and where appropriate communicated to consumers, their family/whānau of choice, visitors, and those commonly associated with providing services. This shall include: (a) Identified risks are monitored, analysed, evaluated, and reviewed at a frequency determined by the severity of PA Low Cornwall has a health and safety committee that collates and discusses staff incidents /accidents. This data is also aggregated at an organisational level and reported monthly. The health and safety committee monitor objectives that are defined in the Bupa Health & Safety Plan. The hazard register at Cornwall park is not up to date. The current hazard register has not been updated to include the identified risks around the outdoor garden, and potential for T-belts to break Ensure the hazard register identifies all current hazards 60 days
180 days Criterion 1.4.2.6 Consumers are provided with safe and accessible external that meet their needs. PA Low are three exit doors to safe and secure external garden areas Two of the exit doors have key coded pads and are kept locked. The service has a rational for the locked doors due to the service deeming the outdoor garden area to be unsafe with uneven surfaces. There is also the potential to abscond or for residents to be in danger from climbing the garden bank. The service has identified as one of the goals to improve the garden providing safety and interest for the residents (link 1.2.1). Advised that staff assist residents to access this area when weather permits and relatives can take residents out at any time. Ensure that is easy access to a safe and secure external garden area so that residents can freely access at any time. 180 days Criterion 1.4.6.2 The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. PA There are dedicated staff for cleaning services. There is one cleaner rostered daily. The shower/bed trolley for use by all residents was unclean (faeces smeared) on the first day of audit and remained unclean on the second day of audit. One of the resident’s communal toilets was found to be in an unreasonable state on the morning of the audit and was unattended up until the end of the audit day. Ensure that all equipment and areas are kept hygienically clean for all residents use. 30 days Criterion 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner. PA Low Corrective action are seen to have been developed and implemented when infection rates exceed the expected targets. In December 2014 an outbreak of diarrhoea and vomiting affecting 10 residents was managed. A case log was documented and advised the outbreak was reported as required. However, there was no records/meeting minutes to identify how the outbreak was There was no records/meeting minutes to identify how the gastro outbreak was managed December 2014 and the quality meeting stated “no IC trends’ Ensure processes are clearly documented and evaluated around management of outbreaks. 180 days