Safe and appropriate environment 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. All building and complied with legislation with a current building warrant of fitness. There was a reactive and preventative maintenance programme including equipment and electrical checks. Residents rooms were of an appropriate size that allowed care to be provided and for the safe use and manoeuvring of mobility aids. Activities occur in any of the lounges and furniture was arranged that ensured residents were able to move freely and safely. Laundry was completed on site and managers and monitored cleaning to ensure that the facility was cleaned to a high standard. Essential emergency and security systems were in place with regular fire drills completed. Call bells were in place. Restraint minimisation and safe practice Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Some standards applicable to this service partially attained and of low risk.
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 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. FA A number of nursing assessments were completed on admission and InterRAI assessments were sighted. Resident information gathered also included a personal profile, social interests and observations of health status. An activities assessment, medical assessment and physiotherapy assessment were also developed. The required assessments, including those conducted by the needs assessors, were sighted in all resident files sampled. The results of the assessment process were transferred onto the lifestyle care plan with outcomes and goals documented. Assessments were then reviewed during the lifestyle care plan review (or as required). Residents and family interviewed reported involvement in the assessment process, and confirmed that there were adequate areas to ensure assessments were conducted in private. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. FA Lifestyle care plans included all personal details, nursing diagnosis, allergies and family/whanau input. Goals were documented, with the required interventions for each section. Additional short term care plans were developed as required. These were signed off when the short term need had resolved. For example: in the event of a wound or an infection. Resident were integrated and included information from allied health providers. Lifestyle care plans were cross reference to additional plans/interventions where these were required. For example: restraint monitoring charts, medication charts and observation recordings. Residents and family interviewed confirmed their involvement in the care planning process. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. FA Lifestyle care plans included concerns/problems, nursing goals and resident goals. Interventions were documented and addressed in each domain/goal or identified problem. Interventions sighted were consistent with best practice when working with older adults. The GP interviewed was satisfied that clinical interventions were implemented in a timely and competent manner. Interventions from allied health providers were given due consideration and this was evident in the files sampled. Standard 1.3.7: Planned Activities FA The activity programme was developed and coordinated by the activities coordinator. The activities coordinator was on site three days per week. Care
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 There were procedures to ensure the service was responsive to resident feedback in relation to heating and ventilation, wherever practicable. Residents were provided with adequate natural light, safe ventilation, and an environment that was maintained at a safe and comfortable temperature. There was a designated external smoking area. Family and residents interviewed confirmed the facilities were maintained at an appropriate temperature in all areas. 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 infection control programme was appropriate for the size and nature of the service to ensure safety for residents, family and staff. Infection control policies and procedures documented the responsibility for infection control. The designated infection control nurse was accountable to the health and safety team and to the nurse manager. Reporting lines were confirmed in interviews with staff. The infection control nurse reported to the nurse manager any significant issues and to the health and safety team on a monthly basis. A monthly risk report was documented including key performance indicators. This provided a baseline for infection type and rate. The care givers interviewed were well informed on the processes to follow to report infections. A resident and staff infection incident register was maintained. The infection control programme was reviewed annually. Standard 3.2: Implementing the infection control programme There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation. FA The infection control programme was implemented and provided education on infection control issues for and residents. The infection control is a registered nurse and confirmed that expertise advice can be readily sought. Appropriate resources were available and provided for the infection control nurse to perform the role effectively. The infection control team were responsible for reviewing and developing policies and procedures when necessary and consultation was sought if required. Infection control was included in the staff induction/orientation programme. Standard 3.3: Policies and procedures Documented policies and procedures for the prevention and control of infection reflect current FA Policies and procedures evidenced current accepted good practice and met compliance requirements. Policies and procedures sighted were