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. The building has a current warrant of fitness and emergency evacuation plan. Ongoing maintenance issues are addressed. Chemicals are stored safely throughout the facility. All bedrooms are single occupancy and some have their own ensuite. There is sufficient space to allow the movement of residents around the facility using mobility aids. There are a number of small lounge and dining areas throughout the facility in addition to its main communal areas. The internal areas can be ventilated and heated. The outdoor areas are safe and easily accessible. There is an emergency management plan in place and adequate civil defence supplies in the event of an emergency. There is an approved evacuation scheme and emergency supplies for at least three days. There is a staff member on duty always with a current first aid/CPR certificate. Cleaning and laundry staff are providing appropriate services. 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. Standards applicable to this service fully attained. Restraint minimisation and safe practice policies and procedures are in place to guide staff in the use of an approved enabler and/or restraint. Policy is aimed at using restraint only as a last resort. Staff receive regular education and training on restraint minimisation. No restraint or enabler was in use at the time of the audit.
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 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 Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.10.7 Advance directives that are made available to service providers are acted on where valid. PA Low All resident files sampled contained an advance directive. In four of six files the form was completed by the resident and the general practitioner (GP) had co-signed and confirmed that the resident was competent to have completed this. The form that was in use on the day of the audit did not allow for a clinically indicated ‘not for resuscitation’ decision. It is designed to be signed by a competent resident only. Two forms had been signed by the GP that the resident was not competent to make an advance directive, and was documented as ‘not for resuscitation’, but there was no indication that this was a decision. Two of six sampled contained advance directives that were not valid. The two forms had been signed by the GP that the resident was not competent to make an advance directive and was documented as ‘not for resuscitation’, but there was no indication that this was a clinically-indicated decision. Ensure that all advance directives are valid. 90 days Criterion 1.1.9.1 Consumers have a right to full and frank PA Low Residents and families interviewed confirmed that they are kept informed. Missing was documented Five of fifteen accident/incident forms and associated progress notes failed to indicate that Ensure documentation evidences families (and/or EPOA) kept