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) Fully 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 43 0 5 2 0 0 Criteria 0 93 0 6 2 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
Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low Policy includes that whenever a resident has a potential or actual knock to the head, neuro observations are to be completed. Three incident forms sampled where the resident had experienced a potential or actual knock to the head documented on the incident form that these had been completed but no observation records were available to support this. incidents where neuro observations were required did not have completed neuro observation forms available to confirm these had occurred. Ensure neuro observations are completed and documented when a resident has a potential head injury. 60 days 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 Moderate CHT has documented requirements to be included in the education programme that includes all required training. Carnarvon has a documented 2016/2017 training plan that does not include all required trainings and several sessions of required training that had been planned had been cancelled. Staff, including registered nurses and healthcare assistants, have attended external training provided by the DHB or hospice, either as small groups or as individuals, depending on spaces available and staff numbers that could be released. Staff training (in required areas) has been provided for the full staff around fire safety, medication management, infection control and health and safety. Education provided has not covered most required topics or providing support to all residents included younger people. Ensure all receive training in all required areas including providing support to meet the needs of all residents. 90 days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, PA Low All medications are stored safely. There are regular checks in place for imprest stock, ‘as required’ medications, medication fridge temperatures, emergency trolley, There were six imprest stock medications that had expired. Ensure all medications in stock are checked for expiry dates.
disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. oxygen and suction checks. Not all imprest stock medications were within the expiry date. 60 days Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Moderate Relevant risk assessments are completed on admission in four of the six reviewed. The outcomes of the risk assessments (including interRAI assessments) are reflected in the care plans. Risk assessments had not been completed on admission for two residents; 1) one respite care resident with a history of falls did not have a falls risk assessment and there were no falls prevention strategies documented and 2) there was no pain and pressure injury risk assessment completed for one resident admitted for palliative care. Ensure applicable risk assessments are completed on admission. 60 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low Five long-term care and one short-term (respite) care plan were reviewed. One other resident file was reviewed for restraint documentation. The care plans for three long-term residents described the current supports to meet the resident’s needs. a) The care plans for two long-term residents (one ARCC and one ACC resident) had not been updated to include interventions for weight loss. b) The short-term care plan for the respite resident had not been updated to include falls prevention strategies or the use and risks of using an enabler (cot sides). c) One long-term resident with a restraint did not have the associated risks of using a restraint documented in the care plan. a) Ensure interventions are documented for residents with weight loss. b) Ensure the respite care are reviewed with each episode of respite care. c) Ensure risks are identified and documented for restraint and enabler use. 60 days Criterion 2.2.2.1 PA Low In the two sampled discussion with the unit manager (the restraint The two resident files sampled that use restraint Ensure assessments that