there is evidence review is commencing. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. PA Moderate Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in to identify opportunities to improve service delivery, and to identify and manage risk. PA Moderate Two resident files were reviewed and in both files, a number of reported incidents did not have an associated form – one incident in file one, and 12 in file two. In file two the resident was a frequent faller, and had supporting documentation in place – including a falls log. Interview informed where a falls log and/or challenging behaviour plan is in place, an incident form is not required. This exemption is not outlined in the incident reporting policy (link 1.2.3). In both resident files, appropriate interventions are recorded in support/care plans to manage care. Incident forms are completed as prescribed in policy. 30 Standard 1.2.5: Consumer Participation Consumers are involved in the planning, implementation, and evaluation at all levels of the service to ensure services are responsive to the needs of individuals. PA Low Criterion 1.2.5.1 The service demonstrates consumer participation in the planning, implementation, monitoring, and evaluation of service delivery. PA Low There is no formal mechanism for consumer input into service planning, implementation, monitoring and evaluation at a management and governance level. Develop a process to ensure consumer input into service planning, implementation, monitoring and evaluation at a management and governance level 180 Criterion 1.2.5.2 Consumers and consumer groups involved in planning, implementation, and evaluation of services have clear UA Low As there is no input at this level there are no consumers or consumer groups Develop terms of reference or a position description for consumers or consumer 180
administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. days. One resident with a recent change in XXXX has had the previous dose administered on one occasion in the past week. One resident with QID XXXX prescribed has not always had these administered QID. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Low Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low (i) There is not a current Building Warrant of Fitness with the previous one having expired in 2012. (ii) The scales have not been calibrated. (i)Continue the process to obtain a building warrant of fitness. (ii) Ensure all medical equipment is calibrated according to manufacturer’s recommendations. 90 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. PA Low Criterion 3.1.3 The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. PA Low Infection control manual was last reviewed 2013 and includes the programme and associated policies. The infection control programme requires annual review. Review and evaluate the infection control programme. 90 Continuous Improvement (CI) Report Code Name Description Attainment Finding
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Standard 1.1.11: Advocacy And Support (HDS(C)S.2008:1.1.11) Service providers recognise and facilitate the of consumers to advocacy/support persons of their choice. Attainment and Risk: FA Evidence: Residents are provided with a copy of the Code of Health and Disability Services Consumer Rights and Advocacy pamphlets on entry. Interviews with the manager, and registered nurse confirm practice. Interviews with residents (three mental health, two intellectual disability, one physical disability and two rest home) confirm that they are aware of their right to access advocacy. Interview with family members (two) of intellectually disabled residents confirm they are provided with opportunities to involved in decisions (link 1.2.6). D4.1d; Discussions with one rest home family member confirm that the service provides opportunities for the family/EPOA to be involved in decisions ARC D4.1e. The resident files include information on residents’ family/whanau and chosen social networks. Criterion 1.1.11.1 (HDS(C)S.2008:1.1.11.1) Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)