Criteria 2 97 0 2 0 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 is accurately documented on the chart reviewed. Evaluation occurs monthly and six monthly as part of the multidisciplinary review. Staff interviewed were fully informed on all aspects of restraint minimisation and safe practice. Restraint management is closely linked to the falls prevention programme undertaken by the service. Restraint is discussed at the monthly restraint meetings and evidenced in the minutes of meetings reviewed. Standard 2.2.4: Evaluation Services evaluate all episodes of restraint. FA The evaluations occur monthly by the restraint committee and six monthly when the multidisciplinary meeting occurs. The impact the restraint has had on the client is monitored as well as the observations and monitoring requirements to maintain the safety of the client. All requirements of this criterion are considered during the review process and are discussed at the restraint meeting held on a monthly basis. The outcome as discussed with the restraint co-ordinator is the focus for the client ensuring safety and care is maximised and not compromised in anyway. Policies and procedures are reviewed annually. The individual client`s nursing care plan is reviewed six monthly or more if required. The education plan for the year was reviewed and restraint minimisation and safe practice is included. Standard 2.2.5: Restraint Monitoring and Quality Review Services demonstrate the monitoring and quality review of their use of restraint. FA The meeting minutes for four months of restraint meetings were reviewed. The meeting agenda included any matters arising from the previous meeting, review of restraint status, restraints discontinued, any new restraints if any is use, monitoring and general business. Any trends are discussed. Restraint use has decreased over the last year. The falls prevention programme is linked to restraint minimisation and safe practice and education is as per the training schedule which is reviewed annually. An annual report is prepared for the Pohlen Trust Board. The policies and procedures have been reviewed 2015 and are current and up-to-date.
Specific results for criterion corrective actions are required 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 Evidence Audit Finding Corrective action required and timeframe for completion (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 Low Staff ongoing education is well planned and provided. The education is appropriate to the service setting and includes education on site as well as access to external education. Records of attendance are maintained. The hospital aids are encouraged to complete an industry approved qualification. There are six staff who have completed one or more industry approved qualification. An additional six staff are in the process. Records are not available to demonstrate the cook has completed a food safety training programme. ‘In house’ food safety training has been provided to other members of the catering team. All staff participate in training as part of the ‘baby friendly hospital’ programme. Records are not available to demonstrate the cook has completed an approved food safety training programme. Ensure records are available to demonstrate that catering staff have completed an appropriate food safety training programme. 180 days Criterion 1.4.2.1 All buildings, and equipment PA Low are required to report any maintenance issues to a designated staff member verbally or by completion of a template form. Records are maintained of all requests and the follow-up action and communications undertaken. Applicable The water temperature in identified patient bathrooms is above Ensure hot water in patient care areas is maintained at the required temperature.