Standards 2 45 0 3 0 0 0 Criteria 2 96 0 2 1 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
Standard 1.2.7: Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. FA There are human resources policies in place, including recruitment, selection, orientation and staff training and development. Seven staff files sampled included evidence of the recruitment process, employment contracts, completed orientation and annual performance appraisals. The orientation programme provides new staff with relevant information for safe work practice and is developed specifically to worker type. Staff interviewed stated that new staff are adequately orientated to the service. A register of practising certificates is maintained There is an annual education and training schedule that is being implemented. Opportunistic education is provided via toolbox talks. There are a wide range of competences completed by staff to ensure a high level of care related competence. Careerforce is undertaken by the caregivers. Education and training for clinical staff is included as part of the Bupa RN specific training programme and RNs can also attend external education provided by the district health board. Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. FA The staffing levels meet contractual requirements. The relieving facility manager and clinical manager are registered nurses who are available during weekdays. Adequate RN cover is provided 24 hours a day, seven days a week including two registered nurses and one enrolled nurse as unit coordinators. RNs are supported by sufficient numbers of healthcare assistants. Interviews with the residents and relatives confirmed staffing overall was satisfactory. Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. FA The residents’ files are appropriate to the service type. Residents entering the service have all relevant initial information recorded within 24 hours of entry into the resident’s individual record. An initial support plan is also developed in this time. Information containing personal resident information is kept confidential and cannot be viewed by other residents or members of the public. Residents’ files are protected from unauthorised access by being held securely. Archived records are secure in separate locked and secure areas. Residents’ files demonstrate service integration. Entries are legible, timed, dated and signed by the relevant caregiver or nurse, including designation.
Services demonstrate that the use of restraint is actively minimised. restraint procedures. Interviews with the caregiver and nursing staff confirm their understanding of restraints and enablers. Enablers are assessed as required for maintaining safety and independence and are used voluntarily by the residents. The hospital has two residents with restraints (bedrails). One resident has an enabler (bedrail) in the hospital. The rest home is restraint free. Standard 2.2.1: Restraint approval and processes Services maintain a process for determining approval of all types of restraint used, restraint processes (including policy and procedure), duration of restraint, and ongoing education on restraint use and this process is made known to service providers and others. FA Suitably qualified and skilled in partnership with the resident and their family/whānau, undertake assessments for restraint. Family are consulted as part of the authorisation and whether previous advance directives related to restraint are in place. Restraint documentation identifies involvement of family. Individual approved restraint is reviewed at least three monthly at Eventhorpe and as part of six monthly MDT review with whānau involvement. The restraint and falls focus group meets monthly and restraint is discussed as part of this group. Standard 2.2.2: Assessment Services shall ensure rigorous assessment of consumers is undertaken, where indicated, in relation to use of restraint. FA Bupa policies and procedures provide guidance and process to ensure a robust assessment process to the use of restraint. Two hospital level residents with bedrails restraint, have an assessment in place that evidences family involvement and consideration of alternatives to restraint. Standard 2.2.3: Safe Restraint Use Services use restraint safely FA Two resident were reviewed for use of restraint. The resident files evidence that consideration to alternatives has been considered in association with the family and GP. There are care plan interventions in place that ensure the risks associated with restraint are mitigated and monitoring is documented as occurring according to the care plan. The monthly restraint and falls focus group monitors and discusses the use of restraint. Standard 2.2.4: Evaluation Services evaluate all episodes of restraint. FA The restraint and falls focus group reviews and evaluates all episodes of restraint and enablers monthly. Restraint usage throughout the organisation is also monitored regularly and is benchmarked. Review of this use across the group is discussed at regional restraint approval groups. Individual episodes of restraint are reviewed at least monthly as part of the monthly review of restraint. Three monthly GP reviews and six monthly MDT also review individual use of restraint.