Criterion 1.3.8.3 PA Low Short term care plans focus on Two residents with weight loss do not have Ensure that all residents have acute and short term needs a term care plan (STCP) developed or acute changes in health status Where progress is different from and are regularly evaluated, the long term care plan (LTCP) updated. either documented on a STCP expected, the service responds resolved or written into the One of these residents had lost eight or updated in the LTCP by initiating changes to the long term care plan as an kilograms following an acute hospital service delivery plan. problem. Short term admission. There is evidence that the care plans included but not resident weight has increased recently. A 90 days limited to; dental care for short term care plan was developed on the broken teeth, toileting, day of audit. Another resident admitted in depression and care of a February 2015 had noted weight loss of fracture. three kilograms in April 2015. The residents long term care plan states for the clinical nurse manage to follow up if there is over one kilogram weight loss in a month. The resident’s weight in May 2015 had a slight increase. Criterion 1.4.1.1 PA Low Chemicals are supplied by an On the day of the cleaner had an Ensure that all chemical have external company. Chemicals unlabelled chemical for use on the cleaning manufactures labels for clear Service providers follow a are labelled with trolley. identification of the chemical documented process for the manufacturers labels, stored and to maintain safe chemical safe and appropriate storage safely and safety data sheets use. and disposal of waste, infectious are available. or hazardous substances that complies with current legislation 90 days and territorial authority requirements. Criterion 1.4.2.1 PA Low There is a Bupa annual is no documented evidence of Ensure that all preventative preventative maintenance preventative maintenance checks completed maintenance and hot water All buildings, plant, and schedule including monthly hot for January, February and March 2015. temperature checks are equipment comply with water temperature checks. Seven formica tops/surrounds of the hand completed as per the Bupa legislation. There are hand basins in the basins in resident rooms were found to be schedules to maintain a safe resident rooms for individual cracked. There is evidence of new hand and appropriate environment. use and maintain infection basins in some resident’s rooms that Ensure that all equipment is control. replaced those that are cracked. safe for resident use.
Criterion 1.3.8.3 Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Low Short term care plans focus on acute and short term needs and are regularly evaluated, resolved or written into the long term care plan as an problem. Short term care plans included but not limited to; dental care for broken teeth, toileting, depression and care of a fracture. Two residents with weight loss do not have a term care plan (STCP) developed or the long term care plan (LTCP) updated. One of these residents had lost eight kilograms following an acute hospital admission. There is evidence that the resident weight has increased recently. A short term care plan was developed on the day of audit. Another resident admitted in February 2015 had noted weight loss of three kilograms in April 2015. The residents long term care plan states for the clinical nurse manage to follow up if there is over one kilogram weight loss in a month. The resident’s weight in May 2015 had a slight increase. Ensure that all residents have acute changes in health status either documented on a STCP or updated in the LTCP 90 days Criterion 1.4.1.1 Service providers follow a documented process for the safe and appropriate storage and disposal of waste, infectious or hazardous substances that complies with current legislation and territorial authority requirements. PA Low Chemicals are supplied by an external company. Chemicals are labelled with manufacturers labels, stored safely and safety data sheets are available. On the day of the cleaner had an unlabelled chemical for use on the cleaning trolley. Ensure that all chemical have manufactures labels for clear identification of the chemical and to maintain safe chemical use. 90 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low There is a Bupa annual preventative maintenance schedule including monthly hot water temperature checks. There are hand basins in the resident rooms for individual use and maintain infection control. is no documented evidence of preventative maintenance checks completed for January, February and March 2015. Seven formica tops/surrounds of the hand basins in resident rooms were found to be cracked. There is evidence of new hand basins in some resident’s rooms that replaced those that are cracked. Ensure that all preventative maintenance and hot water temperature checks are completed as per the Bupa schedules to maintain a safe and appropriate environment. Ensure that all equipment is safe for resident use.