Attainment against the Health and Disability Services Standards The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit. Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section. For more information on the standards, please click here. For more information on the different types of audits and what they cover please click here. Standard with desired outcome Attainment Audit Evidence Rating Standard 3.5: Surveillance FA Surveillance is appropriate to that recommended for long-term care facilities, with infection prevention definitions reflecting a focus on symptoms rather than laboratory Surveillance for infection is carried out in results. The infection control nurse interviewed reported the following is included in accordance with agreed objectives, priorities, surveillance for example, urinary tract infections, soft tissue, fungal, eye, and methods that have been specified in the the upper and lower respiratory tract and other skin conditions. When an infection control programme. infection is identified, a record of this is documented on the infection reporting form used by the service provider. The infection control nurse reviews all of the reported infections. Monthly data is collated and analysed to identify any trends, positive causative factors and required actions. All results of surveillance are reported to the clinical manager for the monthly key performance indicator reporting to support office management team. The results of surveillance are shared with staff via staff meetings (minutes sighted) and at staff handovers. Handover was observed in the hospital between shifts and examples of infection prevention and control issues were explained by the registered nurse providing the handover to ensure early intervention occurs. Graphs are produced that identify trends for the current year and a summary is documented. Data is benchmarked with other services in the organisation and this provides assurance that infection rates in the facility are below average for the sector.
Attainment against the Health and Disability Services Standards The following table contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit. Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section. For more information on the standards, please click here. For more information on the different types of audits and what they cover please click here. Standard with desired outcome Attainment Rating Audit Evidence Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. FA Surveillance is appropriate to that recommended for long-term care facilities, with infection prevention definitions reflecting a focus on symptoms rather than laboratory results. The infection control nurse interviewed reported the following is included in surveillance for example, urinary tract infections, soft tissue, fungal, eye, the upper and lower respiratory tract and other skin conditions. When an infection is identified, a record of this is documented on the infection reporting form used by the service provider. The infection control nurse reviews all of the reported infections. Monthly data is collated and analysed to identify any trends, positive causative factors and required actions. All results of surveillance are reported to the clinical manager for the monthly key performance indicator reporting to support office management team. The results of surveillance are shared with staff via staff meetings (minutes sighted) and at staff handovers. Handover was observed in the hospital between shifts and examples of infection prevention and control issues were explained by the registered nurse providing the handover to ensure early intervention occurs. Graphs are produced that identify trends for the current year and a summary is documented. Data is benchmarked with other services in the organisation and this provides assurance that infection rates in the facility are below average for the sector.