Standard 1.3.4: Assessment FA A number of nursing assessments were completed on admission and InterRAI assessments were sighted. Resident information gathered also Consumers' needs, support requirements, and included a personal profile, social interests and observations of health preferences are gathered and recorded in a timely status. An activities assessment, medical assessment and physiotherapy manner. assessment were also developed. The required assessments, including those conducted by the needs assessors, were sighted in all resident files sampled. The results of the assessment process were transferred onto the lifestyle care plan with outcomes and goals documented. Assessments were then reviewed during the lifestyle care plan review (or as required). Residents and family interviewed reported involvement in the assessment process, and confirmed that there were adequate areas to ensure assessments were conducted in private. Standard 1.3.5: Planning FA Lifestyle care plans included all personal details, nursing diagnosis, allergies and family/whanau input. Goals were documented, with the required Consumers' service delivery plans are consumer interventions for each section. Additional short term care plans were focused, integrated, and promote continuity of service developed as required. These were signed off when the short term need had delivery. resolved. For example: in the event of a wound or an infection. Resident were integrated and included information from allied health providers. Lifestyle care plans were cross reference to additional plans/interventions where these were required. For example: restraint monitoring charts, medication charts and observation recordings. Residents and family interviewed confirmed their involvement in the care planning process. Standard 1.3.6: Service Delivery/Interventions FA Lifestyle care plans included concerns/problems, nursing goals and resident goals. Interventions were documented and addressed in each domain/goal Consumers receive adequate and appropriate or identified problem. Interventions sighted were consistent with best services in order to meet their assessed needs and practice when working with older adults. The GP interviewed was satisfied desired outcomes. that clinical interventions were implemented in a timely and competent manner. Interventions from allied health providers were given due consideration and this was evident in the files sampled. Standard 1.3.7: Planned Activities FA The activity programme was developed and coordinated by the activities coordinator. The activities coordinator was on site three days per week. Care
Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. FA A number of nursing assessments were completed on admission and InterRAI assessments were sighted. Resident information gathered also included a personal profile, social interests and observations of health status. An activities assessment, medical assessment and physiotherapy assessment were also developed. The required assessments, including those conducted by the needs assessors, were sighted in all resident files sampled. The results of the assessment process were transferred onto the lifestyle care plan with outcomes and goals documented. Assessments were then reviewed during the lifestyle care plan review (or as required). Residents and family interviewed reported involvement in the assessment process, and confirmed that there were adequate areas to ensure assessments were conducted in private. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. FA Lifestyle care plans included all personal details, nursing diagnosis, allergies and family/whanau input. Goals were documented, with the required interventions for each section. Additional short term care plans were developed as required. These were signed off when the short term need had resolved. For example: in the event of a wound or an infection. Resident were integrated and included information from allied health providers. Lifestyle care plans were cross reference to additional plans/interventions where these were required. For example: restraint monitoring charts, medication charts and observation recordings. Residents and family interviewed confirmed their involvement in the care planning process. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. FA Lifestyle care plans included concerns/problems, nursing goals and resident goals. Interventions were documented and addressed in each domain/goal or identified problem. Interventions sighted were consistent with best practice when working with older adults. The GP interviewed was satisfied that clinical interventions were implemented in a timely and competent manner. Interventions from allied health providers were given due consideration and this was evident in the files sampled. Standard 1.3.7: Planned Activities FA The activity programme was developed and coordinated by the activities coordinator. The activities coordinator was on site three days per week. Care
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