180 days Criterion 1.4.2.6 PA Low are three exit doors to Two of the exit doors have key coded pads Ensure that is easy safe and secure external and are kept locked. The service has a access to a safe and secure Consumers are provided with garden areas rational for the locked doors due to the external garden area so that safe and accessible external service deeming the outdoor garden area to residents can freely access at that meet their needs. be unsafe with uneven surfaces. There is any time. also the potential to abscond or for residents to be in danger from climbing the garden bank. The service has identified as one of 180 days the goals to improve the garden providing safety and interest for the residents (link 1.2.1). Advised that staff assist residents to access this area when weather permits and relatives can take residents out at any time. Criterion 1.4.6.2 PA There are dedicated staff for The shower/bed trolley for use by all Ensure that all equipment and cleaning services. There is residents was unclean (faeces smeared) on areas are kept hygienically The methods, frequency, and one cleaner rostered daily. the first day of audit and remained unclean clean for all residents use. materials used for cleaning and on the second day of audit. One of the laundry processes are resident’s communal toilets was found to be monitored for effectiveness. in an unreasonable state on the morning of 30 days the audit and was unattended up until the end of the audit day. Criterion 3.5.7 PA Low Corrective action are seen There was no records/meeting minutes to Ensure processes are clearly to have been developed and identify how the gastro outbreak was documented and evaluated Results of surveillance, implemented when infection managed December 2014 and the quality around management of conclusions, and specific rates exceed the expected meeting stated IC trends’ outbreaks. “no recommendations to assist in targets. In December 2014 an achieving infection reduction outbreak of diarrhoea and and prevention outcomes are vomiting affecting 10 residents 180 days acted upon, evaluated, and was managed. A case log reported to relevant personnel was documented and advised and management in a timely the outbreak was reported as manner. required. However, there was no records/meeting minutes to identify how the outbreak was
180 days Criterion 1.4.2.6 Consumers are provided with safe and accessible external that meet their needs. PA Low are three exit doors to safe and secure external garden areas Two of the exit doors have key coded pads and are kept locked. The service has a rational for the locked doors due to the service deeming the outdoor garden area to be unsafe with uneven surfaces. There is also the potential to abscond or for residents to be in danger from climbing the garden bank. The service has identified as one of the goals to improve the garden providing safety and interest for the residents (link 1.2.1). Advised that staff assist residents to access this area when weather permits and relatives can take residents out at any time. Ensure that is easy access to a safe and secure external garden area so that residents can freely access at any time. 180 days Criterion 1.4.6.2 The methods, frequency, and materials used for cleaning and laundry processes are monitored for effectiveness. PA There are dedicated staff for cleaning services. There is one cleaner rostered daily. The shower/bed trolley for use by all residents was unclean (faeces smeared) on the first day of audit and remained unclean on the second day of audit. One of the resident’s communal toilets was found to be in an unreasonable state on the morning of the audit and was unattended up until the end of the audit day. Ensure that all equipment and areas are kept hygienically clean for all residents use. 30 days Criterion 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner. PA Low Corrective action are seen to have been developed and implemented when infection rates exceed the expected targets. In December 2014 an outbreak of diarrhoea and vomiting affecting 10 residents was managed. A case log was documented and advised the outbreak was reported as required. However, there was no records/meeting minutes to identify how the outbreak was There was no records/meeting minutes to identify how the gastro outbreak was managed December 2014 and the quality meeting stated “no IC trends’ Ensure processes are clearly documented and evaluated around management of outbreaks. 180 days
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