Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Criterion with desired Attainment Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.3.6 PA Low Beetham Healthcare have an The 2015 internal audit schedule has not Ensure that the internal internal programme (schedule) been fully adhered to. Not all 2015 audit schedule is followed Quality improvement data that monitors key aspects of the corrective action plans have been and that all corrective are collected, analysed, service. Some audits and completed and signed off. action plans are completed and evaluated and the corresponding corrective actions and signed off. results communicated to have not been fully completed. service providers and, Corrective action plans are where appropriate, developed and documented, 90 days consumers. dependant where opportunities for improvements are identified. Criterion 1.3.5.2 PA Low The service has a Maori Health Plan Three resident files were reviewed for Ensure that residents with in place that describes individual residents who identify as Maori, one identified cultural needs Service delivery plans cultural assessments for Maori from the dementia unit, and two hospital. have this documented in describe the required residents that guide staff in the The care plans, including activities plans, their care plans support and/or intervention delivery of culturally safe and do not include cultural care and activities to achieve the desired acceptable care. Not all residents specific to Maori needs. outcomes identified by the with cultural needs had this 60 days ongoing assessment process.
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Beetham Healthcare have an internal programme (schedule) that monitors key aspects of the service. Some audits and corresponding corrective actions have not been fully completed. Corrective action plans are developed and documented, dependant where opportunities for improvements are identified. The 2015 internal audit schedule has not been fully adhered to. Not all 2015 corrective action plans have been completed and signed off. Ensure that the internal audit schedule is followed and that all corrective action plans are completed and signed off. 90 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low The service has a Maori Health Plan in place that describes individual cultural assessments for Maori residents that guide staff in the delivery of culturally safe and acceptable care. Not all residents with cultural needs had this Three resident files were reviewed for residents who identify as Maori, one from the dementia unit, and two hospital. The care plans, including activities plans, do not include cultural care and activities specific to Maori needs. Ensure that residents with identified cultural needs have this documented in their care plans 60 days