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 Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.3.6 PA Low Incident/accident data is linked to the quality and was no documented evidence Ensure that the risk management programme and is used for that the resident/relative survey has resident/relative Quality improvement data comparative purposes. The internal audit been completed in 2016 as per the survey is completed are collected, analysed, programme regularly assesses service schedule. Since the draft report the annually as per the and evaluated and the performance and this is also discussed at service has advised that a 2017 schedule. results communicated to staff/quality management meetings. Corrective survey has been circulated, and service providers and, actions have been generated and completed for they have 16 replies so far. An where appropriate, any audit outcomes less than 100%. There is independent person is set up to 90 days consumers. documented evidence of discussion around quality analyse them. data and quality activities at the staff and quality meetings. Opportunities for improvement are identified through the various quality activities. Resident/relative satisfaction surveys are scheduled to be completed annually. Criterion 1.2.7.2 PA Low The recruitment policy specifies a recruitment Three of six staff files reviewed did Ensure that all staff process that includes two referees are contacted, not have documented evidence of have two reference Professional qualifications interviewing, police vetting and an offer of reference checks being completed. checks completed are validated, including employment which is then followed by an
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 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 Incident/accident data is linked to the quality and risk management programme and is used for comparative purposes. The internal audit programme regularly assesses service performance and this is also discussed at staff/quality management meetings. Corrective actions have been generated and completed for any audit outcomes less than 100%. There is documented evidence of discussion around quality data and quality activities at the staff and quality meetings. Opportunities for improvement are identified through the various quality activities. Resident/relative satisfaction surveys are scheduled to be completed annually. was no documented evidence that the resident/relative survey has been completed in 2016 as per the schedule. Since the draft report the service has advised that a 2017 survey has been circulated, and they have 16 replies so far. An independent person is set up to analyse them. Ensure that the resident/relative survey is completed annually as per the schedule. 90 days Criterion 1.2.7.2 Professional qualifications are validated, including PA Low The recruitment policy specifies a recruitment process that includes two referees are contacted, interviewing, police vetting and an offer of employment which is then followed by an Three of six staff files reviewed did not have documented evidence of reference checks being completed. Ensure that all staff have two reference checks completed