for one resident who identifies as 90 days Māori. Criterion 1.2.3.6 PA Low The clinical nurse manager is Quality data is not trended and Ensure that the responsible for collecting adverse analysed. Staff are not kept informed quality data Quality improvement data are event data and implementation of the regarding trends in adverse events. collected is collected, analysed, and evaluated and internal audit programme, as per the trended and the results communicated to service internal audit schedule. Quality analysed, and that providers and, where appropriate, improvement data is collected around this information is consumers. falls, skin tears, infections, and other shared with staff. adverse events, but there is little evidence to support that this data is being trended and analysed. Staff are 90 days informed regarding the number and type of adverse events each month but are not informed around trends in data or what the data is reflecting. Staff are informed of internal audit results, as evidenced in staff meeting minutes. Criterion 1.2.3.8 PA Low A corrective action planning process is i) Corrective action are not regularly i) Ensure to be completed where internal audits being developed where opportunities for corrective action A corrective action plan addressing reflect sub-optimal results. However, improvement are identified. ii) Where are areas requiring improvement in order corrective action plans were not corrective action plans are documented, established where to meet the specified Standard or consistently being established when there is a lack of consistent evidence of opportunities for requirements is developed and required. Where corrective action these plans being implemented, with improvements are implemented. plans are developed, there are gaps in off by the person(s) responsible. identified. ii) the documentation around Ensure that implementation and sign-off of these established corrective action plans. corrective action plans are implemented and are signed-off by the person(s) responsible.
for one resident who identifies as Māori. 90 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 The clinical nurse manager is responsible for collecting adverse event data and implementation of the internal audit programme, as per the internal audit schedule. Quality improvement data is collected around falls, skin tears, infections, and other adverse events, but there is little evidence to support that this data is being trended and analysed. Staff are informed regarding the number and type of adverse events each month but are not informed around trends in data or what the data is reflecting. Staff are informed of internal audit results, as evidenced in staff meeting minutes. Quality data is not trended and analysed. Staff are not kept informed regarding trends in adverse events. Ensure that the quality data collected is trended and analysed, and that this information is shared with staff. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low A corrective action planning process is to be completed where internal audits reflect sub-optimal results. However, corrective action plans were not consistently being established when required. Where corrective action plans are developed, there are gaps in the documentation around implementation and sign-off of these corrective action plans. i) Corrective action are not regularly being developed where opportunities for improvement are identified. ii) Where corrective action plans are documented, there is a lack of consistent evidence of these plans being implemented, with by the person(s) responsible. i) Ensure corrective action are established where opportunities for improvements are identified. ii) Ensure that established corrective action plans are implemented and are signed-off by the person(s) responsible. off