evaluated and the results being critically and indicators and adverse communicated to service comprehensively events are being critically providers and, where analysed to identify to analysed to identify any appropriate, consumers. identify any trends. trends. HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan PA High (i)Corrective action plans Provide documented 30 addressing areas requiring are not being evidence that corrective improvement in order to meet consistently developed to action plans are being the specified Standard or address all areas developed, implemented, requirements is developed and identified as requiring monitored, and signed off as implemented. improvement; (ii) having been completed Corrective action plans within identified timeframes. reviewed do not consistently provide evidence that the corrective action plan has been implemented, monitored, and signed off as having been completed; and (iii) timeframes for completion of the corrective actions are not being consistently documented. (See also link criterion 1.3.12.1) HDS(C)S.2008 Standard 1.2.7: Human resource management PA Low Human Resource processes are conducted in Management accordance with good employment practice and meet the requirements of legislation. HDS(C)S.2008 Criterion 1.2.7.4 New service providers receive PA Low There is no documented Provide confirmation that all 180 an orientation/induction evidence available on all new staff complete an programme that covers the staff files reviewed orientation that covers the essential components of the indicating that all staff essential components of the service provided. have completed an service provided. orientation programme. HDS(C)S.2008 Criterion 1.2.7.5 A system to identify, plan, PA Moderate (i)Staff training records Provide documented 90 facilitate, and record ongoing are disjointed and it is evidence that (i) an education for service providers difficult to clearly education ascertain what education programme is developed
evaluated and the results communicated to service providers and, where appropriate, consumers. being critically and comprehensively analysed to identify to identify any trends. indicators and adverse events are being critically analysed to identify any trends. HDS(C)S.2008 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 High (i)Corrective action plans are not being consistently developed to address all areas identified as requiring improvement; (ii) Corrective action plans reviewed do not consistently provide evidence that the corrective action plan has been implemented, monitored, and signed off as having been completed; and (iii) timeframes for completion of the corrective actions are not being consistently documented. (See also link criterion 1.3.12.1) Provide documented evidence that corrective action plans are being developed, implemented, monitored, and signed off as having been completed within identified timeframes. 30 HDS(C)S.2008 Standard 1.2.7: Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low HDS(C)S.2008 Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low There is no documented evidence available on all staff files reviewed indicating that all staff have completed an orientation programme. Provide confirmation that all new staff complete an orientation that covers the essential components of the service provided. 180 HDS(C)S.2008 Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers PA Moderate (i)Staff training records are disjointed and it is difficult to clearly ascertain what education Provide documented evidence that (i) an education programme is developed 90