Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical 0 48 0 2 0 0 0 Standards 0 99 0 2 0 0 0 Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited 0 0 0 0 0 0 0 0 Standards 0 0 0 0 0 0 0 0 Criteria Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) Standard 1.2.3: The organisation has an established, PA Low HDS(C)S.2008 Quality And documented, and maintained quality Risk and risk management system that Management reflects continuous quality Systems improvement principles. Criterion A corrective action plan addressing PA Low Corrective actions that are Provide documented evidence 180 HDS(C)S.2008 1.2.3.8 areas requiring improvement in order documented following internal that (i) corrective action plans are to meet the specified Standard or audits at Brydon Complex and developed, implemented, requirements is developed and Te Mahana Rest Home are vague monitored and signed off as implemented. and do not clearly describe the being completed that addresses corrective action required to all areas identified as requiring address any shortfalls that are improvement in internal audits; identified during the internal audit. (ii) the person/s responsible for The corrective action/s do not implementing the corrective identify the person responsible for action and the timeframes for implementing the corrective implementation are documented. action/s, do not have a timeframe for implementing the corrective action/s and do not provide evidence the corrective action plan/s has been implemented,
Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 48 0 2 0 0 0 Criteria 0 99 0 2 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 0 Criteria 0 0 0 0 0 0 0 0 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low 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 Low Corrective actions that are documented following internal audits at Brydon Complex and Te Mahana Rest Home are vague and do not clearly describe the corrective action required to address any shortfalls that are identified during the internal audit. The corrective action/s do not identify the person responsible for implementing the corrective action/s, do not have a timeframe for implementing the corrective action/s and do not provide evidence the corrective action plan/s has been implemented, Provide documented evidence that (i) corrective action plans are developed, implemented, monitored and signed off as being completed that addresses all areas identified as requiring improvement in internal audits; (ii) the person/s responsible for implementing the corrective action and the timeframes for implementation are documented. 180