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 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 outcome Audit Evidence Audit Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.3.6 PA Low Quality data has been collected and There was not documented Ensure that quality the number of incidents and evidence that quality data data is analysed for Quality improvement data are collected, infections by type has been reported has been analysed for trends and that analysed, and evaluated and the results to staff at quality/health and safety trends. these are communicated to service providers and, where meetings. The service has recently communicated to appropriate, consumers. been linked to the CHT data staff. collection system which will provide graphs and benchmarking. 90 days Criterion 1.2.4.2 PA Low The unit manager and area manager An incident involving a Ensure that all are familiar with situations requiring police investigation was not incidents are notified The service provider understands their statutory essential notification. Oversight notified to HealthCERT. to HealthCERT and/or regulatory obligations in relation to meant that a police investigation was where this is essential notification reporting and the correct not notified, required. authority is notified where required. 90 days
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 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 Quality data has been collected and the number of incidents and infections by type has been reported to staff at quality/health and safety meetings. The service has recently been linked to the CHT data collection system which will provide graphs and benchmarking. There was not documented evidence that quality data has been analysed for trends. Ensure that quality data is analysed for trends and that these are communicated to staff. 90 days Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. PA Low The unit manager and area manager are familiar with situations requiring essential notification. Oversight meant that a police investigation was not notified, An incident involving a police investigation was not notified to HealthCERT. Ensure that all incidents are notified to HealthCERT where this is required. 90 days