delivery, meet the continence and pressure injury prevention including resident 90 days requirements of legislation, policies. The resident self-medicating policy has competency. and are reviewed at been reviewed but not updated to reflect the regular intervals as defined current medication guidelines. by policy. Criterion 1.2.3.5 PA Low The meeting schedule for 2014 included Resident and management Ensure that meetings are management, staff and resident meetings. Staff meetings have not been held held as scheduled Key components of service meetings have been held one to two monthly. as per meeting planner. delivery shall be explicitly One resident meeting was held in September linked to the quality 2014. The management meeting has not been 90 days management system. conducted. Advised that quality data is reported to staff via the staff meeting and this was evidenced in staff meeting minutes reviewed. Criterion 1.2.3.6 PA Quality improvement activities as the quality plan, Collation and analysis of Ensure that collation and Moderate include the annual resident and family survey, incidents and accident reports analysis of incident and Quality improvement data gathering of incidents and accidents data, internal for December 2014 and accident data is are collected, analysed, audits, meetings, complaints and resident January 2015 has not been conducted in a timely and evaluated and the feedback and provide for the collection of conducted. manner. results communicated to information. The resident survey was conducted service providers and, in February 2013 and the collation and analysis of where appropriate, the results has been conducted by the nurse 60 days consumers. manager with feedback provided to staff and residents. The service has addressed this previous finding. Internal audits are conducted as per the internal audit schedule. Incidents and accidents data has been collected monthly and advised that the nurse manager collates this information. Analysis was noted not to have been conducted for December 2014 and January 2015 collection of incident reports. Criterion 1.2.3.8 PA Internal audits have been conducted as per the Corrective actions have not Ensure that corrective Moderate audit schedule as evidenced in the documentation been developed and actions are developed and A corrective action plan reviewed. On review of the audits conducted it is completed following internal followed through for all addressing areas requiring noted that corrective actions have not been fully audits and where short falls in of non-compliance improvement in order to developed, completed and signed off for all audits. service have been identified. meet the specified
delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. continence and pressure injury prevention policies. The resident self-medicating policy has been reviewed but not updated to reflect the current medication guidelines. including resident competency. 90 days Criterion 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system. PA Low The meeting schedule for 2014 included management, staff and resident meetings. Staff meetings have been held one to two monthly. One resident meeting was held in September 2014. The management meeting has not been conducted. Advised that quality data is reported to staff via the staff meeting and this was evidenced in staff meeting minutes reviewed. Resident and management meetings have not been held as per meeting planner. Ensure that meetings are held as scheduled 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 Moderate Quality improvement activities as the quality plan, include the annual resident and family survey, gathering of incidents and accidents data, internal audits, meetings, complaints and resident feedback and provide for the collection of information. The resident survey was conducted in February 2013 and the collation and analysis of the results has been conducted by the nurse manager with feedback provided to staff and residents. The service has addressed this previous finding. Internal audits are conducted as per the internal audit schedule. Incidents and accidents data has been collected monthly and advised that the nurse manager collates this information. Analysis was noted not to have been conducted for December 2014 and January 2015 collection of incident reports. Collation and analysis of incidents and accident reports for December 2014 and January 2015 has not been conducted. Ensure that collation and analysis of incident and accident data is conducted in a timely manner. 60 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified PA Moderate Internal audits have been conducted as per the audit schedule as evidenced in the documentation reviewed. On review of the audits conducted it is noted that corrective actions have not been fully developed, completed and signed off for all audits. Corrective actions have not been developed and completed following internal audits and where short falls in service have been identified. Ensure that corrective actions are developed and followed through for all of non-compliance