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 their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If 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 Audit Evidence Audit Finding Corrective action desired outcome Rating required and timeframe for completion (days) Criterion 1.1.13.1 PA Low The service has a complaints management policy that complies Two of three complaints Ensure that complaints with the requirements of the Code. The service has complaint received were not management complies The service has an forms available throughout the facility. The CEO (interviewed) responded to within the with the requirements easily accessed, advised that complaints are documented in the complaints register. timeframes required by of the Code and the responsive, and fair All complaints are investigated and where required, corrective the Code. organisational policy complaints process, actions are implemented. Not all complaints had been managed on complaints which is documented within the required timeframes. management. and complies with Right 10 of the Code. 90 days Criterion 1.2.3.6 PA Low The service has a documented quality improvement programme. i) Fourteen of forty i) Ensure that the This programme includes an annual audit schedule. Not all audits internal audits scheduled monitoring schedule is Quality improvement on the schedule have been completed. Quality improvement data have not been fully implemented. data are collected, is collected monthly across a number of areas, including (but not completed as per the analysed, and ii) Ensure that all limited to): clinical indicators, health and safety, infection control, audit schedule. evaluated and the quality improvement accidents and incidents and complaints. This information is results ii) Quality improvement data is trended and collated monthly and the information is communicated to staff at communicated to data is not consistently analysed and the
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 their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If 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 1.1.13.1 The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. PA Low The service has a complaints management policy that complies with the requirements of the Code. The service has complaint forms available throughout the facility. The CEO (interviewed) advised that complaints are documented in the complaints register. All complaints are investigated and where required, corrective actions are implemented. Not all complaints had been managed within the required timeframes. Two of three complaints received were not responded to within the timeframes required by the Code. Ensure that complaints management complies with the requirements of the Code and the organisational policy on complaints management. 90 days Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to PA Low The service has a documented quality improvement programme. This programme includes an annual audit schedule. Not all audits on the schedule have been completed. Quality improvement data is collected monthly across a number of areas, including (but not limited to): clinical indicators, health and safety, infection control, accidents and incidents and complaints. This information is collated monthly and the information is communicated to staff at i) Fourteen of forty internal audits scheduled have not been completed as per the audit schedule. ii) Quality improvement data is not consistently i) Ensure that the monitoring schedule is fully implemented. ii) Ensure that all quality improvement data is trended and analysed and the