Specific results for criterion 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 Attainment Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.7.5 PA Low Staff training is provided at least 2x monthly Two caregivers who work in Ensure that all caregivers and all core subjects have been covered in the the facility have not completed working in the facility are A system to identify, programme in the past two years. Also staff the required dementia specific enrolled and have plan, facilitate, and receive extra training via toolbox talks. There national qualification. Both completed record ongoing education are a number of competencies completed by caregivers have been education modules for service providers to staff. Staff have received education in the employed for over one year. within the required provide safe and management of challenging behaviours timeframes. effective services to however, not all caregivers who work regularly consumers. in the facility have completed the required dementia-specific national qualification. 90 days All registered nurses hold a champion role in; nutrition & weight, incident reporting, behaviour documents, TPR, Doctors Rounds, care plans, emergency equipment, Wounds and Medication Criterion 1.3.5.2 PA Low The RNs complete assessments to identify the Three of seven files sampled Ensure that clinical risk care needs of the resident and use this did not include interventions or assessments are Service delivery plans information to inform the development of the interventions were not completed where indicated describe the required
Specific results for criterion 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 Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low Staff training is provided at least 2x monthly and all core subjects have been covered in the programme in the past two years. Also staff receive extra training via toolbox talks. There are a number of competencies completed by staff. Staff have received education in the management of challenging behaviours however, not all caregivers who work regularly in the facility have completed the required dementia-specific national qualification. All registered nurses hold a champion role in; nutrition & weight, incident reporting, behaviour documents, TPR, Doctors Rounds, care plans, emergency equipment, Wounds and Medication Two caregivers who work in the facility have not completed the required dementia specific national qualification. Both caregivers have been employed for over one year. Ensure that all caregivers working in the facility are enrolled and have completed education modules within the required timeframes. 90 days Criterion 1.3.5.2 Service delivery plans describe the required PA Low The RNs complete assessments to identify the care needs of the resident and use this information to inform the development of the Three of seven files sampled did not include interventions or interventions were not Ensure that clinical risk assessments are completed where indicated
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