to the manager when completed. were missing in three of evidenced in the staff These were missing in a sample of five staff files reviewed. file. Ensure staff files selected for review. (Note: evidence of four of five staff files selected for completed review were employed over the past orientation year). Job descriptions were missing programmes are in a selection of staff files. held in staff files. 90 days Criterion 1.2.7.5 PA Low An education and training programme in-service Ensure staff attend is in place for staff. Education was attendance rates have education and A system to identify, plan, facilitate, and record not provided during the first half of fallen below 50%. training, meeting ongoing education for service providers to provide the year but has totalled more than contractual safe and effective services to consumers. eight hours during the second half of requirements. 2015. Staff attendance is less than Training on restraint 50%. minimisation and safe practice is overdue. 90 days Criterion 1.3.12.3 PA Registered nurses are responsible for No staff medication Staff who administer Moderate administration of medications. None competencies have been medication are Service providers responsible for medicine of the registered nurses employed completed in 2015. required to have their management are competent to perform the function have completed a medication medication for each stage they manage. competency since July 2014. Six of competency checked the registered nurses have a current annually syringe driver competency. 30 days Criterion 2.1.1.4 PA Low Three residents’ files whereby An assessment for one Ensure residents enablers (bedrails) were in place resident with enabler use undergo an The use of enablers shall be voluntary and the were reviewed. In one residents’ file, was completed 30 days assessment for least restrictive option to meet the needs of the the assessment for the use of
to the manager when completed. These were missing in a sample of staff files selected for review. (Note: four of five staff files selected for review were employed over the past year). Job descriptions were missing in a selection of staff files. were missing in three of five staff files reviewed. evidenced in the staff file. Ensure evidence of completed orientation programmes are held in staff files. 90 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 An education and training programme is in place for staff. Education was not provided during the first half of the year but has totalled more than eight hours during the second half of 2015. Staff attendance is less than 50%. in-service attendance rates have fallen below 50%. Ensure staff attend education and training, meeting contractual requirements. Training on restraint minimisation and safe practice is overdue. 90 days Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate Registered nurses are responsible for administration of medications. None of the registered nurses employed have completed a medication competency since July 2014. Six of the registered nurses have a current syringe driver competency. No staff medication competencies have been completed in 2015. Staff who administer medication are required to have their medication competency checked annually 30 days Criterion 2.1.1.4 The use of enablers shall be voluntary and the least restrictive option to meet the needs of the PA Low Three residents’ files whereby enablers (bedrails) were in place were reviewed. In one residents’ file, the assessment for the use of An assessment for one resident with enabler use was completed 30 days Ensure residents undergo an assessment for
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