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 desired outcome Audit Evidence Audit Finding Corrective action required and Rating timeframe for completion (days) Criterion 1.1.13.3 PA The service has a complaints/complements register in The last recorded Provide evidence Low place which identifies the complaint made, the dates and complaint documented that all complaints An up-to-date complaints register is actions taken. Complaints forms can be easily accessed in the complaints are entered into the maintained that includes all from a holder located at the nurses’ station. register is dated complaints register. complaints, dates, and actions taken. Documentation shows that appropriate actions are taken August 2016. Two when dealing with complaints, however, not all recent complaints are complaints are entered into the complaints register. The not identified in the 180 days facility manager located documentation related to two complaints register, complaints which have occurred since the last entry was one of which is related made in the complaints register which identify the actions to a serious issue and taken to date to manage the complaints. Both these remains open under complaints remain open at the time of audit. police investigation. Criterion 1.1.4.3 PA One of one files reviewed evidenced an initial A resident whom Ensure all residents Low assessment at time of admission of a resident in the affiliates with their who affiliate with The organisation plans to ensure Māori dementia unit whom affiliated with their Maori culture. Maori culture does not their Maori culture receive services commensurate with The short term and long term care plan evidenced have a Maori Health are supported by a their needs. interventions and the Maori Health plan was not plan Maori Health plan. implemented. English was documented as 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 1.1.13.3 An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. PA Low The service has a complaints/complements register in place which identifies the complaint made, the dates and actions taken. Complaints forms can be easily accessed from a holder located at the nurses’ station. Documentation shows that appropriate actions are taken when dealing with complaints, however, not all complaints are entered into the complaints register. The facility manager located documentation related to two complaints which have occurred since the last entry was made in the complaints register which identify the actions taken to date to manage the complaints. Both these complaints remain open at the time of audit. The last recorded complaint documented in the complaints register is dated August 2016. Two recent complaints are not identified in the complaints register, one of which is related to a serious issue and remains open under police investigation. Provide evidence that all complaints are entered into the complaints register. 180 days Criterion 1.1.4.3 The organisation plans to ensure Māori receive services commensurate with their needs. PA Low One of one files reviewed evidenced an initial assessment at time of admission of a resident in the dementia unit whom affiliated with their Maori culture. The short term and long term care plan evidenced interventions and the Maori Health plan was not implemented. English was documented as the A resident whom affiliates with their Maori culture does not have a Maori Health plan Ensure all residents who affiliate with their Maori culture are supported by a Maori Health plan.
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