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 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 1.2.3.6 PA Low Quality data including infection control, health There is no documented Ensure staff are aware of and safety, education, concerns/complaints and evidence of the outcomes of the outcomes of internal Quality improvement data enablers/restraint is discussed at meetings as internal audits discussed at audits. Collate survey are collected, analysed, sighted in the meeting minutes. Staff confirm meetings. The results of results and ensure and evaluated and the discussion is held around quality data. Annual surveys have not been outcomes are feedback results communicated to staff and resident/relative satisfaction surveys collated, feedback to to staff and participants. service providers and, have been completed annually. Internal audits participants or discussed at where appropriate, have been completed as per schedule and meetings. consumers. include environmental and clinical audits. 90 days Corrective action plans were raised for identified deficits. Criterion 1.2.4.2 PA The manager is aware of essential notification There was no evidence of DHB Ensure the DHB is Moderate to the DHB for outbreaks, emergency facility notification following an notified for all essential The service provider events, coroner enquiry and change of manager absconding incident involving a notifications under understands their statutory etc. police search. Section 31. and/or regulatory obligations in relation to essential notification 30 days reporting and the correct
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 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 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality data including infection control, health and safety, education, concerns/complaints and enablers/restraint is discussed at meetings as sighted in the meeting minutes. Staff confirm discussion is held around quality data. Annual staff and resident/relative satisfaction surveys have been completed annually. Internal audits have been completed as per schedule and include environmental and clinical audits. Corrective action plans were raised for identified deficits. There is no documented evidence of the outcomes of internal audits discussed at meetings. The results of surveys have not been collated, feedback to participants or discussed at meetings. Ensure staff are aware of the outcomes of internal audits. Collate survey results and ensure outcomes are feedback to staff and participants. 90 days Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct PA Moderate The manager is aware of essential notification to the DHB for outbreaks, emergency facility events, coroner enquiry and change of manager etc. There was no evidence of DHB notification following an absconding incident involving a police search. Ensure the DHB is notified for all essential notifications under Section 31. 30 days
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