service providers staff meetings. The collated information is not consistently trended trended and analysed to results communicated and, where and analysed to identify opportunities for improvement. identify opportunities for to staff and residents appropriate, improvement. where appropriate. consumers. 90 days Criterion 1.2.3.8 PA Low The service captures quality improvement data (clinical indicators, i) Corrective action plans i-ii) Ensure that health and safety, infection control, accidents and incidents and are not consistently corrective actions A corrective action complaints). The service participates in an external benchmarking documented where plans are documented plan addressing initiative with four facilities in Northland. The benchmarking opportunities for where opportunities for areas requiring group meet quarterly to discuss the collated data set. improvements are improvement are improvement in order identified. noted and the to meet the specified Where the internal and external quality data is identifying corrective action plans Standard or opportunities for improvement at the service, corrective action ii) Not all corrective are then implemented, requirements is plans are not consistently being documented. Where corrective action plans are reviewed and signed developed and action plans have been developed, these are not consistently evaluated and signed off off once completed. implemented. evaluated and signed out. when completed. 90 days Criterion 1.2.7.5 PA Low As part of the quality management programme, an annual i)The education plan for i) Ensure the annual education plan has been documented. The education plan for 2016 and the education education plan is fully A system to identify, 2016 was not fully implemented and the education plan for 2017 plan 2017 (year to date) implemented. plan, facilitate, and year to date has not yet been fully implemented. However, staff have not been fully record ongoing ii) Ensure that all staff have been provided with eight hours of professional development implemented. education for service complete the required annually which covers the training requirements of the Health and providers to provide ii) Three of six files performance reviews. Disability Sector Standards. Staff have completed the required safe and effective sampled (cleaner, competencies in relation to manual handling, health and safety, services to registered nurse and infection control, medication management and food safety. One of consumers. clinical manager) could 90 days six registered nurses have completed their interRAI training. The not evidence that the organisational policy requires all staff to have a performance review required performance within three months of commencing work and then at least reviews had been annually. Not all staff have completed the required performance completed. reviews.
service providers and, where appropriate, consumers. staff meetings. The collated information is not consistently trended and analysed to identify opportunities for improvement. trended and analysed to identify opportunities for improvement. results communicated to staff and residents where appropriate. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low The service captures quality improvement data (clinical indicators, health and safety, infection control, accidents and incidents and complaints). The service participates in an external benchmarking initiative with four facilities in Northland. The benchmarking group meet quarterly to discuss the collated data set. Where the internal and external quality data is identifying opportunities for improvement at the service, corrective action plans are not consistently being documented. Where corrective action plans have been developed, these are not consistently evaluated and signed out. i) Corrective action plans are not consistently documented where opportunities for improvements are identified. ii) Not all corrective action plans are evaluated and signed off when completed. i-ii) Ensure that corrective actions plans are documented where opportunities for improvement are noted and the corrective action plans are then implemented, reviewed and signed off once completed. 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 As part of the quality management programme, an annual education plan has been documented. The education plan for 2016 was not fully implemented and the education plan for 2017 year to date has not yet been fully implemented. However, staff have been provided with eight hours of professional development annually which covers the training requirements of the Health and Disability Sector Standards. Staff have completed the required competencies in relation to manual handling, health and safety, infection control, medication management and food safety. One of six registered nurses have completed their interRAI training. The organisational policy requires all staff to have a performance review within three months of commencing work and then at least annually. Not all staff have completed the required performance reviews. i)The education plan for 2016 and the education plan 2017 (year to date) have not been fully implemented. ii) Three of six files sampled (cleaner, registered nurse and clinical manager) could not evidence that the required performance reviews had been completed. i) Ensure the annual education plan is fully implemented. ii) Ensure that all staff complete the required performance reviews. 90 days
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