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 Attainment Audit Evidence Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.1.13.1 PA Low Five complaints received for 2015 evidence One written complaint from Ensure that all that appropriate follow up and response was June 2015 has not been complaints are The service has an easily initiated within the expected time frames. responded to, as advised by responded to within accessed, responsive, and Outcomes from investigations have included the complainant. service policy fair complaints process, staff feedback, staff training and performance timeframes. which is documented and management where required. Toolbox talks complies with Right 10 of the have been initiated with staff to reduce Code. incidence of repeat complaints. A resident 60 days interviewed advised that follow up on a written complaint had not been provided. It was identified that the complaint had been misplaced on the manager’s desk and this was addressed during the audit. Criterion 1.2.7.5 PA Low Certification: The clinical manager maintains a Certification: Two caregivers Certification: Ensure that competency spreadsheet for all staff. who work in the psychogeriatric all care staff who work in A system to identify, plan, Education sessions are provided at least unit have not completed the the psychogeriatric facilitate, and record ongoing weekly in the form of face to face in-service required dementia unit unit/s have completed education for service sessions, self-directed learning, took box talks, standards. Both have been the required dementia
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 Attainment Rating Audit Evidence Finding Corrective action required and timeframe for completion (days) Criterion 1.1.13.1 The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. PA Low Five complaints received for 2015 evidence that appropriate follow up and response was initiated within the expected time frames. Outcomes from investigations have included staff feedback, staff training and performance management where required. Toolbox talks have been initiated with staff to reduce incidence of repeat complaints. A resident interviewed advised that follow up on a written complaint had not been provided. It was identified that the complaint had been misplaced on the manager’s desk and this was addressed during the audit. One written complaint from June 2015 has not been responded to, as advised by the complainant. Ensure that all complaints are responded to within service policy timeframes. 60 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service PA Low Certification: The clinical manager maintains a competency spreadsheet for all staff. Education sessions are provided at least weekly in the form of face to face in-service sessions, self-directed learning, took box talks, Certification: Two caregivers who work in the psychogeriatric unit have not completed the required dementia unit standards. Both have been Certification: Ensure that all care staff who work in the psychogeriatric unit/s have completed the required dementia
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