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 outcome Audit Evidence Audit Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.3.6 PA Low The facility’s quality plan 2015 is There is a lack of Ensure that quality linked to the Terence Kennedy documented evidence to data is collected, Quality improvement data are collected, analysed, Quality and Safety Policy and Plan reflect quality and risk analysed and shared and evaluated and the results communicated to 2014-2016. The quality and risk data is being collected, with in staff service providers and, where appropriate, management programme includes analysed and results meetings. consumers. data collection and an internal audit provided to staff in staff programme although there was no meeting. Note: this evidence of data being collated and finding does not include 90 days analysed. The manager reports that the infection control data collection was taking place surveillance programme electronically but that this information or complaints received. has been corrupted due to a computer virus and is no longer retrievable. The staff meeting minutes template includes space to inform staff about the number of adverse events but this section of the meeting template has been left blank. Staff are kept
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 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 The facility’s quality plan 2015 is linked to the Terence Kennedy Quality and Safety Policy and Plan 2014-2016. The quality and risk management programme includes data collection and an internal audit programme although there was no evidence of data being collated and analysed. The manager reports that data collection was taking place electronically but that this information has been corrupted due to a computer virus and is no longer retrievable. The staff meeting minutes template includes space to inform staff about the number of adverse events but this section of the meeting template has been left blank. Staff are kept There is a lack of documented evidence to reflect quality and risk data is being collected, analysed and results provided to staff in staff meeting. Note: this finding does not include the infection control surveillance programme or complaints received. Ensure that quality data is collected, analysed and shared with in staff meetings. 90 days
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