the CPR form signed by a relative and four out of four dementia care CPR forms had been signed by a relative. The GP had not stated on the one hospital and four dementia care CPR forms if the resident is competent or not competent. Standard 1.2.3: The organisation has an PA Low HDS(C)S.2008 Quality And Risk established, documented, and Management maintained quality and risk Systems management system that reflects continuous quality improvement principles. HDS(C)S.2008 Criterion 1.2.3.6 Quality improvement data are PA Low (i) There are only health and Ensure that health and 90 collected, analysed, and safety/quality meeting minutes safety/quality meetings occur evaluated and the results available for May and June in regularly and that quality data communicated to service 2014. (ii) May meeting minutes trends analysis outcomes are providers and, where do not reflect discussion of discussed in these and appropriate, consumers. incidents or infections and June registered nurse meetings. minutes do not reflect discussion Ensure that complaints around incident trends. (iii) investigations required Registered nurse meeting outcomes including discussion minutes for February, June and in meetings occurs. September 2014 (all that are available) do not reflect discussion of incident or infection trends; (iiv) Three complaints in 2014 document on the complaint investigation that there is to be discussion at registered staff meetings. Registered nurse meeting minutes do not reflect this occurring and this is an area requiring improvement HDS(C)S.2008 Standard 1.2.4: All adverse, unplanned, or PA Adverse Event untoward events are Moderate Reporting systematically recorded by the service and reported to affected
the CPR form signed by a relative and four out of four dementia care CPR forms had been signed by a relative. The GP had not stated on the one hospital and four dementia care CPR forms if the resident is competent or not competent. HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 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 (i) There are only health and safety/quality meeting minutes available for May and June in 2014. (ii) May meeting minutes do not reflect discussion of incidents or infections and June minutes do not reflect discussion around incident trends. (iii) Registered nurse meeting minutes for February, June and September 2014 (all that are available) do not reflect discussion of incident or infection trends; (iiv) Three complaints in 2014 document on the complaint investigation that there is to be discussion at registered staff meetings. Registered nurse meeting minutes do not reflect this occurring and this is an area requiring improvement Ensure that health and safety/quality meetings occur regularly and that quality data trends analysis outcomes are discussed in these and registered nurse meetings. Ensure that complaints investigations required outcomes including discussion in meetings occurs. 90 HDS(C)S.2008 Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected PA Moderate
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