Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a these is a message data to display” then no continuous improvements were recorded as part of this of this “no audit. Criterion with desired outcome Attainment Audit Evidence Finding Rating Criterion 1.1.8.1 CI The service has identified that clinical The service identified an increase in challenging reporting to appropriate meetings has behaviours in February (four) and March (five) in 2016. The service provides an been a great improvement since last There were staff incidents reported in relation to environment that encourages audit. They have implemented facility, challenging behaviours with two in March and four in good practice, which should clinical managers and training June 2016. In July 2016, the service implemented an include evidence-based practice. coordinator reports for the monthly action plan to reduce the number of challenging quality meetings. The service is currently behaviours. There was a team approach to implement developing KPIs within the Arvida Group. the goals” including improved communication “Cressy However, they are still to set group and mentoring and training sessions for all staff. There benchmarking but Ilam have continued were regular meetings held with the clinical manager, with internal benchmarking with five other charge nurse, diversional therapist and caregivers to facilities. The service is proactive in identify individual resident de-escalation techniques. implementing quality improvements. The All behaviour assessments, behaviour charts and following have been implemented (but care plans were reviewed to ensure all triggers not limited to) dietary needs, residents and alternative de-escalation strategies were diversional therapy in apartments, needle documented to inform staff of early warning signs and stick injuries prevention, H&S injury interventions that were successful. Meaningful – activities to reduce behaviours have been introduced
Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Finding Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The service has identified that clinical reporting to appropriate meetings has been a great improvement since last audit. They have implemented facility, clinical managers and training coordinator reports for the monthly quality meetings. The service is currently developing KPIs within the Arvida Group. However, they are still to set group benchmarking but Ilam have continued with internal benchmarking with five other facilities. The service is proactive in implementing quality improvements. The following have been implemented (but not limited to) dietary needs, residents diversional therapy in apartments, needle stick injuries – prevention, H&S injury The service identified an increase in challenging behaviours in February (four) and March (five) in 2016. There were staff incidents reported in relation to challenging behaviours with two in March and four in June 2016. In July 2016, the service implemented an action plan to reduce the number of challenging behaviours. There was a team approach to implement the “Cressy goals” including improved communication and mentoring and training sessions for all staff. There were regular meetings held with the clinical manager, charge nurse, diversional therapist and caregivers to identify individual resident de-escalation techniques. All behaviour assessments, behaviour charts and care plans were reviewed to ensure all triggers and alternative de-escalation strategies were documented to inform staff of early warning signs and interventions that were successful. Meaningful activities to reduce behaviours have been introduced
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