there is evidence review is commencing. Standard All adverse, unplanned, or untoward PA 1.2.4: Adverse events are systematically recorded by Moderate Event the service and reported to affected Reporting consumers and where appropriate their family/whānau of choice in an open manner. Criterion The service provider documents PA Two resident files were reviewed and Incident forms are completed 30 1.2.4.3 adverse, unplanned, or untoward events Moderate in both files, a number of reported as prescribed in policy. including service shortfalls in to incidents did not have an associated identify opportunities to improve service form one incident in file one, and 12 – delivery, and to identify and manage in file two. In file two the resident was risk. a frequent faller, and had supporting documentation in place including a – falls log. Interview informed where a falls log and/or challenging behaviour plan is in place, an incident form is not required. This exemption is not outlined in the incident reporting policy (link 1.2.3). In both resident files, appropriate interventions are recorded in support/care plans to manage care. Standard Consumers are involved in the planning, PA Low 1.2.5: implementation, and evaluation at all Consumer levels of the service to ensure services Participation are responsive to the needs of individuals. Criterion The service demonstrates consumer PA Low There is no formal mechanism for Develop a process to ensure 180 1.2.5.1 participation in the planning, consumer input into service planning, consumer input into service implementation, monitoring, and implementation, monitoring and planning, implementation, evaluation of service delivery. evaluation at a management and monitoring and evaluation at a governance level. management and governance level Criterion Consumers and consumer groups UA Low As there is no input at this level there Develop terms of reference or 180 1.2.5.2 involved in planning, implementation, are no consumers or consumer groups a position description for and evaluation of services have clear consumers or consumer
there is evidence review is commencing. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. PA Moderate Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in to identify opportunities to improve service delivery, and to identify and manage risk. PA Moderate Two resident files were reviewed and in both files, a number of reported incidents did not have an associated form – one incident in file one, and 12 in file two. In file two the resident was a frequent faller, and had supporting documentation in place – including a falls log. Interview informed where a falls log and/or challenging behaviour plan is in place, an incident form is not required. This exemption is not outlined in the incident reporting policy (link 1.2.3). In both resident files, appropriate interventions are recorded in support/care plans to manage care. Incident forms are completed as prescribed in policy. 30 Standard 1.2.5: Consumer Participation Consumers are involved in the planning, implementation, and evaluation at all levels of the service to ensure services are responsive to the needs of individuals. PA Low Criterion 1.2.5.1 The service demonstrates consumer participation in the planning, implementation, monitoring, and evaluation of service delivery. PA Low There is no formal mechanism for consumer input into service planning, implementation, monitoring and evaluation at a management and governance level. Develop a process to ensure consumer input into service planning, implementation, monitoring and evaluation at a management and governance level 180 Criterion 1.2.5.2 Consumers and consumer groups involved in planning, implementation, and evaluation of services have clear UA Low As there is no input at this level there are no consumers or consumer groups Develop terms of reference or a position description for consumers or consumer 180
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