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 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 Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.7.4 PA Low There is a planned three-week The orientation programme has not Ensure staff complete orientation for staff who have been yet commenced. the orientation New service providers receive an employed to work in the dementia care programme as orientation/induction programme unit. The orientation commences on 7 scheduled over three that covers the essential November 2016. All new and existing weeks. components of the service staff will receive orientation to the unit, provided. emergency procedures, call bell system and attend a planned fire drill. Over the Prior to occupancy three weeks, mandatory and clinical days education will be completed and competencies completed such as medication, nutrition and infection control and first aid. Criterion 1.3.12.1 PA Low There is a separate medication room The medication room is not Implement a safe located within the new dementia care ready for use or secure. transition for the A medicines management system unit. The medication cabinets and medication system. is implemented to manage the controlled drugs safe and locks are yet safe and appropriate prescribing, to be installed and completed. The
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 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 Finding Corrective action required and timeframe for completion (days) Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low There is a planned three-week orientation for staff who have been employed to work in the dementia care unit. The orientation commences on 7 November 2016. All new and existing staff will receive orientation to the unit, emergency procedures, call bell system and attend a planned fire drill. Over the three weeks, mandatory and clinical education will be completed and competencies completed such as medication, nutrition and infection control and first aid. The orientation programme has not yet commenced. Ensure staff complete the orientation programme as scheduled over three weeks. Prior to occupancy days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, PA Low There is a separate medication room located within the new dementia care unit. The medication cabinets and controlled drugs safe and locks are yet to be installed and completed. The The medication room is not ready for use or secure. Implement a safe transition for the medication system.
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