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 required and timeframe Rating for completion (days) Criterion 1.2.3.6 PA Low Quality data is collected and collated. Although staff reported Provide documented The staff member responsible reported they discuss analysis evidence that quality Quality improvement data are collected, graphs are generated. However, these and trends during their data is analysed to analysed, and evaluated and the results are basic and staff reported they have not staff meetings, there identify trends and that communicated to service providers and, where seen them. Staff reported they discuss was no documented this is reported back to appropriate, consumers. the clinical indicators during the staff evidence that clinical staff. meetings to identify any trends. There indicators are analysed was no documented evidence to support to identify any trends. this. There was documented numbers of Meeting minutes 180 days clinical indicators for the month, but no evidenced numbers evidence of any analysis to identify only are reported back trends. to staff, apart from falls with injury or without injury. Criterion 1.2.3.8 PA Low Corrective action plans were evidenced Corrective action plans Develop and implement in the quality and staff meeting minutes. are not always corrective action plans A corrective action plan addressing areas Some internal audits had corrective developed following for all deficits identified requiring improvement in order to meet the action plans, but these were inconsistent deficits identified. and documented what the problem was, Where corrective action
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 Quality data is collected and collated. The staff member responsible reported graphs are generated. However, these are basic and staff reported they have not seen them. Staff reported they discuss the clinical indicators during the staff meetings to identify any trends. There was no documented evidence to support this. There was documented numbers of clinical indicators for the month, but no evidence of any analysis to identify trends. Although staff reported they discuss analysis and trends during their staff meetings, there was no documented evidence that clinical indicators are analysed to identify any trends. Meeting minutes evidenced numbers only are reported back to staff, apart from falls with injury or without injury. Provide documented evidence that quality data is analysed to identify trends and that this is reported back to staff. 180 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the PA Low Corrective action plans were evidenced in the quality and staff meeting minutes. Some internal audits had corrective action plans, but these were inconsistent and documented what the problem was, Corrective action plans are not always developed following deficits identified. Where corrective action Develop and implement corrective action plans for all deficits identified
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