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 Attainment Audit Evidence Audit Finding Corrective action outcome Rating required and timeframe for completion (days) Criterion 1.2.3.3 PA Policies, procedures, work instruction and forms are At the time of audit there The service Moderate available in both hard copy versions and electronically. Work are around 50% of the establishes the exact The service develops is in progress to consolidate and update the around 600 approximate 600 policies number of overdue and implements policies documents on the electronic data base. The current and other documents policies and and procedures that are electronic document control system, discussed and overdue for review in the procedures and aligned with current reviewed with the quality and development coordinator, electronic data base. There implements a process good practice and shows that many of the policies/documents are overdue for are also paper version of to ensure these are service delivery, meet review; however, the number overdue for review was not policies available for use in reviewed at regular the requirements of easily established and was unknown. The coordinator the clinical areas that are intervals, aligned with legislation, and are reports this is around 50% of the 600 documents. In the one overdue for review and/or current good practice reviewed at regular resident home where policies were discussed and reviewed, are redundant. and document intervals as defined by the paper version of the clinical policy manual had no controlled. policy. policies that were current; some being at least 10 years overdue for review, many of these now being obsolete. There was both an Elizabeth Knox infection control policy 90 days manual and an externally supplied infection control manual available, with staff assuming the externally supplied manual was the one to refer to.
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 Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.3 The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. PA Moderate Policies, procedures, work instruction and forms are available in both hard copy versions and electronically. Work is in progress to consolidate and update the around 600 documents on the electronic data base. The current electronic document control system, discussed and reviewed with the quality and development coordinator, shows that many of the policies/documents are overdue for review; however, the number overdue for review was not easily established and was unknown. The coordinator reports this is around 50% of the 600 documents. In the one resident home where policies were discussed and reviewed, the paper version of the clinical policy manual had no policies that were current; some being at least 10 years overdue for review, many of these now being obsolete. There was both an Elizabeth Knox infection control policy manual and an externally supplied infection control manual available, with staff assuming the externally supplied manual was the one to refer to. At the time of audit there are around 50% of the approximate 600 policies and other documents overdue for review in the electronic data base. There are also paper version of policies available for use in the clinical areas that are overdue for review and/or are redundant. The service establishes the exact number of overdue policies and procedures and implements a process to ensure these are reviewed at regular intervals, aligned with current good practice and document controlled. 90 days
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