and, where appropriate, discussions around quality and risk collated is also consumers. management programme findings. analysed. (iii) Ensure staff are informed of the findings. 90 days Criterion 1.2.3.8 PA A corrective action form is completed Corrective action forms are completed where Ensure there is Low when opportunities for improvements opportunities for improvements are identified, but are evidence of A corrective action plan are identified. Corrective actions were not consistently signed off when implemented. corrective actions addressing areas not consistently signed off by being implemented. requiring improvement management, to evidence in order to meet the implementation. specified Standard or 90 days requirements is developed and implemented. Criterion 1.2.8.1 PA Current staffing levels meet contractual The staffing plan for the reconfiguration of 15 hospital Ensure a staffing Low requirements. An RN is scheduled to beds does not identify staffing requirements on plan is developed to There is a clearly begin providing an additional 24 hours the number of hospital beds occupied. The service determine the documented and of cover (three days a week). This has not determined how many more staff will need to number and skill implemented process addition to staff is based on the current be employed to cover the increase in hospital mix of staff required which determines resident mix of 37 rest home level residents. as the number of service provider levels residents and 22 hospital level hospital level and skill mixes in order residents. It is unclear how staffing residents increases. to provide safe service levels will be adjusted if more hospital Ensure adequate delivery. level residents are admitted to the staff are available service. (The owner was not available to manage the during the audit and the facility manager increase in hospital did not have this information). residents. Prior to occupancy days
and, where appropriate, consumers. discussions around quality and risk management programme findings. collated is also analysed. (iii) Ensure staff are informed of the findings. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low A corrective action form is completed when opportunities for improvements are identified. Corrective actions were not consistently signed off by management, to evidence implementation. Corrective action forms are completed where opportunities for improvements are identified, but are not consistently signed off when implemented. Ensure there is evidence of corrective actions being implemented. 90 days Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low Current staffing levels meet contractual requirements. An RN is scheduled to begin providing an additional 24 hours of cover (three days a week). This addition to staff is based on the current resident mix of 37 rest home level residents and 22 hospital level residents. It is unclear how staffing levels will be adjusted if more hospital level residents are admitted to the service. (The owner was not available during the audit and the facility manager did not have this information). The staffing plan for the reconfiguration of 15 hospital beds does not identify staffing requirements on the number of hospital beds occupied. The service has not determined how many more staff will need to be employed to cover the increase in hospital residents. Ensure a staffing plan is developed to determine the number and skill mix of staff required as the number of hospital level residents increases. Ensure adequate staff are available to manage the increase in hospital residents. Prior to occupancy days
AuditSummary_PRMS_CommunicatePublish_000001204001.docx