Policies did not consistently reference best practice documents or legislation and some policies were not relevant to the level of care required for residents, for example the oxygen policy. Criterion 1.2.3.7 PA Low Internal audits have been implemented as per Achievement against Monitor progress against the the internal audit schedule. Records of internal the business and risk business and risk A process to measure achievement audits are maintained. This was a previous area management plans management plans. against the quality and risk requiring improvement. had not occurred. management plan is implemented. A business and risk management plan is in 90 days place. This was developed after the last audit. The plan includes methods for monitoring achievement against business and risk goals, however the required review against the plan was yet to occur. Criterion 1.2.3.8 PA Low A corrective action process has been There was Document actions taken and implemented. This was identified as a previous insufficient evidence close all corrective actions. A corrective action plan addressing area requiring improvement, however not all that all corrective areas requiring improvement in order corrective actions sampled included documented actions had been to meet the specified Standard or evidence that corrective actions had been addressed and/or 90 days requirements is developed and addressed, or that the corrective actions has closed. implemented. been closed. Criterion 1.2.9.7 PA Low Hard copy files storage is secure. Some The security Implement a process which electronic security was in place, however procedures for ensures the security, and Information of a private or personal electronic security procedures, for example electronic resident accessibility, of electronic nature is maintained in a secure backup, could not be confirmed. records could not be resident records at all times. manner that is not publicly accessible confirmed. or observable. 180 days Criterion 1.3.12.3 PA High All staff administering oral medications have Medication Ensure that all staff current medication competencies. The CM, RN competencies have administering insulin have Service providers responsible for and a healthcare assistant (HCA) had followed not been maintained. the required competencies. medicine management are competent
Policies did not consistently reference best practice documents or legislation and some policies were not relevant to the level of care required for residents, for example the oxygen policy. Criterion 1.2.3.7 A process to measure achievement against the quality and risk management plan is implemented. PA Low Internal audits have been implemented as per the internal audit schedule. Records of internal audits are maintained. This was a previous area requiring improvement. A business and risk management plan is in place. This was developed after the last audit. The plan includes methods for monitoring achievement against business and risk goals, however the required review against the plan was yet to occur. Achievement against the business and risk management plans had not occurred. Monitor progress against the business and risk management plans. 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 process has been implemented. This was identified as a previous area requiring improvement, however not all corrective actions sampled included documented evidence that corrective actions had been addressed, or that the corrective actions has been closed. There was insufficient evidence that all corrective actions had been addressed and/or closed. Document actions taken and close all corrective actions. 90 days Criterion 1.2.9.7 Information of a private or personal nature is maintained in a secure manner that is not publicly accessible or observable. PA Low Hard copy files storage is secure. Some electronic security was in place, however electronic security procedures, for example backup, could not be confirmed. The security procedures for electronic resident records could not be confirmed. Implement a process which ensures the security, and accessibility, of electronic resident records at all times. 180 days Criterion 1.3.12.3 Service providers responsible for medicine management are competent PA High All staff administering oral medications have current medication competencies. The CM, RN and a healthcare assistant (HCA) had followed Medication competencies have not been maintained. Ensure that all staff administering insulin have the required competencies.
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