Specific results for criterion 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 Audit Evidence Audit Finding Corrective desired outcome Rating action required and timeframe for completion (days) Criterion 1.2.3.6 PA Low Glenburn has a meeting schedule in place that Meeting minutes do not consistently record Ensure meeting is being implemented including bimonthly quality inclusion of incidents and/or internal minutes include Quality meetings, qualified staff and staff meetings in Examples include: discussion improvement data each clinical area. There are also two monthly about internal are collected, a) Qualified staff meetings: In minutes sighted for infection control meetings and health and safety audit and analysed, and 18 September 2014, 15 May 2014 and 1 January meetings. All meetings are minuted. resident evaluated and the 2014 there are no recorded discussion of incidents, incidents results and the 15 May 2014 and 1 January 2014 minutes including communicated to have no discussion of internal audits. trending and service providers preventative b) Ward meetings in the four units Manuka, Koru, – and, where actions. Kowhai and Rata do not record incidents in the appropriate, June/July meeting minutes. consumers. 90 days Criterion 1.3.6.1 PA Low When a resident's condition alters, the Interventions are not documented in the care plan Ensure registered nurse initiates a review and if for a) rest home resident re-commenced on protein interventions required, GP, or nurse specialist consultation. drinks as per the written evaluation. The resident are documented
Specific results for criterion 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 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 Glenburn has a meeting schedule in place that is being implemented including bimonthly quality meetings, qualified staff and staff meetings in each clinical area. There are also two monthly infection control meetings and health and safety meetings. All meetings are minuted. Meeting minutes do not consistently record inclusion of incidents and/or internal Examples include: a) Qualified staff meetings: In minutes sighted for 18 September 2014, 15 May 2014 and 1 January 2014 there are no recorded discussion of incidents, and the 15 May 2014 and 1 January 2014 minutes have no discussion of internal audits. b) Ward meetings in the four units – Manuka, Koru, Kowhai and Rata do not record incidents in the June/July meeting minutes. Ensure meeting minutes include discussion about internal audit and resident incidents including trending and preventative actions. 90 days Criterion 1.3.6.1 PA Low When a resident's condition alters, the registered nurse initiates a review and if required, GP, or nurse specialist consultation. Interventions are not documented in the care plan for a) rest home resident re-commenced on protein drinks as per the written evaluation. The resident Ensure interventions are documented
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