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 1.2.4.3 PA Low The adverse event reporting policy includes the definitions The incident report analysis Ensure all reported of accidents, incidents, falls and injury. There is a template summary did not include all events are The service provider form that staff are required to use to report accidents and reported events. For example, consistently documents adverse, incidents and these forms are sighted to have been unwitnessed while being included in the unplanned, or completed for applicable events documented in the reported, were not consistently incident and/or untoward events residents’ files sampled. This includes near miss events included in the monthly data accident analysis. including service and medication related events. Where events have been analysis. shortfalls in order to reported there is evidence of investigation and appropriate identify opportunities to follow-up. Short term care plans were sighted in the 180 days improve service applicable residents’ files reviewed. delivery, and to identify and manage risk. Incidents were observed to be discussed by staff during shift handover including any ongoing care required. The staff report this was their normal practice. The number and themes of incidents and accidents were discussed and reported at the regular staff meetings as confirmed by staff interviewed and reported in the meeting minutes. While unwitnessed falls were being reported as an incident, all data was not currently included in
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 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low The adverse event reporting policy includes the definitions of accidents, incidents, falls and injury. There is a template form that staff are required to use to report accidents and incidents and these forms are sighted to have been completed for applicable events documented in the residents’ files sampled. This includes near miss events and medication related events. Where events have been reported there is evidence of investigation and appropriate follow-up. Short term care plans were sighted in the applicable residents’ files reviewed. Incidents were observed to be discussed by staff during shift handover including any ongoing care required. The staff report this was their normal practice. The number and themes of incidents and accidents were discussed and reported at the regular staff meetings as confirmed by staff interviewed and reported in the meeting minutes. While unwitnessed falls were being reported as an incident, all data was not currently included in The incident report analysis summary did not include all reported events. For example, unwitnessed while being reported, were not consistently included in the monthly data analysis. Ensure all reported events are consistently included in the incident and/or accident analysis. 180 days
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