Standard 1.2.3: The organisation has PA Low HDS(C)S.2008 Quality And Risk an established, Management documented, and Systems maintained quality and risk management system that reflects continuous quality improvement principles. HDS(C)S.2008 Criterion 1.2.3.8 A corrective action PA Low The internal audit schedule is Ensure that required 180 plan addressing implemented. The internal audits corrective action plans requiring completed between March to August resulting from internal improvement in order 2014 were reviewed, and audit audit activity is to meet the specified summaries and action plans are implemented. Standard or completed where a noncompliance is requirements is identified. In two occasions, corrective developed and action plan identified required actions implemented. but they were not documented as completed. Clinical file audit completed in May 2014 showed 89% compliance, and audit summary identified issues around compliance. The required corrective action plan was to re-audit in two months which was not completed. A care plan audit was completed in May 2014 and identified 90.5% Required action plan was identified as month follow up” but this has not “one been documented as actioned. Interview with the clinical manager also confirmed that required actions have not yet been implemented. HDS(C)S.2008 Standard 1.2.8: Consumers receive PA Service Provider timely, appropriate, Moderate Availability and safe service from suitably qualified/skilled and/or experienced service providers.
HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan addressing requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low The internal audit schedule is implemented. The internal audits completed between March to August 2014 were reviewed, and audit summaries and action plans are completed where a noncompliance is identified. In two occasions, corrective action plan identified required actions but they were not documented as completed. Clinical file audit completed in May 2014 showed 89% compliance, and audit summary identified issues around The required corrective action plan was to re-audit in two months which was not completed. A care plan audit was completed in May 2014 and identified 90.5% compliance. Required action plan was identified as “one month follow up” but this has not been documented as actioned. Interview with the clinical manager also confirmed that required actions have not yet been implemented. Ensure that required corrective action plans resulting from internal audit activity is implemented. 180 HDS(C)S.2008 Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. PA Moderate
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