Specific results for criterion where a continuous improvement has been recorded As well as standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message data to display” then no continuous improvements were recorded as part of this of this “no audit. Criterion with desired Attainment Rating Audit Evidence Audit Finding outcome Criterion 1.2.3.8 CI Quality initiatives are developed in response to Quality initiatives are identified and identified areas requiring improvement. These implemented. Once completed a formal A corrective action plan range from concerns raised by residents about the review is conducted which includes addressing areas requiring quality and enjoyment of meals, monitoring call bell consideration of improvement in service improvement in order to meet response times and the palliative care suites to delivery as a result of the initiative. All the specified Standard or better support residents and their family/whanau at initiatives are discussed and evaluated at requirements is developed and end of life. the monthly management meetings. This implemented. initiative overall enables improvements in All initiatives have been documented and those service delivery to be the ongoing focus of which are completed have a formal review. The the staff and management team. reviews and outcome of each initiative is discussed at the monthly management meeting when the Interview with a range of staff members quality plan is discussed as part of monitoring and identify that they are able to make tracking progress against the quality plan. improvements to anything which is identified as requiring improvement and they showed pride in the initiatives which have been implemented to date. The results of a range
Specific results for criterion where a continuous improvement has been recorded As well as standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding 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. CI Quality initiatives are developed in response to identified areas requiring improvement. These range from concerns raised by residents about the quality and enjoyment of meals, monitoring call bell response times and the palliative care suites to better support residents and their family/whanau at end of life. All initiatives have been documented and those which are completed have a formal review. The reviews and outcome of each initiative is discussed at the monthly management meeting when the quality plan is discussed as part of monitoring and tracking progress against the quality plan. Quality initiatives are identified and implemented. Once completed a formal review is conducted which includes consideration of improvement in service delivery as a result of the initiative. All initiatives are discussed and evaluated at the monthly management meetings. This initiative overall enables improvements in service delivery to be the ongoing focus of the staff and management team. Interview with a range of staff members identify that they are able to make improvements to anything which is identified as requiring improvement and they showed pride in the initiatives which have been implemented to date. The results of a range
AuditSummary_PRMS_CommunicatePublish_000001594005.docx