should include evidence-based 1.3.12.6) There was also insufficient evidence practice has not 90 days practice. that care planning meets all requirements (refer been maintained. criteria 1.3.7.1 and 1.3.8.2) and that clinical policies and procedures have been developed in line with best practice (refer 1.2.3.3). Criterion 1.2.1.3 PA Low The facility manager is suitably qualified. The Annual training Maintain annual training facility manager’s job description outlines requirements for the requirements for the person The organisation is managed by a authority, accountability and responsibility. The role of the facility in the role of facility suitably qualified and/or experienced facility manager has been in the position since manager have not manager person with authority, accountability, February 2015 and is yet to access the required been maintained. and responsibility for the provision of training for this role. It was stated by the facility services. manager that training needs had not been 90 days discussed. Criterion 1.2.2.1 PA The deputising role had been discussed with the There is no suitably Appoint a suitably qualified clinical manager however the clinical manager qualified and/or person to perform the During a temporary absence a suitably had not agreed to perform this role and a formal experienced person manager’s role during the qualified and/or experienced person arrangement was not in place. to perform the facility facility manager’s temporary performs the manager's role. manager’s role absence. during a temporary absence. 60 days Criterion 1.2.3.3 PA Low New policies and procedures have been Not all the Ensure all the requirements developed. Policies include the the date and requirements of of policies and procedures The service develops and implements who authorised the policy. As policies are policies and are met. This includes the policies and procedures that are received they are printed and placed in the procedures have appropriateness, aligned with current good practice and appropriate section in the policy manuals and been met. accessibility and service delivery, meet the made available to staff in the nurses’ station. A maintenance of documents requirements of legislation, and are few electronic policies had not been made and references to best reviewed at regular intervals as available to staff and there had been insufficient practice/legislation. defined by policy. time following the receipt of the policies to train staff about their content. 90 days A document control process is in place however policy manuals did not have an index that was easy to follow.
should include evidence-based practice. 1.3.12.6) There was also insufficient evidence that care planning meets all requirements (refer criteria 1.3.7.1 and 1.3.8.2) and that clinical policies and procedures have been developed in line with best practice (refer 1.2.3.3). practice has not been maintained. 90 days Criterion 1.2.1.3 The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services. PA Low The facility manager is suitably qualified. The facility manager’s job description outlines authority, accountability and responsibility. The facility manager has been in the position since February 2015 and is yet to access the required training for this role. It was stated by the facility manager that training needs had not been discussed. Annual training requirements for the role of the facility manager have not been maintained. Maintain annual training requirements for the person in the role of facility manager 90 days Criterion 1.2.2.1 During a temporary absence a suitably qualified and/or experienced person performs the manager's role. PA The deputising role had been discussed with the clinical manager however the clinical manager had not agreed to perform this role and a formal arrangement was not in place. There is no suitably qualified and/or experienced person to perform the facility manager’s role during a temporary absence. Appoint a suitably qualified person to perform the manager’s role during the facility manager’s temporary absence. 60 days Criterion 1.2.3.3 The service develops and implements policies and procedures that are aligned with current good practice and service delivery, meet the requirements of legislation, and are reviewed at regular intervals as defined by policy. PA Low New policies and procedures have been developed. Policies include the the date and who authorised the policy. As policies are received they are printed and placed in the appropriate section in the policy manuals and made available to staff in the nurses’ station. A few electronic policies had not been made available to staff and there had been insufficient time following the receipt of the policies to train staff about their content. A document control process is in place however policy manuals did not have an index that was easy to follow. Not all the requirements of policies and procedures have been met. Ensure all the requirements of policies and procedures are met. This includes the appropriateness, accessibility and maintenance of documents and references to best practice/legislation. 90 days
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