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 1.2.3.6 PA Low Data that is collected each month including Missing in the meeting minutes is Ensure discussions (but not limited to) residents’ falls, documented evidence of communicating relating to quality Quality improvement challenging behaviour, infections, pressure quality and risk activities and findings with and risk are data are collected, areas, and wounds are collated and The village manager reports steps were documented in the analysed, and evaluated compared on a month-by-month basis. undertaken in December 2014 to ensure that applicable meeting and the results Results are analysed and evaluated. The staff meeting minutes consistently reflect minutes. communicated to service village manager and clinical manager quality and risk management information. providers and, report that this data is then communicated appropriate, consumers. to staff in the full staff meetings and in the 180 days RN meetings although meeting minutes do not consistently reflect this finding. Criterion 1.3.12.6 PA Low The previous audit identified issues with The following shortfalls in documentation Ensure the the standard of documentation which were identified: (i) the allergy status of 2 of 29 documentation of Medicine management related to the charting of medicines by residents receiving dementia services medicines information is recorded medical staff and the signing by nursing (sample extended) was not recorded; and (ii) management meets to a level of detail, and staff on the administration chart. This audit 1 of 20 residents (sample extended) receiving policy. communicated to found that improvements have been made hospital services did not have photographic consumers at a in both areas, however further
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 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, appropriate, consumers. PA Low Data that is collected each month including (but not limited to) residents’ falls, challenging behaviour, infections, pressure areas, and wounds are collated and compared on a month-by-month basis. Results are analysed and evaluated. The village manager and clinical manager report that this data is then communicated to staff in the full staff meetings and in the RN meetings although meeting minutes do not consistently reflect this finding. Missing in the meeting minutes is documented evidence of communicating quality and risk activities and findings with The village manager reports steps were undertaken in December 2014 to ensure that staff meeting minutes consistently reflect quality and risk management information. Ensure discussions relating to quality and risk are documented in the applicable meeting minutes. 180 days Criterion 1.3.12.6 Medicine management information is recorded to a level of detail, and communicated to consumers at a PA Low The previous audit identified issues with the standard of documentation which related to the charting of medicines by medical staff and the signing by nursing staff on the administration chart. This audit found that improvements have been made in both areas, however further The following shortfalls in documentation were identified: (i) the allergy status of 2 of 29 residents receiving dementia services (sample extended) was not recorded; and (ii) 1 of 20 residents (sample extended) receiving hospital services did not have photographic Ensure the documentation of medicines management meets policy.
AuditSummary_PRMS_CommunicatePublish_000000953002.docx