summaries are entered into the database. Criterion 1.2.3.6 PA Low Quality and risk performance is is no documented evidence that quality Ensure that all quality reported across the facility meetings, data is reported to staff at the general staff data is reported to all Quality improvement data through the communication book, meeting since April 2014. staff at the facility are collected, analysed, and also to the organisation's meetings and that this is and evaluated and the management team documented. results communicated to service providers and, where appropriate, 90 days consumers. Criterion 1.2.3.8 PA Moderate summaries are entered into the Clinical audits completed in May and August Ensure that corrective database. Benchmarking reports are 2014 with 93% compliance, cleaning audits actions are developed for A corrective action plan generated throughout the year to completed in August and September 2014 areas of audits/surveys addressing areas review performance over a 12 month with 93% and 83 % compliance and the that have not reached requiring improvement in period. The service continues to annual satisfaction survey in November 2013 compliance. order to meet the collect data to support the do not show evidence of corrective actions specified Standard or implementation of QIP's. developed as a result of shortfalls identified. requirements is 30 days developed and implemented. Criterion 1.3.12.5 PA Low Policy states that self-medication Two of two self-medicating residents had no Ensure that all must be monitored every shift. documentation to evidence they had been residents The facilitation of safe monitored have self-medication self-administration of monitored and that this is medicines by consumers documented every shift. where appropriate. 30 days Criterion 1.3.6.1 PA Moderate Selwyn Heights provides services for (i)One resident in the hospital (tracer) had (i), (ii), (iii) ensure that all residents requiring rest home and changes in weight and neither the dietician, residents have The provision of services hospital of care. The care being GP or Nurse Practitioner were notified when documented and/or interventions are provided is consistent with the needs the weight dropped in three weeks. (ii)Two assessments, care plans consistent with, and of residents as evidenced in four of residents with a fall documented on an and interventions to meet contribute to, meeting the six files sampled. incident form had no clear interventions in consumers' assessed
summaries are entered into the database. Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality and risk performance is reported across the facility meetings, through the communication book, and also to the organisation's management team is no documented evidence that quality data is reported to staff at the general staff meeting since April 2014. Ensure that all quality data is reported to all staff at the facility meetings and that this is documented. 90 days 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. PA Moderate summaries are entered into the database. Benchmarking reports are generated throughout the year to review performance over a 12 month period. The service continues to collect data to support the implementation of QIP's. Clinical audits completed in May and August 2014 with 93% compliance, cleaning audits completed in August and September 2014 with 93% and 83 % compliance and the annual satisfaction survey in November 2013 do not show evidence of corrective actions developed as a result of shortfalls identified. Ensure that corrective actions are developed for areas of audits/surveys that have not reached compliance. 30 days Criterion 1.3.12.5 The facilitation of safe self-administration of medicines by consumers where appropriate. PA Low Policy states that self-medication must be monitored every shift. Two of two self-medicating residents had no documentation to evidence they had been monitored Ensure that all residents have self-medication monitored and that this is documented every shift. 30 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed PA Moderate Selwyn Heights provides services for residents requiring rest home and hospital of care. The care being provided is consistent with the needs of residents as evidenced in four of six files sampled. (i)One resident in the hospital (tracer) had changes in weight and neither the dietician, GP or Nurse Practitioner were notified when the weight dropped in three weeks. (ii)Two residents with a fall documented on an incident form had no clear interventions in (i), (ii), (iii) ensure that all residents have documented assessments, care plans and interventions to meet
AuditSummary_PRMS_CommunicatePublish_000000935001.docx