employment and annually thereafter. Two of manager also does not have a 90 days five files evidenced signed job descriptions. signed job description or contract. Criterion 1.2.7.4 PA Low The service has orientation processes in Four of six files reviewed do Ensure that all new place including a buddy system for new staff not evidence that orientation staff complete the New service providers receive an members to work alongside more experienced packs have been completed. orientation and orientation/induction programme staff. The orientation package includes health induction programme that covers the essential and safety, infection control and familiarisation and that this is components of the service with policies and procedures. Two of six staff recorded. provided. files reviewed evidence that orientation packages and documentation have been completed. 90 days Criterion 1.3.13.5 PA Low Kitchen was observed to be clean and tidy. One surface in food preparation Ensure that food Staff conduct kitchen cleaning and sign off area and one in storage area do storage and food All aspects of food procurement, when this is completed. There are two not meet infection control preparation comply production, preparation, storage, surfaces, one in the kitchen and one in the requirements. Not all staff have with legislation and transportation, delivery, and pantry that do not comply with infection control completed food safety training. guidelines and staff disposal comply with current requirements. Interview with the cook There is inconsistency of taking complete food safety legislation, and guidelines. confirmed they have conducted food safety of food temperatures. Decanted training. training. food is not dated. 90 days Criterion 1.3.4.2 PA Initial assessments and initial care plans are Risk assessments and risk Ensure that all required Moderate conducted on admission. Four of four files reassessments are completed risk assessments are The needs, outcomes, and/or reviewed evidenced risk assessments have inconsistently. completed. goals of consumers are identified not all been completed and reassessed when via the assessment process and required. are documented to serve as the 90 days basis for service delivery planning. Criterion 1.3.8.2 PA Care plan evaluation are conducted six Care plan evaluation does not Ensure that care plan Moderate monthly, however there was evidence the consistently record the degree evaluations record the Evaluations are documented, evaluations did not always record the degree of achievement to the degree of achievement consumer-focused, indicate the of achievement towards meeting the intervention provided and towards meeting degree of achievement or residents’ desired outcomes. Activities care resident’s outcomes
employment and annually thereafter. Two of five files evidenced signed job descriptions. manager also does not have a signed job description or contract. 90 days Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low The service has orientation processes in place including a buddy system for new staff members to work alongside more experienced staff. The orientation package includes health and safety, infection control and familiarisation with policies and procedures. Two of six staff files reviewed evidence that orientation packages and documentation have been completed. Four of six files reviewed do not evidence that orientation packs have been completed. Ensure that all new staff complete the orientation and induction programme and that this is recorded. 90 days Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines. PA Low Kitchen was observed to be clean and tidy. Staff conduct kitchen cleaning and sign off when this is completed. There are two surfaces, one in the kitchen and one in the pantry that do not comply with infection control requirements. Interview with the cook confirmed they have conducted food safety training. One surface in food preparation area and one in storage area do not meet infection control requirements. Not all staff have completed food safety training. There is inconsistency of taking of food temperatures. Decanted food is not dated. Ensure that food storage and food preparation comply with legislation and guidelines and staff complete food safety training. 90 days Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Moderate Initial assessments and initial care plans are conducted on admission. Four of four files reviewed evidenced risk assessments have not all been completed and reassessed when required. Risk assessments and risk reassessments are completed inconsistently. Ensure that all required risk assessments are completed. 90 days Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or PA Moderate Care plan evaluation are conducted six monthly, however there was evidence the evaluations did not always record the degree of achievement towards meeting the residents’ desired outcomes. Activities care Care plan evaluation does not consistently record the degree of achievement to the intervention provided and Ensure that care plan evaluations record the degree of achievement towards meeting resident’s outcomes
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