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 Audit Evidence Audit Finding outcome Rating Criterion 1.2.3.6 CI There is a comprehensive quality and risk management process in place. Monitoring in Quality improvement data Bupa Cornwell is active in analysing data collected each area is completed monthly, quarterly, are collected, analysed, and monthly, around accidents and incidents, infection or annually, as designated by the evaluated and the results control, restraint etc. The care home manager internal auditing programme schedule. Audit communicated to service discusses the data and any identified trends or issues summaries and action plans are completed as providers and, at the quality meetings and staff meetings. Any required, depending on the result of the audit. appropriate, consumers. identified common themes around incidents/infections Key issues are reported at the quality committee etc. results in further education and toolbox sessions. meeting and an action plan is identified. These have been addressed in meeting minutes a) Due to the high number of resident falls in 2016, sighted. Benchmarking reports are generated the facility implemented a falls prevention programme throughout the year to review performance over in May 2016, which focused on identifying strategies a 12-month period. for the reduction of resident falls. Quality improvement plans are utilised and Strategies include: residents experiencing frequent document actions that have improved outcomes falls had an increase in monitoring to pre-empt or efficiencies in the facility. The service impromptu activity, ensuring good hydration, falls continues to collect data to support the focus group, falls prevention education for staff
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 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, appropriate, consumers. CI There is a comprehensive quality and risk management process in place. Monitoring in each area is completed monthly, quarterly, or annually, as designated by the internal auditing programme schedule. Audit summaries and action plans are completed as required, depending on the result of the audit. Key issues are reported at the quality committee meeting and an action plan is identified. These have been addressed in meeting minutes sighted. Benchmarking reports are generated throughout the year to review performance over a 12-month period. Quality improvement plans are utilised and document actions that have improved outcomes or efficiencies in the facility. The service continues to collect data to support the Bupa Cornwell is active in analysing data collected monthly, around accidents and incidents, infection control, restraint etc. The care home manager discusses the data and any identified trends or issues at the quality meetings and staff meetings. Any identified common themes around incidents/infections etc. results in further education and toolbox sessions. a) Due to the high number of resident falls in 2016, the facility implemented a falls prevention programme in May 2016, which focused on identifying strategies for the reduction of resident falls. Strategies include: residents experiencing frequent falls had an increase in monitoring to pre-empt impromptu activity, ensuring good hydration, falls focus group, falls prevention education for staff
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