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 outcome Attainment Audit Evidence Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.3.6 PA Low There is a documented Despite recurring issues all facility Ensure meetings are meeting schedule with meetings except restraint have only held at a frequency to Quality improvement data are collected, meetings occurring at various occurred three-monthly. Staff ensure that issues are analysed, and evaluated and the results intervals. Most are report not feeling well informed. The promptly addressed communicated to service providers and, but these have not service has remained consistently and that staff are well where appropriate, consumers. always occurred regularly. above benchmarks in several areas informed. Where through late 2016 and 2017 YTD. quality data is Corrective action plans, focussing evaluated and on individual residents have not corrective actions been reviewed and updated despite initiated; ensure these being ineffective. are reviewed for effectiveness and amended where needed. 60 days
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 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, where appropriate, consumers. PA Low There is a documented meeting schedule with meetings occurring at various intervals. Most are but these have not always occurred regularly. Despite recurring issues all facility meetings except restraint have only occurred three-monthly. Staff report not feeling well informed. The service has remained consistently above benchmarks in several areas through late 2016 and 2017 YTD. Corrective action plans, focussing on individual residents have not been reviewed and updated despite being ineffective. Ensure meetings are held at a frequency to ensure that issues are promptly addressed and that staff are well informed. Where quality data is evaluated and corrective actions initiated; ensure these are reviewed for effectiveness and amended where needed. 60 days
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