Attainment Rating Unattained Negligible Risk (UA Negligible) Unattained Low Risk (UA Low) Unattained Moderate Risk (UA Moderate) Unattained High Risk (UA High) Unattained Critical Risk (UA Critical) Standards 0 0 0 0 0 Criteria 0 0 0 0 0
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
response to the support and/or intervention, and progress towards meeting the desired outcome. plan were conducted, however they were not evaluated six monthly. progress towards meeting the desired outcomes. Activities care plans have not been evaluated six monthly. and that activities care plans are reviewed six monthly. 90 days
Specific results for criterion a continuous improvement has been recorded As well as whole 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. No data to display End of the report.