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
Specific results for criterion 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 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 Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low Staff training is provided at least 2x monthly and all core subjects have been covered in the programme in the past two years. Also staff receive extra training via toolbox talks. There are a number of competencies completed by staff. Staff have received education in the management of challenging behaviours however, not all caregivers who work regularly in the facility have completed the required dementia-specific national qualification. All registered nurses hold a champion role in; nutrition & weight, incident reporting, behaviour documents, TPR, Doctors Rounds, care plans, emergency equipment, Wounds and Medication Two caregivers who work in the facility have not completed the required dementia specific national qualification. Both caregivers have been employed for over one year. Ensure that all caregivers working in the facility are enrolled and have completed education modules within the required timeframes. 90 days Criterion 1.3.5.2 Service delivery plans describe the required PA Low The RNs complete assessments to identify the care needs of the resident and use this information to inform the development of the Three of seven files sampled did not include interventions or interventions were not Ensure that clinical risk assessments are completed where indicated
support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. care plan. Not all care plan interventions for assessed care needs are documented in the long term care plans in sufficient detail to guide the care staff. There is evidence of the use of short-term care plans and these have signed out or added to the long-term care plan, if not resolved. documented in sufficient detail to guide the care staff in the management of seizures and diabetic emergencies. and the care plan interventions are documented in sufficient detail to guide the care staff. 90 days
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