Summary of attainment The following table summarises the number of standards and criteria audited and the ratings they were awarded. Attainment Rating Continuous Improvement (CI) Attained (FA) Partially Attained Negligible Risk (PA Negligible) Partially Attained Low Risk (PA Low) Partially Attained Moderate Risk (PA Moderate) Partially Attained High Risk (PA High) Partially Attained Critical Risk (PA Critical) Standards Criteria 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 Criteria
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 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 Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.1.1 The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. PA Low There is a 2010-2015 risk management plan, a pandemic health plan and a 2014-2015 business plan. The business plan for Summerset in the Sun includes six business goals. Summerset has a ‘clinical audit, training and compliance’ calendar that is being implemented at Summerset in the Sun. The calendar schedules the training and audit (etal) requirements for the month and the village manager completes a ‘best practice’ sheet There is no transition plan or link to the business plan in regards to the new building and increase in bed/staff numbers Ensure a transition plan around the increase in service is included as part of the business plan 90 Days
confirming completion of requirements Criterion 1.2.8.1 is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low There is a Safe staffing policy and Safe Staffing procedure, which describes staffing and is based on benchmarking information. The policy also states that a developing care centre will have a higher staff to resident ratio in the initial build in occupancy to ensure safe staffing practices. (i) The current nurses’ station is a distance from the upstairs wing. Advised that a small nurse’s station is to be placed at the start of the wing (ii) Currently the night staff are responsible for laundry. Due to the size of the growing facility, this should be reviewed; (iii) Staff have not yet been employed for the new dual purpose upstairs wing. (i)Ensure a nurses station is installed as discussed; (ii) Review responsibilities for laundry; (iii) Ensure appropriate trained staff in place for new wing prior to occupancy of residents within the upstairs wing. Prior to occupancy Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. PA Moderate There is evidence of the GP being involved in the six month MTD meetings with families. The GP visits weekly and is available on call. A verbal and written handover at the beginning of each shift where any issues or changes in resident status is discussed. Progress notes are maintained on every shift by caregivers or more often if there are any changes. RNs write in the medical continuation notes at least weekly and with significant events. A review of progress notes identified lack of follow through and integration. The registered nurses write progress notes in the medical notes. There is no link to the caregiver’s progress notes. Ensure progress notes are integrated and identify link and follow through of care. 60 Days