Summary of attainment The following summarises the number of standards and criteria audited and the ratings they were awarded. Attainment Rating Continuous Improvement (CI) Fully 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 0 12 0 4 1 0 0 Criteria 0 35 0 5 1 0 0 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 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 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 Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Incident/accident forms include space for staff to document that family are being kept informed following an adverse event. Evidence of this being documented was missing five of the thirteen incident/accident forms that were randomly selected for review, although all four families interviewed report that they are kept informed of their family’s health status, including following an adverse event. Documentation in five of thirteen incident/accident forms fails to reflect families being informed following an adverse event. Ensure there is documented evidence of open disclosure with families following an adverse event unless directed otherwise by the resident or family. 90 days Criterion 1.2.3.4 There is a document control system to manage the policies and procedures. This system shall ensure PA Low A document control policy is in place that states policies are to be reviewed every two years, with designated policies targeted for review every two months. The current policies and Policies and procedures have not been reviewed since March 2013. Ensure policies and procedures are regularly reviewed as per the facility
frames that safely meet the needs of the consumer. was developed within three weeks of admission. Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low Two of five care plans reviewed described the residents’ needs and care interventions required to support the residents’ independence and wellbeing. Care plans are readily available for caregivers. Caregivers interviewed were knowledgeable in individual resident cares. Three out of five resident care plans sampled did not describe the supports and/or interventions required for one resident’s mood and behaviour management, as identified in the InterRAI assessment tool. One resident with a chronic urinary tract infection did not have prevention and management interventions recorded and one resident with deteriorating mental health does not have a recent review and increase in medications recorded. Ensure individual care plans describe the required supports and/or interventions to achieve resident goals. 60 days