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) 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 0 0 0 Criteria 0 28 0 8 0 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 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 1.2.7.3 The appointment of appropriate service providers to safely meet the needs of consumers. PA Low The management team are in the process of employing staff for the opening of the first dementia unit and the hospital unit. Currently they have four caregivers working in the dual-purpose unit that have completed dementia specific standards and will transfer and commence in the dementia unit on opening. A unit coordinator (RN) experienced in dementia level care is yet to be employed. An experienced aged care RN currently working as an RN in the dual-purpose unit is being primed for the unit coordinator role in rest home and the current unit coordinator in the dual-purpose unit will go to the hospital unit as unit coordinator. The service is in the process of interviewing for more staff with the intention to have these appointed prior to occupancy. Advised that the following positions need to be filled before opening; Unit coordinator for dementia units; two RNs for hospital, six caregivers for dementia and hospital, three housekeepers and one physiotherapy assistant. The service is currently interviewing for more staff with the intention to have these appointed prior to occupancy. Not all positions in the initial roster are filled. (i) Dementia Unit: Ensure there is sufficient staff employed to cover the roster. Ensure the unit coordinator (RN position) is filled and the person is experienced in dementia level care. Ensure the DT positions are in place and the DT is skilled in assessment, implementation and evaluation of diversional and motivational recreation. (ii) Hospital Unit: Ensure there is sufficient staff employed to cover the