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 40 0 4 1 0 0 Criteria 0 88 0 4 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 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 Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.4.3 The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. PA Low The adverse event reporting policy includes the definitions of accidents, incidents, falls and injury. There is a template form that staff are required to use to report accidents and incidents and these forms are sighted to have been completed for applicable events documented in the residents’ files sampled. This includes near miss events and medication related events. Where events have been reported there is evidence of investigation and appropriate follow-up. Short term care plans were sighted in the applicable residents’ files reviewed. Incidents were observed to be discussed by staff during shift handover including any ongoing care required. The staff report this was their normal practice. The number and themes of incidents and accidents were discussed and reported at the regular staff meetings as confirmed by staff interviewed and reported in the meeting minutes. While unwitnessed falls were being reported as an incident, all data was not currently included in The incident report analysis summary did not include all reported events. For example, unwitnessed while being reported, were not consistently included in the monthly data analysis. Ensure all reported events are consistently included in the incident and/or accident analysis. 180 days
confirmed with the RN, manager and other staff during interview. The RN role will become vacant at the end of January 2015. The manager advised that where required a registered nurse has been obtained from a nursing bureau and records sighted verified this. Where possible the same RN is requested to assist with continuity of care. All staff have a current first aid certificate. All current staff have been offered employment by the prospective manager as confirmed during interview with the manager, the prospective manager and staff. A registered nurse has yet to be recruited by the prospective owner. The prospective owner has a staffing policy which meets the ARRC contract requirements. Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in to comply with legislation, protocols, and guidelines. PA Low medication records were randomly selected to review. Four of the eight records have not been completed appropriately by the prescriber. Some short course medications which have been completed have not been signed or dated by the prescriber when discontinued. Ensure all discontinued medications are signed and dated by the prescriber. 180 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low An external company undertakes performance monitoring checking of one piece of clinical equipment. The tympanic thermometer and pulse oximeter have not been tested in the last 12 months. Weighing scales are reported to be hired from an external company when resident weights required to be checked. Electrical safety test and tagging of electrical appliances was overdue (due June 2014). Performance monitoring testing of the pulse oximeter and tympanic thermometer has not occurred in the last 12 months. Ensure test and tagging of electronic equipment is current and all clinical equipment has performance monitoring tests