shortfalls, significant action is needed to achieve the required levels of performance Some standards applicable to this service unattained and of moderate or high risk Consumer Rights Day of Audit 16-Sep-13 Assessment Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Some standards applicable to this service partially attained and of low risk Organisational Management Day of Audit 16-Sep-13 Assessment Includes 9 standards that support an outcome where consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Standards applicable to this service fully attained Continuum of Service Delivery Day of Audit 16-Sep-13 Assessment Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk Safe and Appropriate Environment Day of Audit 16-Sep-13 Assessment Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Standards applicable to this service fully attained Restraint Minimisation and Safe Practice Day of Audit 16-Sep-13 Assessment Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service fully attained
Auditor 2 Auditor 3 Auditor 4 Auditor 5 Auditor 6 Clinical Expert Technical Expert Consumer Auditor Peer Review Auditor XXXXXXX 2 Total Audit Hours on site 16.00 Total Audit Hours off site (system generated) 11.00 Total Audit Hours 27.00 Staff Records Reviewed 5 of 25 Client Records Reviewed (numeric) 7 of 28 Number of Client Records Reviewed using Tracer Methodology 1 of 7 Staff Interviewed 7 of 25 Management Interviewed (numeric) 1 of 1 Relatives Interviewed (numeric) 7 Consumers Interviewed 4 of 28 Number of Medication Records Reviewed 14 of 28 GP’s Interviewed (aged residential care and residential disability) (numeric) 1
Standard 2.2.1 Restraint approval and processes Not Applicable 0 0 0 0 0 3 Standard 2.2.2 Assessment Not Applicable 0 0 0 0 0 2 Standard 2.2.3 Safe restraint use Not Applicable 0 0 0 0 0 6 Standard 2.2.4 Evaluation Not Applicable 0 0 0 0 0 3 Standard 2.2.5 Restraint monitoring and quality review Not Applicable 0 0 0 0 0 1 Standard 2.3.1 Safe seclusion use 0 0 0 0 0 5 Standard 2.3.2 Approved seclusion 0 0 0 0 0 4 Restraint Minimisation and Safe Practice Standards (of 6): N/A: 5 CI:0 FA: 1 PA Neg: 0 PA Low: 0 PA Mod: 0 PA High: 0 PA Crit: 0 UA Neg: 0 UA Low: 0 UA Mod: 0 UA High: 0 UA Crit: 0 Criteria (of 21): CI:0 FA:1 PA:0 UA:0 NA: 0 Infection Prevention and Control Attainment CI FA PA UA NA of Standard 3.1 Infection control management FA 0 3 0 0 0 9 Standard 3.2 Implementing the infection control programme FA 0 1 0 0 0 4 Standard 3.3 Policies and procedures FA 0 1 0 0 0 3 Standard 3.4 Education FA 0 2 0 0 0 5 Standard 3.5 Surveillance FA 0 2 0 0 0 8 Standard 3.6 Antimicrobial usage 0 0 0 0 0 5