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 Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) 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 Moderate There are appropriate numbers of health care assistants on morning and afternoon shifts with staff rostered onto the hospital and dementia unit overnight. The two health care assistants in the dementia unit include one who is able to support staff in the hospital with any cares required overnight. They are also required to support residents in the rest home. The rest home is an ‘L’ shape with hallways leading to the hospital area where the registered nurse and the health care assistant are based overnight. Fourteen residents requiring rest home level of care are based in the rest home area and there is a potential risk of staff being busy overnight in the hospital and dementia unit and of not recognising that these residents need assistance. The roster was adjusted to base the second health care assistant from the dementia unit in the rest home area overnight. Ensure that staff are based in the rest home area and responsive to residents overnight. 30 days Criterion 1.4.2.4 The physical environment minimises risk of harm, promotes safe mobility, aids PA Low There is a kitchen in the dementia unit. Residents are able to access the oven (switch located in a cupboard) and a microwave. There is a snib lock on the inside of the The switch for the oven is in a cupboard that is potentially able to be locked (unlocked on the day of the audit). The microwave is potentially able to be used by Ensure residents are safe when they are in the dementia unit kitchen.
independence and is appropriate to the needs of the consumer/group. door into the kitchen. A new lock was put on the cupboard where the oven switch is located on the day of the audit. residents although the switch is behind the microwave. 30 days Criterion 1.4.7.1 Service providers receive appropriate information, training, and equipment to respond to identified emergency and security situations. This shall include fire safety and emergency procedures. PA Low The orientation programme includes fire and security training. Staff confirm their awareness of emergency procedures. is an expectation that staff have emergency evacuation drills six monthly. The service has provided emergency drills in October 2013 and August 2014. The newly appointed business and care manager is a fire officer and is aware of expectations. Emergency evacuation drills have not been completed six monthly as per policy. Ensure that evacuation drills are completed six monthly as per policy 30 days