zilongwang/ReadingBank huggingface dataset:
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 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Moderate Short-term care plans provide interventions and guidance for care staff when a resident health status changes. Not all health status changes and interventions had been documented in a STCP or updated in the LTCP. Not all interventions were implemented to support the resident’s needs. All falls were recorded on the accident incident form with evidence of timely RN assessment, however there were no neurological observations post unwitnessed falls. 1) There were no short-term care plans or interventions in the LTCP for; (i) two hospital residents with pressure injuries, (ii) another hospital resident with a pressure injury and weight loss, (iii) one rest home with seizures, and (iv) one rest home resident with challenging behaviours as documented on two accident/incident forms. 2) A faulty air alternating mattress had not been replaced or available for a hospital resident with pressure injuries (link hospital tracer). 3) There were no neurological observations for seven unwitnessed falls for the month of December 2017 (noting there was no evidence that the resident had hit their head). 1) Ensure STCPs (or the LTCP updated) to include interventions to support short-term needs. 2) Ensure there is adequate pressure injury equipment available. 3) Ensure neurological observations are completed for unwitnessed falls. 30 days
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 45 0 0 0 0 0 Criteria 0 93 0 0 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
confirmed their awareness of the corrective actions and feel they have had positive outcomes. This is supported by the overall resident/family satisfaction survey results which gained a 96% rating. Resident and family satisfaction surveys are completed annually. The most recent survey, June 2018, showed that all areas of service gained a higher rating in all areas from the 2017 year. Issues raised in the 2017 satisfaction survey such as food services have corrective actions shown with staff responsibilities and outcomes identified. Corrective actions included ensuring all residents’ food needs are catered for and this includes the introduction of an off-site specialist pureed food company supplying pureed food and the use of food moulds to make the meal look more attractive. Residents and families interviewed confirmed there has been an improvement in food services over the past year. The facility has undertaken a project around this process and outcomes are yet to be fully evaluated. The Orchards has four active quality improvements which they are working on. These are the introduction of an electronic programme to access off-site clinical information such as blood tests, hourly electronic fridge testing of temperatures to prevent food spoilage, residents on fortified foods and those having puree food is being linked to monitoring of residents weight to ensure they increase or remain stable, and the ongoing management of falls with a 30% of falls as a set goal. Policies reviewed cover all necessary aspects of the service and contractual requirements, including reference to the interRAI Long Term Care Facility (LTCF) assessment tool and process. This process is managed at head office and all policies are based on best practice and were current. The document control system ensures a systematic and regular review process, referencing of relevant sources, approval, distribution and removal of obsolete documents. The management team described the processes for the identification, monitoring, review and reporting of risks and development of mitigation strategies. The nurse manager is familiar with the Health and Safety at Work Act (2015) and has implemented requirements. The health and safety committee review all new risks and they are entered into the risk register and discussed at staff meetings as appropriate. A full review of the risk register occurs annually. There is a current hazardous substance register.
A number of shortfalls that require specific action to address Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk Major 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 General overview of the audit Radius Kensington is and operated by Radius Residential Care Limited. The service provides care for up to 97 residents requiring rest home, hospital (geriatric and medical), residential physical disability and dementia level of care. On the day of the audit there were 79 residents. This certification audit was conducted against the relevant Health and Disability standards and the contract with the district health board. The audit process included a review of policies and procedures; the review of resident’s and staff files, observations and interviews with residents, relatives, staff, management, general practitioner and physiotherapist. The service is managed by a facility manager/registered nurse who has experience in aged care management. She is supported by a Radius regional manager and a clinical nurse manager. Residents, relatives and the GP interviewed spoke positively about the service provided at Kensington. This audit has identified an area for improvement around resuscitation documentation. The service has been awarded a continuous improvement around meeting the recreational preferences for the younger persons who reside at the facility.
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 a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Evidence Audit Finding Criterion 1.3.7.1 Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer. CI Bradford Manor plan activities around the resident’s interests and current ability. The diversional therapist is dedicated to providing an activities programme that suits the needs of residents as conditions change. The programme is designed to offer residents the opportunity to try something new, or maintain or improve current level of activity. A new tar sealed pathway has been developed around the building from the front gate around the property to the rear door leading into the small lounge to encourage residents to become more active. Residents previously used a path, which was slippery in the winter. The new tar sealed path allows residents to walk in a loop around the building through all seasons. Staff reported the residents were very interested in the development of the path, which they report has encouraged the residents to go out for walks. There is a walking group, where a group of residents, the diversional therapist and a volunteer go to the botanical gardens for a walk each week. The path is used to gauge the fitness of the residents as they need to be able to walk around the “loop” three times (measured distance between the benches at the gardens) to be able
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 5 44 0 1 0 0 0 Criteria 6 94 0 1 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 a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The service is committed to providing high quality end of life care. The service has received more than double the referrals from hospice in 2018 to date than for 2017. In January 2017 the service identified an improvement was required around a high number of incidents of challenging behaviour in the care centre. Malvina Major Malvina strives to be an excellent provider of end of life care. To achieve this the service have implemented the following a) developed an excellent working relationship with Mary Potter Hospice and GPs, b) developed a palliative care champion for the service, c) continuing education and hosting of palliative care sessions at Malvina Major, d) accessed new innovative funding for RNs to participate in the link-nurse programme whereby the RNs work alongside experienced practitioners at the hospice for five days, e) weekly palliative care rounds at Malvina Major with the palliative care nurse specialist and f) the hospice doctors and nurse specialist have access to the one chart for prompt symptom management. There continues to be effective and regular communication with families. The service links to many areas of palliative care resources and host events and conferences, and attends meetings and reviews palliative care objectives in consultation with hospice and other community agencies. Complimentary letters, cards and emails were
Infection prevention and control The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The GHG clinical manager is the infection control coordinator with support from the registered nurses. A suite of infection control policies and guidelines meet infection control standards. Staff receive annual infection control education. Surveillance data is collected and collated. Benchmarking of data occurs. 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 14 0 5 0 0 0 Criteria 0 32 0 7 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
Criteria 1 92 0 0 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 a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Criterion 1.3.13.1 Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group. CI Consultation with residents and their families about food, fluids and the meals service, occurs frequently. This occurs via random meal audits, through surveys and at monthly resident meetings. Tarahill Rest home continues to serve its main meal at night because that is what residents prefer. The efforts and attention to food and nutrition services in this home are a real feature. Resident and family feedback about meals and the quality of food services continues to receive 100% satisfaction. The service responds immediately to any resident’s request for change. End of the report.
I. Compensation for Owners and Employees I.1. Bonuses. Did the Company pay, or accrue for, bonuses earned by owners or employees during the period covered by the latest indirect cost rate schedule? Yes No - If “yes,” were the bonuses included in the submitted overhead rate? Yes No N/A - Was any portion of these bonuses excluded from the submitted overhead rate? Yes No N/A Comment: Does the Company have a written bonus plan? Yes. Please provide a copy of the plan. No. Please describe how bonuses are determined and how this is communicated to employees. Are all employees eligible for the bonuses? Yes No. If “no,” please explain: I.2. Executive Compensation. Has the Company, an independent CPA, or compensation consultant performed an evaluation of executive compensation for reasonableness in accordance with FAR 31.205-6? (See AASHTO Guide Section 7.5.) Yes No - If “yes,” describe the methodology used and how this process has been documented: J. Related-Party Transactions J.1. Related Employees. Please provide the following information for all employees who are related to the parties listed in the Ownership Table (Table 1) shown in A.5: Table 3: Employees Related to Company Owners Name or ID: Title/Position: Bonus: Other Compensation: Total Compensation: 1 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related (e.g., spouse, parent, child, sibling, in law): 2 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related: 3 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related: 4 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related: 5 $ $ $ $
Total Hours Worked During Year: Job Duties: Related to: How Related: 6 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related: 7 $ $ $ $ Total Hours Worked During Year: Job Duties: Related to: How Related: 8 $ $ $ $ Hours Worked During Year: Job Duties: Related to: How Related: Name or ID: Title/Position: Wages/Salary: Other Compensation: Total Compensation: 9 $ $ $ $ Hours Worked During Year: Job Duties: Related to: How Related: 10 $ $ $ $ Hours Worked During Year: Job Duties: Related to: How Related: J.2. Related Vendors. Please provide the following information for all vendors related to the parties listed in the Ownership Table (Table 1) shown in A.5: 4: Vendors Related to Company Owners Name: Contact Information: How Related: Products/Services Provided: Total Payments During Year: $ $ $ $ $ $ $ $ $ $ $
2.2 Discussions with NIPSA through JNCC are ongoing regarding the restructure of the Administration team. NIPSA returned to management to confirm that 3 of 4 staff involved had requested voluntary redundancy. 2.3 The move to the Northern Ireland Civil Service Policies has been agreed and is awaiting sign off with staff. (Paragraph 2.2 of previous minutes refers). 2.4 The NIO and NIHRC Framework document is with NIO for approval and we are awaiting feedback. (Paragraph 3.1 of the previous minutes refers). 2.5 The Business Continuity Plan is to be shared with staff in April. (Paragraph 5.4 of the previous minutes refers). 2.6 A film is being recorded at the International Committee (ICC) of the UN in March for the NICS (AP) project that will include interviews from senior civil servants including Malcolm McKibben. (Paragraph 8 of the previous minutes refers). 3. Internal Audit 3.1 The Committee noted the progress in implementing the Internal Audit recommendations from 2012/13 and the reasons for the 3 outstanding recommendations regarding ICT Policy and Procedures. 3.2 The Committee noted the progress report on outstanding issues from the Internal Audit 2013/14. 3.3 The Committee considered the outcome of the recent follow-up review audit fieldwork for 2013/14. 3.4 The Committee noted the Progress Report from the Internal Auditors. 4. Update on a proposed Human Rights Inquiry Ms Angela Stevens, Caseworker, joined the meeting at 2:50pm. 4.1 The Committee was an update on the proposed Human Rights Inquiry.
Document Control Change Record Version Status Date of Change Reason for Change Draft v 1.1 10th June 2013 Initial draft for comments from audit committee with a view to finalise by October meeting. Draft v 1.2 2nd October 2013 Further suggested revisions for review by audit committee Draft 1.3 8th October Approved subject to minor changes Draft 1.4 6th January 2014 amendments to ToR, reporting 1.6 10th Feb 2015 Minor amendments to wording and work plan. 2.0 8tht March 2016 Review by Audit Committee 2.1 11th May 2016 Finalisation following Audit Committee comments Draft 2.2 28 2017 Updated of Audit Committee review FINAL 2.3 10 May 2017 Updated following Audit Committee review Reviewers Name Position Version Reviewed Committee V1.2 Audit Committee V1.4 Committee – 18 Feb 2015 V1.6 Secretary, Corporate Secretary, EMT, Audit Committee V2.0 Audit Committee V2.2 Distribution of Approved Version Name of person or group Position Version Released Executive Management Group V 1.3 EMT V1.6
___________________________________ Director ___________________________________ Name of Director (Print Name) ___________________________________ Director/Company Secretary ___________________________________ Name of Director/Company Secretary (Print Name) OR Executed by by its Authorised Representative: ___________________________________ Witness ___________________________________ Name of witness (Print Name) ___________________________________ Authorised Representative ___________________________________ Name of Authorised Representative (Print Name) A copy of the signatory’s authority must be attached.
Team Lead Auditor XXXXXXX Hours on site 7 off site 4 Other Auditors XXXXXXX Total hours on site 6.5 Total hours off site 4 Technical Experts Total hours on site hours off site Consumer Auditors hours on site hours off site Peer Reviewer XXXXXXX Hours 2 Sample Totals Total audit hours on site 13.5 Total audit hours off site 10 Total audit hours 23.5 Number of residents interviewed 3 Number of staff interviewed 8 Number of managers interviewed 1 Number of residents’ records reviewed 5 Number of records reviewed 6 Total number of managers (headcount) 1 Number of medication records reviewed 10 Total number of staff (headcount) 50 Number of relatives interviewed 2 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed 0
Audit Issue Action Plans Checklist Who is this guide for? If you are a BSC Party or Party Agent that has received an Audit Issue with either a Medium or Higher rating, you will be asked to submit an Error and Failure Resolution (EFR) plan. This guide will help you prepare your EFR plan. What is EFR? EFR is a Performance Assurance Technique which helps ensure that, where Settlement Risks are detected, adequate plans are put in place to address them. For more information please refer to our guidance Key timescales You need to send your EFR in and amend them as set out below (all are also contained within ). Action Timescale Who? 1 ELEXON informs you which of your Audit Issues require an EFR action plan to be submitted within 20 Working Days. The notification will be sent by ELEXON once the Auditor has confirmed the ratings for each audit issue it has identified. ELEXON - The EFR team will usually send the email to you and copy your OSM in the correspondence. 2 Upon receiving the notification, you should send ELEXON a plan to address the error or failure. 20 WD Audited organisation 3 ELEXON then reviews the plan and either; baselines the plan if we are satisfied with it or; provide comments on the plan explaining where changes or further considerations are needed. If ELEXON returns comments, the updated plan is required within 10 WD (in accordance with . 20 WD ELEXON – Your OSM will be the main point of contact regarding this 4 You should update the plan to address ELEXON comments. 10 WD Audited organisation 5 Step 3 and 4 have to be completed again until a plan is baselined. See steps 3 and 4
(iv) Recycled water quality Attach copies of your RABQSA Recycled Water QMS Auditor certification (or higher) -or equivalent - and Audit Log. (v) Sewage management Provide the following details for projects where you have previously completed sewage management audits. You must have completed a minimum of 4 sewage management audits, totalling not less than 20 days, as a member of an audit team. These audits must have occurred within the last 2 years from the date of application.
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 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 Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Glenburn has a meeting schedule in place that is being implemented including bimonthly quality meetings, qualified staff and staff meetings in each clinical area. There are also two monthly infection control meetings and health and safety meetings. All meetings are minuted. Meeting minutes do not consistently record inclusion of incidents and/or internal Examples include: a) Qualified staff meetings: In minutes sighted for 18 September 2014, 15 May 2014 and 1 January 2014 there are no recorded discussion of incidents, and the 15 May 2014 and 1 January 2014 minutes have no discussion of internal audits. b) Ward meetings in the four units – Manuka, Koru, Kowhai and Rata do not record incidents in the June/July meeting minutes. Ensure meeting minutes include discussion about internal audit and resident incidents including trending and preventative actions. 90 days Criterion 1.3.6.1 PA Low When a resident's condition alters, the registered nurse initiates a review and if required, GP, or nurse specialist consultation. Interventions are not documented in the care plan for a) rest home resident re-commenced on protein drinks as per the written evaluation. The resident Ensure interventions are documented
Appendix 5 COUNTY NAME TEXAS JUVENILE JUSTICE DEPARTMENT GRANT FUNDS SAMPLE STATEMENT OF REVENUES, EXPENDITURES AND CHANGES IN FUND BALANCE BY CONTRACT BUDGET AND ACTUAL (REGULATORY BASIS) FOR THE YEAR ENDED AUGUST 31, 2017 Grant A-17-XXX Grant R-17-XXX Final Budget Actual Final Budget Actual Revenues: TJJD Funds $600,000 $ 575,000 $ 25,000 $14,000 $10,000 $4,000 Total Revenues 600,000 575,000 25,000 $14,000 $10,000 $4,000 - Expenditures: Basic Probation Services Community Programs Pre Post Adjudications 550,000 525,000 25,000 - Commitment Division - - - - - - - - - Mental Health Services 50,000 50,000 - - - - - - - Prevention and Intervention - - - - - - - - - Region - - - $14,000 - $10,000 - $4,000 - - - - Total Expenditures 600,000 575,000 25,000 $14,000 $10,000 $4,000 - Excess Revenues over - - - - - - - - - Expenditures Fund Balance- Beginning of Year - - - - - - - - - Fund of Year $ - $ - $ - $ - $ - $ - $ - $ - $ - Additional Information: Refunds Paid to TJJD. (Include all refunds whether paid during or subsequent to year end) 8/15/2016 $25,000 10/1/2016 $4,000
Paediatric Prescribing An audit tool Patient number Date Weight Allergy information Identifiers correct Prescription or Transcription (P/T) Correct dose Correct frequency Correct Writing legible Correct spelling Prescription signed No abbreviations No amendments No allergy Renal insufficiency Interactions/CIs Stopped appropriately Medication Description of Error code(s) 1 2 3 4 5 6 7 8 9 10 11
Prescription or Transcription (P/T) Correct dose Correct frequency Correct route Writing legible Correct spelling Prescription signed No abbreviations No amendments No known allergy Renal insufficiency Interactions/CIs Stopped appropriately Description of error Error code(s) 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Appendix 1 Minimum Quality Standards Audit Tool / Checklist Tool for Initial Child Protection Conference Reports Content Standard Yes No N/A Comments 1 Details of conference Subject / date / time / author/ designation / date 2 History of agency involvement Chronology /detailed account of involvement and outcomes where appropriate 3 Issues / presenting problems Details of issues Plain Language used 4 Other agencies involved Details provided 5 Family composition Genogram /family tree/ or known family structure provided 6 Legal status of child Details provided (if known) 7 Child / young person’s developmental needs Agency report provides a professional assessment of the child’s needs Detail observations if child seen 8 Parenting capacity Agency report provides a professional assessment of parenting capacity Adult services Detail observations of child parent interactions if seen 9 Family & environmental factors Agency report provides a professional assessment of the family & environmental factors Adult services
Consider family & environmental factors (i.e. Probation OASYS information) 10 Analysis of current situation Concerns identified, and historical information analysed in context of current situation Plain Language used 11 Changes required Report identifies what needs to change Plain Language used 12 Factors helping change Helping factors identified Plain Language used 13 Factors blocking change Blocks to change identified Plain Language used 14 Recommendations to conference Recommendation made 15 Views of parent/carer & child if appropriate Views of parent/ carer & child (if appropriate) clearly recorded Report was clearly understood by parent/carer & child (if appropriate) 16 Agency signature All appropriate signatures on the report 17 Parent/carer signatures Report shared with parents/carers/child at least 2 days in advance of conference Report signed 18 Report sent to SCU at least 2 days in advance of CP Conference Report received by SCU at least 2 days in advance
Audit tool for Child Protection Review Conference Reports Content Standard Yes No N/A Comments 1 Details of conference Subject / date / time / author/ designation / date 2 Child Protection Plan Problems that initially brought the child to conference clearly outlined CP Plan identifies changes required 3 Core Groups Details of core groups held Outline of issues discussed & decisions made 4 Progress against the CP Plan Details provided of progress against the plan Any other factors are analysed in relation to the plan & possible impact on the 5 Recommendation Recommendation made re CP Plan 6 of parent/carer & child if appropriate of parent/ carer & child (if appropriate) clearly recorded Report was clearly understood by parent/carer & child (if appropriate) 7 Agency signature All appropriate signatures on the report 8 Parent/carer signatures Report shared with parents/carers/child at least 2 days in advance of conference Report signed 9 Report sent to SCU at least 2 days in advance of CP Conference Report received by SCU at least 2 days in advance
Health Drop in Come and get advice from the health visiting team and have your baby weighed. All you need to bring is your child’s red book. east child and family health team: (01254) 283699 11am – 1pm Breastfeeding Group A social, friendly group. Meet other mums. Trained staff if you need help. Pregnant mums welcome. 1pm – 2.30pm The children’s centres are now on Facebook. Log on and like us at
Training is time consuming but we feel worth the investment. We have had consistently good feedback from our trainees and we have been pleased by their exam success and their career progress A marker of our success is the number of our previous trainees who are now working at Audley Mills and in local practices. As far as we know, all of our alumni remain in primary care. This is where our previous trainees are now providing primary care: Amrit Rehal Seye Arikawe Timothy Wright Luke Whiting Sheela Vootkur Mike O’Keefe Jonathan Rouse Rohan Subasinghe Rowan Brown Peter Long Olu Omoseni Subatra Basu Louise Nobel Uzo Odina Sharon Hadley Nithya Vishwanath Judit Gobolyos Bunmi Mabo Anita Mehmet Ahmed Lawal Tahera Chaudrey Alex Bradford Mohammed Akhter Caroline Wiltshire Mohammed Hashmi Godwin Adegbite Mara Mitrea Stephan Claridge Winnie Chiu Amber Khan Amuche Elba Muryum Thapper Olivia Ariyo
LANGUAGES French and English – native languages Spanish – oral and written proficiency German and Russian – oral and written basic competency AZLA/TL3C Joint Fall 2014 Conference Entre Amig@s Spanish Conversation Club at ASU ASU 2015, 2016 & 2017 Language Fair ASU Night of the Open Door 2017
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 4 40 0 1 0 0 0 Criteria 4 88 0 1 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 Finding Corrective action required and timeframe for completion (days) Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low Monitoring forms available for use include; fluid balance, continence diary, monthly blood pressure and weight monitoring, nutritional food and fluid monitoring record, two hourly turning chart, Iowa pain monitoring too, neurological observations and behaviour chart. Five of six care plans reviewed reflected current needs. There is an improvement required around the use of assessment and monitoring tools to reflect the resident’s health status. One resident returned from hospital following a fall with a diagnosis of postural hypotension. There is no evidence of blood pressure monitoring on return to the facility, post medication review. The short term care plan does not identify the residents falls risk. The resident is on regular and ‘as required’ pain relief. There is no documentation/monitoring of the effectiveness of pain relief for breakthrough pain as recorded in the progress notes. Ensure risk assessments are reviewed with changes to health status. Ensure monitoring tools reflect the resident’s current clinical status. 90 days
Lack of understanding of Understanding by Design process Review Introduction to UbD from additional information on Stage 1 of Understanding by Design Share unit created by UbD team (4th grade) Assist grade levels in getting started in the design of unit plans following Stage 1 of Understanding by Design. Administrators; Understanding by Design Team; 4th Early Adopters Team; Literacy Coach; October 16, 2015 PDD; ongoing $0 Unit plans designed by early adopters; ideas documented for upcoming units As indicated on the Parent Survey, parents would like a workshop on how to help with homework. Search for resources for ideas for how teachers can help parents with homework and for parent workshop ideas. Ask for teacher volunteers to plan Parent Night on the topic of helping with homework. Plan a evening where parents assemble in cafeteria for a keynote speaker. Plan 8 sessions for teachers to select 3 to attend. Each session will be 30 minutes each. Plan for topics Administration; Teacher volunteer leaders; Literacy Coach Evening in November cost of paper for fliers, newsletters, and materials Flyer for program; newsletter; website; marquee
to include Helpful Hints for Completing Homework, Organizing Homework Time and Stations, Do’s and Don’ts of Homework Help, ADHD Homework Organization, Homework Bag and Caddy Ideas. Provide materials and ideas for parents to take with them. As indicated on the Student Survey, students indicated they have never participated in lessons on Organizational Skills. Research ideas on conducting an Organizational Skills workshop for students. Ask for teacher volunteers to conduct various sessions of the workshop. Plan 8 different sessions of which students select 3 to attend. Plan activities for topics to include Executive Functioning Skills, Organizational Skills Apps, Organizational Skills for Students with Learning Disabilities, Organizational Skills for Students ADHD, Organizational Skills for Students ASD Cost of copies and materials Flyers, newsletters, marquee, website, materials
contribute to, meeting the consumers' assessed needs, and desired outcomes. intervention changes following review or change in health status in seven of ten files reviewed. incident form did not have a STCP, interventions in LTCP or RN follow up; (iii) One residents incident form and caregiver progress notes identified a large bruise, there was no RN follow up or documented interventions for eight days. support the residents identified health 60 days
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
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 D19.3b; There is an incident reporting policy that includes definitions, and outlines responsibilities including immediate action, reporting, monitoring and corrective action to minimise and debriefing. All resident accident/incidents are reported on the correct form. There is documentation in the health status summary of all incidents. There is no evidence of neurological observations for three hospital residents and one dementia care resident following falls with head injury. Ensure neurological observations are commenced for all falls with head injury. 90 days 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 Moderate Medication charts were reviewed for 18 residents (six rest home, six hospital and six dementia residents). All charts reviewed identified that the GP or nurse practitioner had seen the resident at least three monthly. All medications were signed for and charted appropriately including reasons for use for PRN medication. Medication charts are legible, and up to date. Medication charts have photo ID’s and allergies noted. i) Residents who are assessed as competent to self-medicate (five hospital residents) are their individual medicine doses by the registered nurse. Residents are left with their medications to take at a time convenient to them. The RN then signs that the resident has taken the medications, however, the nurse has not witnessed the ingestion of the medicines. This practice does not align with facility policy for administration; ii) residents with insulin are given the correct doses at the correct time as per the medication order, however, signing for the insulin is not recorded on a separate signing sheet. It is included in the general pre-packed medications signing sheet. Specific times and dose are not recorded. Two staff check all insulin prior to administration. iii) one resident on two weekly antipsychotic injections has missed a dose. i) ensure correct and safe procedure is followed when administering medications as per facility policy and medicine care guidelines 2011; ii) document insulin doses on separate signing sheets. iii) ensure antipsychotic injections are given as prescribed. 30 days
AUFA Annual Conference 2018 Location: SpringHill Suites - Downtown October 11, 2018 7:30 - 8:00 Registration and Refreshments Lisa Sosebee, Alabama Cooperative Extension System 8:00 – 8:30 President’s Message Executive Director’s Report ISA Southern & Tree Fund Update Rhett Murphy Fred Kapp Dr. Beau Brodbeck 8:30 – 9:30 Tree Life and Thriving Futures in Communities Dr. Kim Professor, UGA Community Forestry, Tree Biology and Health Care 9:30 – 9:40 Break and Refreshments 9:40 – 10:40 Invasive Species Loewenstein, ACES Forestry and Wildlife Specialist 10:40 – 11:40 Drought, Heat and Tree Life Dr. Kim Coder 11:40 – 12:40 Lunch, provided on-site Concurrent Session A: Community and Municipal Forestry 12:40 – 1:40 The What, Why and How of Creating High-Performance Urban Trees Matthew Werle, Green-Blue Urban 1:40 – 1:55 1:55 – 2:55 Alabama's Variety of Oaks Nancy Loewenstein
2:55 – 3:50 health care and Bio-char, (the new kid on the block…) Jim Cortese, Consulting Arborist, TIPCO, Inc. 3:50 – 4:00 Adjourn and Sign for ISA, RF and Pesticide Re-Certification CEUs/Points Concurrent Session B: Utility Urban Forestry 12:40 – 1:40 Building a Vegetation Management Program from Scratch Josh Roberts, Riviera Utilities 1:40 – 1:55 1:55 – 2:55 ANSI Z133 and A300 Updates Kevin Myers, ACRT, Inc. 2:55 – 3:55 Managing Complexity in Business: What We Have Learned in the Vegetation Management Industry Adam Morgan, Chem-Pro Services 3:55 – 4:00 Adjourn and Sign for ISA, RF and Pesticide Re-Certification CEUs/Points 6:00 AUFA Annual Conference Dinner Site TBD Please note tuition breaks in attached fee schedule for five or more employees from the same employer and discounts for pre-registration by September 25th.
Specific results for criterion corrective actions are required 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 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system. PA Low There is evidence that quality improvement data was collected on a regular basis. Documentation included a written report to the GM monthly with detail of key components and outcomes. Staff meetings include health and safety and infection control (IC), but did not include complaints, clinical incidents, and restraint or survey/feedback findings. The facility and services manager reports that the operations meetings will recommence in early 2015 to address this. There was not a specific link between all quality improvement data at a facility level in a quality management meeting forum. All quality improvement data is linked to the quality management system. 180 days Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low There has been a noticed improvement in the collection and analyses of quality improvement data over the past two months. Documentation was sighted of incident reporting, complaints management, infection control and event reporting, being collected and analysed. Quality improvement data was collected and analysed, but had not yet been analysed nor results reported to service providers Quality improvement data is collected, analysed and evaluated.
A number of shortfalls that require specific action to address Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk Major 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 General overview of the audit Freeling Holt is a trust with a board providing a governance role. This surveillance audit was undertaken to establish compliance with the Health and Disability Services Standards and the district health board contract. The service provides rest home and hospital level care for up to 32 residents with 31 residents during the audit. Some residents had physical disabilities and some were under the age of 65 years. A manager has been in the role for a year. Staffing was appropriate to support the needs of residents. There was a quality and risk management programme in place that included review of incidents, complaints, implementation of an internal audit programme and a health a safety programme. There were no improvements required at the last certification audit. Improvements are required to the following: notifications following adverse events, integration of resident records, wound management, review of care plans, and documentation of administration of medication.