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Outcome of Quality Review process Print  Print

At the completion of the quality review process service providers are sent an outcome letter that notifies them of the outcome of their quality review and any further actions that will occur, as described below.

  • Outcome 1 Letter advises that the service provider will be required to submit an annual improvement plan (with the possibility of a short visit) 12 months following the on-site visit.

  • Outcome 2 Letter advises that the service provider will be required to submit an updated improvement plan in the next six months, +/- have an additional on-site visit to review progress against the improvement plan, and submit an annual improvement plan 12 months after the original on-site visit.

  • Outcome 3 Letter advises that the service provider will be required to submit an updated improvement plan in the next three months, have an additional on-site visit to review progress against the improvement plan within the next six months and submit an annual improvement plan 12 months after the original on-site visit.

If an Outcome 3 Letter is provided, the service provider may be referred to program management for appropriate action or for compliance action (as applicable). Service providers may also be required to take remedial action prior to the development of the improvement plan.

(Reference: Community Care Common Standards Guide, section 2.6.4, p.18)

 
Special projects Print  Print

WA Country Health Service – Residential Aged Care Project

The CommunityWest Quality department is working with the WA Country Health Service (WACHS) Department of Health and Aged and Continuing Care Directorate to implement a quality standards framework for the aged care component of WACHS services.

Each Home and Community Care service in WACHS will participate in a Quality Review against the Community Care Common Standards, and each residential aged care service of WACHS will undergo a Quality Review against selected expected outcomes of the Accreditation Standards.

Transitional Care Project

The CommunityWest Quality department is working with the Department of Health and Aged and the Continuing Care Directorate to implement a quality standards framework for the Transitional Care Program.

Each Transitional Care community care service will participate in a Quality Review against the Transitional Care Program Quality Standards.

 
Quality Review Documentation Print  Print

These documents will need to be presented to our Quality Reviewers during the on-site visit.

Quality Review documentation checklist

  • A copy of your HACC contract.

  • Copy of board member files (if applicable); agendas and minutes of board meetings; or senior management and directorate meetings; or internal reports for Local Government providers.

  • Your Policy and Procedures Manual.

  • Copies of all completed forms (e.g. assessment tool, service agreement, care/support plan, staff management forms, medication, authority to act as an advocate, etc.).

  • Copies of service brochures, handbooks, newsletters and other key information  documents.

  • A sample of client files (e.g.10% sample size or no more than 20 with a mix of new and existing service users across all service types).

  • A sample of staff files (10% or no more than 20 with a mix of newly employed and existing staff).

  • A sample of volunteer files (10% or no more than 20 with a mix of newly recruited and existing volunteers).

  • Copies of completed feedback information (e.g. 'tell us what you think' forms, survey results, hazard reports, incident forms, medication errors and complaints – formal and informal).

  • Copies of minutes of staff, board and network meetings attended.

  • Copies of brokerage/contractor agreements and documents (if applicable).

  • Any relevant quality assurance process documents (e.g. Continuous Improvement plan, strategic plan).

  • Other documents you have referred to in your self assessment not listed here, that could provide outcome evidence against any of the Standards.

 

Note - Quality Reviewers will need to randomly select the following:

  • Client records for each type of service you provide (e.g. support plans, progress notes, medication management information, home files and service agreements as applicable).

  • Staff records, including a mix of new and longer-serving staff across a range of positions.

  • Volunteer records (if applicable), including a mix of new and longer-serving volunteers across a range of positions.

 
Minimum Annual Improvement Plan Print  Print

 What you need to know about an Improvement Plan:

  • Following agreement on your Improvement Plan, our team will tell you when your Plan needs to be updated and re-submitted
  • Our Quality department will send you a reminder 4 weeks before your updated Improvement Plan is due.

 

Self-identified improvement

It is expected that in your annual Improvement Plan, in addition to updated information on improvements identified in the Quality Review, you would also wish to inform the Quality team of self-identified improvements you have achieved or been working over the course of the year.

Self-identified improvements may include trends that have been actioned from collation of comments, complaints, feedback, incident, accident reporting, audits and any other information-gathering mechanisms.

 
Improvement Plan Print  Print

 

  • Your Improvement Plan must be submitted within 10 working days of receiving your Quality Review report.

  •  Our team reviews your Improvement Plan and may negotiate changes and timeframes for improvement with you, especially if immediate improvements are required.

  •  The contents of your Improvement Plan is agreed with the Quality Review team and a final copy will be sent to you along with your outcome letter.

 
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