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ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

All Wales Fundamentals of Care Audit Tool 1 Amended Pilot Audit Tool June 2010

INTRODUCTION One of the recommendations of the Free to Lead, Free to Care, Empowering Ward Sisters/Charge Nurses Ministerial

Task and Finish Group: was that “All ward sister/charge nurses should have access to an All Wales Audit Tool which should be developed to measure standards against the Fundamentals of Care Standards published in 2003. Reports arising from use of this Audit

Tool should be distributed to the NHS Board and the Chief Nursing Officer, Wales”. The NHS within Wales is constantly changing and adapting using both Government and Professional frameworks and standards to meet the continuing demand for health care. This is a challenge and we have tried to maintain the

founding principles as we evolve. Here, fairness, effectiveness, efficiency, responsiveness, integration, accountability and flexibility, are but a few ways that we will need to measure the standards of our service, whilst working in partnership with patients. It can be argued that quality depends as much on people as it does on systems and techniques; it is with this in mind that the All Wales Fundamentals of Care Audit tool is designed.

The Fundamentals of Care document directs that all standards are to be met and compliance systematically monitored. It is the responsibility of the organisation providing that care and the staff they employ to implement,

evaluate and audit these standards.

It is important that this is not seen as a paper exercise, it is an opportunity to recognise good practice and to identify areas where work can be undertaken to develop or alter service provision, in order to improve the patient

experience.

Fundamentals of Care is a Health and Social Care document which aims to improve the quality of fundamental aspects of care for users who are acutely or chronically ill, frail or disabled regardless of where or why they need this care.

The initiative grew out of concern about the following: ♦ Inconsistency of standards across service settings and areas ♦ Emphasis, until recently, on service efficiency and cost, rather than quality of care ♦ Common themes in complaints and compliments



♦ Increasing expectations of service users ♦ Lack of clarity for service users ♦ Increasing focus on regulation and performance

In recognition of the fact that the process of care is as important to the patient experience as the outcome of that care, this document lists 12 aspects of care pertinent to adults.

� Communication and Information

� Respecting people � Ensuring Safety � Promoting Independence � Relationships

� Sleep, rest and activity � Ensuring comfort, alleviating pain � Personal Hygiene and appearance � Eating and Drinking � Oral Health and hygiene

� Toilet needs � Preventing pressure sores

THE AUDIT TOOL

It is intended that the ward sister/charge nurse has ownership and responsibility of this audit tool. Each section of

the audit tool states the principle for that aspect of care, as written in the Fundamentals of Care document. Within a box, there is a brief summary of the STANDARDS FOR HEALTH SERVICES for Wales and relevant national guidance.

Data collated from completion of this audit tool will be used by the Director of Nursing to measure compliance with the standards of the Fundamentals of Care throughout the organisation. The audit results will be presented by the Director of Nursing to the organisational board in October of each year and an Action Plan addressing the areas for improvement forwarded to the Chief Nursing Office for Wales by November of each year.

This audit package is simple to use, yet comprehensive and measures the real essentials of care and care delivery. The tool is refreshing in that it has a practical approach which covers consumer elements as well as professional

aspects. A prime focus of audit is effective care. However, it is also essential to measure appropriateness and acceptability, this tool goes some way to achieving this.



The audit data will be collated electronically via the HOWIS web site. The audit tool can be completed electronically at ward site with for those with access to wireless computers. A paper copy of the audit tool can be downloaded and data entered following completion of the audit.

FUNCTIONAL REQUIREMENTS Security

• A username and password protected system will be provided with unlimited password availability. Only nominated individuals within NHS organisations and WAG will be provided with passwords that will enable them to enter data into the system and to view assessments. The following levels of access will be made

available:

o Assessor – read/write: can update assessments for a Ward. o Ward Sister/Charge Nurse – read/write: can update assessments and create action plans for a Ward o Divisional Nurse – read only: sees information, summaries and action plans from all Wards within their Trust, and can add comments

o Director of Nursing – read only: sees information, summaries and action plans from all Wards within their Trust and can add and amend comments

o WAG user – read only: sees submitted information and summaries from all Trusts, but not action plans

o Super User (WAG, HSW) – performs administration functions.

• Users will have the facility to change their password to one of their own choosing once they have logged on to the system.

• The system will ‘time-out’ after 60 minutes of inactivity. • The system will include an audit trail that records any changes made.

DATA ENTRY

Each section of the audit tool contains a series of corporate, operational and user questions.



• Corporate questions help assess the resources and facilities available within the ward/service area that

enable employees to deliver the standard of healthcare and service required, for example Policy, Education and Training, staff and patient information, equipment and furnishings etc

• Operational questions measure the level of compliance with the required standard

• User questions establish if we are delivering the standard of care/service we perceive we are delivering. In areas where patients are unable to answer user questions please ask next of kin, family or patients carer, for example Mental Health, Learning Disabilities or EMI patients

To aid completion of these standards, it will be possible to print paper-based versions of these forms, for completion in Wards where no computer is readily available. The assessor at Ward level checks every audit item in the standard and notes whether the item fails or meets the

standard, and answers Yes, No or Not Applicable. Text boxes exist for the assessor to enter qualitative information such as issues identified, areas of improvement and examples of good practice. NB: if the No box is checked then the “comments” and “action” boxes are mandatory. If the Yes box is checked then the “good practice” box is mandatory.

A summary sheet is created from the responses given, with additional text boxes for issues of concern and areas of good practice not identified in the questionnaire.

One point will be awarded for every standard achieved and no points will be awarded for non-compliance of the

standard. Where staff and users are consulted in answering the questions one point is awarded only if all staff and patients confirm the standard has been achieved. No points will be awarded if one or more staff or patients give a

negative response. A rating is calculated as follows:

Possible Score: Add the number of Applicable questions in each standard section together

Actual Score: Add the number of YES answers in each standard section together

Rating: Total number of YES answers ÷ Total number of Applicable questions x 100

The rating will be converted to a 1-5 score to match the STANDARDS FOR HEALTH SERVICES rating system. Each question contributes equally to the final score; there is no system of weighting particular questions.



Ward Sisters/Charge Nurses will be able to collate this information to create an Action Plan. Against each issue

identified in the assessment, the Ward Sister/Charge Nurse will propose an action, and assign it to a lead person with a review date.

Question Number Issues Identified Proposed Action Lead Person Review Date

The data entry process occurs annually with final submissions to be carried out in June/July, although the tool will be flexible enough to cope with irregular assessment periods. Organisations may also wish to complete the assessment process more frequently.

Reporting

Ward Sisters/Charge Nurses will be able to summarise all assessments for their Ward in a number of ways, filtered by the following criteria:

• View all Yes answers across all standards • View all No answers across all standards • Collated summary sheets across all standards • View Audit scores across all standards

Quantitative reports can also be filtered by type of question, e.g. Corporate/Operational/User.

Divisional Nurses and Directors of Nursing will be able to view a similar range of reports, collated by organisation, with the ability to drill down to view data at ward and assessment level. WAG users will be able to view collated data and Divisional Nurse reports only.

Benchmarking graphs will also be available, showing anonymised graphs by standard.



General Advice

Each question in the audit gives guidance on how to gather the information to answer. E.g. Check 5 documents /ask 5 members of staff. You will also need to select 5 patients for each standard and give them a questionnaire. They

need not necessarily be the same 5 patients for each standard. In order for the results of this audit to be unbiased, it is important that patients and data are selected at random. Some examples of how this might be done include;

• If you have 20 patients on the ward select every 4th one for inclusion or, • If you have 30 patients, select every 6th etc. or, • Select a patient from in the first bed from each bay. Thus is to ensure unbiased patient selection. Remember, the frail, elderly and vulnerable patients are the very ones whose experience we need to capture – do not avoid including this type of patient.

Where patients are unable to complete the questionnaires a relative, carer or advocate may do this.



FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION & INFORMATION

Principle: You will receive full information about your care in a language and manner sensitive to your needs

The Health & Social Care Guide for Wales (2002)

Nursing & Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide:

to consent to examination or treatment (2002)

STANDARDS FOR HEALTH SERVICES IN WALES

STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

STANDARD 8: CARE PLANNING AND PROVISION

STANDARD 9: PATIENT INFORMATION AND CONSENT

STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT

STANDARD 23: DEALING WITH CONCERNS AND MANAGING

INCIDENTS

METHOD QUESTION YES NO N/

A

Issues identified Improvements to be

made

Good Practice

1

Check 5

Documents

Are the patients demographic details clearly

recorded on the patient’s documentation?

Patients name, address, date of birth and

identification number (n.h.s. number /

hospital number) must be recorded on every sheet of paper within the patients nursing

and medical record.

� Standards for Health Services: 20c

2

Check 5

Documents

Has each patient been fully assessed on admission in respect of their communication

needs?

Each patient should have an initial assessment on admission recording their

communication needs.

� Fundamentals of Care Standard:-

1.1, 3.3, 8.1 � Standards for Health Services: 18e

3

Check 5 Documents

Is the patient’s preferred language clearly

Indicated in the patients nursing records?

The patients preferred language and method

of communication should be recorded in

patients records

� Fundamentals of Care Standard: 1.3

� Standards for Health Services: 18e

Does each patient have an individual care



FUNDAMENTALS OF CARE

STANDARD 1: COMMUNICATION & INFORMATION

Principle: You will receive full information about your care in a language

and manner sensitive to your needs


Nursing & Midwifery Council Code of professional Conduct (2008)

Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002)


STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK STANDARD 8: CARE PLANNING AND PROVISION


STANDARD 18: COMMUNICATING EFFECTIVELY

STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING

INCIDENTS


A


made

Good Practice

4

Check 5 Documents

plan?

There should be an individual Care Plan designed specifically for the needs of each

patient.

� Fundamentals of Care Standard:- 1.1, 3.7, 4.2, 8.1

� Standards for Health Services: 8

5

Check 5 Documents

Ask staff

Is there documented evidence Care Plans

are discussed and agreed with patients?

Care plan documents should b readily

available to patients.

� Fundamentals of Care Standard:- 1.4

� Standards for Health Services: 9b

6

Check 5 Documents

Are contact details regarding next of kin

clearly recorded in patient’s documentation?

Contact details of next of kin must be

recorded in patients documentation


7

Ask 5 staff

Are there systems in place to obtain patients

and carers views with regard to the service

receive?

Patients and user should be provided with an opportunity to express their views and

opinions on the service they receive.
















INCIDENTS


A


made

Good Practice


8

Ask 5 staff

Check

Document

Is there an available up to date list of interpreters that is easily acceptable?

All wards/departments should have details of

the availability of interpreters and how to contact them.


9

Check

notice boards

Is there information clearly displayed within

the ward on how to make a complaint?

Information on how to make a complaint should be clearly displayed on the

ward/department.

� Standards for Health Services: 18d (links to 23)

10

Ask 5 Staff

Are there mechanisms/policy in place to

defuse complaints?

There should be an agreed organisational procedure/policy available on how to defuse

a complaint.


11

Ask 5 staff

Do patients receive a general information

booklet/leaflet/about the hospital

/department/ward prior to admission or on arrival?
















INCIDENTS


A


made

Good Practice

All patients should receive information on

the hospital/ward/department prior to or on

admission.

� Standards for Health Services: 18d

12

Ask staff

Is there a policy for the use of mobile

phones?

Guidelines should be available on the use of mobile phones within the organisation.




Please ask 5 patients the following questions. Tick the appropriate box to record the demographic details.

Q1: Who has answered

these questions

Yes

Q2: Is the patient Yes Q3: Age of patient Yes

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Patient Male Under 16

Relative/Carer Female 16-25

Other e.g. advocate Other 26-45

45-65

66-85

Over 85

Patients Questions

QUESTION YES NO N/A General Comments

Patient number 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comment Ward Managers Comment

13

Were you able to speak to staff in a

language of your choice? � Standards for Health Services: 2, 18, 5b

14

If you have a communication disability

(hearing, verbal or sight) were your

needs met? � Standards for Health Services: 2,

18e, 5b

15

Were you given an opportunity to ask

questions about your care? � Standards for Health Services:

9b,5b

16

Were your questions answered in a

way that you could clearly

understand?

� Standards for Health Services: 9a,

5b

17

Were you able to contact your family

by telephone when necessary? � Standards for Health Services: 18e,

5b

18

Are there any things you would

change? � Standards for Health Services: 5b,

5c




STANDARD 2: RESPECTING PEOPLE

Principle: Your human rights to dignity, privacy and informed choice will be

protected at all times, and the care provided will take account of your

individual needs, abilities and wishes

STANDARD 5: RELATIONSHIPS

Principle: You will be encouraged to maintain your involvement with family,

friends and to develop relationships with others, according to your wishes.




STANDARD 10: DIGNITY AND RESPECT

STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY

STANDARD 19: INFORMATION MANAGEMENT AND

COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING

STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

DEVELOPMENT

METHOD QUESTION YES NO N/A

Issues identified Improvements to be made

Good Practice

1

Check 5 Documents

Has the patient’s dignity and respect needs

been assessed and documented on

admission?

All patient areas should offer privacy or be

screened.

� Fundamentals of Care Standard: 2.4,

8.3


2

Check 5

Documents

Do patients identified with privacy and

dignity needs have care plans to address these needs?

The patients plan of care should reflect identified needs

� Fundamentals of Care Section : 2

� Standards for Health Services: 8a

3

Check 5

Documents

Is there documented evidence that a plan

of care has been agreed with the patient?


� Standards for Health Services: 8a and 9a

4

Check 5

Does the patient documentation indicate the patients preferred name?






protected at all times, and the care provided will take account of your individual needs, abilities and wishes


Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes.


STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK


STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT

STANDARD 12: ENVIRONMENT


STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY

STANDARD 24: WORKFORCE PLANNING

STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT



Good Practice

Documents Patients preferred name should be documented in nursing/medical records.

Patients will be addressed by their

preferred name.

� Fundamentals of Care Section: 2.4


5

Ask staff

Are Care Plans available for the patient to

see?

Care plan documents should be readily

available to patients.

� Fundamentals of Care Standard: 1.4 � Standards for Health Services: 8a and

9a

6

Check 5 documents

Has a carer’s needs assessment been

completed?

The carer’s needs should be documented in

nursing record.

� Fundamentals of Care Standard: 5 � Standards for Health Services: 18b

7

Check 5

Documents

Is there documented evidence stating the

patients cultural and spiritual needs?

Patient’s documentation should include written comments regarding the patients

cultural and spiritual needs




















Good Practice


3.7, 11.1


8

Ask staff

Are staff aware of Data Protection (Caldicott) requirements and patient

confidentiality

All staff should be aware of Data Protection

requirements and confidentiality

� Fundamentals of Care Section: 1.5 � Standards for Health Services: 19a

9

Check

Is patient information securely stored to

ensure confidentiality?

Patient records should be stored in

accordance with Caldicott guidelines.

(Secure trolley within the ward or department )



10

Check 5

Documents

Is there written evidence in the patients

nursing/medical profile to indicate that

sharing of information has been discussed.

Patient documentation should state if information can be shared with a third

party and with whom it can be shared with.




















Good Practice

� Fundamentals of Care Section: 2


11

Check

Is each patient area individually screened

to ensure privacy?

All patient areas should be screened or offer privacy

� Fundamentals of Care Standard:- 2.4, 8.3


12

Ask staff

Are efforts made to ensure that privacy is

respected during intimate procedures e.g.

washing, dressing, toileting & clinical

interventions (e.g. promotion of a culture where no one walks behind closed screens

without asking permission and laminated

signs are used to promote this?)

� Standards for Health Service: 10

13

Ask staff

When needed, are hospital gowns and

night attire for patient use easily accessible?

Gowns and night attire should be accessible for patients if required.


14 Do these gowns promote patient dignity?




















Good Practice

Ask staff

Are they of appropriate size and fit, do they

fasten adequately?

� Standards for Health Services 10

15

ask staff

Is there a facility for patients to talk in

confidence to staff (e.g. quiet room/office)

� Fundamentals of care standard: 5

� Standards for Health Services 9, 12c

16

Ask staff

Is there a comfortable and quiet seating

area available for patients to spend time with their visitors away from the bedside?

� Fundamentals of care standard: 5.2


17

Ask staff

Check

Are there facilities available for close

relatives / friends to stay over night if

necessary?

Appropriate facilities will be available for relatives and friends to stay over night if

necessary



18

Ask staff

Where necessary, are visiting hours flexible

and adjusted according to the needs of the patient?




















Good Practice

People are able to receive visitors within reasonable hours, sensitive to the needs of

others.

� Fundamentals of Care Standard: 5.1 � Standards for Health Services: 10

19

Ask staff

Is a Registered Nurse available to speak to relatives at visiting time?

Always be welcoming in your approach to visitors, showing courtesy and patience at

all time

� Fundamental of Care: 5 � Standards for Health Services: 9b, 24a

20

Ask Staff

check

Can patients access information in an appropriate format for their needs?

Information should be available in appropriate format. E.g. Braille, video,

cassette, large print and languages

� Standards for Health Services: 9a, 18b

21

Ask staff

Are patients able to access advice and

support as needed?

People are able to access free and

independent advice so that they can make choices about their care and lifestyle e.g.

counselling services, patient advocacy,




















Good Practice

community health council etc

� Fundamentals of Care Section: 2.2


22

Ask staff

Check for

documented

evidence

Have all staff attended Diversity, Equality & Human Rights Training?

All staff should attend training on Diversity

& Equality and Human Rights.

� Fundamentals of Care Section: 2

� Standards for Health Services: 2, 26b

23

Ask staff Check

Have all staff attended Protection of

Vulnerable Adults (POVA) training.

Documented evidence should be available stating staff had attended POVA Training


24

Ask staff check

Is there single sex accommodation for

sleeping, washing and toileting?

Single sex accommodation should be available for patients when necessary





Q1. Who has answered these questions

Yes

Q.2 Is the patient Yes Q3. Age of patient Yes

Number of Patient 1 2 3 4 5 Number of Patient 1 2 3 4 5 Number of Patient 1 2 3 4 5




45-65

66-85

Over 85

Patients Questions

QUESTION YES NO N/A General Comment

Patient number 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patients Comment Ward Managers Comment

25 Do you feel that you have been treated with respect and politeness

during your episode of care?

People are treated with respect,

courtesy and politeness

� Fundamentals of Care: 2.1 � Standards for Health Services: 5b,

10

26 Has your privacy been respected

during washing, dressing and toileting

etc?

� Standards for Health Services: 5b,

10

27

Did people use your correct/preferred name or title when speaking to you?


10





28 Were you able to see and discuss your

nursing care plans with a Registered/Qualified Nurse? Ward

Sister/Staff Nurse


9b

29 When discussing confidential or

personal issues were you given

sufficient privacy?


10

30 Were you asked about sharing personal information with others?


18c

31 Could you understand the information that was given to you? (Written or

verbal)

� Standards for Health Services:5b, 9

32 Were your relatives/carer’s able to

speak to a Nurse at visiting time if they wanted to?


18b

33 Do you know the name of the doctor

responsible for your treatment?

� Standards for Health Services: 5b, 9b





34 Do you know the name of the Ward

Sister or Nurse in charge of your care

� Standards for Health Services: 5b, 9b

35 Are there any things you would change?


FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY

Principle: Your health, safety and welfare will be actively promoted and

protected. Risks will be identified, monitored and where possible, reduced or

prevented


STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY

PLANNING ARRANGEMENTS

STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK STANDARD 12: ENVIRONMENT

STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND

DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY

STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS


DEVELOPMENT

METHOD QUESTION YES NO N/A Issues identified Improvements to be

made

Good

Practice

INFECTION CONTROL

1

Evidence of

documentation

Is there a programme of Infection Control

Audit, which includes your ward? There should be regular programme of

Infection Control Audits.

� Standards for Health Services: 6a, 13a






prevented






and DECONTAMINATION

STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS

STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY



DEVELOPMENT

METHOD QUESTION YES NO N/A Issues identified Improvements to be made

Good Practice

2

Ask 5 Staff Check

Document

Do staff have access to an Infection Control

Policy?

All wards & departments should have access

to a Control of Infection Manual.


3

Check Ward/dept

Resources

Does the caring environment encourage compliance with hand decontamination?

Alcohol hand rub is sited in convenient

locations. A hand washing poster indicating approved hand-washing method located

near at least one hand wash basin. Clinical

wash hand basins should be appropriately sited i.e. in / adjacent to each patient area.

During audit hand decontamination to be observed being undertaken appropriately in

at least two staff members.

� Fundamentals of Care Standard 3.1 & 3.6


4 Ask 5 Staff

Check Document

Do you have a designated person or link

nurse responsible for taking the lead in Infection Control Issues?

Does the department have a designated link

person for infection control?






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice



5

Check ward records for

documented

evidence

Have all staff attended training relating to

Infection Control within the last year?

All staff should attend Infection Control

Training and regular updates AS PER Health Board Policy.

� Fundamentals of Care 3.6

� Standards for Health Services 13c, 26b

6

Ask 5 Staff

Are staff aware of the correct procedure for

source isolating patients?

All staff should be aware of the correct

procedure for source isolating patients.

� Fundamentals of Care 3.6 � Standards for Health Services 13a

7 Ask 5 Staff

Are staff aware of the MRSA Screening policy for their speciality?

All staff should be aware of the MRSA screening policy. � Standards for Health Services 13a

Are sharps bins placed appropriately within






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

8

Check

Observe

the Department?

Sharps bins should be placed out of the reach of children and away from public

areas. Wall brackets should be used to

secure sharps boxes.


� Standards for Health Services 13d

9

Ask 5 Staff

Are staff aware of the correct procedure for bagging and sending infected linen to the

laundry?


10 Check &

Observe

Is clinical waste disposed of in the

appropriate bin?

Waste should be segregated and disposed of

in the correct type of waste bin. A choice of

clinical and domestic waste bins and sharp

boxes should be available.

� Fundamentals of Care Standard 3.2

� Standards for Health Services 13a, 13d

MANUAL HANDLING

11 Check

Document

Is there a Health Board local policy for Minimal Manual handling?






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

There should be a local policy for minimal

manual handling.


� Standards for Health Services 22b

12

Ask 5 Staff

Are all employees aware of Health Board &

Local Policies and know where they are

located?

All employees should be aware of Health Board & Local Policies and where they can

be located.



13 Check ward

records

Have all staff received training or an update

in Moving & Handling procedures in the past year?

All staff should have received training or up

date in the past year.


� Standards for Health Services 22b, 26b

14 Check 5

patient Have all patients had a manual handling risk






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

records assessment completed?

All patients should have a manual handling

risk assessment completed.


� Standards for Health Services 22a

15

Check5

patients records

Are Manual Handling risk assessments

regularly reviewed?

All risk assessments should be reviewed as

and when situations change.

� Fundamentals of Care Standard 3.3 � Standards for Health Services 22a

16 Check patient

records

If found to be at risk, is a care plan initiated?

All those found to be at risk should have a care plan initiated.



17 Check ward

Have all staff received training or an update

in Display Screen Equipment Policy (DSE) DSE policies should be available for all staff.






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

records


� Standards for Health Services 22a, 26b

18 Check

Is there documented evidence that hoist slings and other manual handling aids are

regularly checked for wear and tear?

There should be documented evidence that

hoist slings and manual handling aids are checked regularly.


� Standards for Health Services 22a,

16b

19 Ask 5 Staff

Check 7 &

Observe

Are appropriate and sufficient handling aids

available for use in Wards/Departments?

There should be appropriate and sufficient

manual handling aids available for use.

� Fundamentals of Care Standard 3.4,

4.4 & 12

� Standards for Health Services 22a, 16c

HEALTH & SAFETY

20

Is there documented evidence that all staff

receive statutory training in Health & Safety






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

Check ward

records

Awareness?

All staff should attend Health & Safety training.

� Fundamentals of Care Standard 3.6 � Standards for Health Services 22b,

26b

21 Observe

Is your ward/ department kept tidy and

uncluttered?

All areas of the department should be clean and uncluttered.


� Standards for Health Services12b, 22a

22

Check

Are entrances and exits clear and accessible?

Entrances and exits should be assessable

� Fundamentals of Care Standard 3.3 � Standards for Health Services 12a,

22a

23

Are alternative lighting facilities available in

the event of a mains power failure?






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

Ask 5

Staff

In the event of a power failure adequate

emergency lighting facilities should be

available e.g. generator, touch.


� Standards for Health Services 4, 12f, 22a

24 Ask 5

Staff

Is there adequate security available in the ward /department at night?


� Standards for Health Services 12d, 22a, 22b

FIRE PRECAUTIONS

25 Check

Are all fire exits clearly marked?

Fire exits should be clearly labelled, using standard signs.



26 Check

Are fire exits kept clear and accessible?

All fire exits should be fully accessible and

not obstructed with equipment, both outside and inside.






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice


� Standards for Health Services 12a, 22a, 22b

27

Check

Are fire restraint doors kept closed?

Fire restraint doors must be closed.

� Fundamentals of Care Standard 3.3 � Standards for Health Services 12d,

22b

28

Ask 5 Staff

Do staff know the location of fire alarms?

� Fundamentals of Care Standard 3.3 � Standards for Health Services 22b

29

Check ward records

Is there documented evidence staff have attended Fire Safety Training in the last

year?

All staff must be undated annual on fire safety training.



Is there documented evidence that staff






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

30

Check ward

records

have attended Basic Life Support Training?

All staff should have attended Basic Life Support Training.



31 Check

Is all medical/clinical equipment regularly maintained?

Clinical / medical equipment should be

maintain in accordance to equipment maintenance programme


32 Ask 5

Staff

Are all staff given adequate training prior to using equipment?

All staff should receive appropriate training

prior to using equipment

� Fundamentals of Care Standard 3.6 � Standard for Health Services 16e

Are staff aware of the Trust incidents

reporting policy?






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

33

Ask 5

Staff

Staff should be aware of the Health Board Incident Reporting Policy



34

Ask 5 Staff

Are all incidents/accidents fully investigated?

All incidents /accidents involving staff

contractors, patients, members of public clinical incidents, near misses and non

clinical incidents must be recorded in the Incident Report Book.


35 Ask 5

Staff

Are Action Plans agreed to prevent reoccurrence of reported incident?

Action Plans should be agreed to prevent

reoccurrence of reported incident.

� Fundamentals of Care Standard 3.3 � Standards for Health Services 23e






prevented






and DECONTAMINATION





DEVELOPMENT


Good Practice

36

Check

C.O.S.H.H.

Are C.O.S.H.H. regulations adhered too?

A C.O.S.H.H. manual should be available in

all wards/departments.

� Fundamentals of Care Standard 3 � Standards for Health Services 22b,

22c



Please ask 5 patients the following questions. Tick the appropriate box to record the demographic details

Q1. Who has answered

these questions

Yes






45-65

66-85

Over 85

Patients Questions – patient feedback 5b


Number of Patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comments Ward Managers Comment

37 Was the space around your bed clean

and uncluttered?

� Standards for Health Services 5b,

12b, 13b

38 Did staff wash their hands or use hand

gel prior to attending to your needs?

� Standards for Health Services 5b, 13a, 13c

39 Was the ward environment appropriate to your needs?


12c

40 Did you feel safe within the ward

environment?


12d

41 Are there any things you would

change?




FUNDAMENTALS OF CARE STANDARD 4: PROMOTING INDEPENDENCE

Principle: The care you receive will respect your choices in making the most

of your ability and desire to care for yourself

Creating a unified & fair system for assessing and managing care. WAG 2002

STANDARDS FOR HEALTH SERVICES

STANDARD 3: HEALTH PROMOTION, PROTECTION AND

IMPROVEMENT STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK



STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND DIAGNOSTIC

SYSTEMS STANDARD 18: COMMUNICATING EFFECTIVELY

STANDARD 20: RECORDS MANAGEMENT


made

Good Practice

1 Check 5

Documents

Have all patients been assessed by staff in

respect of their self care abilities?

� Fundamentals of care 4.2 � Standards for Health Services 8a, 8b

2

Check 5

Documents

Do patients with identified self care deficits have care plans to address these needs?

� Fundamentals of care 4.2 � Standards for Health Services 8a

3

Check 5 Documents

Is there written evidence of long-term/discharge planning for patients with

new/increased self care deficits or long term

problems?


4 Check 5

Documents

Where appropriate is there written evidence

of the patients family/carers being involved in the long term/discharge planning?

There should be written evidence of

family/carer’s wishes recorded in patient plan of care.

� Standards for Health Services 8a, 9b, 18b, 20c

5

Ask 5

Is there satisfactory access to an occupational therapist?









IMPROVEMENT




STANDARD 12: ENVIRONMENT STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND DIAGNOSTIC

SYSTEMS



Good Practice

staff

An occupational therapist should be available when required.



6 Ask 5 staff

Is there satisfactory access to a

physiotherapist service?

There is satisfactory access to the

physiotherapy service

� Fundamentals of Care Standard: 4.4 � Standards for Health Services 8b

7

Ask 5 staff

Is there satisfactory access to a speech &

language therapist if required?

Speech therapy should be available if

requested.



8

Ask 5 staff

Is there satisfactory access to a social

worker?

There should be a regular opportunity for

patients to discuss problems with a social worker.


� Standards for Health Services 8c









IMPROVEMENT




STANDARD 12: ENVIRONMENT STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND DIAGNOSTIC

SYSTEMS



Good Practice

9

Ask 5 Staff

Observe

Does the ward/department have access to washing/bathing and toilet facilities for the

disabled?

Access to facilities for the disabled must be available.

� Fundamentals of Care Standard 4.6 � Standards for Health Services 12c

10

Ask 5 Staff

Is there adequate provision of equipment in the ward/department to meet the needs of

the service?

The ward/department should have access to sufficient equipment to provide a safe

service e.g. walking aids, hoist

� Standards for Health Services 12c, 16c

11

Ask 5 staff

Are patients discharge plans delayed due to the lack of access to adequate equipment?

Equipment for home use should be readily

available to support patients on discharge from hospital.






these questions

Yes






45-65

66-85

Over 85



Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comment Ward Managers Comment

12

Are you included in any decision

making regarding your choice and ability to care for yourself?


9b

13 Have you been asked what your needs and requirements will be on leaving

hospital to maintain your well being?

� Standards for Health Services 5b,8a

14 If appropriate are your family/friends

or carers involved in planning for your return home?

� Standards for Health Services 5b, 8a, 9b

15 Are you happy with the arrangements that have been discussed?


8a





16 Are you encouraged to be involved in

your treatment and care?


17 Are you encouraged to maintain your independence?


5b

18 If well enough, are you encouraged to dress in your own day clothes?

� Standards for Health Services 5b,10, 8b


change?





STANDARD 6 SLEEP, REST AND ACTIVITY

Principle: Consideration will be given to your environment and comfort so

you may rest and sleep


STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE


STANDARD 12: ENVIRONMENTS

National Service Framework for Older People: medicines & older people


made

Good Practice

1

Check 5 documents

Is there documented evidence the patient’s

sleep pattern has been assessed on admission?

There should be written evidence relating to

the patients night time requirements / sleep


2 Check 5

documents

Where sleep has been poor/disturbed is there written evidence of the action taken to

assess the problem?

Patients sleep patterns should be record in

patient’s plan of care.


3

Observe

Is there an area that patients can go to

during the night if they are wakeful?

Every effort should be made to prevent restless patients disturbing other patients.


4

Ask 5 staff

Are there sufficient pillows available for the

needs of the patients?

Patient’s should have the required number of pillows to meet their individual needs.










STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE STANDARD 8: CARE PLANNING AND PROVISION




Good Practice

5 Ask 5

staff

Are there sufficient blankets available for the needs of the patient?

Additional blankets should be available if

required.


6 Ask 5

staff

Is there a protected rest period for patients during the day?

A quiet period should be agreed to allow

patients to rest.


7

Ask 5 staff

Is there a core period of at least 7 hours

between the completion of night -time

settling routines and the start of routine morning activity?

Patients should have a core rest period of 7

hrs.


8

Ask 5 staff

Is there a policy relating to an agreed time

when the movement of patients/beds are

restricted?

Avoidance of ward transfers out of hours other than for a clinical reason.














Good Practice

9 Ask 5

staff

Observe

Are lights in sleeping areas, other then over the bed nightlights, switched off/dimmed at

night?

Dimmer lights should be available during the night.


10

Ask 5

Staff

Are staff aware that when necessary the

tone on phones and call bells can be turned down at night?


11 Ask 5

Staff

Do all nurses working at night have soft soled shoes?

All Nurse must wear soft soled shoes.

12

Check

Do all radios have personnel headphones?

Personal headphones should be available for

all patient radios facilities.

13

Observe & Test

Are windows free from draughts when

closed?

Windows should be secure and free from draughts.






Yes






45-65

66-85

Over 85

Patients Questions



14 Are you able to sleep by night?

If no, please give reason why not.


15 If your sleep is disturbed are you

supported and made comfortable?


16 Are you given an opportunity to rest

during the day?

If no, please give reason why not.


17 Are you given headphones when listening to the radio/television?


18 Do you have enough pillows?


19 Do you have enough blankets?







change?





STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN

Principle: You will be helped to be as comfortable and pain free as your

condition and circumstances allow



STANDARD 8: CARE PLANNING AND PROVISION STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE





DEVELOPMENT


made

Good Practice

1

Check 5

documents

Is there written evidence that the patients

pain relief management has been discussed on admission?

An agreed plan of care to manage the patients discomfort should be available.


2

Check 5 documents

Is there written evidence that the plan to manage the patients pain has been

implemented?

A pain management plan should be available.


3 Check 5

documents

Is there written evidence that the management of pain is being reviewed and

evaluated?

The patient’s pain management plan must be

reviewed and updated regularly


4

Ask staff

Do you have access to the equipment

needed to make patients comfortable?

Beds, mattress, syringe drivers, tens machine, hot/cold pads

� Standards for Health Services 10, 16c




STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN

Principle: You will be helped to be as comfortable and pain free as your condition and circumstances allow




STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE STANDARD 10: DIGNITY AND RESPECT


STANDARD 23: DEALING WITH CONCERNS AND MANAGING

INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

DEVELOPMENT


made

Good Practice

5

Check 5 documents


concerns and anxieties have been assessed?

� Standards for Health Services 9b, 10, 20c,

23a

6

Ask staff

Is there satisfactory access to a pain Management team / service?


7

Check 5

documents

Is there evidence that the plan to manage the patient’s concerns and anxieties have

been implemented?

An agreed plan of care to manage the

patients emotional need should be available


8

Ask staff

Is there access to a specialist support

services e.g. counselling services, psychiatry service if required?


9

Ask staff

Have any staff completed training/course

pain management?


10

Ask staff

Have any staff attended training on End of

Life Care Pathway?






these questions

Yes






45-65

66-85

Over 85



Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comments Ward Managers Comment

11

Are you encouraged to express your,

pain, discomfort, distress or anxieties?


10, 23a

12

Has your pain, discomfort or anxiety

been acted upon in a timely manner?


8a, 10, 23a

13

Are there any things you would change?





STANDARD 8 PERSONAL HYGIENE, APPEARANCE & FOOT CARE

Principle: You will be supported to be as independent as possible

in taking care of your personal hygiene, appearance and feet






STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND DECONTAMINATION

STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND

DIAGNOSTIC SYSTEMS STANDARD 20: RECORDS MANAGEMENT


QUESTION YES NO N/A Issues identified Improvements to be

made

Good Practice

1

Check 5

documents


personal hygiene needs have been assessed?

The patient’s hygiene needs should be assed on admission.

� Standards for Health Services: 8a, 10

2

Check 5

documents

Where necessary are there care plans to

address these needs?

Patients at risk should have a care plan.

� Standards for Health Services: 8a, 10

3

check

Are there designated male & female toilets on

your ward/department?

Ward/department areas must provide

designated male and female toilet facilities.

� Standards for Health Services: 10, 12c

4

Observe

Are there designated male and female

washing/shower facilities?

2 baths or 2 showers would be available

within the ward/department.


5

Observe

Are there sufficient bathing/shower facilities

on the ward/department to meet the needs of





Principle: You will be supported to be as independent as possible in taking care of your personal hygiene, appearance and feet




STANDARD 8: CARE PLANNING AND PROVISION STANDARD 10: DIGNITY AND RESPECT



AND DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND

DIAGNOSTIC SYSTEMS STANDARD 20: RECORDS MANAGEMENT STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY

QUESTION YES NO N/A Issues identified Improvements to be made

Good Practice

the patient?


6 Observe

Are individual wash bowls cleaned after each

use, stored dry and inverted at patient’s bedside or are disposable wash bowls used?

Bowls should be cleaned and stored correctly

after each use or disposable bowls provided.


7

check

Does every washing area have a mirror, which can be used whilst seated and

standing?

A mirror should be accessible in washing areas.


8

Ask staff

Are mirrors available to patients unable to

visit the bathroom?

Mirrors should be available for patients restrict to bed.


9 Check

Are shaver sockets available in washing

bathing areas?

Shaving sockets should be available in















Good Practice

washing areas.


10

Check Ask

5 Staff

Are showering facilities available for patients

with mobility difficulties i.e. wheel chair access, perching stool & grab rails.

� Standards for Health Services: 2a, 12c

11

check

Is there at least one bathing/showering

facility with use of a mechanical hoist if required?

At least one bathing /showering area should

be accessible for use of mechanical aids.

� Standards for Health Services: 12a, 12c, 13c, 16c

12 Ask 5 staff

Does the ward/department have access to a

Podiatrist?

Staff should have access to a podiatrist if required.


13 Check 5

documents

Is there written evidence that the patients foot care needs have been assessed on

admission?

The patient’s foot care needs should be

assessed on admission.















Good Practice


14 Ask 5 staff

For patients who are not self-caring are their finger and toe-nails cut?

A risk assessment should be undertaken on

patients finger/toe –nails.


15 Ask 5

staff

Do you have access to nail cutting equipment?

Appropriate equipment for the cutting of

patients nail should be available.


16 Ask 5

Staff

Is there a system in operation for patient’s

personal laundry when it is not possible for it

to be done by family/friends?

There should be systems in place to ensure patients personal laundry is cleaned when

there are no family or friends available. E.g. washing machines, patient’s laundry bags.


17 Ask 5

Staff

Do you have access to toiletries for patients

who are unable to provide their own?

In an emergency toothpaste, toothbrushes















Good Practice

and soap should be available for patients


18 Ask 5

Staff

Are there processes in place to ensure that

ward/department toiletries are patient specific (to prevent the spread of infection)






these questions

Yes






45-65

66-85

Over 85




17

Have you been able to wash/bath/shower as frequently as

you wish?

� Standards for Health Services:

5b,10, 13c

18

If you needed assistance with

washing/bathing has this been

provided sensitively?

� Standards for Health Services: 5b, 10

19





FUNDAMENTALS OF CARE STANDARD 9 EATING & DRINKING

Principle: You will be offered a choice of food and drink that meets your

nutritional and personal requirements and provided with any assistance that you need to eat and drink



STANDARD 8: CARE PLANNING AND PROVISION STANDARD 14: NUTRITION


made

Good Practice

1

Check 5 Documents

Has a Nutritional Risk Assessment been

completed for every patient within 24hrs of admission?

Nutritional Risk assessment will be

completed on all patients within 24hrs of

admission.

� Fundamentals of Care Standard 2.3, 9.5


2

Check 5 Documents

Has a swallow screening/assessment

been undertaken on relevant patients on admission?

A swallow assessment must be

undertaken on relevant Patients


3

Ask 5 staff

Do patients wait longer than 48hrs for a full swallowing assessment to be

undertaken?

A full swallowing assessment should be

completed within 48hrs of admission


4 Check 5

Documents

Are identified nutritional requirements

(special diets) reflected in the patient care plan?

The patients nutritional needs must be

recorded in the plan of care

� Standards for Health Services 8a, 14a

Have all patients had their weight





nutritional and personal requirements and provided with any assistance that

you need to eat and drink




STANDARD 14: NUTRITION


made

Good Practice

5

Check 5

Documents

recorded on admission?

All patients must be weighed on admission and weight recorded


6

Ask 5 staff Check

documentation

for patients identified at

Risk

Are there documented records (food chart/fluid balance charts) in use for

patients identified at Risk?

Were appropriate food charts, fluid

balance charts must be completed for patients identified at risk


7 Check 5

Documents

Have patients with food charts been weighed at the stipulated intervals?

Patient on food charts must be weighed

weekly.


8

Check documents

Ask Staff

Has a dietician been contacted regarding all patients identified at nutritional risk

following assessment?

A dietician should be available on request to provide appropriate advice.


9 Observe

Ask staff/ check Care

plan

Are special diets provided in accordance

to patient’s medical need?

This includes texture modification, medically indicated, cultural Needs etc.

� Standards for Health Services 8a, 14d












made

Good Practice

10

Ask patient

Observe

Are patients in a comfortable position for

eating: are bed tables within easy

reach?

Patients should be in a comfortable and safe position for eating.


11

Ask staff

Are patients given the opportunity to wash their hands prior to eating meals?

All patients must be offered an opportunity to wash their hands prior to

meals.

� Standards for Health Services 13c, 14b

12 Ask staff

Observe

Are there systems in place to enable staff to identify patients with special

requirements?

Red trays, assistance with eating, Traffic

lights, special diets.


14a, 14b

13

Ask patient Observe

Do patients who need assistance to eat or are served with red trays receive the

assistance/supervision they need?

Assistances must be available to feed

venerable patients. Qualified nursing staff must be responsible for patients

using red trays.


Is the temperature of hot food confirmed












made

Good Practice

14

Ask 5 staff

Check

to be above 63 degrees centigrade prior

to serving meals?

Temperature of the food must be

checked before serving.


15 Ask staff

Are meals times on the

ward/department protected e.g. uninterrupted by ward rounds, medicine

rounds, visitors and noise?

Meals times should be protected and

free from disturbances.


16

Observe

Do all patients (other than those with

restricted fluid intake) have drinking water available within reach?

Fresh drinking water should be available and in reach of patients.


14b, 14e

17

Ask staff

Are meals readily available for patients

who have missed a meal time?

Provision to ensure food is available for

patients who have missed meals should be available.

� Standards for Health Services 14e

18 Ask staff

Are snacks available for patients who are hungry between meals?

Snacks should be available if required












made

Good Practice

for patients.

� Standards for Health Services 14e

19

Check documented

evidence training

manual Ask staff

Have any staff completed a food

handling course?

Staff should complete a food handling course?






Yes






45-65

66-85

Over 85




20

Are you offered a choice of meals?

� Standards for Health Services 5b, 14d

21

Is the food the right temperature?


14d

22

Have you enjoyed the meals offered

to you?

� Standards for Health Services 5b, 14d

23

If you have missed a meal were arrangements made to provide you

with food?


14e

24

If you have special dietary needs are

these being met?

� Standards for Health Services 5b, 14a





25

Were you disturbed whilst eating

your meals?


26

Were you provided with assistance if

necessary in a timely manner?


14b

27

Does the nurse in charge ensure that all you have received the correct

meal?


14b

28

Are there any things you would

change?




FUNDAMENTALS OF CARE STANDARD 10 ORAL HEALTH & HYGIENE

Principle: You will be supported to maintain a healthy, comfortable mouth and pain free teeth and gums, enabling you to eat well and prevent related

problems



STANDARD 8: CARE PLANNING AND PROVISION STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

AND DECONTAMINATION


Good Practice

1 Check 5

Documents

Have all patients had an assessment of their oral health & hygiene needs at the time of

admission?

Patient’s oral health and hygiene needs

must be assessed on admission


2

Check 5 documents

Is there a care plan in place to address identified needs?

All patients should have an agreed care plan to address their oral hygiene needs.


3

Ask 5 staff

Check

documented evidence

Is there evidence that patient’s who need

assistance with oral hygiene/cleaning their

teeth twice daily receive the assistance required?

Is there documented evidence recording the patient’s oral hygiene care.


4 Ask 5 staff

Are toothbrushes and toothpaste available for patients admitted without them?

Toothbrushes and toothpaste should be available for patients.


5 Are suitable containers available for the



FUNDAMENTALS OF CARE STANDARD 10

ORAL HEALTH & HYGIENE

Principle: You will be supported to maintain a healthy, comfortable mouth

and pain free teeth and gums, enabling you to eat well and prevent related problems




STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND DECONTAMINATION


made

Good Practice

Ask 5 staff storage of patient’s dentures?

Suitable contains should be available to

store patients dentures.


6

Ask 5 Staff

Is there satisfactory access to a dentist?

Appropriate facilities should be available for

patients requiring dental care.






Yes






45-65

66-85

Over 85



Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patients Comments/Issue Ward Managers Comment

7

Do you feel you are encouraged to

continue with your normal mouth hygiene?


13c

8

As part of your care plan was mouth

hygiene discussed with you?


8a

9

If you have a specific problem with

your teeth, dentures or gums were

you referred to a dentist?

� Standards for Health Services: 5b, 8a

10

If referred to a dentist were you seen

promptly?


8a



11




TOILET NEEDS

Principle: Appropriate, discreet and prompt assistance will be provided as necessary taking into account your specific needs and privacy




STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND

DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC

SYSTEMS


made

Good Practice

1

Check 5 documents

Have all patients on admission been

assessed in respect of their toileting needs?

Patient’s toileting requirements must be

assessed on admission and recorded in the plan of care.


2 Check 5

Documents


There should be documented evidence of an

agreed care plan.


3 Check 5

documents

Is there satisfactory access to continence advisor/link nurse?

There should be access to a continence/link

nurse advisor when required.


4

Check

Are there hand washing facilities and paper

towels in each toilet?



FUNDAMENTALS OF CARE STANDARD 11 TOILET NEEDS







DECONTAMINATION

STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC SYSTEMS


Good Practice

Hand washing facilities and paper towels must be available in all toileting areas.


5

Ask 5

Staff

Are patients given the opportunity to wash

their hands after using a commode or bedpan?

All patients should be encouraged to wash

their after using a commode or bedpan. Bed patient should be offered the opportunity to

wash their hands.


6 Check

Can patients easily reach call bells when using the toilet, commode or bedpan?

Call bells should be available in toilets and

should be easily reached.


7 Ask 5

Staff

Are call bells answered within 5 minutes?

Patient call bells should be answered within five minutes.


8

Check

Are facilities available within each toilet for the disposal of sanitary products?

Are appropriate bins available for the disposal of sanitary products?










DECONTAMINATION



Good Practice

� Standards for Health Services: 12c, 13d

9

Check facilities

Are toilets clean, in good state of repair

and working order?

Toilets must be in good repair and working.


10

Check Ask 5

Staff

Are there adequate sluicing facilities in good working order?

Sluicing facilities must be in good working

order.

� Standards for Health Services: 12c, 16c

11 Ask 5 staff

& check

Are toilets large enough to accommodate mechanical aids/hoist?

At least one toilet should be large enough

to accommodate mechanical aids/hoist on the ward/department.


12

Ask 5 staff

Are there sufficient commodes/bedpans

available for patient to be able to use without delay?

The ward/department should have

sufficient commodes and bedpans to meet the needs of the patients.

• Standards for Health Services: 16c

13

Observe

Is the ward free of visible urine bottles,

bedpans etc?










DECONTAMINATION



Good Practice

Urine bottles must be appropriately stored

and out of sight.

� Standards for Health Services: 10, 12d,

12e





these questions

Yes






45-65

66-85

Over 85



Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comment Ward Managers

Comment

14

Have your toileting needs been

discussed with you?

� Standards for Health

Services: 5b, 8a

15

If you needed to use a

commode or bedpan was your request attended to promptly?

Within five minutes of

requesting.


Services: 5b, 10

16

Can you easily reach a call bell

when using the toilet, commode or bedpan?


Services: 5b, 10

17

When using the toilet were you

given enough privacy?


Services: 5b, 10




Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patient Comment Ward Managers

Comment

18

After toileting did you have

access to (or offered) hand washing facilities?

� Standards for Health Services: 5b, 13c

19 Do you find the toilet facilities

clean and well equipped?


Services: 5b, 13c

20 Are toilets well sign posted?

� Standards for Health Services: 5b, 12c

21 Are there any things you would change?


Services: 5b




PREVENTING PRESSURE SORES/PRESSURE ULCERS

Principle: You will be helped to look after your skin and every effort will be

made to prevent you from developing pressures sores






STANDARD 14: NUTRITION STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND

DIAGNOSTIC SYSTEMS

STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

DEVELOPMENT


made

Good Practice

1 Check

Documents

Have all patients been assessed on

admission for their risk of developing

pressure damage?

Patient are assessed on admission by a

registered nurse for risk of developing

pressure sores and a care plan devised.

� Fundamentals of Care 12.1

� Standards for Health Services: 7c, 8a

2

Check documents




3

Ask staff

Check

Documents

Is there an established risk assessment

tool for predicting risk of pressure sores?

All patients should be assessed using a

recognised risk assessment tool and the

information documented in the Care Plan.


12 � Standards for Health Services: 8a

4 Check nursing

documentation

Is there evidence of ongoing risk

assessment and evaluation of care to





Principle: You will be helped to look after your skin and every effort will be made to prevent you from developing pressures sores



STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE

STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT



STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND DIAGNOSTIC SYSTEMS

STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT


Good Practice

for written evidence

prevent the patient developing pressure sores?

� Fundamentals of Care Standard:- 4.4, 12.1

� Standards for Health Services: 7c, 22a

2

Ask5 Staff

Is there written advice/information given

to patients regarding prevention of pressure sores?



5

Check 5 patient

documents

Is there a risk assessment tool for the

safe handling and movement of the patient in use?

� Fundamentals of Care Standard 12.2 � Standards for Health Services: 22a

6

Ask 5 Staff

Do staff have access to appropriate moving and handling aids



7

Check ward staff training

records

Have all staff received training on

assessment of risk and prevention of

pressure sores?

Staff should have received training in the















Good Practice

assessing and prevention of pressure damage.


8 Ask 5 staff

Is there satisfactory access to pressure relieving and reducing equipment within

the in patient environment?


� Standards for Health Services: 12c, 16c

9 Check 5

documents

If the patient is assessed as at risk of developing pressure sores, is there

evidence of other relevant risk

assessments being completed: nutritional

risk assessment,



9.1

Check

documents

Continence assessment?


9.2

Check documents

Condition of skin?
















Good Practice

9.3 Check

documents

Mobility of patient?




Yes






45-65

66-85

Over 85



Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patients Comments Ward Manager Comment




Number of patient 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 Patients Comments Ward Manager Comment

10

Are you aware of any measures being taken to prevent you getting sore

area’s (pressure sores) on your skin/body during your stay?

� Standards for Health Services: 5b, 8a, 9a

11

Were you and or your relatives/carers

given any information on how to prevent sore area’s occurring on your

body especially on your

bottom/elbows/heels?

� Standards for Health Services: 5b, 9a

12

Do you understand the information

you have been given?


9a

13

Were you encouraged to mobilize and sit out of bed?


8a

14





WARD/DEPARTMENT SECTION SUMMARY SHEET

SECTION SUMMARY

EVIDENCE OF GOOD PRACTICE

OPPORTUNITIES FOR IMPROVEMENT



ACTION PLAN

Questio

n No

Issues Identified Proposed Action to be taken Review Date/Lead

Person



OVERALL AUDIT SCORE SHEET

STANDARD 1 Communication & Information STANDARD 2 Respecting People

STANDARD 5 Relationships

Total number of questions


Total number of applicable questions


Total number of YES answers


Total number of NO answers


STANDARD 3 Ensuring Safety STANDARD 4 Promoting Independence

Total number of questions Total number of questions

Total number of applicable questions Total number of applicable questions

Total number of YES answers Total number of YES answers



STANDARD 6 Sleep, Rest & Activity STANDARD 7 Ensuring Comfort & Alleviating Pain











OVERALL AUDIT SCORE SHEET continued

STANDARD 8 Personal Hygiene & Appearance STANDARD 9 Eating & Drinking









STANDARD 10 Toilet Needs STANDARD 11 Oral Hygiene









STANDARD 12 Preventing Pressure Sores /Ulcers



