Fundamentals of Care Audit Tool - v3 Audit Tool.pdfALL WALES FUNDAMENTALS OF CARE AUDIT TOOL All Wales Fundamentals of Care Audit Tool 3 Amended Pilot Audit Tool June 2010 The audit data will be collated ...

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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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 2 Amended Pilot Audit Tool June 2010

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 3 Amended Pilot Audit Tool June 2010

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 4 Amended Pilot Audit Tool June 2010

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 5 Amended Pilot Audit Tool June 2010

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 6 Amended Pilot Audit Tool June 2010

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 7 Amended Pilot Audit Tool June 2010

    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 patients 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 patients 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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 8 Amended Pilot Audit Tool June 2010

    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

    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 patients documentation?

    Contact details of next of kin must be

    recorded in patients documentation

    Standards for Health Services: 18b

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 9 Amended Pilot Audit Tool June 2010

    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

    Standards for Health Services: 5c

    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.

    Standards for Health Services: 18e

    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.

    Standards for Health Services: 23

    11

    Ask 5 staff

    Do patients receive a general information

    booklet/leaflet/about the hospital

    /department/ward prior to admission or on arrival?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 10 Amended Pilot Audit Tool June 2010

    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

    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.

    Standards for Health Services: 18

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 11 Amended Pilot Audit Tool June 2010

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 12 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

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

    STANDARD 9: PATIENT INFORMATION AND CONSENT

    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 patients 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

    Standards for Health Services: 10

    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?

    Fundamentals of Care Standard: 1.1 Standards for Health Services: 8a and

    9a

    4

    Check 5

    Does the patient documentation indicate the patients preferred name?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 13 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    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 Standards for Health Services: 18e

    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 carers needs assessment been

    completed?

    The carers 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?

    Patients documentation should include written comments regarding the patients

    cultural and spiritual needs

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 14 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    Fundamentals of Care Standard: 1.1,

    3.7, 11.1

    Standards for Health Services: 10

    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 )

    Fundamentals of Care Standard: 1.5 Standards for Health Services: 19a

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 15 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    Fundamentals of Care Section: 2 Standards for Health Services: 18c

    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

    Standards for Health Services: 12e

    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.

    Standards for Health Services: 10

    14 Do these gowns promote patient dignity?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 16 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    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 Standards for Health Services: 12e

    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

    Fundamentals of Care Standard: 5.5 Standards for Health Services: 12c

    18

    Ask staff

    Where necessary, are visiting hours flexible

    and adjusted according to the needs of the patient?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 17 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    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,

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 18 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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.

    STANDARDS FOR HEALTH SERVICES IN WALES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT 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

    community health council etc

    Fundamentals of Care Section: 2.2 Standards for Health Services: 23c

    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

    Standards for Health Services: 11c

    24

    Ask staff check

    Is there single sex accommodation for

    sleeping, washing and toileting?

    Single sex accommodation should be available for patients when necessary

    Standards for Health Services: 12e

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 19 Amended Pilot Audit Tool June 2010

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

    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

    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 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?

    Standards for Health Services: 5b,

    10

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 20 Amended Pilot Audit Tool June 2010

    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

    28 Were you able to see and discuss your

    nursing care plans with a Registered/Qualified Nurse? Ward

    Sister/Staff Nurse

    Standards for Health Services: 5b, 9b

    29 When discussing confidential or

    personal issues were you given

    sufficient privacy?

    Standards for Health Services: 5b, 10

    30 Were you asked about sharing personal information with others?

    Standards for Health Services: 5b,

    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/carers able to

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

    Standards for Health Services: 5b,

    18b

    33 Do you know the name of the doctor

    responsible for your treatment?

    Standards for Health Services: 5b, 9b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 21 Amended Pilot Audit Tool June 2010

    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

    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?

    Standards for Health Services: 5b

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 22 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    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.

    Standards for Health Services: 13a

    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 Standards for Health Services: 13c

    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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 23 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    Fundamentals of Care Standard: 3.6 Standards for Health Services: 13c

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 24 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    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.

    Fundamentals of Care Standard 3.1 & 3.2 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?

    Standards for Health Services 13d

    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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 25 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    There should be a local policy for minimal

    manual handling.

    Fundamentals of Care Standard 3.6 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.

    Fundamentals of Care Standard 3.6 Standards for Health Services 22b

    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.

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

    26b

    14 Check 5

    patient Have all patients had a manual handling risk

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 26 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    records assessment completed?

    All patients should have a manual handling

    risk assessment completed.

    Fundamentals of Care Standard 3.3 & 12.4

    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.

    Fundamentals of Care Standard 3.3 Standards for Health Services 22a

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 27 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    records

    Fundamentals of Care Standard 3.6 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.

    Fundamentals of Care Standard 3.4 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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 28 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    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.

    Fundamentals of Care Standard 3.3 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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 29 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    Ask 5

    Staff

    In the event of a power failure adequate

    emergency lighting facilities should be

    available e.g. generator, touch.

    Fundamentals of Care Standard 3.3 Standards for Health Services 4,

    12f, 22a

    24 Ask 5

    Staff

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

    Fundamentals of Care Standard 3.3 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.

    Fundamentals of Care Standard 3.3 Standards for Health Services 22a

    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.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 30 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    Fundamentals of Care Standard 3.3 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.

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

    26b

    Is there documented evidence that staff

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 31 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    30

    Check ward

    records

    have attended Basic Life Support Training?

    All staff should have attended Basic Life Support Training.

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

    26b

    31 Check

    Is all medical/clinical equipment regularly maintained?

    Clinical / medical equipment should be

    maintain in accordance to equipment maintenance programme

    Fundamentals of Care Standard 3.4 Standards for Health Services 16b

    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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 32 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    Good Practice

    33

    Ask 5

    Staff

    Staff should be aware of the Health Board Incident Reporting Policy

    Fundamentals of Care Standard 3.3 Standards for Health Services 23a

    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.

    Fundamentals of Care Standard 3.3 Standards for Health Services 23b

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 33 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES IN WALES

    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

    STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 34 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comment

    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?

    Standards for Health Services 5b,

    12c

    40 Did you feel safe within the ward

    environment?

    Standards for Health Services 5b,

    12d

    41 Are there any things you would

    change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 35 Amended Pilot Audit Tool June 2010

    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 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT

    STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

    STANDARD 16: MEDCIAL DEVICES, EQUIPMENT AND DIAGNOSTIC

    SYSTEMS STANDARD 18: COMMUNICATING EFFECTIVELY

    STANDARD 20: RECORDS MANAGEMENT

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

    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?

    Standards for Health Services 8a, 20c

    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/carers 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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 36 Amended Pilot Audit Tool June 2010

    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 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT

    STANDARD 10: DIGNITY AND RESPECT

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

    SYSTEMS

    STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT

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

    Good Practice

    staff

    An occupational therapist should be available when required.

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

    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.

    Fundamentals of Care Standard 4.2 Standards for Health Services 8b

    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.

    Fundamentals of Care Standard 4.4 Standards for Health Services 8c

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 37 Amended Pilot Audit Tool June 2010

    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 8: CARE PLANNING AND PROVISION

    STANDARD 9: PATIENT INFORMATION AND CONSENT

    STANDARD 10: DIGNITY AND RESPECT

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

    SYSTEMS

    STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT

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

    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.

    Standards for Health Services 8a, 16c

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 38 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comments

    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?

    Standards for Health Services 5b, 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?

    Standards for Health Services 5b,

    8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 39 Amended Pilot Audit Tool June 2010

    QUESTION YES NO N/A General Comments

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

    16 Are you encouraged to be involved in

    your treatment and care?

    Standards for Health Services 5b, 9b

    17 Are you encouraged to maintain your independence?

    Standards for Health Services 3b, 5b

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

    Standards for Health Services 5b,10, 8b

    19 Are there any things you would

    change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 40 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    STANDARD 6 SLEEP, REST AND ACTIVITY

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

    you may rest and sleep

    STANDARDS FOR HEALTH SERVICES

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

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 12: ENVIRONMENTS

    National Service Framework for Older People: medicines & older people

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

    made

    Good Practice

    1

    Check 5 documents

    Is there documented evidence the patients

    sleep pattern has been assessed on admission?

    There should be written evidence relating to

    the patients night time requirements / sleep

    Standards for Health Services 8a

    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

    patients plan of care.

    Standards for Health Services 8a

    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.

    Standards for Health Services 12c

    4

    Ask 5 staff

    Are there sufficient pillows available for the

    needs of the patients?

    Patients should have the required number of pillows to meet their individual needs.

    Standards for Health Services 8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 41 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    STANDARD 6 SLEEP, REST AND ACTIVITY

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

    you may rest and sleep

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENTS

    National Service Framework for Older People: medicines & older people

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

    Good Practice

    5 Ask 5

    staff

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

    Additional blankets should be available if

    required.

    Standards for Health Services 8a

    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.

    Standards for Health Services 8a

    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.

    Standards for Health Services 8a

    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.

    Standards for Health Services 8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 42 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    STANDARD 6 SLEEP, REST AND ACTIVITY

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

    you may rest and sleep

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENTS

    National Service Framework for Older People: medicines & older people

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

    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.

    Standards for Health Services 8a, 12c

    10

    Ask 5

    Staff

    Are staff aware that when necessary the

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

    Standards for Health Services 12c

    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.

    Standards for Health Services 12c

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 43 Amended Pilot Audit Tool June 2010

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

    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

    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

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

    14 Are you able to sleep by night?

    If no, please give reason why not.

    Standards for Health Services: 5b

    15 If your sleep is disturbed are you

    supported and made comfortable?

    Standards for Health Services: 5b

    16 Are you given an opportunity to rest

    during the day?

    If no, please give reason why not.

    Standards for Health Services: 5b

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

    Standards for Health Services: 5b

    18 Do you have enough pillows?

    Standards for Health Services: 5b

    19 Do you have enough blankets?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 44 Amended Pilot Audit Tool June 2010

    QUESTION YES NO N/A General Comments

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

    20 Are there any things you would

    change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 45 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN

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

    condition and circumstances allow

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 10: DIGNITY AND RESPECT

    STANDARD 20: RECORDS MANAGEMENT

    STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS

    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

    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.

    Standards for Health Services 8a

    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.

    Standards for Health Services 7c

    3 Check 5

    documents

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

    evaluated?

    The patients pain management plan must be

    reviewed and updated regularly

    Standards for Health Services 8a

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 46 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN

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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

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

    STANDARD 20: RECORDS MANAGEMENT

    STANDARD 23: DEALING WITH CONCERNS AND MANAGING

    INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL

    DEVELOPMENT

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

    made

    Good Practice

    5

    Check 5 documents

    Is there written evidence that the patients

    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?

    Standards for Health Services 8a

    7

    Check 5

    documents

    Is there evidence that the plan to manage the patients concerns and anxieties have

    been implemented?

    An agreed plan of care to manage the

    patients emotional need should be available

    Standards for Health Services 8a, 20c

    8

    Ask staff

    Is there access to a specialist support

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

    Standards for Health Services 8a

    9

    Ask staff

    Have any staff completed training/course

    pain management?

    Standards for Health Services 26a

    10

    Ask staff

    Have any staff attended training on End of

    Life Care Pathway?

    Standards for Health Services 26a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 47 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comment

    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?

    Standards for Health Services 5b, 10, 23a

    12

    Has your pain, discomfort or anxiety

    been acted upon in a timely manner?

    Standards for Health Services 5b, 8a, 10, 23a

    13

    Are there any things you would change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 48 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

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

    STANDARD 10: DIGNITY AND RESPECT

    STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) 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

    1

    Check 5

    documents

    Is there written evidence that the patients

    personal hygiene needs have been assessed?

    The patients 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.

    Standards for Health Services: 10, 12c

    5

    Observe

    Are there sufficient bathing/shower facilities

    on the ward/department to meet the needs of

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 49 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

    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?

    Standards for Health Services: 10, 12c

    6 Observe

    Are individual wash bowls cleaned after each

    use, stored dry and inverted at patients bedside or are disposable wash bowls used?

    Bowls should be cleaned and stored correctly

    after each use or disposable bowls provided.

    Standards for Health Services: 13b

    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.

    Standards for Health Services: 10, 12c

    8

    Ask staff

    Are mirrors available to patients unable to

    visit the bathroom?

    Mirrors should be available for patients restrict to bed.

    Standards for Health Services: 10

    9 Check

    Are shaver sockets available in washing

    bathing areas?

    Shaving sockets should be available in

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 50 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

    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

    washing areas.

    Standards for Health Services: 12c 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.

    Standards for Health Services: 8a

    13 Check 5

    documents

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

    admission?

    The patients foot care needs should be

    assessed on admission.

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 51 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

    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

    Standards for Health Services: 8a, 20c

    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.

    Standards for Health Services: 8a, 22a

    15 Ask 5

    staff

    Do you have access to nail cutting equipment?

    Appropriate equipment for the cutting of

    patients nail should be available.

    Standards for Health Services: 16c

    16 Ask 5

    Staff

    Is there a system in operation for patients

    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, patients laundry bags.

    Standards for Health Services: 13c

    17 Ask 5

    Staff

    Do you have access to toiletries for patients

    who are unable to provide their own?

    In an emergency toothpaste, toothbrushes

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 52 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC)

    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

    and soap should be available for patients

    Standards for Health Services: 13c

    18 Ask 5

    Staff

    Are there processes in place to ensure that

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

    Standards for Health Services: 13c

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 53 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comment

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

    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

    Are there any things you would change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 54 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION STANDARD 14: NUTRITION

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

    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

    Standards for Health Services 14a

    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

    Standards for Health Services 14b

    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

    Standards for Health Services 14b

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 55 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 14: NUTRITION

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

    made

    Good Practice

    5

    Check 5

    Documents

    recorded on admission?

    All patients must be weighed on admission and weight recorded

    Standards for Health Services 8a

    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

    Standards for Health Services 8a, 14a

    7 Check 5

    Documents

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

    Patient on food charts must be weighed

    weekly.

    Standards for Health Services 8a, 14a

    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.

    Standards for Health Services 8a, 14a

    9 Observe

    Ask staff/ check Care

    plan

    Are special diets provided in accordance

    to patients medical need?

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

    Standards for Health Services 8a, 14d

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 56 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 14: NUTRITION

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

    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.

    Standards for Health Services 14b

    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.

    Standards for Health Services 8a, 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.

    Standards for Health Services 14b

    Is the temperature of hot food confirmed

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 57 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 14: NUTRITION

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

    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.

    Standards for Health Services 14d

    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.

    Standards for Health Services 14b

    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.

    Standards for Health Services 14a,

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 58 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 14: NUTRITION

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

    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?

    Standards for Health Services 14d

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 59 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comment

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

    20

    Are you offered a choice of meals?

    Standards for Health Services 5b, 14d

    21

    Is the food the right temperature?

    Standards for Health Services 5b, 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?

    Standards for Health Services 5b, 14e

    24

    If you have special dietary needs are

    these being met?

    Standards for Health Services 5b, 14a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 60 Amended Pilot Audit Tool June 2010

    QUESTION YES NO N/A General Comment

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

    25

    Were you disturbed whilst eating

    your meals?

    Standards for Health Services 5b, 14b

    26

    Were you provided with assistance if

    necessary in a timely manner?

    Standards for Health Services 5b, 14b

    27

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

    meal?

    Standards for Health Services 5b, 14b

    28

    Are there any things you would

    change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 61 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    AND DECONTAMINATION

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

    Good Practice

    1 Check 5

    Documents

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

    admission?

    Patients oral health and hygiene needs

    must be assessed on admission

    Standards for Health Services: 8a

    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.

    Standards for Health Services: 8a

    3

    Ask 5 staff

    Check

    documented evidence

    Is there evidence that patients who need

    assistance with oral hygiene/cleaning their

    teeth twice daily receive the assistance required?

    Is there documented evidence recording the patients oral hygiene care.

    Standards for Health Services: 13c

    4 Ask 5 staff

    Are toothbrushes and toothpaste available for patients admitted without them?

    Toothbrushes and toothpaste should be available for patients.

    Standards for Health Services: 13c

    5 Are suitable containers available for the

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 62 Amended Pilot Audit Tool June 2010

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

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

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

    made

    Good Practice

    Ask 5 staff storage of patients dentures?

    Suitable contains should be available to

    store patients dentures.

    Standards for Health Services: 13c

    6

    Ask 5 Staff

    Is there satisfactory access to a dentist?

    Appropriate facilities should be available for

    patients requiring dental care.

    Standards for Health Services: 8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 63 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comments

    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?

    Standards for Health Services: 5b, 13c

    8

    As part of your care plan was mouth

    hygiene discussed with you?

    Standards for Health Services: 5b, 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?

    Standards for Health Services: 5b, 8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 64 Amended Pilot Audit Tool June 2010

    11

    Are there any things you would change?

    Standards for Health Services: 5b

    FUNDAMENTALS OF CARE STANDARD 11

    TOILET NEEDS

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

    STANDARDS FOR HEALTH SERVICES

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

    STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND

    DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC

    SYSTEMS

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

    made

    Good Practice

    1

    Check 5 documents

    Have all patients on admission been

    assessed in respect of their toileting needs?

    Patients toileting requirements must be

    assessed on admission and recorded in the plan of care.

    Standards for Health Services: 8a

    2 Check 5

    Documents

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

    There should be documented evidence of an

    agreed care plan.

    Standards for Health Services: 8a

    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.

    Standards for Health Services: 8a

    4

    Check

    Are there hand washing facilities and paper

    towels in each toilet?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 65 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 11 TOILET NEEDS

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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND

    DECONTAMINATION

    STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC SYSTEMS

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

    Good Practice

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

    Standards for Health Services: 13c

    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.

    Standards for Health Services: 13c

    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.

    Standards for Health Services: 10

    7 Ask 5

    Staff

    Are call bells answered within 5 minutes?

    Patient call bells should be answered within five minutes.

    Standards for Health Services: 10

    8

    Check

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

    Are appropriate bins available for the disposal of sanitary products?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 66 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 11 TOILET NEEDS

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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND

    DECONTAMINATION

    STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC SYSTEMS

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

    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.

    Standards for Health Services: 12c

    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.

    Standards for Health Services: 12a, 12c

    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?

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 67 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 11 TOILET NEEDS

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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 8: CARE PLANNING AND PROVISION

    STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT

    STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) AND

    DECONTAMINATION

    STANDARD 16: MEDICAL DEVICES, EQUIPMENT AND DIAGNOSTIC SYSTEMS

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

    Good Practice

    Urine bottles must be appropriately stored

    and out of sight.

    Standards for Health Services: 10, 12d,

    12e

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 68 Amended Pilot Audit Tool June 2010

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

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comments

    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.

    Standards for Health

    Services: 5b, 10

    16

    Can you easily reach a call bell

    when using the toilet, commode or bedpan?

    Standards for Health

    Services: 5b, 10

    17

    When using the toilet were you

    given enough privacy?

    Standards for Health

    Services: 5b, 10

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 69 Amended Pilot Audit Tool June 2010

    QUESTION YES NO N/A General Comments

    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?

    Standards for Health

    Services: 5b, 13c

    20 Are toilets well sign posted?

    Standards for Health Services: 5b, 12c

    21 Are there any things you would change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 70 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 12

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

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

    STANDARD 9: PATIENT INFORMATION AND CONSENT

    STANDARD 12: ENVIRONMENT

    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

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

    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

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

    Fundamentals of Care Standard 12.5

    Standards for Health Services: 8a

    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.

    Fundamentals of Care Standard: 3.3, 12

    Standards for Health Services: 8a

    4 Check nursing

    documentation

    Is there evidence of ongoing risk

    assessment and evaluation of care to

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 71 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 12

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE

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

    STANDARD 12: ENVIRONMENT

    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

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

    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?

    Fundamentals of Care Standard 12.2 Standards for Health Services: 9a

    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

    Fundamentals of Care Standard 12.3 Standards for Health Services: 16c

    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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 72 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 12

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE

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

    STANDARD 12: ENVIRONMENT

    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

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

    Good Practice

    assessing and prevention of pressure damage.

    Standards for Health Services: 26a

    8 Ask 5 staff

    Is there satisfactory access to pressure relieving and reducing equipment within

    the in patient environment?

    Fundamentals of Care Standard 12.3 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,

    Fundamentals of Care Standard 12.5 Standards for Health Services: 8a, 14a

    9.1

    Check

    documents

    Continence assessment?

    Fundamentals of Care Standard 12.5 Standards for Health Services: 8a

    9.2

    Check documents

    Condition of skin?

    Fundamentals of Care Standard 12.5 Standards for Health Services: 8a

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 73 Amended Pilot Audit Tool June 2010

    FUNDAMENTALS OF CARE STANDARD 12

    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

    STANDARDS FOR HEALTH SERVICES

    STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK

    STANDARD 7: SAFE AND CLINICALLY EFFECTIVE CARE

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

    STANDARD 12: ENVIRONMENT

    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

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

    Good Practice

    9.3 Check

    documents

    Mobility of patient?

    Fundamentals of Care Standard 12.5 Standards for Health Services: 22a

    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

    Patient Male Under 16

    Relative/Carer Female 16-25

    Other e.g. advocate Other 26-45

    45-65

    66-85

    Over 85

    Patients Questions patient feedback 5b

    QUESTION YES NO N/A General Comments

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

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 74 Amended Pilot Audit Tool June 2010

    QUESTION YES NO N/A General Comments

    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

    areas (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 areas 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?

    Standards for Health Services: 5b, 9a

    13

    Were you encouraged to mobilize and sit out of bed?

    Standards for Health Services: 5b,

    8a

    14

    Are there any things you would change?

    Standards for Health Services: 5b

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 75 Amended Pilot Audit Tool June 2010

    WARD/DEPARTMENT SECTION SUMMARY SHEET

    SECTION SUMMARY

    EVIDENCE OF GOOD PRACTICE

    OPPORTUNITIES FOR IMPROVEMENT

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 76 Amended Pilot Audit Tool June 2010

    ACTION PLAN

    Questio

    n No

    Issues Identified Proposed Action to be taken Review Date/Lead

    Person

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 77 Amended Pilot Audit Tool June 2010

    OVERALL AUDIT SCORE SHEET

    STANDARD 1 Communication & Information STANDARD 2 Respecting People

    STANDARD 5 Relationships

    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

    Total number of NO 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

    Total number of NO answers

    Total number of NO answers

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

    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

    Total number of NO answers

    Total number of NO answers

  • ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL

    All Wales Fundamentals of Care Audit Tool 78 Amended Pilot Audit Tool June 2010

    OVERALL AUDIT SCORE SHEET continued

    STANDARD 8 Personal Hygiene & Appearance STANDARD 9 Eating & Drinking

    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

    Total number of NO answers

    Total number of NO answers

    STANDARD 10 Toilet Needs STANDARD 11 Oral Hygiene

    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

    Total number of NO answers

    Total number of NO answers

    STANDARD 12 Preventing Pressure Sores /Ulcers

    Total number of questions

    Total number of applicable questions

    Total number of YES answers

    Total number of NO answers

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