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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<ul><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 1 Amended Pilot Audit Tool June 2010 </p><p>INTRODUCTION One of the recommendations of the Free to Lead, Free to Care, Empowering Ward Sisters/Charge Nurses Ministerial </p><p>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 </p><p>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 </p><p>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. </p><p>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, </p><p>evaluate and audit these standards. </p><p>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 </p><p>experience. </p><p>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. </p><p>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 </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 2 Amended Pilot Audit Tool June 2010 </p><p> Increasing expectations of service users Lack of clarity for service users Increasing focus on regulation and performance </p><p>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. </p><p> 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 </p><p>THE AUDIT TOOL </p><p> It is intended that the ward sister/charge nurse has ownership and responsibility of this audit tool. Each section of </p><p>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. </p><p>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. </p><p> 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 </p><p>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. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 3 Amended Pilot Audit Tool June 2010 </p><p>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. </p><p> FUNCTIONAL REQUIREMENTS Security </p><p> 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 </p><p>available: </p><p>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 </p><p>o Director of Nursing read only: sees information, summaries and action plans from all Wards within their Trust and can add and amend comments </p><p>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. </p><p> Users will have the facility to change their password to one of their own choosing once they have logged on to the system. </p><p> The system will time-out after 60 minutes of inactivity. The system will include an audit trail that records any changes made. </p><p> DATA ENTRY </p><p> Each section of the audit tool contains a series of corporate, operational and user questions. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 4 Amended Pilot Audit Tool June 2010 </p><p> 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 </p><p> 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 </p><p>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 </p><p>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. </p><p>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. </p><p> One point will be awarded for every standard achieved and no points will be awarded for non-compliance of the </p><p>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 </p><p>negative response. A rating is calculated as follows: </p><p>Possible Score: Add the number of Applicable questions in each standard section together </p><p>Actual Score: Add the number of YES answers in each standard section together </p><p>Rating: Total number of YES answers Total number of Applicable questions x 100 </p><p>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. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 5 Amended Pilot Audit Tool June 2010 </p><p>Ward Sisters/Charge Nurses will be able to collate this information to create an Action Plan. Against each issue </p><p>identified in the assessment, the Ward Sister/Charge Nurse will propose an action, and assign it to a lead person with a review date. </p><p>Question Number Issues Identified Proposed Action Lead Person Review Date </p><p> 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. </p><p>Reporting </p><p>Ward Sisters/Charge Nurses will be able to summarise all assessments for their Ward in a number of ways, filtered by the following criteria: </p><p> 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 </p><p> Quantitative reports can also be filtered by type of question, e.g. Corporate/Operational/User. </p><p> 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. </p><p> Benchmarking graphs will also be available, showing anonymised graphs by standard. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 6 Amended Pilot Audit Tool June 2010 </p><p>General Advice </p><p> 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 </p><p>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; </p><p> 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. </p><p>Where patients are unable to complete the questionnaires a relative, carer or advocate may do this. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 7 Amended Pilot Audit Tool June 2010 </p><p>FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION &amp; INFORMATION </p><p>Principle: You will receive full information about your care in a language and manner sensitive to your needs </p><p>The Health &amp; Social Care Guide for Wales (2002) </p><p>Nursing &amp; Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide: </p><p>to consent to examination or treatment (2002) </p><p>STANDARDS FOR HEALTH SERVICES IN WALES </p><p>STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK </p><p>STANDARD 8: CARE PLANNING AND PROVISION </p><p>STANDARD 9: PATIENT INFORMATION AND CONSENT </p><p>STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT </p><p>STANDARD 23: DEALING WITH CONCERNS AND MANAGING </p><p>INCIDENTS </p><p>METHOD QUESTION YES NO N/</p><p>A </p><p>Issues identified Improvements to be </p><p>made </p><p>Good Practice </p><p>1 </p><p>Check 5 </p><p>Documents </p><p>Are the patients demographic details clearly </p><p>recorded on the patients documentation? </p><p>Patients name, address, date of birth and </p><p>identification number (n.h.s. number / </p><p>hospital number) must be recorded on every sheet of paper within the patients nursing </p><p>and medical record. </p><p> Standards for Health Services: 20c </p><p>2 </p><p>Check 5 </p><p>Documents </p><p>Has each patient been fully assessed on admission in respect of their communication </p><p>needs? </p><p>Each patient should have an initial assessment on admission recording their </p><p>communication needs. </p><p> Fundamentals of Care Standard:- </p><p>1.1, 3.3, 8.1 Standards for Health Services: 18e </p><p>3 </p><p>Check 5 Documents </p><p>Is the patients preferred language clearly </p><p>Indicated in the patients nursing records? </p><p> The patients preferred language and method </p><p>of communication should be recorded in </p><p>patients records </p><p> Fundamentals of Care Standard: 1.3 Standards for Health Services: 18e </p><p> Does each patient have an individual care </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 8 Amended Pilot Audit Tool June 2010 </p><p>FUNDAMENTALS OF CARE </p><p>STANDARD 1: COMMUNICATION &amp; INFORMATION </p><p>Principle: You will receive full information about your care in a language </p><p>and manner sensitive to your needs </p><p>The Health &amp; Social Care Guide for Wales (2002) </p><p>Nursing &amp; Midwifery Council Code of professional Conduct (2008) </p><p>Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002) </p><p>STANDARDS FOR HEALTH SERVICES IN WALES </p><p>STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS </p><p>STANDARD 5: CITIZEN ENGAGEMENT AND FEEDBACK STANDARD 8: CARE PLANNING AND PROVISION </p><p>STANDARD 9: PATIENT INFORMATION AND CONSENT </p><p>STANDARD 18: COMMUNICATING EFFECTIVELY </p><p>STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING </p><p>INCIDENTS </p><p>METHOD QUESTION YES NO N/</p><p>A </p><p>Issues identified Improvements to be </p><p>made </p><p>Good Practice </p><p>4 </p><p>Check 5 Documents </p><p>plan? </p><p>There should be an individual Care Plan designed specifically for the needs of each </p><p>patient. </p><p> Fundamentals of Care Standard:- 1.1, 3.7, 4.2, 8.1 </p><p> Standards for Health Services: 8 </p><p> 5 </p><p>Check 5 Documents </p><p>Ask staff </p><p>Is there documented evidence Care Plans </p><p>are discussed and agreed with patients? </p><p> Care plan documents should b readily </p><p>available to patients. </p><p> Fundamentals of Care Standard:- 1.4 </p><p> Standards for Health Services: 9b </p><p>6 </p><p>Check 5 Documents </p><p>Are contact details regarding next of kin </p><p>clearly recorded in patients documentation? </p><p> Contact details of next of kin must be </p><p>recorded in patients documentation </p><p> Standards for Health Services: 18b </p><p> 7 </p><p> Ask 5 staff </p><p>Are there systems in place to obtain patients </p><p>and carers views with regard to the service </p><p>receive? </p><p>Patients and user should be provided with an opportunity to express their views and </p><p>opinions on the service they receive. </p></li><li><p>ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL </p><p>All Wales Fundamentals of Care Audit Tool 9 Amended Pilot Audi...</p></li></ul>

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