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1… Fundamentals of Care Annual Audit 2014

Fundamentals of Care Annual Audit Report 2014


INDEX

Page

1. Executive Summary 3-4

2. Situation 5

3. Background 6

4. Assessment 6-8

4.1 Fundamentals of Care Standards - Review of Operational

Questions and User Experience feedback

8-11

4.1.1 Overall Summary

4.1.2 Std 1 - Communication and information

4.1.3 Std 2 and 5 - Respecting people & relationships

4.1.4 Std 3 – Ensuring safety

4.1.5 Std 4 – Promoting independence

4.1.6 Std 6 – Rest & sleep

4.1.7 Std 7 Ensuring comfort, alleviating pain

4.1.8 Std 8 Personal hygiene, appearance & foot care

4.1.9 Std 9 Eating and drinking

4.1.10 Std 10 Oral health & hygiene

4.1.11 Std 11 – toileting needs

4.1.12 Std 12 – preventing pressure sores

12

12

16

20

23

26

27

28

31

34

35

36

4.2 Fundamentals of Care Staff Survey 38

5. Community Nursing 40

5.1 Findings 41

6. Monitoring and Assurance 41

7. Conclusion 42

8. References 44

9. Appendix A 45


1 Executive Summary

Abertawe Bro Morgannwg University (ABMU) Health Board Quality Strategy, Quality Delivery Plan and Patient Experience Plan embrace the philosophy of

putting patients at the centre of everything we do to deliver safe and effective care, ensuring excellent patient (carer/user) experience and excellent staff

experience. Nursing is the largest workforce within ABMU Health Board. It is essential that every nurse at all levels knows what is the expectation of them

and are euip to deliver. We need to ensure that the Health Board nursing standards of care are clearly outlined, that all staff are trained and competent to

deliver these and that the Senior Nurses are monitoring compliance by visible leadership across all clinical services on a daily basis.

The Health Board will ensure that it abides by the Nursing, Midwifery Council

(NMC) requirements and supports a professional clinical workforce with the

appropriate skills and knowledge for the role. The Dignity and Respect in Care Programme for Wales was launched by The Welsh Assembly Government in

October 2007. ABMU Health Board and its preceding organisations have been firmly committed to this programme. The Dignity in Care Programme is clearly

aligned to the Empowering Ward Sisters Programme and progress is reported to ABMU Health Board’s Quality and Safety Committee. Treating others with dignity

and respect is a core value of ABMU Health Board. Dignified care of older people in both social and healthcare settings has been given a high priority in the

strategic development of the Health Board and in the work of the Western Bay Partnership between ABMU and its three Local Authorities.

The Francis review (February 2013) of care delivered at Mid Staffordshire NHS

Foundation Trust identified 5 key themes, underpinned by the requirement for a fundamental quality improvement culture and the adoption of common values

across organisations focusing on:

Fundamental standards Openness, transparency and candour

Compassionate, caring and committed staff Strong, patient centred healthcare leadership

Accurate, useful and relevant information

As you will be aware, following concerns raised in 2012 about the quality of care at the Princess of Wales and Neath Port Talbot Hospitals, Professor Mark

Drakeford , Minister for Health and Social Services commissioned Professor June Andrews to lead an Independent Review into quality and Care for Older People at

the Princess of Wales and Neath Port Talbot Hospitals. The Andrews Review

“Trusted to Care”.

If ABMU Board adopts the recommendations and acts with conviction and determination, there is no reason to believe that the issues raised in this report

cannot be fully resolved.....” Andrews, Butler, "Trusted to Care" (2014)

http://www.wales.nhs.uk/sitesplus/863/opendoc/240096


The first and most urgent action taken was to help restore public confidence and to make 100% sure that we are not continuing with the five practices highlighted

which were defined as “never events”:

Patients being given prescribed medication but then not being observed taking it. Staff signing the medicines chart to say that a patient has taken medication when

they have not seen this. Inappropriate use of sedation for “aggression. Patients being told to go to the toilet in bed.

In addition we must ensure that patients are appropriately hydrated.

The Fundamentals of Care (FOC) National Audit System has been further updated during 2014 to ensure that it supports these values, providing quality

assurance and identifying improvements where required within services, Health Boards and across NHS Wales. The 2014 NHS Wales FOC National Audit results

provide assurance from the operational audit, patient survey and staff survey where compliance with the 12 standards and excellent experience is

demonstrated. It enables nursing sisters and teams to focus on key areas of

improvements scores are reported below the 85% compliance rate. One of the main changes implemented in the Health Board for this year’s audit was to adopt

a peer review process (A peer review is a process where the audited does not directly manage the area and is therefore independent), reducing the possibility

of being bias. Directorates/ Localities were asked to ensure that this process was in place across their areas. This has been a criticism in the past in relation to

self-auditing. The detailed results of each question within the audit are presented in this report, the summary findings include:

12.Feedback from patients confirms that a high standard of care is provided across the Health Board but there is a need to focus improvement around Standard 6

(Sleep, Rest and Activity).

13.The Operational Audit confirms high compliance in seven standards with a green RAG (Red, Amber, Green) rating score and Amber rating in three standards which include Standard 2&5 (Respecting people & relationships), Standard 8 (Personal

hygiene, appearance and foot care), and Standard 10 which is the lowest at 76.6% (Oral health and hygiene), this however shows an improvement from the

2013 audit. The overall score for the operational standards were 88% with a green RAG rating score.

14.The staff survey results indicated there is a requirement to focus on how we work

and support staff, building trust and ownership, and being part of an effective

team.

I would like to extend my gratitude to all the patients, carers and staff involved

with the 2014 FOC audit process and assisting with providing assurance of where we are providing excellent standards with fundamentals of care and identifying

where we need to focus our continuous quality improvement.

Mr Rory Farrelly Director of Nursing Midwifery & Patient Experience


2. Situation

The 2014 Fundamentals of Care annual audit was undertaken in 159 areas across Abertawe Bro Morgannwg University Health Board (ABMU Health Board)

as well as 3 pilot areas within the District nursing service between 1st October and 30th November 2014. The 2013 audit report included 89 areas.

The areas who undertook the audit are:

Swansea Locality Hospital Based Services

NPT Locality Hospital Based Services

Princess of Wales Hospital MSK

Learning Disabilities Surgical Services

Regional Services Clinical Support Service

Mental Health

The results of the 159 areas that undertook the audit are included in the main

body of this report. The results of the 3 District Nursing teams have been excluded from the main body of the report and are included in a separate

section. A full report is sent to Welsh Government to formulate a National report.

The narrative of this report will focus on areas of key practice, which were

identified from last year’s audit and where focused development work has been undertaken. It will also attempt to recognize and explain any areas of concerns

that emerge from this year’s audit and what we plan to do about this in the coming period. The compliance levels are given as percentages, The majority of

the questions included in the 2014 audit are the same as those included in the 2013 audit and therefore this report will draw some comparisons with the results

from the 2013 audit. However, it is recognised that there are limitations in making summative comparisons as there were only 89 areas included in the

previous audit and there are a number of specialist audit tools which have been adapted for this year’s audit.

A full report is presented to Welsh Government annually in order to formulate a

national response, the results from the Fundamentals of Care audit should not be used to compare organisations across NHS Wales, as it is difficult to draw a

direct comparison due to differences in organisation size and complexity. The

findings of the FOC report are presented as an average All Wales percentage compliance. The FOC audit results generated are for local measurement to

inform quality improvements and to share and celebrate good practice.


3. Background

The Fundamentals of Care (FOC) Standards (2003) have been developed and implemented to improve the quality of fundamental aspects of health and social

care for patients and service users in Wales. Each year, the NHS in Wales undertakes a National Audit of care and service delivery against the 12

Fundamentals of Care Standards. This provides a mechanism which:

Enables patients/carers to: Share their views and experiences on what we do well and where we need to

improve, which will be used to help improve the services we provide

Have a voice in the quality of the care they receive

Empowers staff to: Make a difference and ensure ownership of their practice

Have a voice in the care that they provide and ensure the focus is on essential elements of care and caring.

Identify areas of good practice and highlight issues for concern Develop action plans to monitor change

Enables organisations to: Have a mechanism to monitor/measure the quality of care

Develop organisational policies and procedures Identify key themes for improvement

Adopt a culture of openness and transparency with the quality standards

The results of the Audit provide an opportunity for staff, organisations and Welsh

Government to reflect on: What are we doing well?

What do we need to improve? How can we improve the experience of our patients and staff?

4. Assessment

a. Learning from the 2013 audit - Following the 2013 national audit the

All Wales Fundamentals of Care Steering Group reviewed and reflected on the audit, which included reviewing the tool and the process and this

informed the work plan for 2014. The Steering Group has achieved a significant amount of work this year in preparation for the 2014 Audit:

i. Reviewing Audit Questions - Following the outcomes of the 2013 Audit, the operational, patient survey and staff survey

questions were reviewed to ensure they reflected feedback from nurses (regarding the applicability/wording of the

questions) and incorporated responses to key reports/documents which had been published. Additional

questions were added in relation to issues highlighted in the


Trusted to Care report; medicines management, continence, hydration and use of sedation.

ii. Extending the Scope - The Annual Fundamentals of Care

Audit is undertaken within the following clinical areas:

General medical wards Surgical wards

Theatres Outpatients Departments

Endoscopy Units Day Surgery Units

Unscheduled Care

Welsh Ambulance Service NHS Trust

In 2014, the Audit was extended to new service areas. In previous years the service areas used the existing audit tool. Discussion was

had with the national leads from each of these specialties to agree a subset of audit questions which were applicable to their service.

These were:

Mental Health Maternity

Neonatal Care Paediatrics

Learning Disabilities District Nursing Service.

iii. Patient Survey: for the 2013 audit, it was agreed that the sample for ward areas would be 50% of patients on the ward

on a given day in October. For the specialties areas, it was agreed that the sample would be every other patients who

attended up to a maximum of 15. It was agreed that Theatres would be excluded from this aspect of the audit.

Feedback from teams across Wales identified that giving out the

patient survey on one given day in October had been very challenging and on reflection, the All Wales Steering Group

acknowledged that this expectation was too restrictive. It was agreed that for the 2014 audit the sample would remain the same

but that teams could chose any day between the 1st October and the 31st October 2014 in which to complete the patient survey

element.

iv. Staff Survey – For the 2013 audit, it was agreed that a paper

version of the survey would be given to all the nursing staff on duty during a given 24 hour period in November 2013. Both

Registered and Unregistered Nurses were included. The data


was then manually entered onto the Fundamentals of Care system.

The All Wales Fundamentals of Care Steering Group members

acknowledged the disadvantages of offering a paper version of the survey and it was agreed that for the 2014 audit, the staff survey

would be offered to staff as an online survey. Anonymity could be guaranteed and also the data would be automatically imported into

the Fundamentals of Care system, eliminating the need to identify someone to data entry the information onto the system. It was

agreed that where possible, staff should be supported to complete the survey online, but a paper version would be available to staff on

request. The online survey was available in both English and Welsh.

The inclusion of members of the multidisciplinary team was also discussed by the All Wales FoC Steering Group. It was agreed that

the occupation list on the online survey would include options for

the wider multidisciplinary teams but that the focus of this year’s audit would again be nursing staff, Health Care support workers and

Theatre staff. This year’s audit included 1,580 staff as well as 82 Community staff. The sample will be extended to multidisciplinary

team members for the 2015 audit

v. Updating Guidance - The “Best Practice Guide for Staff” was updated to provide details of the purpose of the Fundamentals

of Care Audit and guidance on how to undertake the audit. Staff were encouraged to conduct peer audits across care

settings and where possible use volunteers to assist patients with completion of surveys.

vi Training Package - With new clinical areas using the

Fundamentals of Care system for the first time, plus the

requirement to help staff understand and use the new functionalities of the system, a training package for staff was

developed.

vii Compliance Matrix - Following consultation with the lead Statistician from Welsh Government the Compliance Matrix was

reviewed to provide a more robust and standardised manner to report audit results. The Compliance Matrix underpins the Action

Planning module and informs priorities for improvement.

b. Review of the Fundamentals of Care System During 2014, there has been significant redevelopment of the

Fundamentals of Care system.

i. Reporting Module – the reporting functionality of the Fundamentals of Care system has been significantly improved to


allow for a greater range of reports to be generated. These include the ability to be able to pull information together into one report.

ii. Action Planning Module – Results from the Fundamentals of Care

Audit can now be quickly and easily pulled in to populate quality improvement action plans. This enables local ownership of findings

to be monitored and actions within time scales. The Action Plans have been designed using SBAR (situation, background, assessment

and recommendations) and align with the model for improvement.

iii. Variable Frequency - the system has been developed to enable users to access the Fundamentals of Care audit tools and utilise

these more often during the year than simply annually. This enables staff to monitor the effectiveness of their action planning through

re-audit and demonstrate continuous improvement.

iv. Undertaking the Fundamentals of Care Audit 2014 - The time span for staff to complete this year’s Audit was 1st October - 30th

November 2014. The Operational Audit was undertaken between 1st October –

30th November

The Patient Survey was undertaken between 1st October – 31st October

The Staff Survey was undertaken between 1st - 16th November

Monitoring Processes In addition to the overall Health Board action plan developed in response to the

Health Board wide findings, at local ward/department level, all areas will be monitored through local performance management arrangements.

Directorates/ Localities – each Directorate/Locality will monitor the results and ongoing actions through their local performance management arrangement

Health Board – The annual audit will be reported to the Quality & Safety

Committee in February 2015.

Other Factors to note

Health Board Nursing Documentation work programme– This report will make reference to the significant work that has been undertaken over the last 12

months within the Health Board to eventually make a whole system change to the Adult nursing documentation in use. The Document uses the 12

fundamentals of care standards as its core data. which reflected the patient’s needs for use in the inpatient wards both in acute and community hospitals. The

document is also aligned to the Integrated Assessment process within the Local Authorities

Having a standard approach:

Ensures consistency in nursing assessment, care planning, implementation of care and evaluation for patients.


Promotes better communication and sharing of information. Facilitates patient involvement in their own care planning/management,

Makes continuity of care easier Improves patient safety.

Is proportionate to patient’s needs.

The key actions/changes required were the:

Development/implementation of a core assessment documents for both

adult inpatients and Community settings, which is compliant with the All Wales minimum dataset and incorporating the Fundamentals of Care, and

also aligned with the integrated assessment process.

Development of key care plans

Establishment of clear governance and quality assurance processes for all

current and future documentation developments

Establishment of processes for auditing and monitoring compliance

The results from the FOC audit are only a part of the bigger picture of the quality of services provided in the organisation. Informationfrom this audit

needs to be incorporated with results from other data sources (e.g mortality

reviews, infection control rates, concerns trends, findings from Executive walkrounds/inspections and clinical audit findings) to determine if

thisorganisation is doing the right thing well and providing care which is dignified, safe and effective to meet the needs of individuals.

Fundamentals of Care Standards

(Operational Questions and User Experience Feedback)

Overall Summary

A comparison between the audit results for 2013 and 2014 has been provided to show where improvements have been noted. It is also important to note that due

to the inclusion of additional specialties for the 2014 the sample size for 2014 was greater than for 2013 and each standard includes additional specialty

specific questions. A number of the 2013 audit questions have also been refined based on the feedback received as part of the review of the 2013 audit.

The 2013 audit provides a baseline from which to compare the actions undertaken since last year’s audit and have improved the services provide to our

patients and service users.

Operational Questions

The 2014 audit results for the 158 clinical areas audited across Abertawe Bro

Morgannwg University (ABMU) Health Board demonstrate that for the operational questions in 8 out of the 12 standards the organisation had met the All Wales

fundamentals of care standards compliance of 85% and all areas except had improved compliance from the 2014 audit. This year the Operational questions

were undertaken as a peer review process. Each Directorate/Locality was


responsible for ensuring that staff changed areas. This was agreed as best practice and the first year that the audit has been undertaken in this way.

Peer review is a practice monitoring program in which the audit is carried out by

a person who is not based in the area or directly responsible for the area. This will provide objective scrutiny of the clinical area reviewed.

As discussed earlier the Three Community areas within the Localities piloted the Fundamentals of Care Audit this year and are not included in the report. They will be presented separately, at the end of the report.

The table belows shows the compliance with the overall standards for the 2013 & 2014 audit.

Operational Question Overall Summary (%)

2013 FOC Audit

2014 FOC Audit

Imp. %

Std 1 Communication and Information 86 90 4

Std 2 & 5 Respecting people and Relationships 81 84 3

Std 3 Ensuring Safety 88 93 5

Std 4 Promoting Independence 88 92 4

Std 6 Rest & Sleep 75 90 15

Std 7 Ensuring Comfort & Alleviating pain 80 85 5

Std 8 Personal hygiene, appearance and foot care 73 84 11 Std 9 Eating and Drinking 85 89 6

Std 10 Oral Health & hygiene 61 77 16

Std 11 Toileting needs 88 92 4

Std 12 Preventing pressure sores 94 95 1

Overall Health Board Score 84 88 4

There are three areas at below 85% and the action plan for improvement will focus particular attention on these which are Standard 2&5 (Respecting people &

relationships) Standard 8 (Personal hygiene, appearance and foot care) Standard 10 ( Oral health & hygiene). All areas showed an improvement from

the previous year.

Patient Surveys (User Experience)

The patient surveys were undertaken during the month of October 2014 across all audit areas within the organisation and across all organisations in Wales, with

the exception of the theatre departments. 1,475 patients as well as 150 patients

in the Community were surveyed across ABMU Health Board.

One of the key changes for this year’s audit, was for the first time Volunteers supported the patients in completing the surveys in many areas, in previous

years the clinical staff have supported this process. In total the Volunteers visited 26 areas in Morriston, 9 areas in Neath Port Talbot, 21 areas in Princess

of Wales and 8 areas in Singleton Hospital.

The table below details the compliance from the 2013 & 2014 audit findings.


4.1.1 User Experience Overall Summary (%)

The combined results for all user experience survey questions demonstrates that the patients surveyed were on the whole very satisfied with the

standards of care that they received from ABMU Health Board.

When specifically asked to rate their overall satisfaction with the care provided to them and their families they gave the organisation a rating of

94% ensuring that Abertawe Bro Morgannwg University Health Board achieved a RAG rating of green in accordance with the All Wales fundamentals

of care audit criteria.This shows a marginal improvement from the previous

year.

All Standards achieved green RAG rating with the exception of Standard 6 Sleep, rest and activity where they scored an overall percentage of 82%, an

amber RAG rating.

4.1.2 Standard 1 - Communication and Information Operational Questions

(Blank areas represent where questions are different)

Standard 1 - Communication and Information 2013

FOC Audit

2014

FOC Audit

For this episode of care, are the patient's demographic details clearly recorded (and where required, has a photograph) on all patient's documentation?

93% 95%

For this episode of care, is there documented evidence that the patient's ability to achieve effective communication has been assessed and discussed with the patient or advocate?

93% 91%

User Experience Overall Summary (%)

2013

FOC Audit

2014

FOC Audit

Imp.

%

Std 1 Communication and Information 95% 93% 2

Std 2 & 5 Respecting people and Relationships 96% 96% 0

Std 3 Ensuring Safety 98% 98% 0

Std 4 Promoting Independence 95% 96% 1

Std 6 Rest & Sleep 83% 82% -1

Std 7 Ensuring Comfort & Alleviating pain 96% 96% 0

Std 8 Personal hygiene, appearance and foot care 98% 98% 0

Std 9 Eating and Drinking 90% 91% 1

Std 10 Oral Health & hygiene 89% 94% 5

Std 11 Toileting needs 98% 95% 3

Std 12 Preventing pressure sores 91% 95% 4

Overall Health Board Score 93% 94%


For this episode of care, where the patient requires assistance to achieve effective communication, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

82% 81%

For this episode of care, is there documented evidence that each plan of care has been assessed and discussed with the patient or advocate?

75% 72%

Is there a clear plan of care following all episodes of care throughout the pregnancy and postnatal period?

99%

For this episode of care, are the contact details of the first point of contact recorded in the patient’s documentation?

97% 96%

In the clinical area, is there accessible information regarding how patients/relatives/advocates can raise a formal or informal concern?

93% 96%

In the clinical area, is there information available regarding unit facilities, local amenities, parking, visiting, local support groups and arrangements for going home?

100%

Do all patients wear an identification band which states their first and last name, date of birth and NHS number?

92% 92%

Is the patient's identity checked visually and verbally prior to giving medication or undertaking a procedure? [2013 Audit ONLY]

99%

Are all clinical staff wearing staff identification badges? 85% 82%

Are all clinical staff complying with the All Wales Dress Code? 99% 94% For patients with no known diagnosis of dementia, delirium or other cognitive impairment at admission, there is documented evidence that within 72 hours of admission, the following screening question has been asked, Have you/has the patient been more forgetful in the past 12 months to the extent that it has significantly affected your/their daily life?

64% 66%

For this episode of care, where the patient has an identified care need in respect of cognitive impairment, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

76% 76%

For this episode of care, where the patient has been assessed under the Mental Health Measure to be a relevant patient, has a Care Treatment Plan been completed?

100%

Is a nurse present to support the patient during formal senior contact between healthcare professionals (for Paeds) doctors/consultants/GPs and patients?

86% 96%

Is the patient's preferred language clearly indicated in the nursing documents? 89%

If a patient's language of need is Welsh, do staff know how to access a Welsh speaking member of staff?

68% 95%

For this episode of care has a developmental assessment been undertaken?

100%

Do women have access to general information about the birth centre/midwife led unit/obstetric unit prior to admission or on arrival?

91%

Is there evidence that women are receiving the Bump, Baby and beyond Book or how to access it online?

78%

Is there evidence that women are informed of the role of supervision and how they can access a supervisor of midwives?

48%



Areas of Good Practice

ABMU Health Board performed strongly in many elements of this standard. Of

particular note was the good practice observed with staff compliance to the ABMU Health Board guidance for the safe administration of medicines.

100% of staff observed checked patient identification verbally and visually prior to the administration of medicines.

Within the Mental Health Directorate 100% of patients who were assessed under the Mental Health Measure had a treatment care plan.

Within Pediatrics 100% of patients had a developmental assessment undertaken.

Care Planning – Communication

Communication is central to all activities provided in the care environment and all human interaction involves communication. When caring for patients, carer`s

and service users who are often experiencing high emotions due to worry, fear and anxiety, clear, regular and consistent communication and information

becomes even more vital. When patients have difficulty communicating or being communicated with, this can significantly impact on well-being, and

relationships. Communicating effectively needs to be recognized as a priority

within the care planning activity. Only 81% of patients with identified communication problems had an up to date care plan which had been reviewed

within the previous 24 hours, although this is not a direct comparism from the previous year where we scored 64% this shows a slight improvement, further

improvements will link closely with the work undertaken as part of the Health Board’s Nursing Documentation group.

Communicating in Welsh

95% of the clinical areas identified the availability of Welsh speaking staff. This is an improvement on the previous year of 68%. Ward staff are aware of the staff

within their area who can speak. Welsh speaking nurses are easily identifiable by the embroidered badge on their uniforms. ABMU Health Board has a regular

Welsh Language Steering Group meeting.

The staff population of ABMU Health Board come from many cultures and

countries around the world and speak many languages and dialects. The Health Board is signed up to use language line and encourage staff to use where

necessary and also utilising staff to translate if appropriate.

Raising a concern

Significant work has been undertaken to ensure that patients are encouraged to raise concerns about the care that they are receiving, ideally at the time that

they are receiving it, so that it can be put right as soon as possible. 96% of the clinical areas confirmed that there is information clearly displayed regarding how

patients/relatives/advocates can raise a formal or informal concern.

Dementia One of the targets of the 1000 Lives Plus ‘Improving Dementia Care’ work

stream is to improve the quality of life and care for people with dementia and


their care-givers. This is a one of the key priorities for the Health Board. One of the targets is to improve the quality of general hospital care for people with

dementia and reduced length of stay. A screening question has been devised and needs to be considered for all patients within 72 hours of admission. The

screening question “have you been more forgetful in the past 12 months?” “Has this affected your daily life?” has been included in the new nursing assessment

document. Only 66% of the patients without a known diagnosis of dementia, delirium or

other cognitive impairment had been asked the screening question within 72 hours of admission. It is expected that as the new nursing assessment document

is embedded into practice that the compliance score will show an improvement. 76% of the patients who had an identified need in respect of cognitive

impairment had an up to date plan of care, which is being implemented and

evaluated and had been reviewed within the last 24 hours. The development of a Health Board care plan for the care of patients with dementia, delirium and/or

cognitive impairment forms part of the wider Health Board documentation work plan. The use of the the ‘Butterfly Scheme’, which is in place is aimed at helping

all staff give people with dementia more effective and appropriate care. The improvements as part of the “Trusted to Care actions” will also help to

address some of the issues, a base line assessment is being carried out in ward areas using an agreed toolkit, which willenable all wards to be assessed, against

to achieve an ‘Ideal Ward Status’. Each ward will set up a Multidisciplinary team to undertake the baseline assessment. The toolkit provides a framework to

develop an action plan. Once all actions have been achieved. The ward will apply for an Ideal ward status. The focus work will initially be around the Acute adult

areas.

Staff Identity 82% of the clinical areas confirmed that all clinical staff was wearing staff

identification badges. The Health Board has recently agreed that a standard name badge will be worn by all Clinical staff; the badge clearly identifies staff

names and position in both English & Welsh. 94% of the clinical areas confirmed that all clinical staff were complying with the

All Wales Dress Code.

Nurse/Health Care Professional This question was first included in the 2013 audit as the Francis Report (2013)

noted, “ward managers and named nurses should be an intrinsic part of medical ward rounds and other contacts between doctors and patients”. The Royal

College of Physicians and the Royal College of Nursing jointly published the “Ward Rounds in Medicine: principles of best practice” (2012) which highlighted

the importance of ward rounds “as an opportunity for the multidisciplinary team

to come together to review a patient’s condition and develop a coordinated plan of care, while facilitating full engagement of the patient and/or their carer in

making shared decisions about care”. 96% of the clinical areas confirmed that a nurse was present during the contact between doctors/consultants/GPs and

patients.This is an improvement from the previous years audit of 86%.


Maternity

This question is in specific relation to Maternity. Only 48% of women are informed of the role of supervision and how they can access supervision? This

has been discussed with the Directorate. Since the introductionof the new model of supervision in Wales(August 2014) there appears to be an increase in the

number of women accessing the 24 hour telephone service. Since the model has been introduced there is an All Wales group to raise the profile.Information has

also been placed on nooticeboards in all Midwifery clinical areas. Since 2014

Supervisors of Midwives wear a different uniform to help distinguish the different role.

User Experience Standard 1

Communication & Information

%

93%

Patients felt they were given a full explanation of

their care

93%

Patients felt they were kept informed regarding

delays

91%

Patients felt they were given information about unit

facilities

94%

Patients felt they were encouraged to attend ward

rounds

91%

Findings

Overall the vast majority of patients who responded were satisfied with the

quality and frequency of information given and the manner in which it was provided. 94% of patients felt that they were always or usually given full

information about their care in a way they could understand.

Patient Comments

“Always available to discuss mums care, medication etc. Although stretched

resources, we could always find someone”.

“Staff always very helpful and explained things to both me and my father in a way I could easily understand”.

“The professional manner in which the staff carried out their duties. Nothing

seemed too much trouble for them”.


4.1.3 Standard 2 and 5 - Respecting People and Relationships Operational Questions.


Standard 2 and 5 - Respecting People and Relationships

2013 FOC Audit

2014 FOC Audit

Does the patient's documentation capture their preferred name and/or title? 87% 90%

For this episode of care, is there documented evidence that an assessment of the carers needs has been considered?

73% 72%

For this episode of care, is there documented evidence that the patient's cultural needs have been assessed and discussed with the patient or advocate?

74% 74%

For this episode of care, is there documented evidence that the patient's spiritual needs has been assessed and discussed with the patient or advocate?

69% 77%

Is there evidence to demonstrate that patient identifiable information is treated in a confidential and secure manner?

98% 95%

For this episode of care, is there written evidence in the patient's clinical notes that the patient's consent to the sharing of information with others has been obtained?

79% 65%

Is there a facility for patients to talk in private to staff (e.g. a quiet room or office)?

99% 97%

Is there a quiet room for patients to spend time with their visitors away from their bedside?

64% 76%

Within the clinical area, are all the bays single sex bays? 72% 81%

Do all patients have access to single sex toilet and washing facilities? 76% 74%

Is there a facility to preserve patient's dignity by communicating to others that care is in progress?

81% 92%

Are there facilities to preserve a mother’s dignity if she wishes to express or feed at the cot side i.e. patient screens?

100%

Can staff demonstrate they know the procedure if a safeguarding concern is identified?

96% 98%

Are there age appropriate playrooms for children/young people?

83%

Are there quiet areas for CYP to complete schoolwork if applicable?

50%


Areas of Good Practice

There was an improvement in the overall compliance.

98% of areas can demonstrate that staff know the procedure if a safeguarding

concern is identified.

97% patients are able to talk in private with staff in a separate room.

Dignity & Respect

All those who provide care have a responsibility to ensure that care should be provided with compassion and empathy and that a patient’s privacy and dignity

are maintained at all time. It is pleasing to note that 92% of areas stated that


there was a facility to communicate care was in progress, an example would be the Red peg symbol. 100% of maternity areas stated that there were facilities to

preserve a mother’s dignity. One of our key expectations is that all patient contact will be conducted with dignity and respect. This area has improved from

the previous year where compliance was 81%

Spiritual and Cultural need Spiritual Care is an integral part of healthcare and endorses the need to respect

the physical, psychological and social life values and beliefs of individuals. The ‘Standards for Spiritual Care Services in the NHS in Wales’ 2010 document was

introduced to facilitate the audit of spiritual care services, to ensure equality across services and to develop an integrated approach to the delivery of religious

and spiritual care. 74% of patients had documented evidence that their cultural

needs had been assessed and discussed with the patient or advocate and 77% of patients had documented evidence that the patient's spiritual needs had been

assessed and discussed with the patient or advocate, this is an improvement from the previous year. The new assessment document includes a space for

spiritual and cultural needs and there needs to be a focus on ensuring this information is accurately recorded, compliance will be monitored via the

Documentation group and audits. The chaplaincy service is currently going through a period of restructure this should also support an improvement.

Provision of Single Sex Facilities There has been considerable focus on ensuring that, where possible, single sex

accommodation is provided to patients admitted to hospital. 81% of areas had facilities of single sex accommodation; the main areas of non compliance are the

assessment areas, and critical care areas. 74% of areas are compliant with

access to toilet and washing facilities. Signage is in place in the majority of areas. As new areas are built and existing areas upgraded this needs to be

considered as a priority. As part of the “Trusted to care actions” Health Board wide signage is being addressed, as currently there is no standardised approach.

The commitment of the Welsh Government to abolish mixed sex accommodation was communicated by the Chief Nursing officer of Wales in August 2010. This

underpinned the recommendations made in the free to lead free to care report (2008) which requires that all new hospitals have single sex wards, that existing

hospitals with mixed sex wards are required to divide such wards and provide separate bathroom facilities. This is backed up by the Department of Health

(2009) and includes Assesments unit, admission wards and Day units, with the exception of clinical need taking priority.

Information Governance The “Confidentiality - Code of Practice for Health and Social Care in Wales”

identified that there are four main requirements to maintaining and improving confidentiality:

PROTECT – look after the patient’s or service user’s information INFORM – ensure that individuals are aware of how their information is

used

PROVIDE CHOICE – allow individuals to decide, where appropriate, whether their information can be disclosed or used in particular ways


IMPROVE – always look for better ways to protect, inform, and provide choice

It is the responsibility of every member of staff working with personal identifiable

information to ensure that it is kept safe and secure at all times and that complete confidentiality is safeguarded. 95% of clinical areas confirmed that

there was evidence to demonstrate that patient identifiable information is treated in a confidential and secure manner. The use of lockable trolleys has been

purchased and now available in many clinical areas. The Health Board has a duty of care in the handling and sharing of information

and 65% of patients had written evidence in their clinical notes that the patient's consent to the sharing of information with others has been obtained. The nursing

assessment documentation asks patients to consent to sharing of information as

a core element. Compliance will be monitored via the Documentation group and audits as part of the implementation process. The need for consenting to share

information is also explained in the nursing documentation guidance notes, that are available. The roll out of the Patient status at a Glance (PSAG) Boards within

the clinical areas help to improve the sharing of key information. Work is in progress to standardise the content and layout of the boards.

Staff are expected to attend an Annual information Governance training session to update on their requirements around confidentiality and sharing and storage

of information.

Carer’s Assessment

In July 2013 the Carer’s Measure was launched in ABMU Health Board in conjunction with local Authority Partners. Most carers have a legal right to an

assessment of their own needs. 72% of patient’s records that were reviewed had

documented evidence that an assessment of the carer’s needs has been considered. This is part of the core nursing documentation and requests staff to

ask if the carer’s require an assessment. Further work is needed to ensure staff understand the rights of carers. Compliance will be monitored as part of the

nursing documentation roll out. Initial findings from audits as part of the documentation implementation plan have showed improvements in this area

further audits will be carried out to monitor compliance.

Paediatrics

In relation to the Paediatric operational question “Are there quiet areas for

Child/Young person’s to complete schoolwork”? Which showed only 50% compliance. Generally children are not in hospital long enough to undertake their

school work. In relation to the question “Are there age appropriate playrooms for children/young people”? Currently there is only one play area in all wards and

outpatient areas, which are not always suitable for older children and young

people. This is due to lack of suitable space. In the new Outpatient Department there will be two separate areas. This will be addressed as part of the

development plans for the future across both sites.


User Experience Standard 2&5

Respecting people & Relationships

%

97%

Patients felt they were treated with Dignity &

Respect

97%

Patients felt they were given privacy 97%

Patients felt that we responded in a timely manner

when called

94%

Patients felt well supported in the care of their baby 100%

Findings

Findings confirm that patients’ experience of a dignified care environment is very

positive.

“I am particularly impressed with how all the staff are courteous and helpful

offering a very personal service, for which I am grateful”.

“Staff very helpful”. “Magnificent staff who have given me the attention that I need to get better. I am really grateful for all the help I am receiving in the Hospital”.

4.1.4 Standard 3 - Ensuring Safety Operational Questions (Blank areas represent where questions are different)

Standard 3 - Ensuring Safety 2013

FOC Audit

2014

FOC Audit

Has the Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months? [2013 Audit ONLY]

97%

If an Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months, please enter the percentage compliance score. [2013 Audit ONLY]

87%

Has a Waste Management Audit been undertaken within the last 12 months? [2013 Audit ONLY]

26%

Has a Waste Management Audit been undertaken within the last 12 months? Please enter the compliance score as a percentage. [2013 Audit ONLY]

55%

Are all medication charts completed with the following information: patient demographics, weight and allergies and it is clear whether there is more than one medication chart?

73%

Is the patient's identity checked visually and verbally prior to giving medication?

91%

Are all medications checked by two qualified nurses?

100%

Is the patient's identity checked visually and verbally prior to undertaking a procedure?

99%

Has the nurse witnessed the patient taking the medication given to them?

99%

Is there evidence that medication is taken in a timely manner and is not left on lockers/around patient beds?

97%

Are all drug cupboards/trolleys locked and secure as per local policy? 97% 96%


Are staff able to give examples of the correct procedure for infection control?

100%

Are staff able to give examples of the correct procedure for isolating patients? 100% 98%

For this episode of care, is there documented evidence that the patient has an up to date manual handling risk assessment?

97% 94%

For this episode of care, where the patient has an identified manual handling risk, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the agreed timescale?

89% 85%

Are any Manual Handling aids and slings regularly checked for wear and tear? 93% 96%

If a patient has been assessed as requiring bed rails, is there an up to date risk assessment in place?

94%

Is the Child/Young Person in an age appropriate bed with cot sides/bed rails in situ?

100%

Within the clinical area, are all fire restraint doors free from obstruction or closed if not automatic self closing?

93% 87%

Is all equipment used up to date with maintenance and calibration? 98% 94%

For this episode of care is there an individual Positive Behaviour Plan in place prescribing individual restrictive practices that can be used to support the patient if need be.

97%

For this episode of care, is there documented evidence that the baby has an up to date Developmental Care assessment?

100%

Have the baby’s dependency needs been individually assessed within the last 24 hours?

100%

Have the babies? Dependency needs been staffed according to their levels of care?

100%

Within the clinical area, babies are safe and secure while on the unit and parents are informed of security arrangements on admission?

100%

Are the security doors and cameras operating effectively?

100%

Are entrances to the Birth Centre/Midwife Led Unit/Obstetric Unit visible both day and night?

100%

Are babies securely and appropriately labelled?

100%

Are all staff aware of what to do in the event of baby abduction?

100%


Good practice Good practice overall in relation to this standard ,many of the questions have

changed since the previous audit. Excellent compliance in a number of areas in particular;

Within paediatrics there is 100% compliance with the checking of

medication.

100% compliance where staff were able to give examples of infection

control procedures.

Excellent compliance around questions relating to maternity.


Manual Handling A patient handling assessment must be undertaken and be accessible to those

needing to assist the patient. The re-assessment of individual patients must occur as appropriate or if there is a change in their condition. 94% of the

patients had documented evidence that the patient had an up to date manual handling risk assessment and of those patients who had an identified manual

handling risk, 85% had an up to date plan of care, which was being implemented and evaluated and had been reviewed within the last 24 hours.

Safety

Maintaining a safe environment is a key aspect of the care that we provide. 88% of the clinical areas stated that all fire restraint doors were free from

obstruction or closed if not automatically self-closing. The narrative notes that there were a small number of occasions when fire doors were

obstructed by equipment.

95% of clinical areas stated that the equipment used in the area were up

to date with maintenance and calibration.

Medication A number of questions have been added this year for the 2014 audit which

specifically relate to medicine, it was agreed that this area would be strengthened following “The Trusted to Care Report” these show that

97% of the clinical areas stated that all the drug cupboards/trolleys were locked and secure as per local policy. There has been ongoing monitoring

of this area as part of the spot checks across the Health Board. Where there is non compliance areas are being addressed, this may include

provision of extra doors and locks. 91% compliance with checking patient’s identity prior to administration. 99% of patients are witnessed taking their medication. 73% are correctly and fully completed, this area needs to be improved and

is now monitored monthly on the care indicators.Local areas will need to

address this.

As part of the ongoing work with the “Trusted to Care action” the Health Board

has strengthed its Medicines administration policy to include a number of appendicies and a consistent approach in addressing any medication errors.

Further indicators around medication monitoring have been added to the FOC monthly care indicators and are audited monthly by Pharmacy.


Ensuring Safety

%

98%

Patients felt that the clinical area was kept clean &

tidy

98%


Patients felt safe 98%

Maternity staff washed their hands before and after

care.

100%

Service users felt safe 93%

Patient Comments

“A calm atmosphere”

“Patient stated that she is happy that the staff look after her”

“Clean but cluttered. Clean comfortable and warm accommodation”.

“Lots of equipment, lack of storage space”

“I feel safe and at ease, if I wanted to ask anything good listeners”.

4.1.5 Standard 4 - Promoting Independence Operational Questions (Blank areas represent where questions are different)

Standard 4 - Promoting Independence 2013 FOC

Audit

2014 FOC

Audit

For this episode care, is there documented evidence that the patient’s level of independence has been assessed and discussed with the patient or advocate?

94% 95%

For this episode of care, where the patient has been identified as requiring support and/or assistance to maximise independence, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

86% 94%

For this episode of care, is there documented evidence the patient's mobility has been assessed and discussed with the patient or advocate?

97% 97%

For this episode of care, where the patient has been identified as requiring support and/or assistance with mobility, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last within the agreed timescale?

86% 90%

For this episode of care, is there documented evidence the patient's risk of falls has been assessed and discussed?

91% 95%

For this episode of care, where the patient has been identified as being at risk of falls, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

91% 87%

Where appropriate, do all patients have written evidence of a discharge assessment and plan?

79% 88%

Where appropriate, do all babies have written evidence of a discharge plan from the point of admission and are continually reviewed, involving both parents and a multidisciplinary team?

70%

Where appropriate, is there written evidence that the patient’s family/carer has been involved in discharge planning?

80% 89%

Within the clinical area, are washing, bathing and toilet facilities suitable for the all service users? [2013 Audit ONLY]

88%


Within the clinical area, are washing and bathing facilities suitable for all Patients?

100%

Within the clinical area, are toilet facilities suitable for all service users?

91%

Does the clinical area allow patients to bring in personal items to assist with patient orientation/familiarity?

93% 100%

For this episode of care, is there documented evidence that mothers who require breastfeeding support and/or assistance has been assessed and discussed?

95%

For this episode of care, where the mother has been identified as requiring support and/or assistance to establish breastfeeding on the unit, prior to going home, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

71%

For this episode of care, is there documented evidence that the mother is shown how to make feeds and sterilise bottles and teats prior to going home?

40%

Is there documented evidence that the mother is shown parent craft skills prior to going home?

83%

Does the clinical area allow for parents to room in with their baby prior to going home?

83%

Where appropriate, is there documented environmental assessment undertaken?

100%


Good Practice

Overall the audit data suggests good practice is being observed and compliance has improved in all areas from the 2013 audit, noting that there are a number of

alternative questions for the 2014 audit. 100% compliance with allowing parents to room in with their babies prior to going

home. 100% compliance with allowing patients to bring in personal items

Level of Independence compliance

Maintaining independence improves quality of life and maximises physical and emotional well being and 95% of patients had evidence that their level of

independence had assessed and discussed with them or advocate and 97% had evidence that the patient’s mobility had been assessed and discussed with the

patient or advocate. Of those patients who were identified as having a problem with independence, 94% had an up to date plan of care, which was being

implemented and evaluated and has been reviewed within the last 24 hours and of those patients who were identified as having a problem with mobility, 90%

had an up to date plan of care, which was being implemented and evaluated and has been reviewed within the last 24 hours.

Falls compliance

Evidence suggests that falls prevention can reduce the number of falls by between 15% and 30%, and that well organised services, based on National

Standards and evidence-based guidelines, can prevent falls and reduce death

and disability from fractures (1000 Lives Plus). Identifying patients at risk of falls


is key and this audit demonstrated that 94% of patients had evidence that their risk of falls had been assessed and discussed with them or their advocate. Of

those 89% had an appropriate plan of care in place. Following discussions with key Consultants around the frailty model, the Documentation Group is looking to

add a key question within the core nursing documentation “has the patient had any falls within the last 12 months” to highlight any risks, especially in patients

over the age of 65years.

Discharge Planning Discharge remains a priority within the Health Board and of those patient records

reviewed, 88% of adult patients had written evidence that the patient’s had a discharge assessment and plan, 70% of babies and 89% had evidence that the

patient’s family/carer had been involved in discharge planning.This shows an

improvement from 2013. Evidence of discharge planning should be clearly visible in documentation and also on the patient at a glance boards which have been

implemented (PSAG) Board rounds are undertaken across the Health Board. A number of other improvement initiatives have also been implemented. Maternity question

95% compliance with documented evidence to support where necessary mothers

requiring assistance with breastfeeding? Only 40% compliance where mothers have been shown to make feeds and

sterilise bottles and teats prior to going home? Following discussion with the Directorate, there are a number of actions taken to address the issues, This is

normal routine postnatal discussion that should be discussed with every bottle feeding mother prior to discharge. There is documentation in place to support.

83% compliance where mothers are shown parent craft skills prior to going home.The Directorate is working towards achieving these standards and will

monitor and expect an improvement.


Promoting independence

%

96%

Patients felt that we responded in a timely manner

when called.

94%

Patients felt that they were able to have

unrestricted access to their baby

100%

Patients felt that they were given help to be as

independent as possible.

97%

Patients were able to stay overnight with their baby 92%

Parents felt they were being prepared to be

confident parents

98%

Motheres felt that they were given help to

independently care for their baby

97%

Patient Comments

“Staff always encouraged my father to walk that little bit further and give him

support when doing so. This helped him greatly”.


“The staff were second to none in all areas during my treatment”.

“I was given plenty of opportunities to be independent and do things for myself, which makes me, feel better, as I find it easier to learn that way”.

4.1.6 Standard 6 - Rest & Sleep Operational Questions (Blank areas represent where questions are different)

Standard 6 - Sleep, Rest and Activity 2013

FOC Audit

2014

FOC Audit

For this episode of care, is there documented evidence that the patient's normal sleep pattern and needs have been assessed and discussed with the patient or advocate?

86% 87%

For this episode of care, where the patient has an identified sleep issue or sleep has been recorded as poor/disrupted is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

59% 78%

Does the clinical area allow for a period of 'quiet time' during the day to ensure that babies have a period of rest/sleep period?

100%

Does the clinical area allow for the lighting particularly during periods of rest and sleep to be individually controlled at the cot side?

100%

Does the clinical area allow for the noise levels particularly during periods of rest and sleep to be controlled at the cot side?

0%

Are lights in sleeping areas, other than the over the bed night lights, switched off or dimmed at night?

100%


Good Practice Introduction of rest periods in a number of clinical areas to help patients

have protected time for their rest. 100% compliance around dimming lights at night.

100% compliance where lighting can be controlled at the cot side.

Adequate sleep and rest is important for mental wellbeing and physical restoration and recovery. Acutely unwell patients deprived of sleep can become

confused and agitated or lethargic and disinterested. Even patients who are reasonably healthy can become agitated and aggressive if their sleep is

continuously disturbed.

Findings

Compliance has improved in this standard. Of the patients notes reviewed 87%

of had evidence that that their normal sleep pattern and needs had been assessed and discussed with the patient or advocate and 78% of patients had an

up to date care plan reflecting this, the previous year showed that there were

only 59% compliance around care planning. The new nursing assessment documentation has a section which asks if there are any difficulties and if there

are requests a care plan. This should improve compliance further as this is rolled out and imbedded across the Health Board.


Within the Neonatal specific tool a question was asked around the ability to

control noise at the cot side. This scored 0%, having discussed this with the Directorates leads, they feel they would not be able to comply with this fully

unless each baby was nursed in a cubicle which would not be practical. There are a number of ward rounds during the day due to the nature of the area. However

they do have mechanisms in place to reduce noise levels, such as visiting is restricted to parents only, and they also have quiet times within the day. This is

the first year to use the Neonatal audit tool following feedback the question may need to be slightly altered.


Sleep, Rest Activity

%

Patients felt that they were able to get enough sleep

& rest.

82%

Findings

Of all twelve standards audited Sleep and Rest was the standard that service users reported most dissatisfaction against this year.

The factors which contribute to disturbances in sleep and rest across all sites

needs to be further explored. Each area will look at improvements wherever possible

Patient Comments

“Disturbed early and woken up to do observations”

“Other patients can be noisy”

4.1.7 Standard 7 - Ensuring Comfort & Alleviating pain Operational

Questions (Blank areas represent where questions are different)

Standard 7 - Ensuring Comfort, Alleviating Pain 2013

FOC Audit

2014

FOC Audit

For this episode of care, is there documented evidence that the patient's pain has been discussed and assessed using an appropriate pain assessment tool?

88% 92%

For this episode of care, where the patient has an identified problem with pain is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

87% 81%

For this episode of care, is there documented evidence that the patient's concerns/anxieties or fears has been assessed and discussed with the patient or advocate?

76% 83%

For this episode of care, is their documented evidence that the baby’s comfort has been discussed and assessed using a developmental care tool?

100%


For this episode of care, where the patient has expressed concerns, anxieties or fears, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

67% 81%

For this episode of care, where the baby has been an identified problem with comfort is their evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hrs?

60%

Does the clinical area allow CYP/family/carers to bring in personal items to assist with CYP? orientation/familiarity/anxiety

100%


Good Practice

Compliance overall has improved. 100% compliance within the clinical areas allowing personal items to be

brought into Hospital. 100% compliance where babies are assessed in respect of their comfort.

Pain Levels of pain is unique to individuals and helping patients manage and relieve

their pain is an important aspect of care and 92% of patients had evidence that their pain had been assessed and discussed with them or their advocate. Of

those patients who were identified as having a problem with pain, 80% had an up to date plan of care, which was being implemented and evaluated and has

been reviewed within the last 24 hours, this is a slight deterioration from the previos year. The Abbey pain tool has been adopted by the Health Board and

used for those patients who are not able to verbalise their pain and the assessment is based on non- verbal signs of a patient being in pain. The pain

assessment for patients who are able to articulate is documented on the NEWS score this is often missed and needs further focus. The Documentation group are

currently looking at care plans across the Health Board and linking with

appropriate specialist Nurses (Pain Management ) to produce relevant care plans.

Anxiety & Fear

Of the patient records reviewed 83% had evidence that the patient’s concerns/anxieties had been assessed and discussed with the patient or

advocate, and only 81% had a care plan in place.


Ensuring comfort alleviating pain

%

96%

Patients felt that they were made to feel

comfortable.

96%

Patients felt they were kept free from pain. 96%

Mothers felt they received pain relief in a timely

manner

98%


Patient Comments

“I have a chronic pain issue, I live with the pain, but they tried”

“I found a high level of care across the hospital”

“There were not always cushions & blankets available”

4.1.8 Standard 8 - Personal Hygiene, Appearance and Foot Care Operational Questions (Blank areas represent where questions are different)

Standard 8 - Personal Hygiene, Appearance and Foot Care

2013 FOC

Audit

2014 FOC

Audit

For this episode of care, is there documented evidence that the patient's hygiene needs have been assessed and discussed with the patient or advocate?

91% 92%

For this episode of care, where the patient's hygiene needs have been identified is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the agreed timescale?

90% 94%

Does the clinical area have access to mirrors for patients to use? 88% 93% For this episode of care, is there documented evidence that the patient's foot and nail condition has been assessed, and discussed with the patient or advocate?

28% 56%

For this episode of care, where the patient has an identified risk or requires assistance with foot or nail care, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the agreed timescale?

36% 51%

Does the clinical area have supplies of toiletries for patients who have been admitted without them?

87% 97%

Does the clinical area have access to appropriate baby clothes for babies who have been admitted without them?

100%

Are there age appropriate facilities for maintaining individual hygiene needs?

83%

Is there evidence in the nursing documentation that the babies nutritional needs have been assessed within 24 hours of their admission?

100%

Are baby baths cleaned after each use and stored dry?

100%

Overall Health Board Score 73 84%

Good Practice

All areas have improved compliance from the 2013 audit.

Personal Hygiene compliance Meeting a patient’s personal hygiene needs is another important aspect of

patient care and of the patient records reviewed, 92% of the patients had evidence that the their personal hygiene needs had been assessed and discussed

with the patient or advocate. Of those patients who were identified as requiring assistance with their personal hygiene needs, 94% had an up to date plan of

care, which was being implemented and evaluated and had been reviewed within


the last 24 hours. This is a similar result to the previous year where there was 90% compliance around care planning. The Documentation group will ensure

care plans are streamlined across the Health Board.

Foot and Nail Care Foot and nail care, including toe and finger nail cutting is a fundamentals aspect

of patient care. Work has been undertaken within the Health Board to address the issues relating to foot care which included

Clarifying who is responsible for meeting this need

Therapy staff that have developed a competency based training programme for use across the Health Board, which is based on the All

Wales guidance. Included as part of the Nursing Documentation Fundamentals of Care

Assessment.

The 2013 results demonstrated poor compliance around this area with only 28%

of patients having evidence that their foot and nail care condition had been assessed and discussed and of those patients identified as requiring assistance

with their foot or nail care, only 36% had an up to date plan of care, which was being implemented and evaluated and had been reviewed within the last 24

hours. The results from the 2014 audit show that 56% of patients have evidence that their foot and nail care condition has been assessed and 51% have an up to

date care plan. This shows an improvement from the previous audit. Further work will be needed to embed and raise awareness and training as well as

ensuring there is appropriate equipment available on the ward areas. A Diabetes foot care pathway is also in place across the Health Board.


Personal hygiene, appearance & foot care.

%

98%

Patients felt that they had their hygiene needs met. 98%

Patients felt that they had access to wash and

shower facilities

96%

Patient Comments

“Always good as gold”


4.1.9 Standard 9 - Eating and Drinking Operational Questions


Standard 9 - Eating and Drinking 2013

FOC Audit

2014

FOC Audit

Is there evidence in the nursing documentation that those patients, who on admission have been assessed as requiring a swallowing assessment, have had this completed within 24 hours of their admission? [2013 Audit ONLY]

63%

For this episode of care, where the patient has an identified swallowing problem, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the agreed timescale?

83%

Prior to eating, are patients that require help, assisted into a suitable position? 93% 100%

Prior to meal service, are bed tables and communal areas cleared and tidied prior to eating?

92% 98%

Are patients meals placed within easy reach? 95% 100%

Are all patients given the opportunity to wash or cleanse their hands with hand wipes prior to eating food?

81% 93%

Are patients given the opportunity to go to the toilet before eating? 93% 97%

Is there evidence that the systems in place to enable staff to identify patients with special eating and drinking requirements are being implemented and their effectiveness evaluated?

90% 98%

Are water jugs changed 3 times daily? 40% 60%

Is drinking water available for patients and where applicable, are drinking water jugs and glasses within the patient's reach? [2013 Audit ONLY]

89%

Is fresh drinking water available for patients?

92%

Are drinking water jugs and glasses within the patient's reach?

92%

During a 24 hour period, are a minimum of 7 beverage rounds are carried out within your clinical area?

72% 95%

Does a Registered Nurse co-ordinate every meal time? 87% 57%

Is there evidence that all members of the nursing team are engaged in the mealtime service?

93% 80%

Does the clinical area have access to weighing scales and a height measurement stick in good working order? [2013 Audit ONLY]

95%

Do nursing staff have access to weighing scales in good working order?

98%

Do nursing staff have access to a height measuring stick/length measurement mat in good working order?

61%

Is a range of snacks available for patients who have missed a meal or who are hungry between meals?

91% 99%

For patients who require a food chart, is there evidence that they are being kept up to date.

90% 99%


Cont.….

Standard 9 - Eating and Drinking 2013

FOC Audit

2014

FOC Audit

For patients who require a food chart, is it signed by a registered nurse for each 24 hour period?

83%

For patients who require a fluid chart, is there evidence that they are kept up to date and evaluated?

96%

For patients who require a fluid chart, is signed by a registered nurse for each 24 hour period?

89% 73%

Is there a system in place to allow family/friends to assist with meal times? 86% 98%

Is there evidence of information available for women and their families on infant feeding?

100%

Have all women had their Body Mass Index recorded at booking? 93%


Good Practice

The overall performance with this standard has improved however areas for

improvement were identified.

Nutrion & Hydration

Meeting the nutritional needs of patients’ remains a key priority for the Health

Board. The Health Board has a Multi-Disciplinary Strategic Nutrition Steering Group and a number of sub-groups which report into the steering group. As well

as key priorities following the external audit findings.from Professor June Andrews. All groups are responsible for coordinating work aimed at improving

nutrition and hydration care; the provision of catering services; and the monitoring, implementation and performance against nutritional standards. Sub

groups of the Nutritional Steering Groups have made a number of improvements

which have been recognised by the Welsh Audit Office, and include the appointment of Housekeeper/Hostess roles in many areas across the Health

Board. Implementation of high protein snacks and snacks for all patients, 99% of areas agreed that snacks were available, in clinical areas, this is an improvement

from the previous year. The Menu planning group have worked closely with the All Wales menu planning group to standardise menus. Provision of meals over

24 hours. The Nutrition Steering Group monitors the implementation of the All Wales Standards for food and Nutritionand reports to the Quaity & Safety

Committee on compliance.

The All Wales Nutrition standards include standards in regards to the provision of

fluids. The audit findings demonstrate the Health Board’s compliance with the key standards.

Water must be available at all times throughout the 24 hours, 91% of the clinical area confirmed that drinking water was available for patients and

where applicable, drinking water jugs and glasses were within the patient's reach.


Water jugs should be changed three times per day - 60% of the clinical areas confirmed that water jugs are changed 3 times daily, although an

improvement from the 2013 audit where there was only 40%. Nursing teams are working with catering managers to improve

7-8 beverages should be offered in any 24-hour period - 57% of the clinical areas confirmed that during a 24-hour period, there are 7 or more

beverage rounds carried out within the clinical area, this shows a deterioration from the previous year of 72% and will need to raised for

improvement, within Directorates/ Localities where this is not being delivered.

Fluid and Food Chart

The audit indicated there is, 97% compliance with keeping fluid charts up to

date, 73% had been signed by a Registered nurse. 99% compliant with food charts up to date and 83% signed by a Registered

nurse. Both these elements are supported by an E Learning package. compliance is

poor. In order to improve compliance E learning packages have been developed by the All Wales Food and Nurtion Group, work is ongoing within the Health

Board to improve compliance, an example, is setting up of group sessions in IT training rooms to support staff with completion. Compliance around this training

is monitored closely at a local level and also by Welsh Government.

Swallow Assessment

83% of patients had an up to date care plan in place in respect of swallowing

problems. Speech and Language staff have worked closely with nursing staff to support training for key areas in relation to education around swallowing

screening. Bedside information has also been produced to support patients and

staff in relation to the specific care required for patients with swallowing difficulties in relation to their nutrition and hydration.

Following an External Reviewt which was undertaken by Professor Andrews and

her Team within two Hospitals in The Health Board, an Action after Andrew’s Task and Finish group was set up to take forward the key recommendations. The

Trusted to Care Report highlighted a number of issues at ward level that must be addressed. The Health Board is concerned to ensure that action is taken by all

wards that provide care to older people to address these issues as a matter of priority; it has therefore introduced the concept of the ‘Ideal Ward’. Whereby the

multi-disciplinary team will be responsible for testing and assessing the ward using an agreed Ward Assessment Toolkit to establish a baseline that will inform

action planning. The toolkit will provide a framework to enable the assessment of compliance with quality standards. A number of key recommendations are

around Nutrition and Hydration. A Policy has also been developed to support

clinical staff in the implementation of protected mealtimes. Screen savers have been adopted onto the intranet site for all staff to raise awareness around the

importance of nutrition & hydration. Coloured glasses and jugs have been implemented in a number of areas for patients who require additional support.

Initiatives have been implemented in areas two examples are the taffic light


system on ward 18 Princess of Wales Hospital for patients at risk, key symbols on patient at a glance boards to raise awareness of patients who requie extra

support. This will inform all members of the multidisciplinary team.


Eating & Drinking.

%

91%

Patients felt that they were provided with water &

drinks.

96%

Patients felt that they were provided with nutritious

snacks.

87%

Were you given help with feeding and drinking if

you needed it?

96%

Patient comments “Anything I wanted, I put on weight food is good”

“More variety of food” “Food was excellent”

“The ice cold water we have is what every area should have” “Water machines in every ward” “When asked for & not asked for drinks are given”

“Would like more sandwich type for vegetarians”

4.1.10 Standard 10 - Oral Health & Hygiene Operational Questions

Standard 10 - Oral Health and Hygiene 2013 FOC Audit

2014 FOC Audit

For this episode of care, is there documented evidence that the patient has been assessed using an evidence based oral health tool with respect to their oral health needs?

59% 77%

For this episode of care, where the patient has an identified risk or requires assistance with oral health, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the agreed timescale?

64% 76%

Overall Health Board Score

61% 77%


Good Practice

Compliance has improved in both areas from the 2013 audit.

Oral health and hygiene is a key priority area for the Health Board. Following

the results of the 2013 audit where only 59% of patients had been assessed in respect of their oral Health Needs. Meetings were set up with the Health Board

lead that is also responsible for the All Wales work. The documentation was

reviewed and following an invite to the documentation group, to raise awareness and further education where required, compliance has improved to 77%. Further

work will be ongoing in key areas where required as part of the Directorate/Locality action plan as well as the documentation group.


Oral Health & Hygiene.

%

Patients felt that they were given help with oral

hygiene if needed.

94%

Patient comments

“They gave me a toothbrush”

“Did not require help”

4.1.11 Standard 11 - Toileting Needs Operational Questions

Standard 11 - Toileting Needs 2013

FOC Audit

2014

FOC Audit

For this episode of care, is there documented evidence that the patient's toilet needs/continence has been assessed and discussed with the patient or advocate?

88% 94%

For this episode of care, where the patient has been identified as requiring assistance with their toilet/continence needs, is there evidence that an appropriate assessment has taken place with an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

87% 90%


The data confirms that compliance with this standard is good in the assessment and planning of patient toileting requirements. The All Wales Bowel and Bladder assessment is used across ABMU Health Board, within the Fundamentals of care

assessment, nursing document there are a number of questions supporting the nursing team to assessment the patients needs, and where necessary refer to


the All Wales continence Bundle, which supports nurses with tools to improve the patient experience and dignity.

Good Practice The Health Board has a Continence Steering group, which leads on continence

management across. The Health Board also has a Continence intranet page. Although this audit confirms high levels of compliance and performance in

assessment of patients, there is needed to remain vigilant. Continence assessments for appropriate patients are also requested as part of the Nursing

Documentation


Toilet needs.

%

Patients felt that they received help quickly to use

the toilet.

95%

Patient Comments

“I have a stoma they gave me soap water & privacy”

“Usually independent have had some accidents staff always helped”

“Would buzz for a while but understand staff were busy”

4.1.12 Standard 12 - Preventing Pressure Sores Operational Questions


Standard 12 - Preventing Pressure Sores 2013 FOC

Audit

2014 FOC

Audit

For this episode of care, is there documented evidence that the patient's skin condition has been assessed and discussed with the patient or advocate?

95% 94%

For this episode of care, is there documented evidence that the baby’s skin integrity has been assessed?

100%

For this episode of care, where the patient has been identified as requiring assistance with looking after their skin, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the agreed timescale?

93% 96%

For this episode of care, where the baby has been identified as requiring assistance with looking after their skin integrity, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

100%



Good Practice

This Tier 1 target is being closely scrutinised. With the aim of reducing to a zero

incidence of pressure damage occurring within the Health Board. Of these patients who were identified as requiring assistance with looking after

their skin, 96% had evidence that they “had an up to date plan of care, which is

being implemented and evaluated and had been reviewed within the last 24 hours”. The Health Board documentation work will look at the development of

care plans relating to pressure damage. The skin bundle is in place across the Health Board.

Within the Neonatal specific tool, there is 100% compliance against assessment

of baby’s skin condition and 100% compliance where the babies have an up to date care plan.

Healthcare acquired pressure ulcers are reported monthly into the National

Nursing Dashboard and also at a local level. This provides a process for reporting, measurement and monitoring of incidents to inform targeted

improvement. Additionally, any incidence of new skin damage/pressure ulcer development Grade 1 or above is reported via the Datix system as a clinical

incident and investigated.

Patient Comments

“I had an information leaflet on admission”

“My mother in law has a special mattress”


Preventing pressure sores ulcers.

%

Patients felt that they were given help to look after

their skin.

95%


2. Fundamentals of Care Staff Survey

For the 2013 annual FOC audit, the staff survey component was introduced. The

main focus was aimed at establishing how valued and supported staff felt by the organisation with their development and their feedback in relation to the care

that they provide to patients and their families.

As well as a number of specific questions to which the staff were asked to respond based on a choice between, always, usually, sometimes and never. Staff were also asked to give a score between 1 and 10, (where 1 is the lowest score

and 10 is excellent) for how they would rate their overall satisfaction with the care that they provide to patients and their families. The 2013 staff survey was

carried out as a paper exercise, the ward managers were then expected to type in the findings, this caused a degree of anxiety due to the confidentiality aspect..

Further work has been undertaken throughout the year in readiness for the 2014 audit which was carried out electronically, staff could access the survey from a

work computer or from home, there were a few issues where computers had not

been updated the system could not always be accessed. In total 1,580 staff took part in the audit, with a further 82 Community staff, this is an increase in

number from the previous year where 578 staff took part in the survey. The staff included were Registered Nurses, Clinical Health Care Support Workers and

Theatre Staff who were all invited to undertake the electronic audit between the 1st-16th November.

The findings give the overall percentage of staff that scored a combination of

always & usually.

The percentage response is detailed below for both 2013 & 2014:

Staff Survey Questions overall Response 2013 2014

Q

1 Our organisation aims to, make sure you are able to access up

to date information in order to be able to do your job. For

example, access to policies, clinical guidelines etc. Do we

achieve this?

92%

92%

Q2

Our organisation aims to, ensure that as an employee you are

treated with dignity and respect. Do we achieve this?

74%

76%

Q

3 Our organisation aims to, make you feel safe at work. Do we

achieve this?

77%

79%

Q4

Our organisation aims to, make you feel you have a positive

contribution to patient care. Do we achieve this?

81%

81%

Q5

Our organisation aims to, provide you with sufficient equipment

to do your job. Do we achieve this?

77%

77%

Q6

Our organisation aims to, provide you with opportunities to

enhance your skills and professional development. Do we

achieve this?

70%

70%

Q7

Our organisation aims to, provide you with feedback on the

outcomes of any incidents/accidents that you report or that are

61%

61%


reported within your clinical area? Do we achieve this?

Q

8 Our organisation aims to, provide you with opportunity to

identify and learn from good practice to bring about

improvements in care. Do we achieve this?

75%

75%

Q

9 Our organisation aims to, provide opportunities for you to raise

any concerns that you have. Do we achieve this?

75%

75%

Q

10

Our organisation aims to, provide you with the opportunity to

establish a work life balance. Do we achieve this?

69%

69%

Q11

Our organisation aims to, make you feel a valued member of

the organisation and have a sense of belonging. Do we achieve

this?

63%

63%

Q1

2

Our organisation aims to, make you feel proud to be a nurse.

Do we achieve this?

65%

65%

Q

13

Aims to put local citizens at the heart of everything we do?

70%

70%

Q1

4

Our organisation aims to, ensure that you have the knowledge

and skills to deliver a consistent standard in the fundamental

aspects of compassionate care. Do we achieve this?

85%

85%

Q

15

Using a scale of 1-10 where 1 is bad and 10 is excellent, how

would you rate your overall satisfaction with the care that you

provide for your patients and their families.

86%

86%

Q

16

Using a scale of 1-10 where 1 is bad and 10 is excellent, how

would you rate your overall satisfaction with your organisation.

71%

71%

Overall Rating 71% 75%

Findings.

The NHS Staff Survey (2013) revealed opportunities and frustrations for staff common to all NHS organisations. The FOC audit will build on those findings and

the FOC staff survey is available to be used at more frequent intervals and be

used as a barometer to continually measure outcomes from improvement work that has been initiated following the NHS staff survey and FOC staff survey and

also the engagement events and workshops within ABMU health Board.

Many of the findings of the 2014 FOC staff survey reflect those of the 2013 NHS

Staff Survey and also the 2013 FOC audits. There is a need for further investigation into all of the domains explored by the audit. The findings will be

shared with workforce and Organistion Development (OD) clollegues within the Health Board. It is essential that we listen and work with our workforce to

improve morale.


Only 61% of staff surveyed agreed that the organisation always or usually provide feedback on the outcome of an incident or accident

that is reported within the clinical areas. We need to ensure we have robust processes in place to learn fron incidents and feedback

to staff

Only 63% of staff feel a valued member of the organisation and have a sense of belonging.

Commentary from staff frequently reflected concerns about current staffing levels and not being a valued member of the organisation.

Nursing staff expressed shared frustrations and difficulties in being able to

deliver the quality of care they aspire to due to the intensity of demand on their time and lack nursing resource. Two actions to support these issues currently

are:

The Nursing Establishment Review

The National Acuity Tool

Nursing Documentation review.

Review of FOC care indicators and information to reduce duplication

These measures aim to ensure that all clinical areas are staffed appropriately, and the acuity tool will enable senior nurses to adjust staffing according to the

fluctuating acuity status of the patients being nursed.

These are measures being taken forward by the organisation to support improvement in the staff and patient experience of care. There is also a need to

constructively engage staff in identifying the factors that they feel would deliver positive outcomes. There have been a number of engagement events for staff as

part on the “Trusted to Care actions”

One initiative that has yielded positive outcomes for staff working in pressured

environments has been the introduction of Schwartz Centre Rounding which is currently being rolled out across the Health Board.. These rounds provide a

forum for staff from a range of disciplines to meet and explore together some of the challenging psychosocial and emotional issues that arise from caring for

patients.

The 2013 FOC audit provides evidence that nursing staff across ABMU Health

Board are predominantly caring, kind and compassionate. The report shows that further commitment is needed to improve this area.

5. Community Nursing

As discussed previously this year within ABMU Health Board, each Locality

nominated one network District Nursing team to undertake a pilot of the Fundamentals of Care. Community teams have not previously been involved in

this Annual Audit. Following discussions with The All Wales District Nursing leads. Intial discussions were held with Locality Heads of Nursing and District Nursing

leads within the Health Board who were all extremely keen to be involved in the

audit.


Three teams in total were nominated each from the Locality areas. Sessions were set up to discuss the logistics of the audit.

The following results show the overall percentage scores for the 12 Standards from an operational.

Overall Summary 2014 Community pilot

Operational

%

Std 1 Communication and Information 94.4%

Std 2 & 5

Respecting people and Relationships 84.7%

Std 3 Ensuring Safety 95.2%

Std 4 Promoting Independence 100%

Std 6 Sleep, Rest and Activity 80%

Std 7 Ensuring Comfort & Alleviating pain 73.3%

Std 8 Personal hygiene, Appearance and

foot care 100%

Std 9 Eating and Drinking 33%

Std 10 Oral Health & hygiene 100%

Std 11 Toilet needs 100%

Std 12 Preventing pressure sores/ Ulcers 100%

Overall Health Board Score 87.3%

5.1 Findings Initial findings indicate there there are a number of questions that have

been recorded as not applicable. In relation to Standard 9, there are a number of questions that are not

applicable with the non compliance around availability of weighing scales and height measuring sticks.

In relation to standard 7 this shows that there is poor compliance around

pain scores. There is excellent compliance in the majority of areas. Findings will be

discussed as part of the District Nursing forum as well as on an All Wales basis with the All Wales professional Nursing team. This work will be taken

forward in readiness for the 2015 audit. All Community staff involved in the audit were very keen to take this work forward.

6. Monitoring and Assurance

The 2014 FOC ABMU Health Board audit provides assurance to Board Members where compliance is reported as high and best practice can be shared as well as

identifying the improvements to be made across all 12 standards, with a focus on three key standards:-


Respecting people and relationships (standard 2&5) Personal hygiene, appearance and foot care (Standard 8)

Oral Health and hygiene (Standard 10)

The monitoring process across the Health Board will be as follows;

The Health Board report will be presented to the Quality & Safety

Committee in February.

The report will be sent to Welsh Government in March

The report will be presented at the Nursing Midwifery Board also in February.

Key members of staff from each Directorate/Locality have been trained in developing an electronic action plan. (This is an enhanchment that has

been added for the 2014 audit, previously this has been paper format).

Each clinical area will be responsible in developing an electronic action plan, which will need to be updated within an appropriate timeframe, until

the actions have been achieved and there are clear outcomes in place.

A number of actions may need to be escalated to senior Nurses and

Directorate/Locality teams.

Each Directorate/Locality/POW Hospital will then develop an action plan,

which will be monitored as part of their governance framework, until clear actions have been achieved, within appropriate timeframes. The matrix will

give guidance on time frames.

Each Directorate/Locality will report their findings to appropriate

Directorate/Boards and monitor through their governace framework.

Directorate/Localities will need to give assurances and outcome to the

Executive team via thieir performance reports.

The Welsh Government requests a National audit yearly. Local areas can

audit more frequently as required.(This is a new enhancement for 2014)

The findings from the Annual Audit should be used in conjunction with other monitoring processes in place.

Improving Quality Together (IQT) model for improvement Bronze and Silver can be used to support improvement projects.

7. Conclusion

The National Annual Fundamentals of Care audit 2014 has generated detailed information to measure the quality of fundamental aspects of health and social

care delivered to our patients across ABMU Health Board. The audit has engaged

patients/carers/service users and staff and has identified compliance scores with operational standards, patient experience and staff feedback. The2014 audit has

shown that there are many improvements from the previous years audit, including Oral Health and Footcare which we now need to make further

improvements. The review of documentation as a whole will be instrumental in addressing anumber of these issues.


The National FOC audit is reported to the Chief Nursing Officer in March 2015. Teams can continue to use the FOC system, to monitor and measure standards

and effects of improvement work taken forward in their local action plans. The FOC audit results provide us with an opportunity to celebrate the excellent care

provided and the positive experiences reported by our patients and service users. It also enables us to prioritise our quality improvements and continued

support and development to improve the experience of our staff. Patients have expressed high levels of satisfaction with the standards of care they have

received from staff within ABMU Health Board and we strive to continue to enhance their experiences. Further work will be continued at a local and All

Wales basis to continue to update and improve the tool. The tool needs to be used in conjunction with other monitoring processes in place to provide clear

evidence of outcomes and triangulate the information. It is also important to

note that the audit can be used at a local level as required. The results of the staff survey has shown that we need further engagements and improvements

within this area. We need to use the raft of information that the survey has provided to learn and make positive improvements.


8. References

1. 1000 Lives+ (2013) Improving Quality Together

2. ABMU Health Board policy on the Administration, supply, ordering

storage, administration and disposal of medicines (2014).

3. Francis, R (2013) Report of the Mid Staffordshire NHS Foundation

Trust Public Enquiry

4. Keogh, B (2013) Review into the quality of care and treatment

provided by 14 hospital trusts in England.

5. NHS Institute for Innovation and Improvement (2008) Model

for Improvement

6. NWIS (2012) Nursing Dashboard

7. Royal College of Physicians (2012) National Early Warning Score

(NEWS) Standardising the assessment of acute illness severity in the NHS, RCP: London

11. Shared Services Partnership Facility Services (2013) WHTM 07-01 - Safer management of healthcare waste

12. WAG (2003) Fundamentals of Care. Guidance for Health and Social Care Staff. Improving the quality of fundamental aspects of health

and social care for adults

13. Welsh Government (2010). Catering and Nutrition Review, Wales

Audit Office, Wales

14. Welsh Government (2011). All Wales Nutrition & Catering

Standards for Food and Fluid Provision for Hospital Patients (http:/www.cymru.gov.uk)

15. Welsh Government (2013) NHS Wales National Clinical Audit and Outcome Review Plan 2013/14

16. Welsh Government (2013) NHS Wales Staff Survey Report: ABMU

Health Board

17. Welsh Government (2013) Safe Care, Compassionate Care. A

National Governance Framework to enable high quality care in NHS Wales

18. Welsh Government (2013) Together for Health: A Diabetes Delivery Plan

i. WG: Wales

19. WAG (2010) Doing Well, Doing Better. Standards for Health

Services in Wales

i. http:www.nhswalesgovernance.com

20.Professor June Andrews & Mark Bultler (2014) Trusted to Care. An independent review at the Princess of Wales Hospital &

Neath Port Talbot Hospital Abertawe Bro Morgannwg University Health Board.

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9 Appendix A: Fundamentals of Care Audit - Compliance Scoring Matrix

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