fundamentals of care - nhs wales of care... · nursing staff were professional kind and helpful ......
TRANSCRIPT
2 Fundamentals of Care Annual Audit 2013 | Welsh Government
INDEX
Page
1. Executive Summary 3
2. Situation 5
3. Background 5
4. Assessment 8
4.1 Fundamentals of Care Standards - Review of Operational
Questions and User Experience feedback
8
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
8
10
13
17
19
21
23
25
27
31
32
33
4.2 Fundamentals of Care Staff Survey 35
5. Recommendations
40
5.1 Actions for improvement 40
5.2 Monitoring and assurance 44
5.3 Conclusion 45
6. References
7. Appendix A - Quality Matrix – compliance scores
Appendix B - Local action plan – PDSA model for improvement
46
48
50
3 Fundamentals of Care Annual Audit 2013 | Welsh Government
1 Executive Summary
Abertawe Bro Morgannwg University 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 ABM Health Board. It is essential that every nurse at all levels knows what the expectations are of them and are equip to
deliver. We need to ensure that the Health Board nursing standards of care delivery are clearly outlined, that all staff are trained and competent to deliver these and
that the Senior Nurses are monitoring compliance with these by visible leadership
across all clinical services on a daily basis.
The Health Board will ensure that it abides by the NMC requirements and supports a professional clinical workforce with the appropriate skill 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
The Fundamentals of Care (FOC) National Audit System has been redesigned during 2012 to ensure that it supports these values, providing quality
assurance and identifying improvements where required within services, health boards and across NHS Wales. The 2013 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 identifies where we need to focus
improvements where scores are reported below the 85% compliance rate. The detailed results of each question within the audit are presented in this
report, the summary findings include:
4 Fundamentals of Care Annual Audit 2013 | Welsh Government
1). Feedback from patients confirms the high standards of care provided across the Health Board and the need to focus improvement around:
Standard 6 (Rest and Sleep). There were a number of general comments which included;
“Very nice staff from nurses to Doctors.
Nursing staff were professional kind and helpful”
2). The operational audit supports the findings in the patient survey and
confirms standards for improvement: Standard 6 (Rest and sleep),
Standard 10 which is the lowest at 61% (Oral health and hygiene), Standard 8 (Personal hygiene, appearance and foot care).
3). The staff survey results align with the findings of the 2013 NHS
Wales staff survey and the actions for improvement are being taken forward with the Health Board workforce team focusing 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 2013 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.
Mrs Christine Williams Acting Director of Nursing
5 Fundamentals of Care Annual Audit 2013 | Welsh Government
Situation
The Fundamentals of Care (FOC) Standards have been developed and implemented to improve the quality of fundamental aspects of health and
social care for patients and service users in Wales. The importance of the National annual FOC audit is emphasised from the findings from the Francis
Enquiry (2013) and Keogh Report (2013). The FOC system complies with Safe Care, Compassionate Care (A National Governance Framework to enable
high quality care in NHS Wales 2013) and with the NHS Wales National Clinical Audit and Outcome Review Plan (2013/14).
The Fundamentals of Care audit system provides assurance to patients, the
public, staff teams, Health Boards/Trusts and Welsh Government by measuring the operational compliance with the 12 FOC standards, user
(patient/carer) experience and also staff experience. The Welsh Government
requires all Welsh Health Boards/Trusts to measure their compliance against the standards by undertaking an annual national FOC audit and these results
are published. It should also be noted that the FOC audit tools within the system can be utilised locally at any time throughout the year to measure
compliance with the 12 FOC standards. The Welsh Government has commissioned a review of 12 FOC standards and the 26 Standards for Health
Services in Wales commencing January 2014.
2 Background
Review of the FOC system 2013
The FOC audit system has been completely reviewed prior to the 2013
National audit which was completed during October and November. The questions to inform the operational, patient and staff surveys were reviewed,
scrutinised and developed to ensure elimination of duplication of data collection and to design an updated audit system that is fit for purpose. The
entire review of the FOC audit system has been completed during 2013 to include:
Full review of all operational audit questions
Full review of the 2003 FOC document, with driver diagrams developed for each standard, and updating the wider multi
professional/agency evidence base for each standard Design of sub-set audit questions for key specialities
Partnership working with the All Wales User group to review/redesign the user questionnaire and involvement of the Welsh Government
statistician to ensure a robust data collection process and validated
system. Redesigning and development of the FOC action plan module to align
with the Model for Improvement to inform quality improvements where non compliance is identified
6 Fundamentals of Care Annual Audit 2013 | Welsh Government
The FOC system implementation was supported by the review of:
The Best Practice Guidance for staff Patient/Carer/Staff information leaflets
A training package to support the implementation of the new FOC system.
And the development of:
A Staff Survey, aligned with the All Wales NHS Staff Survey
A Compliance Matrix and user guide (85% compliance measure required for each standard). The RAG red, amber, green scoring
system has been used throughout this report to present the report,
see appendix1.
Purpose of the FOC system
The results of the FOC audits provide patients, staff teams, Health Boards/Trusts and Welsh Government with rich data to identify:
1. What we are doing well
2. What we need to improve 3. How we can improve the experience of patients and staff
The audit 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
To have a voice in the quality of the care they receive It ensures an openness and transparency with the quality standards
It empowers staff:
To make a difference and ensures ownership of their practice
To have a voice in the care that they provide and ensure the focus is on essential elements of care and caring.
To identify areas of good practice and highlight issues for concern To develop action plans which enables them to monitor change
It enables organisations:
To have a mechanism to monitor/measure the quality of care
To develop organisational policies and procedures
To identify key themes for improvement
The new FOC audit tool has been designed with teams across NHS Wales to ensure that the questions are specifically tailored to meet the needs of
general wards, outpatient departments, operating theatres, endoscopy suites,
7 Fundamentals of Care Annual Audit 2013 | Welsh Government
day patient units and Unscheduled Care (accident and emergency departments).
The FOC National Audit Autumn 2013 The 2013 National FOC audit was completed during 1st October 2013- 30th
November 2013 using the:
1. Patient survey 2. Staff survey
3. Operational audit
The FOC audit involved asking patients about their experiences of care;
asking staff about their experience of working within the Health Board, and observing delivery of care and the assessment of the operational application
of the 12 FOC standards. This included:
Examination of patient records respectively to measure compliance against the standards and triangulation of information
Observation of clinical practice Environmental assessment
Guidance was obtained from the chief Statistician in the Welsh Government
to provide assurance of the validity of the FOC system and data collection methodology, and part of the guidance provided was to undertake patient
and staff surveys across Wales on the same date to ensure uniformity.
It should be noted that the Action Planning module within the updated FOC
system has been aligned with Improving Quality Together, using the Model for Improvement tools (SBAR – situation, background, assessment,
recommendations and PDSA cycles – plan, do, study, act). This strengthens ownership of quality improvement locally within teams and across the Health
Board.
The FOC system is not used to compare organisations across NHS Wales. The FOC audit results generated are for local measurement to inform quality
improvements, learning and to share and celebrate good practice.
Learning and feedback from using the new FOC audit system in practice will inform an evaluation and future changes that may be required to continually
enhance the national FOC system. During 2014 the All Wales FOC system will be designed specifically for a wider set of services: Mental Health,
Paediatrics, Neonatal Care, Maternity, Community and Learning Disabilities,
with the staff survey being expanded to all members of the multidisciplinary team.
8 Fundamentals of Care Annual Audit 2013 | Welsh Government
4 Assessment
4.1 Fundamentals of Care Standards
(Operational Questions and User Experience Feedback)
4.1.1 Overall Summary
In light of the significant revisions made to the format, number and types of questions included in this year’s audit, no direct comparison can be drawn between the 2013 and previous annual audits. It is also important to
note that the operational, patient experience and staff survey questions have been reviewed independently and not combined as in previous audits.
It is intended that the 2013 audit will form a baseline for the 2014 and subsequent audits.
Operational Questions
The 2013 audit results for the 89 clinical areas audited across Abertawe Bro Morgannwg University Health Board (ABMUHB) demonstrate that for
the operational questions in 5 out of the 12 standards the organisation had met the All Wales fundamentals of care standards compliance of 85% and
over. Five areas were identified for improvement, but no areas were noted as a major concern.
Table 1
Operational Question Overall Summary RAG %
Std 1 Communication and Information 86%
Std 2 & 5 Respecting people and Relationships 81%
Std 3 Ensuring Safety 88%
Std 4 Promoting Independence 88%
Std 6 Rest & Sleep 75%
Std 7 Ensuring Comfort & Alleviating pain 80%
Std 8 Personal hygiene, appearance and foot care 73%
Std 9 Eating and Drinking 85%
Std 10 Oral Health & hygiene 61%
Std 11 Toileting needs 88%
Std 12 Preventing pressure sores 94%
Overall Health Board Score 84%
9 Fundamentals of Care Annual Audit 2013 | Welsh Government
The action plan for improvement will focus particular attention on Standard 6 (Rest and sleep), Standard 8 (Personal hygiene, appearance and foot
care) Standard 10 (Oral health and hygiene), Standard 2&5 (Respecting people & relationships) and standard 7 (Ensuring comfort & alleviating
pain).
User Experience
The user experience surveys were undertaken on the 6th November 2013
across all audit areas within the organisation and across all organisations in Wales, except within theatre departments. 935 patients/carers were
surveyed across ABMU Health Board.
Graph 1
Overall User Experience Summary (All Questions)
The combined results for all user experience survey questions demonstrates that the patients surveyed were 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 89.77% 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.
75.62%
18.13% 4.26% 0.99%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
10 Fundamentals of Care Annual Audit 2013 | Welsh Government
4.1.2 Standard 1 - Communication and Information Operational Questions
Table 2
Standard 1 Operational Questions RAG %
Q1 Are the patient's demographic details clearly recorded on all the
patient's documentation? 93%
Q2 Is there documented evidence that the patient's ability to
achieve effective communication has been assessed and
discussed with the patient or advocate?
93%
Q3 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 last 24 hours?
82%
Q4 Is there documented evidence that each plan of care has been
assessed and discussed with the patient or advocate? 75%
Q5 Are the contact details of the first point of contact recorded in
the patient’s documentation? 97%
Q6 Is there information clearly displayed regarding how
patients/relatives/advocates can raise a formal or informal
concern?
93%
Q7 Do all patients wear an identification band which states their
first and last name, date of birth and NHS number? 92%
Q8 Is the patient's identity checked visually and verbally prior to
giving medication or undertaking a procedure? 99%
Q9 Are all clinical staff wearing staff identification badges? 85%
Q10 Are all clinical staff complying with the All Wales Dress Code? 99%
Q11 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 screening
question been asked?
64%
Q12 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 last 24 hours?
76%
Q13 Are all medication charts completed clearly and is patient
information complete? 76%
Q14 Is a nurse present during the contact between
doctors/consultants/GPs and patients? 86%
Q15 Are patients able to communicate in Welsh with nursing staff in
the clinical area, if they wish to? 68%
Overall Score 86%
11 Fundamentals of Care Annual Audit 2013 | Welsh Government
Medicines management
ABMU Health Board performed strongly in 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.
99% of staff observed checked patient identification verbally and visually prior to the administration of medicines and 92% of patients were wearing
appropriately completed identification bands.
All Wales dress code
Compliance with the All Wales dress code was high at 99%, but the
numbers of clinical staff wearing identification badges was only 85% which demonstrates a need for improvement. This has been reported in other
forums where service users have stated that they did not know the name
of the nurse or doctor looking after them. As well as the use of appropriate identification badges this might also reflect the need for staff to introduce
themselves to patients and carers on each contact.
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 64% of patients with identified communication problems had
an up to date care plan which had been reviewed within the previous 24
hours and only 75% showed documented evidence that the plan had been discussed with the patient or their carer.
Cognition Screening
Within Standard 1 the area in which ABMU Health Board failed to reach an
acceptable level of performance was in ensuring that the agreed cognition screening question had been asked at admission or within 72 hours only
64% of patients were asked the question. As part of the Fundamentals of Care nursing Documentation patients are asked if they have any mental
Health issues or confusion as well as difficulties in communicating. Further work is needed in relation to this area.
Question 12 explored the availability of a care plan to manage cognitive
impairment. Only 75% of patients had an up to date care plan. Further work is required in this area.
The Learning Disability pathway has been implemented across ABMU Health Board. Work is also ongoing via the Dementia steering group to look
at piloting a pathway for Dementia patients who are admitted into the
12 Fundamentals of Care Annual Audit 2013 | Welsh Government
acute Hospitals across ABMU Health Board. Key assessments are included in the pathway.
Communicating in Welsh
68% of the clinical areas which responded to the audit question identified the availability of Welsh speaking staff. Ward sisters/ Charge Nurses 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, where concerns and initiatives are raised.
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. Also utilising staff to translate if appropriate.
Good Practice
Preferred language is clearly requested on the front page of the nursing documentation.
Following the clinical meeting with Doctor Staff update patients/relatives with any changes.
Patients and relatives are fully involved with care planning and updating
where necessary.
Butterfly Scheme in Clinical areas for patients with a known diagnosed
Dementia or acute confusion
.
User Experience Question 99
Throughout your stay/attendance, how often did you feel that you and those that care for you were given full information about your care in a
way that you could understand?
Graph 2
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
73.35%
21.90%
4.31% 0.43%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
100%
Always Usually Sometimes Never
13 Fundamentals of Care Annual Audit 2013 | Welsh Government
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
“The reassurance by the Doctors and nurses throughout the whole day has been very comforting”.
“I have a special diet and the staff were more than happy to ensure
diet was arranged”.
Standard 2 and 5 - Respecting people and Relationships
Operational Questions
Table 3
Standard 2 and 5 Operational Questions RAG %
Q16 Does the patient's documentation capture their preferred name
and/or title? 87%
Q17 Is there documented evidence that an assessment of the carers
needs has been considered? 73%
Q18 Is there documented evidence that the patient's cultural needs
has been assessed and discussed with the patient or advocate? 74%
Q19 Is there documented evidence that the patient's spiritual needs
has been assessed and discussed with the patient or advocate? 69%
Q20 Is there evidence to demonstrate that patient identifiable
information is treated in a confidential and secure manner? 98%
Q21 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%
Q22 Is there a facility for patients to talk in private to staff (e.g. a
quiet room or office)? 99%
Q23 Is there a quiet room for patients to spend time with their
visitors away from their bedside? 64%
Q24 Within the clinical area, are all the bays single sex bays? 72%
Q25 Do all patients have access to single sex toilet and washing
facilities? 76%
Q26 Is there a facility to preserve patient dignity by communicating
to others that care is in progress? 81%
Q27 Can staff demonstrate they know the procedure if a
safeguarding concern is identified? 96%
Overall Score 81%
14 Fundamentals of Care Annual Audit 2013 | Welsh Government
Patient Privacy
The audit information suggests that patient privacy and dignity is receiving
consideration however further improvement is needed in this area. Good practice is demonstrated by the use of red pegs or signs to promote
privacy and reduce interruptions to the patient whilst receiving care. In 96% of cases staff demonstrated knowledge of the procedure to safeguard
a vulnerable patient and 99% of areas have a quiet room that can be utilized for conversations between patients and staff to protect their
privacy. Only 64% of areas have access to a quiet room for patients to spend time with their family away from the bedside.
Single Sex Toilets and Bays
Further reinforcement and compliance is required around this area. All staff are encouraged to utilize signage to ensure there is designated male and
female toilet facilities. Where clinical areas are being updated consideration is required to achieve single sex facilities.
Carers Needs
In July 2013 the Carer`s Measure was launched in ABMU Health Board in conjunction with Local Authority partners. This measure has been
highlighted to staff as part of sessions that have been undertaken with the roll out of nursing documentation and there is more work to be completed
to ensure all staff achieve the outcome in understanding the rights of carers. A score of 73% was achieved for this question.
Cultural and Spiritual Needs
The scores were only 74% and 69% for these questions, and therefore not much evidence to suggest that the patient’s cultural or spiritual needs had
been assessed or discussed with the patient or their advocate. Wales now has a multi-cultural, multi-faith society and this is reflected in the service
user population. Spiritual and religious care has been shown to be important to patients and is acknowledged to have a significant and
beneficial impact on patient outcomes.
To ensure patient needs are met and the organization is compliant with the
spiritual standards, greater emphasis will need to be placed on this area of assessment and discussion in the future.
Security of Patient Information
In November 2013 Welsh Government introduced legislation to ensure
integrated assessment, planning and review for an older person takes place between health and social services. To meet the requirements of the
legislation a core data set was identified. Consent to share information with others is one of the key areas identified within the Integrated Assessment
core data set. From April 2014 all patients (or their advocate) will be required to acknowledge and document consent to the inter agency sharing
of information. Nursing documentation has already been adjusted to accommodate this process. This area has been highlighted in many nursing
15 Fundamentals of Care Annual Audit 2013 | Welsh Government
forums throughout the year and although compliance has improved to 79% further reinforcement will be needed to achieve full compliance.
Good Practice
A task and finish group has been set up to take forward the work in relation to the integrated assessment process, this group links closely with the
Health Board Nursing Documentation group.
There are clear signs in place to identify male and female toilet and
bathroom facilities in the majority of areas.
Experience
Question 100
Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect?
Graph 3
Findings
Findings confirm that patients’ experience of a dignified care environment is very positive. 98% of patients surveyed reported that they were always
or usually treated with dignity and respect.
Dignity and respect training is ongoing across ABMU Health Board the patient experience teams encourage patients/relatives/carers to provide
regular feedback in relation to this area. Clinical staff are encouraged to monitor their areas to make continuous improvements. Environmental
audits are part of the POINT Reviews (Patient Orientation to Nuture Teams) audits are carried out by senior nursing teams. Patient experience reports
are closely monitored by staff. Staff also encourage the completion of the
friends and family test and monitor feedback to improve practice.
Patient commentary overwhelmingly reflects the patience, kindness and caring attitudes they have experienced from ABMU Health Board staff.
Examples include:
“I was always treated with Dignity and Respect and witnessed other
patient’s dignity being maintained”.
“Friendly good humoured staff that were always helpful. I was
checked on regularly and made comfortable”.
87.27%
11.23% 1.50% 0.00%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
16 Fundamentals of Care Annual Audit 2013 | Welsh Government
Question 101
Throughout your stay/attendance, how often did you feel that you were
given the privacy that you needed?
Graph 4
Findings
96% of patients surveyed reported that they were always or usually given the privacy that they needed.
Patient Comments
“The door in the consultantation room can be shut for privacy”.
80.64%
15.83% 3.21% 0.32%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
17 Fundamentals of Care Annual Audit 2013 | Welsh Government
4.1.3 Standard 3 – Ensuring Safety Operational Questions
Table 4
Standard 3 Operational Questions RAG %
Q28 Has the Infection Prevention & Control Audit (ICNA) been
undertaken within the last 12 months? 97%
Q29 If an Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months, please enter the percentage compliance score.
87%
Q30 Has a Waste Management Audit been undertaken within the last
12 months? 26%
Q31 Has a Waste Management Audit been undertaken within the last
12 months. Please enter the compliance score as a percentage. 55%
Q32 Are staff able to give examples of the correct procedure for
source isolating patients? 100%
Q33 For this episode of care, is there documented evidence that the patient has an up to date manual handling risk assessment?
97%
Q34 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 last 24 hours?
89%
Q35 Are any Manual Handling aids and slings regularly checked for
wear and tear? 98%
Q36 Within the clinical area, are all fire restraint doors free from
obstruction or closed if not automatic self closing? 93%
Q37 Is the equipment used in the clinical area up to date with
maintenance and calibration? 98%
Q38 Are all drug cupboards/trolleys locked and secure as per local
policy? 97%
Overall Score 88%
ABMU Health Board Quality Strategy aims to improve safe and effective care and patient experience. Audit data confirms the excellent compliance
in practice in key areas of this standard.
Good practice
Good practice is demonstrated in the safety checks carried out on moving and handling aids and the calibration and maintenance of equipment.
100% awareness was demonstrated when staff were questioned about the
procedure for source isolation of patients.
Improvement in compliance around the locking of Drug cupboards. Audits
have been carried out in all ward areas across ABMU Health Board.
18 Fundamentals of Care Annual Audit 2013 | Welsh Government
Waste management
Only 26% of the clinical areas surveyed had a waste management audit undertaken. There appeared to be lack of clarity and understanding around
this question. As a Health Board we have discussed this issue with the environmental officer, who suggests that the audits legally required are pre
acceptance audits, which are not scored on a ward by ward basis. However issues are ranked according to severity. The audits do not cover each ward
each year but are a representative sample as determined by the external
auditor. There are plans to audit Singleton, Morriston and Princess of Wales Hospital in march. This information will be feedback to the All Wales FOC
steering group.
User Experience
Question 103
Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy and not cluttered?
Graph 5
Question 108
Throughout your stay/attendance, how often did you feel that you were made to feel safe?
Graph 6
Findings
98% of patients who responded felt that the clinical area was always or usually clean, tidy and uncluttered.
98% of patients said that they were always or usually made to feel safe while in or attending ABMU Health Board hospitals
80.69%
17.92%
1.29% 0.11% 0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
88.03%
10.75% 1.11% 0.11%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
19 Fundamentals of Care Annual Audit 2013 | Welsh Government
Patient Comments
“Lovely clean ward all the time”.
“First impression very clean”.
“Very safe”.
“Cluttered due to lack of space”.
4.1.4 Standard 4 - Promoting Independence
Operational Questions
Table 5
Standard 4 Operational Questions RAG %
Q39 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%
Q40 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 last 24 hours?
86%
Q41 For this episode of care, is there documented evidence the
patient's mobility has been assessed and discussed with the
patient or advocate?
97%
Q42 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 24 hours?
86%
Q43 For this episode of care, is there documented evidence the
patient's risk of falls has been assessed and discussed? 91%
Q44 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 last 24 hours?
91%
Q45 Where appropriate, do all patients have written evidence of a
discharge assessment and plan? 79%
Q46 Where appropriate, is there written evidence that the patient's
family/carer has been involved in discharge planning? 80%
Q47 Within the clinical area, are washing, bathing and toilet facilities
suitable for the all service users? 88%
Q48 Does the clinical area allow patients to bring in personal items
to assist with patient orientation/familiarity? 93%
Overall Score 88%
Good Practice
Overall the audit data suggests good practice is being observed with the assessment of patient mobility and risk of falls. Compliance is monitored
20 Fundamentals of Care Annual Audit 2013 | Welsh Government
via POINT reviews and also as part of the FOC care indicators. Spot checks are also carried out via the senior nursing teams.
Discharge Planning
Two areas in which documentary evidence of robust practice is less evident relate to discharge assessment and planning and involvement of the
patient’s family. Estimated date of discharge (EDD) is used across ABMU Health Board as a guide to proactively plan the patient journey through the
hospital system and reduce delays in ensuring all requirements for a safe discharge are anticipated and organized in advance of being medically fit to
leave hospital. The audit results suggest that in more than 20% of cases there is no evidence of plans being developed. The consequence of this
could be unnecessary delays in discharge putting the patient more at risk
of hospital acquired complications and avoidable pressures on hospital bed occupancy. 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 in a number of areas
and are being implemented across ABMU Health Board. A number of other improvement initiatives have also been implemented.
User Experience
Question 102 Throughout your stay/attendance, how often did you feel that you were
given help to be as independent as you can and wish to be? Graph 7
Question 104
Throughout your stay/attendance, how often did you feel that when you called us that we responded in a timely manner?
Graph 8
79.40%
16.91%
3.36% 0.34% 0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
68.31%
26.54%
4.93% 0.22% 0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
21 Fundamentals of Care Annual Audit 2013 | Welsh Government
Findings
More than 96% of patients expressed satisfaction that they were always or
usually assisted to be as independent.
94% of respondents were always or usually responded to in a timely
manner.
Patient Comments
“I was always encouraged by all the team to promote independence”.
“Nurses busy at all times but did their best to respond”.
“Very happy with care”.
“Staff always busy but did their best”.
4.1.5 Standard 6 - Rest & Sleep Operational Questions
Table 6
Standard 6 Operational Questions RAG %
Q49 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%
Q50 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 last 24 hours?
59%
Overall Score 75%
Findings
Within Standard 6 there were only two operational questions asked. These were specifically focused on whether a sleep history was recorded and once
needs were assessed whether an appropriate plan of care was formulated, reviewed and evaluated regularly. Although 86% of the notes examined
showed evidence of an assessment being undertaken and discussed, only 59% of patients identified as having problems sleeping had a care plan
which reflected the issues.
For all patients admitted to hospital the environment is alien to their usual
experience. Sharing a multi occupied room, unfamiliar noises, over stimulation; sleeping in a single bed with a very firm mattress; are all
factors which might interfere with normal sleep patterns.
22 Fundamentals of Care Annual Audit 2013 | Welsh Government
Good Practice
Some wards, with appreciation of these issues have introduced rest periods during the day to help patients have protected time for their rest.
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.
User Experience
Question 109
Throughout your stay, how often did you feel that you were able to get enough rest and sleep?
Graph 9
Findings
Of all twelve standards audited Sleep and Rest was the standard that
service users reported most dissatisfaction.
Patient feedback aligns with the operational audit findings, 80% of patients agreed that they were always or usually able to get enough rest and sleep
while in hospital. The overall operational score was 75%
The factors which contribute to disturbances in sleep and rest across all
sites needs to be further explored. To identify the factors to consider when formulating plans of care. Each area will look at improvements wherever
possible
Patient Comments
“Very noisy ward”.
“Bins noisy”.
“Other patient’s noisy.”
“One patient very confused and noisy”.
50.21%
30.35% 16.60%
2.84% 0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
23 Fundamentals of Care Annual Audit 2013 | Welsh Government
4.1.6 Standard 7 - Ensuring Comfort & Alleviating pain Operational Questions
Table 7
Standard 7 Operational Questions RAG %
Q51 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%
Q52 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 last 24 hours?
87%
Q53 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%
Q54 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 last 24 hours?
67%
Overall Score 80%
Pain
The National Early Warning System (NEWS) for early assessment of the deteriorating patient has been implemented within adult areas in ABMU
Health Board. This tool provides a scoring system aligned with the vital signs of the patient to provide early alerts to altered stability of the
patient’s physical condition. One of the elements included within the tool is a numerical pain score to capture a tangible measure of the patient’s
description of any pain they might be experiencing.
.
Anxiety & Fear
There is less evidence that robust systems are in place to consider the concerns, anxieties and fears experienced by patients. Although patient
comments identify that staff were kind, considerate and informally addressed many of the anxieties they experienced, tools such as the
Hospital Anxiety and Depression Scale (HADS) are not universally used as a measure.
Good Practice
The Abbey Pain score tool has also been piloted for patients who are not
able to clearly communicate their level of pain. Local audits have also recently been carried out across the Health Board to improve awareness
and compliance. Training sessions have also been undertaken across ABMU Health Board
24 Fundamentals of Care Annual Audit 2013 | Welsh Government
User Experience Question 110
Throughout your stay, how often did you feel that you were made to feel comfortable?
Graph 10
Question 111
Throughout your stay/attendance, how often did you feel that you were, as far
as possible, kept free from pain?
Graph 11
Findings
97% of patients felt that they were always or usually made to feel comfortable and 97% of patients were always or usually kept free from
pain.
Patient Comments
“More pillows”.
“No pain”.
“There were a high number of patients that have responded as not
applicable to this question”.
79.52%
17.57% 2.64% 0.26%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
78.49%
18.69%
2.18% 0.64% 0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
25 Fundamentals of Care Annual Audit 2013 | Welsh Government
4.1.7 Standard 8 - Personal hygiene, appearance & foot care
Operational Questions
Table 8
Standard 8 Operational Questions RAG %
Q55 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%
Q56 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 last 24 hours?
90%
Q57 Does the clinical area have access to mirrors for patients to
use? 88%
Q58 For this episode of care, is there documented evidence that the
patient's foot and nail condition has been assessed using a
recognised, evidence based tool and discussed with the patient
or advocate?
28%
Q59 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
last 24 hours?
36%
Q60 Does the clinical area have supplies of toiletries for patients who
have been admitted without them? 87%
Overall Score 73%
Hygiene
Data confirms evidence of good practice in the assessment and planning of
patient hygiene needs. In 91% of cases reviewed there was written evidence that hygiene needs had been assessed and discussed with
patients and 90% of patient records had documentary evidence of up to date care plans.
Foot care The audit findings confirm that the performance is less than satisfactory in
the consideration of foot care needs. Nursing notes show very little evidence that foot and nail care is being considered when the nursing
needs assessment is completed. This should be clearly documented within
the Fundamentals of care nursing assessment. Only 28% of notes showed any written evidence of an assessment using a recognised tool has taken
Place and discussed with the patient. Only 36% of those with an identified risk had evidence of an up to date care plan which had been reviewed in
the previous 24 hours.
26 Fundamentals of Care Annual Audit 2013 | Welsh Government
Good Practice
A Diabetes Foot Care Pathway Group has been set up in ABM Health Board. Discussions have been around the importance of foot examinations and
early identification of problems as vital for all patients with an ‘at risk’ foot. Patients with Diabetes and/or Peripheral Arterial Disease are amongst the
largest groupings.
User Experience
Question 112
Throughout your stay, how often did you feel that your personal hygiene needs were met?
Graph 12
Findings
96% of patients felt that their personal hygiene needs were always or
usually met.
Patient Comments
“Not enough bathrooms”.
“Nurses regularly soaked my feet in a bowl”.
83.71%
13.48% 1.83% 0.98%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
27 Fundamentals of Care Annual Audit 2013 | Welsh Government
4.1.8 Standard 9 - Eating and Drinking
Operational Questions
Table 9
Standard 9 Operational Questions
RAG %
Q61 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?
63%
Q62 Prior to meal times, are patients that require help assisted into
a suitable position? 93%
Q63 Prior to meal service, are bed tables and communal areas
cleared and tidied for the meal? 92%
Q64 Are patients meals placed within easy reach? 95%
Q65 Are all patients given the opportunity to wash or cleanse their
hands with hand wipes prior to eating meals? 81%
Q66 Are patients given the opportunity to go to the toilet before
meal time? 93%
Q67 Is there evidence that the systems in place to enable staff to
identify patients with special requirements are being
implemented and their effectiveness evaluated?
90%
Q68 Are water jugs changed 3 times daily? 40%
Q69 Is drinking water available for patients and where applicable,
are drinking water jugs and glasses within the patient's reach? 89%
Q70 During a 24 hour period, how many beverage rounds are
carried out within your clinical area? 72%
Q71 Does a Registered Nurse supervise every meal time? 87%
Q72 Is there evidence that all members of the nursing team are
engaged in the mealtime service? 93%
Q73 Does the clinical area have access to weighing scales and a
height measurement stick in good working order? 95%
Q74 Is a range of snacks available for patients who have missed a
meal or who are hungry between meals? 91%
Q75 For patients who require a food chart, is there evidence that
they are being kept up to date and evaluated? 90%
Q76 For patients who require a fluid chart, is there evidence that
they are kept up to date and evaluated? 89%
Q77 Is there a system in place to allow family/friends to assist with
meal times? 86%
Overall Score 85%
28 Fundamentals of Care Annual Audit 2013 | Welsh Government
Overall performance with this standard demonstrated high compliance however areas for improvement were identified.
Fluids
The All Wales Nutrition and Catering Standards for Food and Fluid for Hospital Inpatients (Welsh Government 2012) provide technical guidance for caterers, dieticians and nursing staff responsible for meeting the nutritional needs of
patients who are capable of eating and drinking. This was published in
response to Welsh Audit Office 2012 Catering and Nutrition Review which identified that although good practice was demonstrated in some areas,
there needed to be more consistent standards of quality and service delivery across Wales.
Within the standards are the requirements that 7 – 8 beverage rounds
take place per day offering hot and cold beverages and water in jugs should be changed three times a day. Data suggests that ABMU Health
Board is achieving seven or more beverage rounds in 72% of areas, but only 40% of areas currently comply with the requirement for replenishing
fresh water jugs. These findings will be shared with catering managers and
are being addressed as part of the Health Board action plan against the All Wales Nutrition and catering Standards for Food and Fluid for Hospital
inpatients.
E- Learning programme
A national nutrition and food chart e-learning programme is available for staff. Current compliance with this e learning tool within the organisation is
poor, ABMU Health Board has provided assurances to Welsh Government of intention to prioritise engagement and work towards achieving the
target of 100% compliance. The All Wales Fluid Chart E-Learning
programme is now also available. Issues around access are currently being addressed. Group Sessions have been undertaken and further sessions are
in the process of being set up. Links have also taken place with the University to improve compliance for student nurses. Compliance is
monitored in clinical areas monthly via the care indicators.
Swallow Assessment
The audit results identifies that 63% of records show documented evidence
that patients with identified swallow problems were assessed within 24 hours of admission by ‘a skilled professional’. Some clinical areas have
specifically engages specially trained nurses in assessing whether a patient has a safe swallow following a stroke as part of the stroke pathway.
Hand washing opportunities for Patients.
81% of patients were offered the opportunity to wash or cleanse their
hands prior to meal times. All patients should have this opportunity and re enforcement is needed at a local leave.
29 Fundamentals of Care Annual Audit 2013 | Welsh Government
Good Practice
Data suggests that good practice is observed in the preparation of patients in readiness for eating to ensure their safety and a more enjoyable
mealtime experience.
Evidence that food and fluid record charts were being accurately
maintained demonstrated excellent compliance with scores at 89% and 90% respectively. Spot checks are carried out by senior nursing staff as
part of the Quality and Nursing Assurance agenda set up by the Acting Director of Nursing. Nutrition is also one of the priorities audited as part of
the POINT review process. Snacks have been implemented across the Health Board as part of the actions within the All Wales Nutrition and
Catering Standards for Food and Fluid for Hospital Inpatients
In addition to the annual FOC audit there is a requirement on all in patient
areas to electronically report monthly monitoring data which includes, nutritional score completed within 24 hours of admission and number of
patients that are re assessed appropriately. This provides an on-going measure of performance and a benchmark against the national
Position. (graph 13)
User Experience
Question 105
Question 105
Throughout your stay, how often did you feel that you were provided with
nutritious food and snacks?
Graph 14
65.32%
22.98% 9.25% 2.46%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
30 Fundamentals of Care Annual Audit 2013 | Welsh Government
Findings
88% of patients felt that they were always or usually provided with nutritious food and snacks.
Patient comments “My snacks were lovely”.
“Biscuits not healthy” “Nutritious food”.
“Breakfast late and a long time before eating since last meal”. “ Food nutritios but not a great taste”.
Question 106
Throughout your stay/attendance, how often did you feel that you were provided with fresh drinking water and plenty of drinks when you need
them? Graph 15
Question 107
Throughout your stay, how often did you feel that you were given help
with feeding and drinking if you needed this? Graph 16
Findings
Patient satisfaction with the availability and quality of food and drink
appears to be high.
88% of patients felt that they were always or usually provided with nutritious food and snacks throughout their hospital stay
83.24%
12.16% 2.70% 1.89%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
81.17%
12.86% 4.38% 1.59%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
31 Fundamentals of Care Annual Audit 2013 | Welsh Government
93% of patients acknowledged that they were always or usually provided with fresh drinking water and plenty of drinks when they
needed them
95% agreed that they were always or usually helped with feeding
and drinking if they needed it
Patient Comments
“A water dispenser is needed”.
“Food not nice don’t like thickened drinks”
“Tea machine excellent idea”.
There were many not applicable answers in relation to question 107
help with eating and drinking.
4.1.9 Standard 10 - Oral Health & Hygiene
Operational Questions
Table 10
Standard 10 Operational Questions RAG %
Q78 For this episode of care, is there documented evidence that the
patient been assessed using the All Wales Oral Health tool with
respect to their oral health needs?
59%
Q79 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 last 24 hours?
64%
Overall Score 61%
The All Wales Oral Health Tool is currently in the process of being introduced across all health boards including ABMU Health Board. This
process is taking place in a partnership between nursing and dental health colleagues. Compliance at present is poor at 59% further work around
education and compliance is needed. The Health Board documentation
nursing group is currently looking at a shortened version of risk assessments to use as a trigger for full risk assessment for suitable
patients. Oral health questions will be part of this assessment.
32 Fundamentals of Care Annual Audit 2013 | Welsh Government
User Experience
Question 114
Throughout your stay, how often did you feel that you were given help, if
required, to make sure that your mouth, teeth and gums were kept clean and healthy?
Graph 17
Findings
90% of patients responded that they were always or usually given the help they needed to ensure their teeth and gums were kept healthy, which
suggests high levels of satisfaction.
Patient comments
“Some nurses always offered me the support and opportunity to clean my
teeth”.
4.1.10 Standard 11 - Toileting Needs
Operational Questions
Table 11
Standard 11 Operational Questions RAG %
Q80 For this episode of care, is there documented evidence that the
patient's toileting needs has been assessed and discussed with
the patient or advocate?
88%
Q81 For this episode of care, where the patient has been identified
as requiring assistance with their toileting 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 last 24 hours?
87%
Overall Score 88%
The data confirms that compliance with this standard is satisfactory in the assessment and planning of patient toileting requirements. The All Wales
Bowel and Bladder assessment is used across ABMU Health Board, and is looking at integrating the All Wales Continence Bundle into its current
Nursing Documentation. This will also be discussed as part of the All Wales Fundamentals of Care Steering group.
64.84%
25.20%
6.45% 3.52%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
33 Fundamentals of Care Annual Audit 2013 | Welsh Government
Good Practice
The Health Board has recently set up an intranet page in relation to continence as part of the work undertaken by the Health Board’s steering
Group. Although this audit confirms high levels of compliance and performance in assessment of patients, there is need to remain vigilant
and pro-active
User Experience
Question 113
Throughout your stay/attendance how often did you feel that if you needed help to use the toilet that we responded quickly and discreetly?
Graph 18
Findings
92% of patients surveyed agreed that their toilet needs were always or usually responded to quickly and discreetly.
Patient Comments
“Nurses busy tried to come as soon as they could”.
“Good explanation where the toilets were”
“My daughter helped me”.
4.1.11 Standard 12 - Preventing Pressure Sores
Operational Questions
Table 12
Standard 12 Operational Questions RAG %
Q83 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%
Q84 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
last 24 hours.
93%
Overall Score 94%
75.20%
17.63% 5.62% 1.56%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
34 Fundamentals of Care Annual Audit 2013 | Welsh Government
The introduction of the NHS Wales skin bundle and daily assessment of a patient’s skin state has ensured a more consistent approach to skin
assessment and care planning. 95% of the patient notes reviewed provided documentary evidence that patients’ skin condition had been assessed and
discussed with the patient or advocate and 93% of patients who were identified to be at risk or needing assistance to maintain skin health had a
care plan which had been reviewed in the previous 24 hours.
Good Practice
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. See Graph 19, ABMU Health Board is
below The All Wales Average.
Graph 19
Source: Nursing & Midwifery Dashboard for Wales, Welsh Government
User Experience
Question 115 Throughout your stay/attendance, how often did you feel that you were
given help to look after your skin to prevent you from getting pressure sores? Graph 20
74.73%
17.62% 4.80% 2.85%
0%
20%
40%
60%
80%
100%
Always Usually Sometimes Never
35 Fundamentals of Care Annual Audit 2013 | Welsh Government
Findings
92% of service users responded that they were always or usually given
help to look after their skin to prevent the formation of pressure ulcers.
Patient Comments
“The nurses were always checking”.
There were no other comments.
4.2 Fundamentals of Care Staff Survey
For the 2013 annual FOC audit, the staff survey component was reintroduced. 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 summarised response to the survey is detailed in table 13.
36 Fundamentals of Care Annual Audit 2013 | Welsh Government
Table 13
Staff Survey Questions Always Usually Sometimes Never
Q85 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?
49.91% 39.71% 9.78% 0.60%
Q86 Our organisation aims to, ensure that as an employee you are treated with
dignity and respect. Do we achieve this?
26.46% 40.98% 29.55% 3.01%
Q87 Our organisation aims to, make you feel safe at work. Do we achieve this? 30.01% 43.10% 23.16% 3.73%
Q88 Our organisation aims to, make you feel you have a positive contribution to
patient care. Do we achieve this?
34.00% 39.38% 24.72% 1.91%
Q89 Our organisation aims to, provide you with sufficient equipment to do your
job. Do we achieve this?
22.19% 47.93% 27.89% 1.99%
Q90 Our organisation aims to, provide you with opportunities to enhance your
skills and professional development. Do we achieve this?
25.43% 35.14% 32.30% 7.13%
Q91 Our organisation aims to, provide you with feedback on the outcomes of any
incidents/accidents that you report or that are reported within your clinical
area? Do we achieve this?
20.66% 24.98% 34.57% 19.79%
Q92 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?
25.69% 40.03% 28.95% 5.33%
Q93 Our organisation aims to, provide opportunities for you to raise any concerns
that you have. Do we achieve this?
32.13% 32.82% 29.63% 5.43%
Q94 Our organisation aims to, provide you with the opportunity to establish a
work life balance. Do we achieve this?
22.60% 40.35% 30.30% 6.75%
Q95 Our organisation aims to, make you feel a valued member of the
organisation and have a sense of belonging. Do we achieve this?
21.54% 31.40% 36.94% 10.12%
Q96 Our organisation aims to, make you feel proud to be a nurse. Do we achieve
this?
22.59% 30.45% 37.25% 9.71%
Q97 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?
32.23% 44.28% 21.05% 2.45%
37 Fundamentals of Care Annual Audit 2013 | Welsh Government
Staff Survey
The FOC staff survey was carried out across Health Boards and Trusts in Wales on October 7th 2013. All registered nurses and clinical health care
support workers on duty in those clinical areas undertaking the annual FOC audit from 7am on that day to 7am on 8th October were given the staff
survey questionnaire at the start of their shift and asked to return the survey before they went off duty. Responses from 578 nurses from across
ABMU Health Board were uploaded into the FOC system.
In 2013 for the first time the FOC staff questions have been considered as a
separate survey to the operational audit. In previous years staff questions were based around operational skills and opinions, but did not focus on the
feelings and personal experiences of working within an organisation. 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.
The NHS Staff Survey provided a census of all grades and professions of
staff within ABMU Health Board the 2013 FOC audit considers responses from Registered Nurses and HCSWs only. The 2013 FOC audit will be
considered alongside the NHS Staff Survey results analysis to add to the rich data already available. Resulting action plans will be aligned with
current improvement work being led by the Workforce and Organisational Development Team.
Many of the findings of the FOC staff survey reflect those of the NHS Staff
Survey. There is a need for further investigation into all of the domains
explored by the audit, however four priority areas for improvement (below 50% satisfaction) important to our staff relate to:
1. Feedback on incidents and accidents
2. Being a valued member of the organisation
3. Being proud to be a nurse
4. Provide you with opportunities to enhance your skills and professional development.
1. 45% of the nurses 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. 19% said that they never receive feedback. This equates with the findings of the NHS Staff Survey and is
a priority for improvement to learn from concerns and incidents to reduce risk of reoccurrence.
2. 52% of nurses reported that they were always or usually made to feel a
valued member of the organisation and had a sense of belonging. 10%
who responded to this question said that this never happened. There is a need to provide regular feedback in all arears and at all levels.
38 Fundamentals of Care Annual Audit 2013 | Welsh Government
3. 53% of the nurses reported that ABMU Health Board always or usually made them feel proud to be a nurse. 9.7% reported that the organisation never
made them feel proud to be a nurse. The NHS Staff Survey identified that those who have experienced an individual appraisal are more likely to hold
positive views than those who have not. Appraisals are monitored closely in
all clinical areas via the FOC Care Indicators. These are discussed as part of the Acting Director of Nursing’s performance Dashboard meetings.
4. 59% of staff reported that ABMU Health Board always or usually provided
opportunities to enhance your skills and professional opportunities. 7% of staff said this never happens.
5. The staff survey reported positively that ABMU Health Board performed well
in the provision of information for staff. 80% of nurses responded that
ABMU Health Board always or usually made sure that staff were able to access up to date information such as policies and guidelines in order to be
able to do their jobs.
Commentary from staff frequently reflected concerns about current staffing levels and the time taken to complete the amount of paperwork which was
expected of them. The OD team has devised a set of health and well being indicators to be used as a ‘Pulse Check’ (questionnaires) for staff across
ABMU Health BOard. This tool considers many of these issues identified by staff and will aim to collect data targeted at specific issues to increase
organisational awareness, target improvement and staff satisfaction with
development work and outcome measures.
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 (from April 2014)
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.
The Transforming Care team is working collaboratively to develop staff awareness of improvement methodology and process and will continue to
support and guide staff in the areas they have identified for development. At present 61 wards have implemented Transforming Care across ABMU
Health Board.
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 piloted in NPT Hospital. These rounds provide a forum for staff from a range of disciplines to meet and explore
39 Fundamentals of Care Annual Audit 2013 | Welsh Government
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.
40 Fundamentals of Care Annual Audit 2013 | Welsh Government
5 Recommendations
5.1 Actions for Improvements (for all elements that scored less than 85% compliance rate)
Standard (Where
applicable)
Action to be taken By whom By When
1
Operational
issue
Care plans should reflect any difficulties the
patient experiences with communication and discussed with the patient/advocate
Senior nurses/ Ward
Managers
Sept
2014
1 Operational
issue
Reinforce the need to complete the memory
screening question within the FOC assessment and look at adding a prompt in relation to the
Butterfly Scheme.
Documentation group June
2014
1 Operational issue
Consideration of memory problems in the care planning process
Documentation group June
2014
1 Operational Issue
Ensure clear documentation on medication charts Ward nursing Staff/Pharmacists/Doctors
Sept
2014
1 Operational Issue
Staff that are able to speak welsh need to wear the All Wales Badge. Raise awareness of the staff
available.
Ward Manager/ Senior NUrse
On going
2&5 Operational issue
Continue to raise staff awareness of carers rights and ensure discussions are documented
Documentation group On-going
2&5 Operational issue
Work with pastoral leads and nurses to identify how best to capture the cultural and spiritual needs of the increasingly diverse patient
population
Pastoral leads
FOC nurse
June 2014
2&5 Operational Monitor compliance around the use of single sex Senior Nurses On
41 Fundamentals of Care Annual Audit 2013 | Welsh Government
issue toilet , bathroom facilities going
2&5 Operational issue
Monitort compliance with obtaining consent to sharing information.
Senior nurse, Documentation group
On going
3 Operational
issue
Identify waste management audit requirement for
all clinical areas and inform ward managers
FOC nurse Feb
2014
4 Operational issue
Work with the Focus on Flow improvement to improve compliance with discharge planning,
documentation and estimated date of discharge, using practice such as board rounds .
Senior nurses On going
Work
4 Operational issue
Promote good practice in recording carer role and document any communication/involvement of family in discharge planning
Senior nurses July 2014
6 Operational & patient issue
Investigate the causes of sleep disturbances for patients and actions for improvement in specific
areas
FOC nurse/ Senior nurse/ Ward Manager
July 2014
7 Operational issue
Promote awareness of the consequences of anxiety and fear and the need for documented
measures and response to interventions
Senior Nurse/ Ward Manager
On going
8 Operational issue
Link wit the ABMU Helath Board Diabetic foot care pathway group and key professionals.
FOC Lead/Documentation group
June 2014
9 Operational issue
Discuss audit findings with speech and language therapy lead to determine next steps to manage timely swallow assessments
FOC nurse
Speech therapist
June 2014
42 Fundamentals of Care Annual Audit 2013 | Welsh Government
Standard (Where applicable)
Action to be taken By whom By When
9 Operational issue
Continue to work through the Health Board action plan in relation to the provision of changing of water jugs and
drink provision
Via Key groups such as the food
service and nutrition group
Ongoing
9 Operational issue
Continue to promote engagement of all staff in protected mealtime and the need for a registered nurse to supervise and offer hand wipes to all patients where
required prior to meal times.
FOC nurse
Senior nurses
On-going
10 Operational
issue
Continue with work in integrating the continence bundle
into the nursing documentation and POINT reviews and FOC audit during 2014
Continence
nurses/ Documentation
group leads
July
2014
10 Operational issue
Closely monitor compliance with oral care bundle. Further education around this area.
Key leads for the roll out/ Senior
nurses.
Sept 2014
staff Where this is not already happening identify appropriate feedback mechanism for staff relating to incidents
reported
HON
Senior nurses
Ward managers
July 2014
staff Support OD with pulse check monitoring of staff well being
HON
Senior nurses
Ward managers
During 2014
Teams Support all areas to develop local FOC action plans using SBAR format & progress using improvement
methodology
HON
Senior Nurses
During 2014
43 Fundamentals of Care Annual Audit 2013 | Welsh Government
5.2 Monitoring and Assurance
The 2013 FOC ABMUHB 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 five key standards:-
Oral Health (Standard 10)
Sleep and rest (Standard 6) Ensuring comfort and alleviating pain (Standard 7)
Ensuring personal hygiene and foot care (Standard 8) Respecting people & relationships (standard 2&5)
Monitoring progress with implementation of the ABMU Health Board FOC action plan for improvement will require:
a. This report will be presented at Directorate/Locality key
meetings to share the findings, alongside the specific Directorate/Locality findings.
b. The report will be presented at the Nursing Midwifery Board
c. The report and action plan will be reported and monitored
through the Quality & safety Board.
d. Support will be provided to clinical teams in developing local
action plans for improvement held locally at ward and Directorate/Locality level and ward/department managers will
be accountable for progress of actions.
e. Implementation of action plans will be monitored and
supported by senior nurses and reported via
Directorate/Locality key meetings to ensure work is completed within an expected time frame or escalated for appropriate
management. The FOC audit compliance scoring matrix provides a guide for the management and monitoring of
actions.
f. Improving Quality Together (IQT) model for improvement
Bronze and Silver level will be applied to support improvement projects
44 Fundamentals of Care Annual Audit 2013 | Welsh Government
5.3 Conclusion
The National annual Fundamentals of Care audit 2013 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.
The National FOC audit is reported to the Chief Nursing Officer in
March 2014 however 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.
45 Fundamentals of Care Annual Audit 2013 | Welsh Government
6 References
1. 1000 Lives+ (2013) Improving Quality Together
2. ABMU Health Board Policy on the supply, ordering storage,
administration and disposal of medicines.
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
46 Fundamentals of Care Annual Audit 2013 | Welsh Government
18. Welsh Government (2013) Together for Health: A Diabetes Delivery Plan
a. WG: Wales
19. WAG (2010) Doing Well, Doing Better. Standards for Health Services in Wales
a. http:www.nhswalesgovernance.com
20. Zigmond, AS. & Snaith, R.P. (1983). The hospital anxiety and depression scale.
Acta Psychiatrica Scandinavica, 67(6): 361-370
47 Fundamentals of Care Annual Audit 2013 | Welsh Government
7 Appendix A: Fundamentals of Care Audit - Compliance Scoring Matrix
Appendix B Local action plan – PDSA – Model for Improvement
49 Fundamentals of Care Annual Audit 2013 | Welsh Government
Ward / Clinic / Department:
Site:
S Situation
B Background
A St. No.
Quest
No. Assessment Include issues identified in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA
Appendix B Local action plan – PDSA – Model for Improvement
50 Fundamentals of Care Annual Audit 2013 | Welsh Government
A
St. No.
Quest
No. Assessment Include issues identified in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA
Appendix B Local action plan – PDSA – Model for Improvement
51 Fundamentals of Care Annual Audit 2013 | Welsh Government
Fundamentals of Care 2013 Annual Audit Ward / Clinic / Department:
Site:
PDSA Cycle No: _______________
Aim [what are you trying to accomplish]:
Measures[how will you know that the change is an improvement]:
Change Describe your test of change: Person / s Responsible
Completion/Review Date
PLAN List the tasks required to set up this test of change Person / s Responsible
Completion/Review Date
Appendix B Local action plan – PDSA – Model for Improvement
52 Fundamentals of Care Annual Audit 2013 | Welsh Government
Fundamentals of Care 2013 Annual Audit
DO Describe what actually happened when you ran the test
STUDY Describe the measured results and how they compared to the predictions
ACT Describe what modifications will be made to the plan for the next cycle