{"text_format":"3","workbook":"xlsx","n_sheets":26,"sheets":["Guidance","Inspection Details","Arrival and Tour","Summary","Key Documents","Timely Care","People's Rights","Feedback","Managing Risk","Infection control","Safeguarding ","Safe Care","Quality Improvement","Workforce","Governance","Evidence capture form","Evidence capture form (2)","Evidence capture form (3)","Evidence capture form (4)","Issues Identified","Good Practice","Feedback meeting notes","Sheet2","Sheet1","Do not delete","Sheet2 (2)"],"not_rendered":{"images":11},"read":"whole","date_system":"1900"}

{"sheet":"Guidance","index":0,"n_rows":71,"n_cols":6,"rows_kept":71,"merged":[[2,1,2,5],[5,2,5,4],[6,2,6,4],[7,2,7,4],[8,2,8,4],[9,2,9,5],[14,2,14,5],[15,2,15,5],[16,2,16,3],[17,2,17,5],[18,2,18,5],[19,2,19,5],[20,2,20,5],[22,2,23,2],[22,3,23,3],[22,4,23,4],[22,5,23,5],[24,2,45,2],[25,3,27,3],[25,5,27,5],[29,3,30,3],[29,5,30,5],[31,3,32,3],[31,5,32,5],[33,3,35,3],[33,5,35,5],[39,3,40,3],[39,5,40,5],[42,3,45,3],[42,5,45,5],[46,2,64,2],[54,3,55,3],[54,5,55,5],[56,3,57,3],[56,5,57,5],[59,3,60,3],[59,5,60,5],[63,3,64,3],[63,5,64,5],[65,2,68,2],[65,3,66,3],[65,5,66,5],[70,2,70,5],[72,2,72,5]]}
[]
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[null,"Tool Guidance"]
[]
[]
[null,null,"GUIDANCE FOR INSPECTORS"]
[null,null,"The Health and Care Standards (opposite) are at the core of HIW’s approach to inspections in NHS Wales. The seven themes are intended to work together. Collectively they describe how a service provides high quality, safe and reliable care centred on the person. The standards are key to the judgements that we make about the quality, safety and effectiveness of services provided to patients "]
[null,null,"There is an expectation that inspection teams will consider all applicable Health and Care Standards during an inspection. However, it may not be possible or necessary to review all standards in detail."]
[null,null,"This workbook aims to guide inspection managers through the inspection. It is important that all aspects of the workbook are completed so that HIW has a comprehensive audit trail for any recommendations made in our inspection reports."]
[null,null,"In the table below there is a list of all Health and Care Standards. To aid consistency in report writing, these have been mapped to the core HIW reporting themes of:"]
[null,null,"·       Patient Experience"]
[null,null,"·       Delivery of Safe and Effective Care"]
[null,null,"·       Quality of Management and Leadership."]
[null,null,"HIW Inspection Managers must record which standards have been assessed. Where it has been decided that standards will not be assessed, record the reason for this. "]
[null,null,"HIW inspection teams include peer reviewers, lay reviewers and HIW inspectors. Each individual has different skills, and will therefore consider different standards. Some standards will be assessed by more than one person to examine the standard from different perspectives. All findings will be collated at the end of the inspection so that the inspection manager can draw comprehensive conclusions about how the service is meeting the standards overall. Guidance as to which role might examine which standard is included in the table on the following page. HIW inspection managers should assign standards and record on the table which person has examined which standard. When you are conducting the inspection and making findings, bare in mind how you triangulate evidence, i.e. not just relying on one piece of evidence from records, but checking this against observations and staff/patient discussions."]
[null,null,"REMEMBER, all members of the inspection team must record the evidence source for their findings. Where the evidence source is a staff interview, you must record the time and date of that conversation. All evidence must be recorded in official HIW workbooks. When making notes, reviewers and inspection managers must be aware of and adhere to Data Protection principles. Notes recorded within this workbook (including any additional pages) and any prescribed inspection tools/checklists may be used should HIW decide to take further action. Therefore, it is important that you record all findings as clearly as you can. "]
[null,null,"Completing the workbook"]
[null,null,"The coloured tabs in this workbook should be used to capture a summary of findings from all discussions.  Staff discussions are to be recorded on a separate discussions notes sheet / evidence capture form."]
[null,null,"Text blue and underlined = Hyperlink to applicable section of the workbook/guidance/legislation/standards."]
[null,null,"Text written in purple = Could be used as staff discussion prompts, as well as key lines of enquiry."]
[null,null,"Where applicable refer to crib sheet for details of staff discussion prompts  "]
[]
[null,null,"HIW Theme","Health and Care Standard","What are we looking for?","Which workbook?"]
[]
[null,null,"Patient Experience","Staying Healthy"]
[{"$nulls":3},"1.1 Health promotion, protection and improvement","Patients should be supported to look after their own health and well-being","LR"]
[{"$nulls":4},"Patients should know what care and support services there are to help them"]
[{"$nulls":4},"Patients should be supported to make choices about their own health and wellbeing"]
[{"$nulls":3},"Dignified Care"]
[{"$nulls":3},"4.1 Dignified Care","Patients should be treated with dignity, respect and kindness","PR / LR"]
[{"$nulls":4},"Patients should have their needs are met whatever your religion, language, culture or feelings"]
[{"$nulls":3},"4.2 Patient Information (including consent)","Patients should have good information about their care that is easy to understand"]
[{"$nulls":4},"Patients should be supported to make choices about their care"]
[{"$nulls":3},"3.2 Communicating effectively","Patients should have their communication needs met","PR / LR"]
[{"$nulls":4},"Patients should be able to understand information about their care and health"]
[{"$nulls":4},"Patients are able to tell health services about what they need or what they think"]
[{"$nulls":3},"Timely Care"]
[{"$nulls":3},"5.1 Timely access","Patients should have the right care at the right time in the right place with the right staff","IM / LR"]
[{"$nulls":3},"Individual Care"]
[{"$nulls":3},"6.1 Planning Care to promote independence","Patients should be supported to look after their own health and well-being"]
[{"$nulls":4},"Patients should be able to make choices about their care"]
[{"$nulls":3},"6.2 Peoples rights","All health services must understand and support equality and human rights for everyone","IM / LR"]
[{"$nulls":3},"6.3 Listening and Learning from feedback","Patients and their families should be able to tell health services about the care they get from health services","IM / LR"]
[{"$nulls":4},"Health services should know what is working well and what is not working well"]
[{"$nulls":4},"Health services should be open and honest with patients when they tell them that something has gone wrong"]
[{"$nulls":4},"Health services should learn from what patients tell them and make services better"]
[null,null,"Delivery of Safe and Effective Care","Safe Care"]
[{"$nulls":3},"2.1 Managing risk and promoting health and safety","Health services must look after patient’s health and safety and make sure that any risks are managed as well as they can","IM / PR / LR"]
[{"$nulls":3},"2.4 Infection Prevention and Control (IPC) and Decontamination","Health services should involve everyone in helping to control and stop infections so that people do not get ill","IM / PR / LR"]
[{"$nulls":3},"2.5 Nutrition and Hydration","Patients should be supported to eat and drink so that they can get better quicker"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time"]
[{"$nulls":3},"2.7 Safeguarding children and adults at risk","Health services must support and protect all children and any adults who are vulnerable or at risk","IM / LR"]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it"]
[{"$nulls":3},"Effective Care"]
[{"$nulls":3},"2.2 Preventing pressure and tissue damage","Patients should be helped to look after their skin","PR"]
[{"$nulls":4},"Health services should make sure that patients do not get sore skin from sitting or lying down for too long"]
[{"$nulls":3},"2.3 Falls Prevention","Health services should check if patients are likely to fall","PR"]
[{"$nulls":4},"Health services should do everything they can to stop people from falling and hurting themselves"]
[{"$nulls":3},"2.9 Medical devices, equipment and diagnostic systems","Health services must make sure that all the equipment they use is safe and works well","PR"]
[{"$nulls":3},"3.1 Safe and Clinically Effective care","Patients should get the right care and support for their needs","IM / LR"]
[{"$nulls":4},"Health services should know the best ways to care and support patients"]
[{"$nulls":3},"3.3 Quality Improvement, Research and Innovation","Health services should look at different ways to make services better based on good research","IM"]
[{"$nulls":3},"3.4 Information Governance and Communications Technology","Health services should have the right information and make sure this information is shared safely"]
[{"$nulls":3},"3.5 Record keeping","It is very important that health services keep good records to make sure patients get the right care"]
[{"$nulls":4},"Health services must follow the rules about how to record information and keep it safe"]
[null,null,"Quality of Management and Leadership","Governance, Leadership and Accountability","All health services should be person centred. They should focus on patient’s needs and listen to them"]
[{"$nulls":4},"Health services should do the right things well, know how well they are doing, be open and honest in everything they do, be caring and kind and work hard"]
[{"$nulls":3},"Staff and Resources"]
[{"$nulls":3},"7.1 Workforce","Health services should have enough staff with the right skills and training to be able to give patients the best care"]
[]
[null,null,"* If standard(s) have not been asssessed, please record the reason(s) for this below:"]

{"sheet":"Inspection Details","index":1,"n_rows":25,"n_cols":4,"rows_kept":25,"merged":[[0,4,0,5],[5,3,5,5],[7,3,7,5],[9,3,9,5],[11,3,11,5],[13,3,13,5],[15,3,15,5],[17,3,17,5],[19,3,19,5],[21,4,21,5],[22,4,22,5],[23,4,23,5],[24,4,24,5]]}
[]
[]
[null,"Inspection Details"]
[]
[]
[null,null,"Reference number",3129]
[]
[null,null,"Inspection Type","Emergency Department (ED)"]
[]
[null,null,"Health Board ","Swansea Bay"]
[]
[null,null,"Name of setting","Morriston ED and Assessment Units"]
[]
[null,null,"Date inspection started","2022-09-05"]
[]
[null,null,"Date inspection completed","2022-09-07"]
[]
[null,null,"Name of Lead HIW Inspector","xxxxxx xxxxxxxx"]
[]
[null,null,"Name of Supporting HIW Inspector","xxxxx xxxxxxxx"]
[]
[null,null,"Inspection team","Peer 1:"]
[{"$nulls":3},"Peer 2:"]
[{"$nulls":3},"Peer 3:"]
[{"$nulls":3},"Patient Experience:"]

{"sheet":"Arrival and Tour","index":2,"n_rows":97,"n_cols":5,"rows_kept":97,"merged":[[0,4,0,5],[4,2,4,5],[5,2,5,5],[8,3,8,5],[12,4,12,5],[13,4,13,5],[14,4,14,5],[15,4,15,5],[19,3,19,5],[23,3,23,5],[27,3,27,5],[31,4,31,5],[32,4,32,5],[33,4,33,5],[34,4,34,5],[35,4,35,5],[39,3,39,5],[43,3,43,5],[44,3,44,5],[45,3,45,5],[46,3,46,5],[51,3,51,5],[55,3,55,5],[59,3,59,5],[63,3,63,5],[67,3,67,5],[71,3,71,5],[75,3,75,5],[79,3,79,5],[84,3,84,5],[88,3,88,5],[92,3,92,5],[96,3,96,5]]}
[]
[]
[null,"Arrival and Initial Discussions"]
[]
[null,null,"Upon arrival at the ward/unit, you will need to introduce yourself and ask to speak to the person in charge. You may want to consider splitting up with some team members having a walk around while the inspection manager speaks to nurse in charge. "]
[null,null,"Introductory discussions agenda:\n• Introduce team and roles\n• Explain purpose of inspection – i.e.  routine or as result of concerns\n• State how long team plan to be onsite – e.g. one day/half day etc.\n• Ask the nurse in charge or Senior Nurse/ Matron to immediately inform the Executive Team, that the HIW inspection team are on site, and are available for discussions if required\n• Give documents list to nurse in charge\n• Arrange to speak to nurse in charge later during the inspection \n• Plans and time for feedback session (including who needs to attend)\n• Check if there are any areas/patients to be aware of i.e. isolation?\n• Check where team can be based/leave bags\n• Check if staff have any initial questions\n\n"]
[]
[]
[null,null,"Time of Arrival ","~ 20.30/45"]
[]
[]
[]
[null,null,"Name of person/people in charge: ","Person in charge:","xxx xxxxx NIC"]
[{"$nulls":3},"Other (please specify):","xxx xxxxx - Clinical Site Matron present "]
[{"$nulls":3},"Other (please specify):"]
[{"$nulls":3},"Other (please specify):"]
[]
[]
[]
[null,null,"Who is the person in overall charge of the hospital? "]
[]
[]
[]
[null,null,"Who is Gold/Silver/Bronze on call out of hours?","NIC aware of process - arrival escalated to Clinical Site Matron"]
[]
[]
[]
[null,null,"Would you like to make anyone else aware of HIW’s arrival? i.e. Who is your line manager? \n\n(If so please record the name and title)\n","As above"]
[]
[]
[]
[null,null,"Number of Beds (in each ED area):","Majors:"]
[{"$nulls":3},"Minors:"]
[{"$nulls":3},"Resuscitation:"]
[{"$nulls":3},"Clinical Decision Unit (if applicable):"]
[{"$nulls":3},"Other areas:"]
[]
[]
[]
[null,null,"Number of Patients","104 pts total, inc. 1 COVID+"]
[]
[]
[]
[null,null,"Staffing and skill mix in relation to the acuity (which areas are staff allocated to, e.g. resus, triage etc.).","Rotas to be reviewed "]
[null,null,"Number of permanent/agency/bank staff","Described a recent heavy loss of staff. Heavily reliant on agency and bank. Same for medical - contracted medical staff. "]
[null,null,"Staffing levels at time of inspection and any new/supernumerary staff","Described many new (nursing) starters coming on board and who are due to come on board. Overseas recruitment has been successful, but sometimes need to improve competencies to ensure staff and patients are fully supported. "]
[null,null,"No. of ENPs","MIU - usually 2 "]
[null,null,"(check if the above is normal level of staffing)"]
[]
[]
[]
[null,null,"Speciality of ward/ service model\ne.g. GP/consultant led"]
[]
[]
[]
[null,null,"Are there any patients subject to DOLS and how are they being supported in the department? ","Handover just took place - doesn't believe there are any DOLS in ED, but possibly in AU's. "]
[]
[]
[]
[null,null,"Are there any patients with safeguarding concerns?","Not at time of arrival"]
[]
[]
[]
[null,null,"Are there any patients with any cognitive impairment, e.g. dementia?\n\nIf so, what is the system to ensure these patients are identified?","Yes - all areas "]
[]
[]
[]
[null,null,"Are there any patients with mental health needs in the department at present?","MH room in use at present "]
[]
[]
[]
[null,null,"Is the department in escalation?","Yes - level 4 - consistent as of late"]
[]
[]
[]
[null,null,"Are there any 4 hour breaches?","Yes"]
[]
[]
[]
[null,null,"Describe conditions in the department  \n\nPrompts: busier than usual, short of staff, patients in ambulances/corridors, escalation level, observation levels, individuals at risk, anywhere we should avoid for clinical reasons i.e. isolation","1. Waiting area extremely congested upon arrival. Medical emergency taking place in waiting aera. No water. \n2. Up to 18hrs - longest wait on ambulance currently (OD) \n3. Nursing complement ok - see above re: levels and review rotas\n"]
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[]
[]
[]
[null,null,"Do you have any concerns about the operation of the department at the moment?  \n\nPrompts: Capacity of staff, overcrowding, high levels of agency staff, environmental risk. Are there any historical issues?","Themes around flow, staffing (turnover and skill mix), consistent demand on front door."]
[]
[]
[]
[null,null,"General observations of department and environment   \n\nPrompts: Observe the clinical areas e.g. general ambience, how busy, noise levels etc. Are the furnishings and fittings in good state of repair and working order, bathrooms and showers, telephones, any areas that require maintenance or present any risks to patients and staff? ","** NOTES FROM TOUR / ORIENTATON with NIC and later Clinical Site Matron **\n1. AMBULANCE traige: \nxxxx xxxx - Pt flow co-ordinator / Up to 18 hrs longest wait currently with OD pt / Ring fenced internal space REACT Blue and red (red - sickest) - for pressure checks, bloods etc / COVID swab on arrival / do esclate if ring fence space is lost / triage nurse - usually a senior triage nurse / aware of immediate release protocol - some issues in number of releases being requested -\n\nResus - x3 bays, 1 x paeds and 1 x negative pressure room \n\nMinors - x2 nurses / carries risk due to placement of majors pts in this area - informs bed mgmt of numbers / pysch room with specialist input until 10pm - in use currently \n\nMinors into majors - 3 cubes / 2 bays - 3 4 5 can be used for COVID+ pts. \n\nRelatives room - small but functional \n\nSurge area (opp. relatives room) - quiet area but need to be careful how pts are placed. 'Essentially a low acuity ward with low NEWS / Generally appeared to be older patients placed and with increased obs etc. \n\nEducation hub - 7am / 7pm handover / safety huddle  8.15 / 10 bed mgmt \n\nPaeds - 4+6 / 2 RN day and night plus medic cover / Described good relations with ward, but now under ED footprint.\n\n** xxxxx sat on floor in minors corridor - on own bedding and looking in discomfort, xxxxx unaware of situ - mentioned to NIC re dignity aspect **\n\nTriage - blue triage 'walk in REACT' - B3 ED assistants works from nurses plan using 'cookbook'. 2 triage  RN otherwise. \n\nSpecialist nurses - in during core hours, fequent attendees, bereavement, xx.\n\nAssessment Units:\n\n1. MAU from November 2022 - new super unit to open with move from Singleton taking place \nRAU / AMAU: Re-utilised as a COVID area but never fully recovered \n2. AMAU Confirmed outbreak status \n3. RAU - currently 18 and 21 bed incorps. discharge lounge by day and beds by night / AMAU 24 \n- RAU: no hand gels (broken), purpose built for COVID red area / 3 bed would be sole discharge lounge if not in escalation / RAU sister by night covers RAU and AMAU / Mixed bays on RAU / curtains not in use anywhere\nUnderstaffed \n\nSDU: \n1. Flow - issue \n2. Staffing 8 day / 7 night / tonight 7/4 / last night 2.5 short \n3. 9 pts / people sitting and largely sleeping in waiting area - mainly waiting for medic review\n4. GP referrals also \n\n\n"]
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[null,null,"What system is used to identify patient status to staff e.g. Are patient status at a glance boards used? \n\nPrompts: Discuss with peer reviewers whether these are up-to-date, include relevant information and if there is information on patients who may be subject to DOLS or patients with cognitive impairment e.g. dementia. ","PSAG,  PC and above bed"]
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[]
[]
[null,null,"Is there clear leadership evident on the ward e.g. is there a registered nurse in charge and are they visible?","Yes "]

{"sheet":"Summary","index":3,"n_rows":28,"n_cols":7,"rows_kept":28,"merged":[[6,2,6,4],[6,6,6,7],[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[21,2,21,4],[22,2,22,4],[23,2,23,4],[24,2,24,4],[27,2,27,4]]}
[]
[]
[null,"Summary",null,"Key Documents","Issues Identified",null,"Good Practice"]
[]
[]
[null,null,"Quality of Patient Experience","Select outcome statement"]
[null,null,"5.1 Timely Care ",null,null,{"$f":"'Timely Care'!D4","v":"Yes"},{"$f":"'Timely Care'!D5","v":"Significant improvement needed"}]
[null,null,"6.2 People's Rights",null,null,{"$f":"'People''s Rights'!D4","v":"Yes"},{"$f":"'People''s Rights'!D5","v":"Select outcome statement"}]
[null,null,"6.3 Listening and Learning from Feedback",null,null,{"$f":"Feedback!D4","v":"Yes"},{"$f":"Feedback!D5","v":"Select outcome statement"}]
[]
[null,null,"Delivery of Safe and Effective Care","Select outcome statement"]
[null,null,"2.1 Managing risk and health and safety",null,null,{"$f":"'Managing Risk'!D4","v":"Yes"},{"$f":"'Managing Risk'!D5","v":"Select outcome statement"}]
[null,null,"2.4 Infection control (IPC)",null,null,{"$f":"'Infection control'!D4","v":"Yes"},{"$f":"'Infection control'!D5","v":"Select outcome statement"}]
[null,null,"2.7 - Safeguarding children and adults at risk",null,null,{"$f":"'Safeguarding '!D4","v":"Yes"},{"$f":"'Safeguarding '!D5","v":"Yes"}]
[null,null,"3.1 Safe and Clinically Effective care",null,null,{"$f":"'Safe Care'!D4","v":"Yes"},{"$f":"'Safe Care'!D5","v":"Select outcome statement"}]
[null,null,"3.3 Quality Improvement, Research and Innovation",null,null,{"$f":"'Quality Improvement'!D4","v":"Yes"},{"$f":"'Quality Improvement'!D5","v":"Select outcome statement"}]
[]
[null,null,"Quality of Leadership and Management","Select outcome statement"]
[null,null,"7.1 – Workforce",null,null,{"$f":"Workforce!D4","v":"Yes"},{"$f":"Workforce!D5","v":"Select outcome statement"}]
[null,null,"Governance, leadership and accountability",null,null,{"$f":"Governance!D4","v":"Yes"},{"$f":"Governance!D5","v":"Select outcome statement"}]
[]
[null,null,"Evidence capture form"]
[null,null,"Evidence capture form(2)"]
[null,null,"Evidence capture form(3)"]
[null,null,"Evidence capture form(4)"]
[]
[]
[null,null,"Feedback meeting notes"]

{"sheet":"Key Documents","index":4,"n_rows":15,"n_cols":8,"rows_kept":15,"merged":[[6,5,6,6],[7,2,7,3],[7,5,7,6],[8,2,8,3],[8,5,8,6],[9,2,9,3],[9,5,9,6],[10,2,10,3],[10,5,10,6],[11,2,11,3],[11,5,11,6],[12,2,12,3],[12,5,12,6],[14,2,28,2]]}
[]
[null,"Key Document Checking"]
[{"$nulls":7},"Back to Summary"]
[]
[]
[]
[null,null,"Key documents required to complete this section:",null,"Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"Any policies/documents relating to staffing and on call arrangements.",null,"Sufficient","See list below. Documents to be reviewed ",null,"No"]
[null,null,"Audits",null,"Sufficient",null,null,"No"]
[null,null,"Evidence from staff meetings/ shared learning",null,"Sufficient",null,null,"No"]
[null,null,"Sample of incident records",null,"Sufficient",null,null,"No"]
[null,null,"Sample of complaint records",null,"Sufficient",null,null,"No"]
[null,null,"Sample of staff files to demonstrate:\no Appraisals\no Supervision\no DBS check, staff photo\no Recruitment/pre-employment checks, references, qualifications/professional body registration, employment history etc.",null,"Not Checked",null,null,"No"]
[]
[null,null,"ADDITIONAL DOCUMENTS OBTAINED LIST: \n- FOC audits. Inc pressure - latest\n- ASMR Board Update \n- Unscheduled care performance data - latest\n- Escalation plan and site reports July and August\n- Complaints and incidents report - July and August \n- ESR and additional training \n- Clinical governannce and Service Group meeting minutes - May - August\n- Weekly senior team minutes - July and August\n- Org structure \n- ED induction handbook, ppt slides\n- Rotas x 3m"]

{"sheet":"Timely Care","index":5,"n_rows":42,"n_cols":9,"rows_kept":42,"merged":[[1,1,1,9],[9,2,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,3],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,3],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,3],[19,6,19,7],[20,2,20,4],[20,6,20,7],[21,2,21,3],[21,6,21,7],[22,2,22,3],[22,6,22,7],[23,2,23,3],[23,6,23,7],[24,2,24,3],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[29,6,29,7],[30,2,30,3],[30,6,30,7],[31,2,31,4],[31,6,31,7],[32,2,32,3],[32,6,32,7],[33,2,33,3],[33,6,33,7],[34,2,34,4],[34,6,34,7],[35,2,35,3],[35,6,35,7],[36,2,36,4],[36,6,36,7],[37,2,37,3],[37,6,37,7],[38,2,38,3],[38,6,38,7],[41,2,41,8]]}
[]
[null,"Quality of Patient Experience - 5.1 Timely Care "]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"Link with peer to consider the following jointly:"]
[null,null,"How does WAST and the department ensure that patient handover times are appropriate and take place within agreed national timescales?"]
[null,null,"WAST / ED: Handover and triage",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What have been the average report of arrival times, handover times and off-loading times been over past 24-48hrs?",null,null,"Yes","Refer to submitted data. Time of arrival: longest wait ~ 18hrs on back of ambulance. Examples of other waits in evidence gathering tab and in records review. ",null,"Yes"]
[null,null,"Are there presently any delays in offloading patients, if yes what are the causes of delays?",null,null,"Yes","Yes - capacity in ED and challenges presented by flow.",null,"Yes"]
[null,null,"How long have you been waiting to offload?",null,null,"Yes","See evidence gathering tab and records review:\n\n6/9 11.25am issues raised by xxxxx and xxx: Patient (spinal injury). Provided with pain relief and water. Had a CT - c spine wasn’t cleared - waiting for MRI due to pins and needles. On spinal board for 6 hours. \n- MH pt from Cefn Coed - (in REACT since around 5/6pm prev. day) - taken back to ambulance awaiting blood transfusion - signficant delay. \n- Older pt - here since 9pm last night - no food provided as of 11am this mornng. Obstruction TBC. \n- Older pt on ambulance - since 1pm prev. day - fractured NOF. Stated uncomfortable on ambulance trolley. ** Appropriate mattress issue\n- Asked triage nurse in ambulance area questions, but was covering break, stated: \"I can't tell you anything, I'm only covering break\". \n",null,"Not Completed"]
[null,null,"What is the patient’s category?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Has the patient been triaged by ED staff and categorised accordingly?",null,null,"Yes","Patients triaged in records reviewed",null,"Not Completed"]
[null,null,"Who is ultimately responsible for the patient?",null,null,"Not Completed","Peer reviewer workbook",null,"Not Completed"]
[null,null,"What is the hospital policy on assessing patients unable to be offloaded? ",null,null,"Yes","Peer reviewer workbook - ED escalation plan obtained. ",null,"Not Completed"]
[null,null,"What arrangements are in place to divert ambulances to alternate ED if appropriate /SOP/ transfer type (medical/surgical)?",null,null,"Not Completed","Peer reviewer workbook",null,"Not Completed"]
[null,null,"Have hospital Medical staff reviewed the patient while waiting to be offloaded?",null,null,"Yes","In most cases yes, but delays observed in relation to furhter tests, reviews etc. Peer reviewer workbook and evidence gathering tab",null,"Not Completed"]
[null,null,"If patient reviewed but no bed in hospital, who is ultimately responsible for the patient?",null,null,"Yes","Evidence of joint care provided by WAST and ED triage staff - use of REACT rooms for tests, pressure checks etc.",null,"Not Completed"]
[null,null,"Have basic needs been met, i.e. nutrition / elimination / SKIN / Hydration / privacy?",null,null,"Yes","Issue with repose mattresses identified by peer reviewer, ED and WAST staff. Unable to use these mattresses on the back of ambulances due to height of bed, normalsiing pt on ambulance etc. Peer review discussed with HB staff - on-going negotiation…\n\nPatients generally observed being brought in for pressure checks etc - but lengths of wait on a trolley not optimal for other patients. Refer to peer reviewer workbook\n\nNutrition - informed that food is available for ambulance patients, but pts and crew told os that this is not always the case (14hrs without food for one female pt and 12 hours for another male).  Water available and can be picked up by crew.",null,"Yes"]
[null,null,"Who liaises between ambulance and hospital (provide updates)?",null,null,"Yes","Pt flow co-ordiantor - Discussion held with Pt flow co-ord xxx xxxxx  - experienced ED nurse in post since January 2021. Recognised need from past HIW report and current pressures. Bridges gap between bed site team, NIC and WAST. All transfers, swaps, arrivals etc into xxx and ambulance triage nurse.",null,"Not Completed"]
[null,null,"Do relevant ED staff attend hospital patient flow meeting?",null,null,"Yes","Good attendance observed",null,"Not Completed"]
[null,null,"What arrangements are in place to receive a divert from other hospitals?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have there been occasions when delays in offloading have resulted in an inability to respond to other urgent calls? Have any such incidents resulted in patient harm?  What evidence is there of this (i.e. Datix report)?",null,null,"Not Completed","Peer reviewer workbook. DATIX and performance data to be reviewed.",null,"Not Completed"]
[null,null,"Are patients being received into the department from ambulances in a timely and effective way?",null,null,"Not Completed","Peer reviewer workbook",null,"Not Completed"]
[]
[null,null,"WAST/ED: Patient flow and escalation",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What is the current capacity within the hospital – empty beds? (Could check this with Clinical Site Manager for example)",null,null,"Not Completed","Peer reviewer workbook",null,"Not Completed"]
[null,null,"What is the process and arrangements for patient flow?",null,null,"Not Completed","As above and Peer reviewer workbook",null,"Not Completed"]
[null,null,"Are there any processes in place to admit directly to wards (if safe to do so), i.e. direct admission to AMAU / SAU / ENT etc.",null,null,"Yes","`Yes to assessment units. E.g GP referral into SDMU and OPAS. Positive outreach and referral process described for OPAS - avoids need for older pt to enter ED and reduces capacity. Good relationships with local care providers and aim to remobilise pts to avoid admittance. Paperwork, studies etc provided and to be reviewed.",null,"Not Completed"]
[null,null,"Do you / who attends the patient flow meetings and how often/times etc.?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What is the hospital’s policy and SOP for escalation status?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have any incidents relating to patient safety/harm been reported in the past twelve months?",null,null,"Yes","Incident document 1/7/22-31/8/22: incidents relating to delayed admissions / access to services at highest 320 in total.  5 severe incidents noted - not immediately clear if all WAST related, but all incidents relate to delayed access. ",null,"Not Completed"]
[null,null,"Have any complaints been received from patients or relatives?",null,null,"Yes","Complaints document: 1/7/22-31/8/22  x 23 - relevant complaints tend to theme around waiting area waits etc, as opposed to ED / WAST",null,"Not Completed"]
[null,null,"Are there any concerns in relation to communication between WAST and hospital teams?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are patients kept in the corridors, if so who’s responsible? ",null,null,"Yes","Generally an avoidance of corridor patients - but examples of poor placement elsewhere - waiting rooms, use of chaired waiitng areas in the department e.g. minors / majors and in assessment units (SDMU in particular) for lenghthy waits in absence of bed space in ED, AU or on a ward. ",null,"Not Completed"]
[null,null,"ENP – do they get involved with patients on ambulances?",{"$nulls":5},"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Issues regarding timely care also present for walk-in pts. See evidence gather tabs and peer reviewer workbook - IA issue based on clinical findings from PR.\n\n"]

{"sheet":"People's Rights","index":6,"n_rows":24,"n_cols":9,"rows_kept":24,"merged":[[1,1,1,9],[8,2,9,4],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[13,2,13,4],[13,6,13,7],[14,2,14,4],[16,2,16,4],[16,6,16,7],[17,2,17,4],[19,2,19,4],[19,6,19,7],[24,2,24,8]]}
[]
[null,"Quality of Patient Experience - 6.2 People's Rights"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"Link with peer to consider the following jointly"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How is equality and diversity promoted within the organisation? ",null,null,"Yes","HB wide policy in place and accessible on intranet",null,"Not Completed"]
[null,null,"Examples – Everyone is treated fairly / equality and diversity policies and processes that includes staff training, feedback mechanisms for patients and staff, equality and diversity officer, formal groups/forums to ensure people with particular protected characteristics can be heard / influence  "]
[null,null,"How are patients and / or staff protected from discrimination? This includes potential harassment and discrimination in relation to protected characteristics under the Equality Act?",null,null,"Yes","ESR training data: combined 65.22%. ",null,"Not Completed"]
[null,null,"Examples – Up to date policy / processes, anti-discrimination training, staff understand what they would do in this instance, feedback mechanisms for patients and staff"]
[]
[null,null,"Can you provide examples where reasonable adjustments are in place or made so that everyone, including individuals with particular protected characteristics, can access and use services on an equal basis?",null,null,"Yes","Department generally accessible in terms of physical access. Good B7 nurses in post re: SG and frequent attendees for example: Processes appear to be robust (see peer reviewer workbook) and joined up. ",null,"Not Completed"]
[null,null,"Examples – Disabled patients and wheelchair access, easy read appointment letters, translation services, advocacy, health passport/this is me documents, commitment not to discharge children and adults dependent on others to bring them to appointments because ‘did not attend/DNA’"]
[]
[null,null,"How does the service ensure that transgender patients are appropriately placed upholding their equality rights? ",null,null,"Yes","Staff described taking a non discriminatory appraoch to all ED attendees. ",null,"Not Completed"]
[null,null,"Example - risk based approach to placement inline with the services policy"]
[]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Feedback","index":7,"n_rows":23,"n_cols":9,"rows_kept":23,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,4],[11,6,11,7],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[16,2,16,4],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[23,2,23,8]]}
[]
[null,"Quality of Patient Experience - 6.3 Listening and Learning from Feedback"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that they listen and learn from feedback?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department gather patients’/carers’ views and make changes as a result? Consider how departments gather views of children and their families also.",null,null,"Yes","Refer to lay reviewer workbook - informed lack of information on display in main patient waiting areas. Staff informed that verbal concerns are directed to the NIC, PALS or by referring to information on the HB website. ",null,"Yes"]
[null,null,"Is there information on how the health board has learned and improved based on feedback received? ",{"$nulls":5},"Not Completed"]
[null,null,"Is Putting Things Right displayed?",null,null,"Yes","Refer to lay reviewer workbook - informed lack of information on display in main patient waiting areas, including PTR.",null,"Yes"]
[]
[null,null,"Review recent complaints/concerns records",null,null,"Question answered?"]
[null,null,"Are there any particular complaints/concerns that give a specific cause for concern in terms of theme?",null,null,"Yes","Large number of complaints and incidents re: communication and issues related to flow (delayed access / admission)",null,"Yes"]
[null,null,"How are complaints/concerns managed and is this system appropriate and effective?",null,null,"Yes","Complaints appear to be responded to and closed appropriately. ",null,"Not Completed"]
[null,null,"Do responses meet specified timescales?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How are verbal/informal concerns (complaints) captured?",null,null,"Yes","As above - complaints records reviewed and verbal complaints are captured.",null,"Not Completed"]
[null,null,"Is there evidence that common themes emerging from complaints are checked and addressed?",null,null,"Yes","Evidence observed in clinical governance meeting minutes, but some issues are not easily fixed. E.g. flow.",null,"Not Completed"]
[null,null,"How is information from complaints shared with staff and is there sharing of learning across ward and health board?",null,null,"Yes","To be reviewed as part of staff questionnaire feedback responses.",null,"Not Completed"]
[]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Managing Risk","index":8,"n_rows":16,"n_cols":9,"rows_kept":16,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,4],[13,6,13,7],[16,2,16,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.1 Managing risk and health and safety"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"How does the department ensure that they manage risks and incidents effectively?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there records of any significant incidents? ",null,null,"Yes","Incident data 1/7/22-31/8/22: largest proportion of incidents (320) in the delayed access / admission to services category. ",null,"Not Completed"]
[null,null,"How are incidents reported? Do staff feel able to report incidents? Is the reporting system effective?",null,null,"Yes","To be reviewed fully as part of staff questionnaire responses - large number of DATIX incidents demonstrate staff capable of and confident in reporting issues relating to adverse patient care - e.g. flow and delayed care.",null,"Not Completed"]
[null,null,"How are incidents dealt with?",null,null,"Yes","Incidents reviewed appeared to have been reviewed and closed promptly. Issues appear to have been discussed in management and governance meetings, but learning appears to be limited due to the nature of the incidents (e.g. lack of flow resulting in harm). ",null,"Yes"]
[null,null,"How is learning shared from incidents? ",null,null,"Yes","To be reviewed fully as part of staff questionnaire responses. Informed that there are staff groups e.g whatsapp and staff room notices, as well as at the usual safety huddle, handovers etc. ",null,"Not Completed"]
[null,null,"What quality audits/risk assessments are in place and are they ensuring that any service risks are identified, monitored and managed?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Infection control","index":9,"n_rows":35,"n_cols":9,"rows_kept":35,"merged":[[1,1,1,9],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,3],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,3],[17,6,17,7],[19,2,19,4],[19,6,19,7],[20,2,20,4],[20,6,20,7],[21,2,21,3],[21,6,21,7],[23,6,23,7],[24,6,24,7],[25,6,25,7],[26,6,26,7],[27,6,27,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[29,6,29,7],[30,2,30,4],[30,6,30,7],[31,2,31,4],[31,6,31,7],[32,2,32,4],[32,6,32,7],[35,2,35,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.4 Infection control (IPC)"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[]
[null,null,"How does the department ensure that infection prevention and control is managed carefully and appropriately?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Link with peer reviewer\nWhat are the current infection rates and does this fit within organisational process?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What changes have been made to the unit due to COVID-19 for example:"]
[null,null,"social distancing",null,null,"Yes","Efforts made to be comply with latest iteration of WG PHW guidelines - but hampered by crowded department and poor flow e.g patients being placed in between beds and crowded waiting areas.",null,"Not Completed"]
[null,null,"enhanced cleaning",null,null,"Yes","Efforts made to be comply with latest iteration of WG PHW guidelines - but hampered by crowded department and poor flow. Hosuekeeping appeared dilligent in their tasks. ",null,"Yes"]
[null,null,"PPE ",null,null,"Yes","Staff observed weating routine and enhanced PPE for actual / query infectious pts. However occassions observed where this was worn inappropriately and not changed at the end of in between clinical and non clincal tasks. Refer to peer reviewer workbook",null,"Yes"]
[null,null,"COVID-19 training",null,null,"Yes","IPC training combined at 58%",null,"Yes"]
[null,null,"Pre-screening for COVID-19",null,null,"Not Completed","Peer reviewer workbook",null,"Not Completed"]
[null,null,"Screening before leaving ED to move patients onto wards",null,null,"Not Completed","IM and Peer reviewer workbook",null,"Not Completed"]
[]
[null,null,"Is there separate area for isolating patients with suspected or confirmed COVID-19?",null,null,"Yes","Negative pressure room available, but informed this is usually ring fenced and not used as a matter of course for issues such as COVID. Areas of the department are designated as COVID and non COVID areas, e.g. REACT.  See above re: PPE usage and peer workbook ",null,"Not Completed"]
[null,null,"How do you manage infected patients E.g. When to isolate, type of precautions, when to sample and/or screen for MRSA, sampling for Cdiff?",null,null,"Yes","As above",null,"Not Completed"]
[null,null,"How do you identify and effectively manage COVID-19 outbreaks / nosocomial transmission?  ",null,null,"Not Completed","Peer reviewer workbook. Local and IPC investigation. ",null,"Not Completed"]
[null,null,"If there have been any cases in the past three months:"]
[null,null,"How did you discuss this with all ward staff?",null,null,"Not Completed","Peer reviewer discussion with IPC lead ",null,"Not Completed"]
[null,null,"Did you follow your Health Board’s policy?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have you been able to identify the root cause? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Were action plans created and implemented? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How did you share lessons learnt?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Request copies of the investigation reports where there have been cases of COVID-19 outbreaks/nosocomial transmission in the past three months on the ward",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What training do staff receive in IPC? Are staff confident in their knowledge, practice and specific roles in relation to IPC?",null,null,"Not Completed","See issue above re: ESR training. IPC team note that they frequently attend the ED to support staff. However some staff noted that they 'never see IPC' in the department. During peak of COVID, more regular input was provided including quick sessions, donning doffing etc.",null,"Not Completed"]
[null,null,"Are there adequate IPC policies and procedures in place and do staff have access to them? Including: Policy on decontamination of medical devices/equipment; Policy on water management? Are policies implemented, i.e. do you observe practice that reflects agreed policies/procedures? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there an ongoing audit programme for IPC compliance and arrangements for feeding back the results?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What support/access is there to occupational health for staff? Are there records on staff immunisation status?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Safeguarding ","index":10,"n_rows":16,"n_cols":9,"rows_kept":16,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[16,2,16,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.7 - Safeguarding children and adults at risk"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Yes"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"What systems and processes are in place to ensure that patients are safeguarded and kept safe from abuse?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Link with peer reviewer\n\nAre there any Deprivation of Liberty Safeguards (DOLS) currently in place? Are staff knowledgeable around deprivation of liberty and in what circumstances they would need to make an application for DOLS? (More applicable for longer-term ED patients).",null,null,"Yes","Informed  in RAU there are xxxx pts requiring an enhanced level of care, bu t no additional nursing or DOLS processes had been consdered.  xxxxxx wandering and wanting to leave. Team informed NIC and DOLS process now under consideration. Staff noted that they would like more training. ",null,"Yes"]
[null,null,"For patients who lack mental capacity are there advocacy arrangements in place?",null,null,"Not Completed","Peer reviewer - services are available, but uptake not known. ",null,"Not Completed"]
[null,null,"Are there any current/recent POVA concerns? If so, who has reported these? Are staff knowledgeable about vulnerable adults procedures, signs of abuse and how they would raise a safeguarding concern? Do policies and procedures meet national recognised guidelines?",null,null,"Yes","SG B7 lead in the department - takes a proactive role and reviews specific cases. Violence prevention referral and sexual exploitation documents in place, used and staff aware of their contents. \n\nESR - 701%",null,"Not Completed"]
[null,null,"Are there any current/recent child safeguarding concerns/treatment of vulnerable children/children in need? If so, who has reported these? Are staff knowledgeable about child safeguarding procedures, signs of abuse and how they would raise a safeguarding concern? Do policies and procedures meet national recognised guidelines?",null,null,"Yes","CEU - xxxx xx  xxxxx in crisis - 1-1 care and staff noted good relations with the childrens wards and CAMHS. \n\nESR - 60%",null,"Not Completed"]
[null,null,"Are you aware of the organisations policies and procedure for safeguarding children and vulnerable adults?",null,null,"Not Completed","Clear HB policies in place. Staff spoken with were knowledgeable of the process to follow and how to access. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Safe Care","index":11,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[14,2,14,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.1 Safe and Clinically Effective care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that they maintain a safe and clinically effective service?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there evidence of audit activity being regularly undertaken? E.g. are results of audits displayed?",null,null,"Yes","Q&S Work programme obtained. Numerous assurance reporting projects, quality projects and audits undertaken by the Service Group directly affecting the ED and assessment units. E.g. SI reviews, compliance with childrens standards in emergency settings, falls and IPC all scheduled in and being undertaken.\n\nThis is in addition to local fundamentals of care audits being undertaken. FOC audits obtained. ",null,"Not Completed"]
[null,null,"Is there evidence that risks are monitored?",null,null,"Yes","Risks appear to be monitored through a multi layer of department and service group governance related meetings. See minutes. ",null,"Not Completed"]
[null,null,"How are quality, safety and risks monitored? E.g. falls risks, use of safety crosses, 1,000 lives 15 steps initiatives",null,null,"Yes","Refer to IM and Peer workbook for assessment areas. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Overall query effectiveness of some FOC audit given some of the findings identified, e.g. IPC and environment. "]

{"sheet":"Quality Improvement","index":12,"n_rows":14,"n_cols":9,"rows_kept":14,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[13,2,13,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.3 Quality Improvement, Research and Innovation"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"How does the department ensure they are continually improving?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What quality improvement activities take place?",null,null,"Yes","Q&S Work programme obtained. Numerous assurance reporting projects, quality projects and audits undertaken by the Service Group directly affecting the ED and assessment units. E.g. SI reviews, compliance with childrens standards in emergency settings, falls and IPC all scheduled in and being undertaken.\n\nThis is in addition to local fundamentals of care audits being undertaken. FOC audits obtained. ",null,"Not Completed"]
[null,null,"What good practice/initiatives and development plans are in place/being developed?",null,null,"Yes","Good initiatives being developed by B7 specialist nurses. Staff informed us that they are given the time to develop initiatives and backing where appropraite. Examples: bereavement - peer reviewed recorded as notable, waiting area, SG and frequent attendees. Appears joined up and linking with the appopriate professionals. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Query audit effectiveness, e.g. IPC, environment etc based on findings. "]

{"sheet":"Workforce","index":13,"n_rows":73,"n_cols":9,"rows_kept":73,"merged":[[1,1,1,9],[8,2,8,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[16,2,16,3],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,3],[19,6,19,7],[20,2,20,3],[20,6,20,7],[21,2,21,3],[21,6,21,7],[22,2,22,4],[22,6,22,7],[24,2,24,3],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[29,6,29,7],[30,2,30,4],[30,6,30,7],[31,2,31,4],[31,6,31,7],[32,2,32,4],[32,6,32,7],[33,2,33,4],[33,6,33,7],[34,2,34,3],[34,6,34,7],[35,2,35,3],[36,2,36,3],[36,6,36,7],[37,2,37,3],[37,6,37,7],[38,2,38,3],[38,6,38,7],[39,2,39,3],[40,2,40,3],[41,2,41,3],[41,6,41,7],[42,2,42,3],[42,6,42,7],[43,2,43,3],[43,6,43,7],[44,2,44,3],[45,2,45,3],[45,6,45,7],[46,2,46,3],[46,6,46,7],[47,2,47,3],[48,2,48,3],[48,6,48,7],[49,2,49,3],[49,6,49,7],[50,2,50,3],[50,6,50,7],[51,2,51,3],[51,6,51,7],[53,2,53,4],[53,6,53,7],[54,2,54,4],[54,6,54,7],[55,2,55,3],[55,6,55,7],[56,2,56,4],[56,6,56,7],[57,2,57,4],[57,6,57,7],[58,2,58,4],[58,6,58,7],[59,2,59,3],[59,6,59,7],[61,2,61,4],[63,2,63,9],[65,2,65,4],[65,6,65,7],[66,2,66,4],[66,6,66,7],[67,2,67,4],[67,6,67,7],[68,2,68,4],[68,6,68,7],[69,2,69,4],[69,6,69,7],[72,2,72,8]]}
[]
[null,"Quality of Leadership and Management - 7.1 – Workforce"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure there are sufficient numbers of appropriately trained staff for the provision of safe, effective patient care?"]
[null,null,"Staffing",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Request and review staff rotas and discuss staffing skill mix with peer reviewer(s)",null,null,"Yes","Rotas obtained. ",null,"Not Completed"]
[null,null,"Explore the current number and skill mix of staff – is this a safe staffing level with appropriate skill mix to run the service safely?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What is the rate of staff turnover/sickness and use of agency staff – how does this impact patient’s care and treatment?",null,null,"Yes","Nursing turnover is high. Recent recruitment efforts to recruitment a number of NQ and overseas nurses. Medical cover is also provided on a high contracted basis. Agency  use high (% - ) Number of staff mentioning loss of experience, staff going to agency and returning, and substantive staff then having to pick up additional work due to inexperience elsewhere. To be fleshed out further when staff questionnaire responses are in.",null,"Yes"]
[null,null,"Is there a Paediatric Emergency Medicine (PEM) consultant with dedicated session time allocated to paediatrics?",null,null,"Yes","CEU staff describe good medic and consultant level input. Also good relations with the main childrens wards. No issues to note re medical cover",null,"Not Completed"]
[null,null,"In departments where children are treated, are there at least two registered children’s nurses?",null,null,"Yes","Always 2 RN, but sometimes only 1 paeds RN. Recruitment process is underway to provide sufficient paediatric nursing covers 5 days per week (document reviewed), but national difficulty in recrutiing some paediatric nurses. Issue raised in previous quality check in June(?) 2021. Need to stabilise this ASAP.",null,"Yes"]
[]
[null,null,"Support and management arrangements",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What support/management arrangements are in place? Do staff feel supported? How do senior managers give support?",null,null,"Yes","Review staff questionnaire responses. Staff appear content with their immediate line management, but less supportive of senior managers. Staff particuarly vocal of positive B8 matron level support.",null,"Not Completed"]
[null,null,"Have any new well-being initiatives been introduced to support staff due to Covid-19?",null,null,"Yes","Wellbeing and health scheme available through occupational health department. General sense of staff supporting one another within the department. Number of staff noting burnout and numbers leaving the department.  ",null,"Not Completed"]
[null,null,"Is there regular supervision and appraisals?",null,null,"Not Completed","Data requested ",null,"Not Completed"]
[null,null,"Are there regular staff/management meetings?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What do you feel is the culture in the department?",null,null,"Yes","XX comments - sense of frustration amongst staff of not being able to deliver the standards of care they would like.  Sense that there is an unrelenting pressure with no easy fixes. Staff noting that support is improving with new matrons coming on board, but system pressures are causing lots of staff to leave and return on agency where they can pick and choose shifts, often for more money. All staff commenting that they are giving their all.",null,"Not Completed"]
[null,null,"Do you feel able to report concerns? How are these dealt with and responded to?",null,null,"Not Completed","See incident tab. Also staff questionnaire to focus on this area in greater depth. Incident data however demonstrates that staff are willing escalate their concerns. This is notable in relation to delayed care and departmental escalation. ",null,"Not Completed"]
[]
[null,null,"Training"]
[null,null,"Ask to see a sample of staff training records/training matrix and staff files",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How is training organised and do staff feel able to access the training they need?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What evidence is there that staff have completed mandatory training? ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"How do senior managers track whether mandatory training has been undertaken?",null,null,"Yes","ESR tracked at multiple levels and reported on at governance meetings. ",null,"Not Completed"]
[null,null,"What preceptorship and mentoring programmes are in place for new members of staff to the department (nursing and medical)? Do staff receive induction?",null,null,"Yes","Confirmed induction and local training arrangements in place for all new starters. Induction materials for nursing and medical staff obtained. Note pressure on substantive staff noted by some staff due to having to impart their knoweldge and professional  know how onto new starters - difficult when there is such a large number. ",null,"Not Completed"]
[null,null,"Where applicable, is competency assessed?",null,null,"Yes","Informed that competencies are identified and signed off as appropriate.",null,"Not Completed"]
[null,null,"For students, is there a learning audit with the University? What are the supervisory arrangements?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"ED considerations for training:\nAdvanced life support / advanced paediatric life support (for APLS must be one member of staff on each shift with this training, or equivalent)\n",null,null,"Yes","See additional training document - staff noted that efforts are being made to prioritise training e.g. observed for B6 staff. However generally low completion across other bands. ",null,"Yes"]
[null,null,"ED considerations for training:\nDe-escalation training",null,null,"Yes","Combined 76%",null,"Not Completed"]
[null,null,"Have staff completed the following recommended training for NHS Wales staff (as endorsed by WG previously):\nLevel 1 (all staff):",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"• Health & Safety ",null,null,"Yes","All % below combined: 58%",null,"Not Completed"]
[null,null,"• Information Governance ",null,null,"Yes",{"v":0.49,"d":"49.00%"},null,"Not Completed"]
[null,null,"• Fire Safety",null,null,"Yes",{"v":0.71,"d":"71%"},null,"Not Completed"]
[null,null,"• Safeguarding Adults",null,null,"Yes",{"v":0.7,"d":"70%"},null,"Yes"]
[null,null,"• Safeguarding Children",null,null,"Yes",{"v":0.6,"d":"60%"},null,"Yes"]
[null,null,"• Mental capacity/ DOLS",null,null,"Yes",null,null,"Not Completed"]
[null,null,"• Treat me Fairly (Equality)",null,null,"Yes",{"v":0.6,"d":"60%"},null,"Not Completed"]
[null,null,"• Infection Prevention and Control",null,null,"Yes",{"v":0.57,"d":"57%"},null,"Yes"]
[null,null,"• Manual Handling",null,null,"Yes",{"v":0.49,"d":"49%"},null,"Not Completed"]
[null,null,"• Resuscitation (all members of staff must also be trained in infant and child basic life support - BLS)",null,null,"Yes","See additional training document - improvement above re: ALS.",null,"Yes"]
[null,null,"• Violence and Aggression Module A",null,null,"Yes",{"v":0.75,"d":"75%"},null,"Not Completed"]
[null,null,"• Dementia Awareness*",null,null,"Yes",{"v":0.82,"d":"82%"},null,"Not Completed"]
[null,null,"*Dementia Awareness is required for staff who have direct contact with patients (including administrative and ancillary staff - e.g. receptionists and porters - as well as healthcare professionals) as per Welsh Health Circular."]
[null,null,"Sepsis:",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"• What training is available to staff?",null,null,"Yes","% not calculated but nursing completion rate appears generally good",null,"Not Completed"]
[null,null,"• How does the health board ensure staff are up to date with guidelines?",null,null,"Yes","See Peer reviewer workbook - knowledge good",null,"Not Completed"]
[null,null,"• What policy or guidelines are in place in relation to managing sepsis?",null,null,"Yes","Appropaite sepsis bundles in place. ",null,"Not Completed"]
[]
[null,null,"Employment information",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"What do department managers understand about the following employment information and do they have access to electronic records with this information?:",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do all staff have a contract of employment?",null,null,"Yes","Yes ",null,"Not Completed"]
[null,null,"How are appropriate pre-employment checks done for all staff? e.g. reference checks, registration/revalidation, DBS requirements",null,null,"Yes","Yes - sample of PINS checked. ",null,"Not Completed"]
[null,null,"Revalidation - What is the process in place to ensure all nursing staff have revalidated and are appropriately registered with the Nursing and Midwifery Council (NMC)?",null,null,"Yes","Yes ",null,"Not Completed"]
[null,null,"Do all staff have relevant, up to date job descriptions which reflect their level of responsibility? ",null,null,"Yes","Yes ",null,"Not Completed"]
[null,null,"Is this regularly reviewed?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Welsh language"]
[]
[null,null,"Key Lines of Enquiry: How do senior managers ensure that the needs of Welsh speaking patients are able to be met?  Including staff awareness of the importance of the Welsh language in providing good healthcare? "]
[]
[null,null,"Do staff have access to Welsh language training?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How are staff made aware of, and supported to deliver the Active Offer?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are staff encouraged to wear a ‘iaith gwaith’ badge, or something similar to indicate they are able to speak Welsh?",null,null,"Yes","Some staff wore Iath Gwaith badges",null,"Not Completed"]
[null,null,"Do staff understand the importance of speaking with patients in their preferred language supporting the delivery of good healthcare?",null,null,"Not Completed","See patient questionnaire responses  and lay reviewer workbook. One issue in ED - patient unable to speak issue and all translation being provided by one family member. Need to use appropraite translation services.",null,"Yes"]
[null,null,"Do language requirements form part of recruitment and workforce planning? ",null,null,"Yes","Forms part of HB strategy ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Medic ESR training genreally lower in a number of areas, e.g. safeguarding. NB some training data included non clinical staff, e.g. porters for courses which do not require their completion - I have removed this from total % in areas identified for improvement in report."]

{"sheet":"Governance","index":14,"n_rows":17,"n_cols":9,"rows_kept":17,"merged":[[1,1,1,9],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,4],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Quality of Leadership and Management - Governance, leadership and accountability"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[]
[null,null,"Is the department well led, with clear lines of responsibility and systems in place to monitor and respond to service needs?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Link with peer reviewer.\n\nWhat are the governance arrangements in place?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do senior managers visit the department and engage with staff on a regular basis?",null,null,"Yes","Senior managers and site managers visible and present during the course of the inspection. Senior nurse manager present to support NIC upon arrival on the first evening. To be fleshed out further once staff questionnaire responses are in.",null,"Not Completed"]
[null,null,"Do staff feel able to escalate?",null,null,"Yes","NIC stated that level 4 has been in situ for some time. Feels comfortable to escalate any concerns regarding the operation of the department. Bronze on call / site management and NIC appeared to gel well together and were aware of the escalation arrangeements relevant to their roles.",null,"Not Completed"]
[null,null,"What on-call arrangements are in place?",null,null,"Yes","Usual matron, departmental managers and site management during core hours. Revertng to usual bronze, silver etc on call when required / OOO. NIC and senior nurse were aware of the on-calls arrangements, as utilised upon our arrival.",null,"Not Completed"]
[null,null,"How is information shared from management to staff/ from staff to management? Are there effective ‘ward to board’ arrangements?",null,null,"Yes",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Evidence capture form","index":15,"n_rows":30,"n_cols":13,"rows_kept":30,"merged":[[1,1,1,12],[10,1,10,12],[12,1,12,12],[13,1,13,5],[13,6,13,12],[14,1,14,5],[14,6,14,12],[15,1,15,5],[15,6,15,12],[16,1,16,12],[17,1,17,5],[17,6,17,12],[18,1,18,5],[18,6,18,12],[19,1,19,5],[19,6,19,12],[20,1,20,5],[20,6,20,12],[25,1,25,12],[26,1,26,12],[27,1,27,12],[28,1,28,12],[29,1,29,12],[30,1,30,12],[31,1,31,12]]}
[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"See notes below"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"To follow up in the morning:\n- SDU: check on overnight patients in waiting area and neighboring assessment area \n- Clarify footprint and roles\n- Provide Lydia with a tour, noting unwell patients etc \n- ED - Ask Avril and Liz to review overnight patients "]
[null,"Running log MP - PR interactions:\n\n6 September \n\n- 11.25am issues raised by Avril and Liz: Patient (spinal injury). Provided with pain relief and water. Had a CT - c spine wasn’t cleared - waiting for MRI due to pins and needles. On spinal board for 6 hours. \n- MH pt from Cefn Coed - (in REACT since around 5/6pm prev. day) - taken back to ambulance awaiting blood transfusion - signficant delay. \n- Older pt on ambulance - here since 9pm last night - no food provided as of 11am this mornng. Obstruction TBC. \n- Asked triage nurse in ambulance area questions, but was covering break, stated: \"I can't tell you anything, I'm only covering break\". \n- Older pt on ambulance - since 1pm prev. day - fracturered NOF. Stated uncomfortable on ambulance trolley. ** Appropriate mattress issue\n- Majors - patient lying on a trolley in between two beds. Issue of dignity, no mobile screens in use and insufficient in any case. ** Still there as of afternoon\n\n- Paeds staffing: usual 2 B6 and 4 B5. Today 1 x B5 senior and 1 x B5 adult - senior paeds nurse attempting to mitigate lack of 2 nurses in a 'controlled manner'. States not enough paeds staff. Need 6.6 total. ** Recruitment underway for a 5 day service at 2 paeds RN's. Still not sufficient for an emergency service. Noted in previous QC.\n\n- Paeds - Pesky course - positive - further training and development opportunity. Additional assurance obtained.\n\n- Pt - admitted yesterday - chest pains and usual MI symptoms - waited 4 hours to be seen. ECG completed. Sent home to see GP. Asked to have bloods done following disclosure of family history, pt told us that this was dismissed and returned today with same chest pains - Refer back to Liz to follow up. \n\n- Liz - NEWS appear to be used and recorded appropriately so far.\n\n- Pt - lady in chair 17 hours - no antibiotics when required - Liz to follow up.\n\n- Pt - gent in chair overnight - as of 9am still there. No blanket or pillow. Stated uncomfortbale throughout night. \n\n- SDU feedback: Busy but feels calm and controlled. Environment generally ok. Issues: IV fluid room unlocked. Waiting area - overnight patients - not appropraite. Hard chairs, cluttered with old equipment stored, belongings strewn over floor (trip hazard). 1 recliner available. \n\n- RAU and SDU staffing pressures: consistently poor in HCA's. SDU: Usual 8 and 6 by day and 7 and 5 by night. 2 HCA down as of today (6th) ** 3 HCA down (7th day) but +1RN in effort to mitigate.\n\n\n- Staff stated that there is a need for 1-1 care for query DOLS pt, but 'not always getting 1-1'. Also, required staffing numbers in RAU not being hit owing to patients being located in discharge lounge at weekend and evening.\n \nRAU - 2 patients passed away behind curtains this week. Expected deaths. No cubicle available to move them to. Did everything to make as dignified as possible, but not conducive to a private space. \n\n- Liz - very good bereavement service - (~200/300 deaths per year). Follow up service. Leaflet with support. ED B7 phones 48 hours after and also sends a card to relatives. Has received some paliaitve care funding for suitable ED space (ceiling tiles with lights and clouds). \n\n- Other good initiative - OPAS - good triage, assessment, liasion. Good links with care home providers. ANP led. Avoids patients getting stuck in the ED and aims to timely discharge without need for admittance to ward wherever possible. ** Refer to paperwork provided. \n\n- Discussion with Delia (B7 triage and flow) - plans in place with estates to help provide additional waiting and triage space to help better manage risk. Delia noted that these plans have been stalled by capital works issues, but are still underway. ** Look into a note at feedback - link to WG waiting area fund?\n\n\n\n\n\n"]
[null,"Running log continued: \n\n- Nutrition (various - compiled):\n1. No water in waiting area on arrival \n2. Lack of food offered for ambulance patients. See crew comments re: 14 and 12 hours\n3. One pt only offered custard and cake despite being diabetic. Nothing else offered (Liz)\n4. Red cross used to support department, but funding taken away (?)\n5. Pts admitted - not offered food (Liz and Lydia)\n6. Record keeping audits ** Review after inspection - issue with intake recording and needs?\n\n- Anita: DoLS pt: wandering, stating want to leave, no consideration of DOLS. ** Anita and Chris to follow up.\n... Update: Staff now considering DOLS.\n\n- Anita: Records in assessment units: only make entries into pt notes once per day. Issue of continuity and contempraneous entries? ** To discuss at feedback\n"]

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[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"See notes below"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"Staff discussions:\n\nDay 2 (first morning 6th)\n\nInitial intro meeting with Emma Mitchell (interim HON AMAU), Kate Hanham (Interim Acute Director), Becs Davies (Deputy HON), Ceri Matthews (Asst. DON)\n\n- Introductions - ran through inspection plan etc.\n- AMAU development - November 2022 new launch. All assessment areas to be pulled into this - front of hopsital. '\n- SDEC review - 15/25 MDT records - NHS Elect - use these???\n- Paeds - new SPA - funding approved to keep \n- RAU essentially care of elderly, but with better flow\n\nDelia L - B7 nurse (traige) - 9.30\n- Plans approved for second triage room (second walk in triage)\n- EDA system to stay - majority B3 or B2>B3 \n- Trialled in May\n- COVID forced change of methods - have to change \n- May / June plans approved - still waiting\n- Zoning or clearer waiting areas part of plan - increases ability of traige nurses to locate patients - sometimes who can't be located or have left.\n- Has the blessing from up above and feels that they have the ability to trial the plans they feel will be of benefit\n\nKate Hannam - new 'super' assessment unit plans - 13.30\n- November 2022 to open\n- ASMR - £3mill build. 45 beds. Aim to minimise referrals to admissions to ED ** Will provide slides \n- Working with WAST for direct admission protocols \n- Consultant led 8-10. 5 consultants \n- SDEC - 11 bed amb. care. \n- Good initiative so far - AP reviewing stack alongside GP's to further reduce admissions \n- '36 hour avr wait for medical beds every day in ED now'\n- Staff consulted - Singleton staff to move to Morriston. \n\nDiscussed findings so far with Kate. Noting issues of flow, timely care as a particular emphasis. \nKate noted risks are noted on HB and local risk register with scores mirrored \n\n\n\n"]

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[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"See notes below"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"Received documents list:\n- FOC audts. Inc pressure \n- ASMR Board Update \n- Unsheduled care performance data \n- Escalation plan and site reports \n- Complaints and incidents report \n- ESR and additional training \n- Clinical governannce and Service Group meeting minutes \n- Weekly senior team minutes \n- Org strcuture \n- ED induction handbook, ppt slides\n- Rotas x 3m"]

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[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]

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[null,"INSPECTION FEEDBACK MEETING NOTES"]
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[null,"Inspection reference number / setting name",null,"FEEDBACK SUMMARY AND ATTENDANCE CAPTURED USING STANDALONE FEEDBACK SHEET."]
[null,"Name of person leading the feedback meeting "]
[null,"Date"]
[null,"Time"]
[null,"Attendees"]
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[null,"All evidence must be recorded in official HIW workbooks"]
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