{"text_format":"3","workbook":"xlsx","n_sheets":27,"sheets":["Guidance","Inspection Details","Arrival and Tour","Summary","Key Documents","People's Rights","Feedback","Managing Risk","Infection Control","Safeguarding","Safe Care","Improvement","Governance","Workforce","Training and Rotas","Evidence capture form","Evidence capture form (2)","Evidence capture form (3)","Evidence capture form (4)","Issues Identified","Good Practice","Feedback meeting notes","Discussions Crib Sheet","Sheet2","Sheet1","Do not delete","Sheet2 (2)"],"not_rendered":{"images":10},"read":"whole","date_system":"1900"}

{"sheet":"Guidance","index":0,"n_rows":73,"n_cols":6,"rows_kept":73,"merged":[[5,2,5,4],[6,2,6,4],[7,2,7,4],[8,2,8,4],[9,2,9,4],[10,2,10,4],[11,2,11,4],[12,2,12,4],[13,2,13,5],[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],[72,2,72,5],[74,2,74,5]]}
[]
[]
[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 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 may 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"]
[{"$nulls":3},"4.1 Dignified Care","Patients should be treated with dignity, respect and kindness","LR"]
[{"$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"]
[{"$nulls":3},"5.1 Timely access","Patients should have the right care at the right time in the right place with the right staff","LR"]
[{"$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","PR / LR"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time","PR"]
[{"$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 / PR / LR"]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it","PR"]
[{"$nulls":3},"Effective Care"]
[{"$nulls":3},"2.2 Preventing pressure and tissue damage","Patients should be helped to look after their skin"]
[{"$nulls":4},"Health services should make sure that patients do not get sore skin from sitting or lying down for too long"]
[{"$nulls":3},"2.3 Falls Prevention","Health services should check if patients are likely to fall"]
[{"$nulls":4},"Health services should do everything they can to stop people from falling and hurting themselves"]
[{"$nulls":3},"2.9 Medical devices, equipment and diagnostic systems","Health services must make sure that all the equipment they use is safe and works well"]
[{"$nulls":3},"3.1 Safe and Clinically Effective care","Patients should get the right care and support for their needs","IM / PR / 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","PR"]
[{"$nulls":4},"Health services must follow the rules about how to record information and keep it safe"]
[null,null,"Quality of Management and Leadership","Governance, Leadership and Accountability","All health services should be person centred. They should focus on patient’s needs and listen to them","IM"]
[{"$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","IM"]
[]
[]
[]
[null,null,"* If standard(s) have not been asssessed, please record the reason(s) for this below:"]

{"sheet":"Inspection Details","index":1,"n_rows":26,"n_cols":5,"rows_kept":26,"merged":[[0,4,0,5],[5,3,5,5],[8,3,8,5],[10,3,10,5],[12,3,12,5],[14,3,14,5],[16,3,16,5],[18,3,18,5],[20,3,20,5],[22,4,22,5],[23,4,23,5],[24,4,24,5],[25,4,25,5]]}
[]
[]
[null,"Inspection Details"]
[]
[]
[null,null,"Reference number"]
[]
[]
[null,null,"Inspection Type","NHS Hospital"]
[]
[null,null,"Health Board ","Swansea Bay"]
[]
[null,null,"Name of setting"]
[]
[null,null,"Date inspection started","2022-09-05"]
[]
[null,null,"Date inspection completed"]
[]
[null,null,"Name of Lead HIW Inspector","xxxxxx    xxxxxxxx"]
[]
[null,null,"Name of Supporting HIW Inspector","xxxxxxxxxxx  xxxxxxxxxxxx"]
[]
[null,null,"Inspection team","Peer 1:","xxxxxxxxxxx   xxxxxxxxx"]
[{"$nulls":3},"Peer 2:","xxxxxxxxxxx   xxxxxxxxx"]
[{"$nulls":3},"Peer 3:","xxxxxxxxxxx   xxxxxxxxx"]
[{"$nulls":3},"Patient Experience:","xxxxxxxxxxx   xxxxxxxxx"]

{"sheet":"Arrival and Tour","index":2,"n_rows":74,"n_cols":5,"rows_kept":74,"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],[31,3,31,5],[36,3,36,5],[37,3,37,5],[38,3,38,5],[39,3,39,5],[44,3,44,5],[48,3,48,5],[52,3,52,5],[56,3,56,5],[61,3,61,5],[65,3,65,5],[69,3,69,5],[73,3,73,5]]}
[]
[]
[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 HIW 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"]
[]
[]
[null,null,"Time of Arrival ","06/09/22 - 09:00am and 10:00am"]
[]
[]
[]
[null,null,"Name of person/people in charge: ","Person in charge:","xxx xxxxx- Sister Band 6"]
[{"$nulls":3},"Other (please specify):","xxxx xxxxxxxl - interim hon 33410"]
[{"$nulls":3},"Other (please specify):","xxxx xxxxxxxx - service director"]
[{"$nulls":3},"Other (please specify):","xxxxxxx xxxxxx - Deputy hon 36641 / xxxxxx 36675"]
[]
[]
[]
[null,null,"Who is the person in overall charge of the hospital? ","xxxxx xxxxx and xxxxx xxxx Band 8, xxxxxx xxxxxx Band 7"]
[]
[]
[]
[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","Senior management team aware of HIW inspection. "]
[]
[]
[]
[null,null,"Number of Beds","35 spaces, patients also accommodated in triage area (can be 25 which will be escalated)"]
[]
[]
[]
[null,null,"Number of Patients","35 +15 and expecting more RAU - 17 + 1 in discharge lounge staff expected to cover if lounge closed. "]
[]
[]
[]
[]
[null,null,"Staffing and skill mix in relation to the acuity (which areas are staff allocated to, e.g. resus, triage etc.)."]
[null,null,"Number of permanent/agency/bank staff","06/09/22 - SAU - should be 8RN and 6HCSW (day) and 7RN and 5HCSW (night) and twilight Band 5 3:30pm - 3:00am  / 8RN and 4HCSW (today) 7RN and 5HCSW (tonight) Band 7 s/n this morning -  07/09/22 - 8RN and 3HCSW includes Band 7 (escalated) and 8RN and 2 HCSW. RAU - shoul be 4Rn and 3 HCSW (day) and (night). 4RN and 3 HCSW (today) 3RN and 2HCSW and need another RN for 1:1.  Has been escalated.  "]
[null,null,"Staffing levels at time of inspection and any new/supernumerary staff","See above - 1RN agency (regular) normally higher. "]
[null,null,"No. of ENPs"]
[null,null,"(check if the above is normal level of staffing)"]
[]
[]
[]
[null,null,"Speciality of ward/ service model\ne.g. GP/consultant led","Surgical assessment"]
[]
[]
[]
[null,null,"Are there any patients subject to DOLS and how are they being supported in the ward/area? ","None"]
[]
[]
[]
[null,null,"Are there any dementia patients? \n\nIf so, what is the system to ensure these patients are identified?\n\n(check if there are any patients awaiting assessment)","Yes - 1 patient Butterfly Scheme all patients assessed added to notes"]
[]
[]
[]
[null,null,"Describe conditions on the ward/area?  \n\nPrompts: busier than usual, short of staff, too many patients for designated beds, observation levels, individuals at risk, anywhere we should avoid for clinical reasons i.e. isolation","Usual level of acuity today. "]
[]
[]
[]
[]
[null,null,"Do you have any concerns about the operation of the ward/area at the moment?  \n\nPrompts: Capacity of staff, overcrowding, high levels of agency staff, environmental risk. Are there any historical issues e.g. falls and what has been put in place to prevent this?","Patients sleeping in a chair in waiting room (abscess in spleen) has gone home now with open access. Ward T and V currently closed causing flow pressures.  "]
[]
[]
[]
[null,null,"General observations of ward/area and environment   \n\nPrompts: Observe the clinical area 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, kitchen, telephones, any areas that require maintenance or present any risks to patients and staff? ","06/09/22 11:25 - Surgical Triage and Surgical Short Stay Unit. Approaching corridor info displayed on staff well-being e.g. well-being apps, support organisations, chaplaincy support and pastoral care;Poster displayed on ways to provide feedback - QR code (leaflets not available);Poster displayed on benefits of good hydration (patients); Working hand sanitising dispensers available. Entrance to Surgical Triage - poster displayed on wearing PPE; poster displayed on infection control information for visitors WC next to waiting room - signage, lovable door, hand washing facilities, BROKEN TOILET ROLL DISPENSER. WC next to quiet room NEEDS SEAL REPLACED BESIDE SINK. Other WCs clean and no issues identified. Patient areas appear clean and generally free from clutter and trip hazards.IV fluids room not locked but staff in attendance directly outside. Clean utility room generally tidy. Patients belongings stored ROOM NOT LOCKED. Dirty Utility room generally tidy, staff confirmed sluice working and if becomes blocked Estates quick to repair. Privacy curtains in use and cubicles available for privacy. Housekeeper confirmed environmental issues reported to Estates but no timescale for repair has been given.  Tea trolley faulty resulting in one trolley being used for whole unit. Bilingual/pictorial signage displayed for WCs, shower, but Welsh language not generally supported. Waiting room - mixture of fixed seating and chairs, cluttered with equipment and filing cabinet, locker, stationery cupboard. 1x recliner chair. 07/09/22 - RAU - Approaching corridor includes audits activity results, information on Sepsis, Falls prevention. Putting Things Right poster displayed but no contact details included. Bilingual signage displayed as for SAU but Welsh language not generally promoted. Privacy curtains used but no cubicles - 2 bays 6 beds and 12 beds.mixed sex bays.  Discharge lounge - 2 patients waiting to go home. Privacy curtains in use. Not all curtains have dates.  Sluice area - tidy and uncluttered, labels used to show commodes have been cleaned. 1 commode BROKEN SINCE 07/08/22. WC /shower x2 opposite  1-12 bay clean, hand washing facilities. Safety crosses displayed - commode cleaning, general safety checks. PPE poster displayed and supplies available. Clean utility room locked to prevent unauthorised access, store room unlocked and venous cannulas stored and butterfly needles in this area.  "]
[]
[]
[]
[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 any DOLS or patients with dementia. \n","COVID -19 , swabbing symptomatic patients. PSAG used and SIGNAL "]
[]
[]
[]
[null,null,"Is there clear leadership evident on the ward e.g. is there a registered nurse in charge and are they visible?","06/09/22 - introductory meeting with senior team. XX provided overview of inspection and reason for visit I.e routine inspection and follow up on previous HIW activity. Contact  details obtained. Clear leadership evident on surgical unit.  "]

{"sheet":"Summary","index":3,"n_rows":34,"n_cols":7,"rows_kept":34,"merged":[[6,2,6,4],[6,6,6,7],[7,2,7,4],[7,6,7,7],[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],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[23,2,23,4],[23,6,23,7],[25,2,25,4],[26,2,26,4],[27,2,27,4],[28,2,28,4],[30,2,30,4],[33,2,33,4]]}
[]
[]
[null,"Summary",null,"Key Documents","Issues Identified",null,"Good Practice"]
[]
[]
[null,null,"Quality of Patient Experience","Select outcome statement"]
[null,null,"6.2 People's Rights",null,null,{"$f":"'People''s Rights'!D4","v":"No"},{"$f":"'People''s Rights'!D5","v":"Select outcome statement"}]
[null,null,"6.3 Listening and Learning from Feedback",null,null,{"$f":"Feedback!D4","v":"No"},{"$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,{"$f":"'Managing Risk'!D4","v":"No"},{"$f":"'Managing Risk'!D5","v":"Select outcome statement"}]
[null,null,"2.4 Infection control (IPC)",null,null,{"$f":"'Infection Control'!D4","v":"No"},{"$f":"'Infection Control'!D5","v":"Select outcome statement"}]
[null,null,"2.7 Safeguarding",null,null,{"$f":"Safeguarding!D4","v":"No"},{"$f":"Safeguarding!D5","v":"Select outcome statement"}]
[null,null,"3.1 Safe and Clinically Effective care",null,null,{"$f":"Improvement!D4","v":"No"},{"$f":"Improvement!D5","v":"Select outcome statement"}]
[null,null,"3.3 Quality Improvement, Research and Innovation",null,null,"No",{"$f":"Improvement!D5","v":"Select outcome statement"}]
[]
[]
[null,null,"Quality of Leadership and Management","Select outcome statement"]
[null,null,"7.1 Workforce",null,null,{"$f":"Workforce!D4","v":"No"},{"$f":"Workforce!D5","v":"Select outcome statement"}]
[null,null,"Governance, leadership and accountability",null,null,{"$f":"Governance!D4","v":"No"},{"$f":"Governance!D5","v":"Select outcome statement"}]
[]
[]
[null,null,"Staff Training and Rotas","Select outcome statement"]
[null,null,"Staff Training and Rotas",null,null,{"$f":"'Training and Rotas'!D4","v":"No"},{"$f":"'Training and Rotas'!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"]
[]
[]
[null,null,"Discussion crib sheet"]

{"sheet":"Key Documents","index":4,"n_rows":23,"n_cols":8,"rows_kept":23,"merged":[[5,2,5,7],[8,5,8,6],[9,5,9,6],[10,5,10,6],[11,5,11,6],[12,5,12,6],[13,5,13,6],[16,5,16,6],[17,5,17,6],[18,5,18,6],[19,5,19,6],[20,5,20,6],[21,5,21,6],[22,5,22,6]]}
[]
[null,"Key Document Checking"]
[{"$nulls":7},"Back to Summary"]
[]
[]
[null,null,"As part of our inspection we will need to review the following documents. Please locate these and create copies were requested. In addition to the below, the inspections manager will advise you if any further documentation is required for the inspection. "]
[]
[null,null,"Please create copies of the following documents:"]
[null,null,"Key documents required to complete this section:","Comments:","Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"Local staff training records (if available), staff training matrix","At a minimum this should include mandatory training","Not Checked",null,null,"No"]
[null,null,"Staff rotas (including bank and agency staff use)","For the last 3 months","Not Checked",null,null,"No"]
[null,null,"Staff induction programme","e.g. new staff, agency/bank staff, students","Not Checked",null,null,"No"]
[null,null,"Copies of relevant audits (if not displayed)","e.g. Patient falls, infection control, pressure ulcers, hand hygiene","Not Checked",null,null,"No"]
[null,null,"Relevant organisational management structure (organisation chart)",null,"Not Checked",null,null,"No"]
[]
[null,null,"Please locate the following documents for HIW to review onsite:"]
[null,null,"Key documents required to complete this section:","Comments:","Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"Patients records (including assessment, care, monitoring and medication records)","We will need to see a sample of patient care records/notes (discuss the sample required with the inspection team peer reviewer)","Not Checked",null,null,"No"]
[null,null,"Complaints policy/procedure\nSame of complaints records ","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Sample of incident records","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Sample of staff files, including appraisals, recruitment and pre-employment checks in accordance with Regulatory requirements","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Medicines management file/policy",null,"Not Checked",null,null,"No"]
[null,null,"Evidence from staff meetings/shared learning","Please inform the inspection manager if records are not available for view","Not Checked",null,null,"No"]

{"sheet":"People's Rights","index":5,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[10,2,10,4],[10,6,10,7],[11,2,11,4],[13,2,13,4],[14,2,14,4],[16,2,16,4],[17,6,17,8],[18,2,18,4],[21,2,21,8]]}
[]
[null,"Quality of Patient Experience - 6.2 People's Rights"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How is equality and diversity promoted within the organisation? ",null,null,"Not Completed",null,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,"Not Completed",null,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,"Not Completed",null,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,"Not Completed",null,null,"Not Completed"]
[null,null,"Example - risk based approach to placement inline with the services policy"]
[]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Feedback","index":6,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,6,11,7],[12,2,12,3],[12,6,12,7],[14,2,14,3],[14,6,14,7],[15,2,15,4],[15,6,15,7],[17,2,17,4],[17,6,17,7],[20,2,20,8]]}
[]
[null,"Quality of Patient Experience - 6.3 Listening and Learning from Feedback"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there Putting Things Right displayed?",null,null,"Yes","SAU - No specific information displayed on PTR. Poster displayed on ways patients can provide feedback poster also displayed on role of Patient Liason Service (PALS). Also contact details of ward managers displayed.  ",null,"Yes"]
[null,null,"Is there information on how the health board has learned and improved based on feedback received? ",null,null,"Yes","SAU - information displayed on action taken as result of feedback but feedback comments displayed. However no date to indicate when feedback was received - all positive comments.   ",null,"Yes"]
[null,null,"Concerns/complaints received "]
[null,null,"Are you aware of any recent/current complaints?",null,null,"Yes","SAU -Band 7 confirmed patients mainly raise concerns / complaints about the waiting time to be seen and surgery being postponed. ",null,"No"]
[null,null,"Complaint records"]
[null,null,"How are verbal/informal concerns (complaints) captured?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there evidence that common themes emerging from complaints are checked and addressed?",null,null,"Yes","\nSAU - Confirmed through discussion with Band 7. Details captured on Datix. ",null,"No"]
[null,null,"Sharing learning "]
[null,null,"How is information from complaints shared with staff and is there sharing of learning across ward and health board?",null,null,"Yes","SAU - Band 7 confirmed information is shared via team meetings and WhatsApp group chat. Team meeting held 17/08/22 and minutes being drafted. Band 7 also discusses concerns/incidents during 1:1 meetings with Band 8 matron.  ",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"07/09/22 - spoke to 5 patients in the waiting room. All confirmed that had arrived this morning either directly from home, via GP or had been seen in ED yesterday. Those seen yesterday were allowed home to return today as no beds available. Generally positive comments, especially regarding staff but 2 said chairs were uncomfortable for sitting for long periods and 1 would appreciate more timely updates about care."]

{"sheet":"Managing Risk","index":7,"n_rows":24,"n_cols":9,"rows_kept":24,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,3],[9,6,9,7],[11,2,11,4],[11,6,11,7],[13,2,13,4],[13,6,13,7],[14,2,14,3],[14,6,14,7],[16,6,16,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[21,2,21,4],[21,6,21,7],[24,2,24,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.1 Managing risk and health and safety"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[null,null,"Significant incidents",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Discuss any significant incidents from intelligence",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Turnover/sickness/vacancies"]
[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","SAU - Good staff retention. Current sickness 7 staff 78, use agency staff can impact negatively if not regular staff unaware of systems and skill levels. ",null,"Not Completed"]
[null,null,"Incident reporting "]
[null,null,"How are risks and incidents reported? i.e. DATIX. ",null,null,"Yes","SAU - Incidents reported via Datix. Suitable arrangements described for recording, investigating and sharing of learning from incidents. Team have a WhatsApp group chat. ",null,"Not Completed"]
[null,null,"Where does this information go?",null,null,"Yes","SAU - Reported via Datix system. ",null,"Not Completed"]
[null,null,"Dealing with incidents"]
[null,null,"How are incidents dealt with? ",null,null,"Yes","SAU - See above.",null,"Not Completed"]
[null,null,"Sharing learning from incidents"]
[null,null,"What is done to ensure lessons are learned following incidents?",null,null,"Yes","SAU - Information shared with staff individually and if needed training provided and if recurrent theme action is taken by speaking to staff team and processed reviewed. ",null,"Not Completed"]
[null,null,"How is information on incidents shared with staff at ward level?",null,null,"Yes","SAU - See above. ",null,"Not Completed"]
[null,null,"Quality audits/risk assessments"]
[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","SAU - Evidence of monthly audits seen June, July, August 2022 - Hand Hygiene, Pressure Ulcers, Cleanliness, Integrated Nursing Assessment, Infection Control Environment and Sharps Audit  No information displayed. ICES not conducted June, Hand Hygiene not conducted August, Cleanliness not always conducted weekly. Band 6 confirmed IPC audits not conducted by IPC Team and Cleanliness audits completed by Housekeeping Team. ",null,"Not Completed"]
[]
[null,null,"Any Additional Comments"]

{"sheet":"Infection Control","index":8,"n_rows":37,"n_cols":9,"rows_kept":37,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[12,2,12,4],[12,6,16,7],[12,8,16,8],[13,2,13,4],[14,2,14,4],[15,2,15,4],[16,2,16,4],[17,2,17,4],[18,2,18,4],[18,5,20,5],[18,6,20,7],[18,8,20,8],[19,2,19,4],[20,2,20,4],[21,2,21,4],[22,2,22,4],[22,6,22,7],[23,2,23,4],[24,2,24,4],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[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],[34,2,34,4],[34,6,34,7],[37,2,37,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.4 Infection control (IPC)"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[null,null,"Infection rates",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What are the current infection rates and does this fit within organisational process?",null,null,"Yes","Band 7 confirmed rates are very good. No recent outbreaks, Patients tend to be admitted with infections and then identified through routine  screening.  ",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","Band 7 confirmed that only patients who are symtomatic or for theatre are screened for COVID-19. ",null,"Not Completed"]
[null,null,"IPC training"]
[null,null,"What are the IPC training compliance levels? ",null,null,"Yes","See training records. Hand hygiene audits seen and 100% compliance.  ",null,"Not Completed"]
[null,null,"o Are C4C scores are greater than 95%?",null,null,"Not Completed"]
[null,null,"o Are hand hygiene scores greater than 95% ",null,null,"Yes"]
[null,null,"o Are there cleaning records and schedules?",null,null,"Not Completed"]
[null,null,"o Are IPC training scores greater than 95%? E.g.  induction, level 1, 2 and Aseptic non touch technique",null,null,"Not Completed"]
[null,null,"Infection control policies and responsibilities"]
[null,null,"Are there adequate IPC policies and procedures in place and do staff have access to them? Including:",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"o Policy on decontamination of medical devices/equipment"]
[null,null,"o Policy on water management"]
[null,null,"Ongoing audits for IPC "]
[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,"Occupational health support"]
[null,null,"What support/access is there to occupational health for staff?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there records on staff immunisation status?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"COVID-19 "]
[null,null,"What changes were made due to COVID-19 e.g. social distancing, cleaning, PPE, specific COVID-19 training, pre-screening for COVID-19, patient visiting, risk assessments, COVID-19 testing",null,null,"Yes","SAU - Some changes introduced during COVID-19 remain e.g. use of face masks, restricted visitors. ",null,"Not Completed"]
[null,null,"How do you identify and effectively manage COVID-19 outbreaks / nosocomial transmission?  ",null,null,"Yes","SAU - When identified as positive for COVID-19, patients are transferred to a cubicle. ",null,"Not Completed"]
[null,null,"If there have been any cases in the past three months:",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How did you discuss this with all ward staff?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Did you follow your Health Board’s policy?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Were you 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,"Any Additional Comments"]

{"sheet":"Safeguarding","index":9,"n_rows":24,"n_cols":9,"rows_kept":24,"merged":[[1,1,1,8],[7,6,7,7],[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],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[16,2,16,4],[16,6,16,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[21,2,21,4],[21,6,21,7],[24,2,24,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.7 Safeguarding children and adults at risk"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[null,null,"Current POVAs and DOLS",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there anyone on the ward who is subject to DOLS and what’s your understanding of this?",null,null,"Yes","SAU - No",null,"Not Completed"]
[null,null,"Are there any current or recent POVAs? If so, who reported these?",null,null,"Yes","SAU - No",null,"Not Completed"]
[null,null,"What has been the outcome of POVA/DOLS referrals?",null,null,"Yes","SAU - Not applicable",null,"Not Completed"]
[null,null,"POVA/DOLS training "]
[null,null,"Do staff have training updates in safeguarding?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are you aware of the recent changes to safeguarding legislation and the implications for staff? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you decide whether deprivation of liberty is or may be necessary? – Who makes this decision?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are less restrictive options considered to avoid DOLS? (ask for details on these)",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Reporting concerns"]
[null,null,"Do you know what to do if you have a safeguarding concern? Who would you report this to?",null,null,"Yes","SAU - Safeguarding policy available on the intranet. Staff expected to complete training. ",null,"Not Completed"]
[null,null,"Are you aware of the organisations policies and procedure for safeguarding children and vulnerable adults?",null,null,"Yes","SAU - Policy confirmed as being available on intranet. All Wales procedures available.  ",null,"Not Completed"]
[null,null,"Advocacy arrangements"]
[null,null,"For patients who lack mental capacity are there advocacy arrangements in place?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Any Additional Comments"]

{"sheet":"Safe Care","index":10,"n_rows":24,"n_cols":9,"rows_kept":24,"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],[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],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[20,2,20,4],[21,2,21,4],[21,6,21,7],[24,2,24,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.1 Safe and Clinically Effective care"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there evidence of audit activity being regularly undertaken? E.g. Are results of audits displayed on the ward, e.g. hand hygiene.  ",null,null,"Yes","SAU - No information displayed on audit activity. Examples of audit activity provided. RAU - information displayed on audit activity, how many falls, pressure ulcers, infection control, hand hygiene. Information also displayed on what is being done to improve compliance - not all information complete. ",null,"Yes"]
[null,null,"Is there evidence risks are monitored?",null,null,"Yes","SAU - Discussions with Band 7 and Band 6 nurses in charge indicated consideration is given to risk when managing patient care. ",null,"Not Completed"]
[]
[null,null,"Sepsis",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"What training is available to staff?",null,null,"Yes","SAU - Training records records confirm sepsis training not delivered since 2019. ",null,"Not Completed"]
[null,null,"How does the health board ensure staff are up to date with guidelines?",null,null,"Yes","SAU - Discussed with Band 6 and 7 guidelines and part of ILS. Sticker affixed to patient notes. ",null,"Not Completed"]
[null,null,"What policy or guidelines are in place in relation to managing sepsis?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"USE ON INSPECTIONS OF ACUTE MEDICAL AND ACUTE SURGICAL WARDS ONLY.",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"Are safe nurse staffing numbers calculated by triangulating patient acuity, quality indicators and professional judgement. ",null,null,"Not applicable",null,null,"Not Completed"]
[null,null,"How often is a review of the required nurse staffing levels undertaken?",null,null,"Not applicable",null,null,"Not Completed"]
[null,null,"What steps are taken if the acuity of the ward changes suddenly?",null,null,"Not applicable",null,null,"Not Completed"]
[null,null,"What impact do long term staff shortages have on compliance with the Act and what support is provided to cope with this?",null,null,"Not applicable",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Improvement","index":11,"n_rows":12,"n_cols":9,"rows_kept":12,"merged":[[1,1,1,9],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[12,2,12,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.3 Quality Improvement, Research and Innovation"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What quality improvement activities take place?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What good practice/initiatives and development plans are in place/being developed? ",null,null,"Yes","SAU - benchmarking against other units, visit planned to same day emergency care unit in Cardiff next week. Previous visit to Swindon Hospital and other areas visit SAU. Following visit to Bath introduced waiting area. Following visit to Swindon adopted same design for new facility - not progressed. ",null,"Not Completed"]
[]
[null,null,"Any Additional Comments"]

{"sheet":"Governance","index":12,"n_rows":14,"n_cols":9,"rows_kept":14,"merged":[[1,1,1,8],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[14,2,14,8]]}
[]
[null,"Quality of Leadership and Management – Governance, leadership and accountability"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What are the governance arrangements in place?",null,null,"Yes","SAU - Management structure in place and represented at HB meetings, clear reporting lines and accountability. ",null,"Not Completed"]
[null,null,"Do senior managers/registered persons visit the service and engage with staff on a regular basis?",null,null,"Yes","SAU - Band 7 confirmed Matron attends ward everyday. Feel supported in role but feel they are out of touch pressures you. ",null,"Not Completed"]
[null,null,"How is info shared from management to staff/ from staff to management?",null,null,"Yes","SAU - Band 7 confirmed sisters meetings weekly and info shared with staff team either verbally or via WhatsApp. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusions"]

{"sheet":"Workforce","index":13,"n_rows":35,"n_cols":9,"rows_kept":35,"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],[14,2,14,4],[14,6,14,7],[15,2,15,4],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[20,2,20,4],[20,6,20,7],[21,2,21,4],[21,6,21,7],[22,2,22,4],[23,2,23,4],[23,6,23,7],[24,2,24,4],[24,6,24,7],[25,2,25,4],[25,6,25,7],[27,2,27,8],[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,"Quality of Leadership and Management – 7.1 Workforce"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Crib sheet","Back to Guidance"]
[]
[null,null,"Number and skill mix of staff",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Do you feel the number of staff on the ward is appropriate for the patients?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you feel the skill mix of staff appropriate to meet patient’s needs?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is acuity considered and arrangements for 1:1 nursing?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you have enough time to give patients the care they need?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Turnover/sickness/vacancies"]
[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,"Not Completed",null,null,"Not Completed"]
[null,null,"Support/management arrangements"]
[null,null,"Is there regular supervision and appraisals?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there regular staff/management meetings?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there sharing of learning such as from incidents and of good practice?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What do you feel is the culture on the ward/area?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you feel able to report concerns? How are these dealt with and responded to?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have any new well-being initiatives been introduced to support staff due to Covid-19?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Training access"]
[null,null,"Do you have access to training and development opportunities to support you in your role?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do senior managers track whether mandatory training has been undertaken?",null,null,"Not Completed",null,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,"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,"Not Completed",null,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",null,null,"Not Completed"]
[null,null,"Do language requirements form part of recruitment and workforce planning? ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Any additional comments:"]

{"sheet":"Training and Rotas","index":14,"n_rows":45,"n_cols":7,"rows_kept":45,"merged":[[1,1,1,7],[9,2,9,3],[10,2,10,3],[11,2,11,4],[12,2,12,4],[23,2,23,3],[25,2,25,3],[26,2,26,3],[27,2,27,3],[28,2,28,3],[29,2,29,3],[30,2,30,4],[31,2,31,3],[31,5,33,5],[31,6,33,6],[32,2,32,3],[33,2,33,3],[34,2,34,4],[37,2,37,6],[40,2,40,6],[42,2,42,4],[45,2,45,6]]}
[]
[null,"Review of staff training information - 7.1 Workforce"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified","Good Practice identified"]
[]
[]
[null,null,"Areas to consider",null,null,"Finding\nPrompts: Include any good practice, suggestions and areas for improvement\n","What is the evidence to support this?"]
[null,null,"Training"]
[null,null,"What evidence is there that staff have completed mandatory training? Where applicable is competency assessed?\ni.e. Is there a completed training matrix available? Are there local staff training records?\n",null,null,"SAU - See training records. Requested 06/09/22.  "]
[null,null,"Have staff completed the following recommended training for NHS Wales staff (as endorsed by WG previously):\nLevel 1 (all staff):"]
[null,null,"• Health & Safety ",null,"No"]
[null,null,"• Information Governance ",null,"No"]
[null,null,"• Fire Safety",null,"No"]
[null,null,"• Safeguarding Adults",null,"No"]
[null,null,"• Safeguarding Children",null,"No"]
[null,null,"• Mental capacity/ DOLS",null,"No"]
[null,null,"• Treat me Fairly (Equality)",null,"No"]
[null,null,"• Infection Prevention and Control",null,"No"]
[null,null,"• Manual Handling",null,"No"]
[null,null,"• Resuscitation ",null,"No"]
[null,null,"• Violence and Aggression Module A",null,"No"]
[null,null,"• Dementia Awareness*",null,"No"]
[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,"What sepsis training is available?"]
[null,null,"Appraisal"]
[null,null,"\nDo all staff have an annual appraisal?\n"]
[null,null,"Employment information"]
[null,null,"What do ward managers understand about the following employment information and do they have access to electronic records with this information?:"]
[null,null,"• Do all staff have a contract of employment?"]
[null,null,"• Do all staff have relevant, up to date job descriptions which reflect their level of responsibility? "]
[null,null,"• Is this regularly reviewed?"]
[null,null,"How are appropriate pre-employment checks done for all staff? e.g. reference checks, GP/Nurse registration/revalidation, DBS requirements"]
[]
[]
[null,"\n","Review of staff rotas - Standard 7.1 - Workforce"]
[]
[]
[null,null,"Note: Discuss staffing skill mix with peer reviewer(s). \nRequest copies of staff rotas as evidence, if concerned about staffing levels. "]
[]
[null,null,"Are there enough staff employed and the right skill mix to run the service safely?"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Evidence capture form","index":15,"n_rows":27,"n_cols":13,"rows_kept":27,"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)"]
[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"]

{"sheet":"Evidence capture form (2)","index":16,"n_rows":27,"n_cols":13,"rows_kept":27,"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)"]
[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"]

{"sheet":"Evidence capture form (3)","index":17,"n_rows":27,"n_cols":13,"rows_kept":27,"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)"]
[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,"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"]

{"sheet":"Issues Identified","index":19,"n_rows":32,"n_cols":16383,"rows_kept":32,"merged":[[3,2,3,4],[4,3,4,4],[5,3,5,4],[6,3,6,4],[7,3,7,4],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,3,12,4],[13,3,13,4],[14,3,14,4],[15,2,15,4],[16,3,16,4],[17,3,17,4],[18,3,18,4],[19,3,19,4],[20,3,20,4],[21,3,21,4],[22,3,22,4],[23,3,23,4],[24,3,24,4],[25,3,25,4],[26,3,26,4],[27,2,27,4],[28,3,28,4],[29,3,29,4],[30,3,30,4],[31,3,31,4],[32,3,32,4],[33,3,33,4],[34,3,34,4],[35,3,35,4],[36,3,36,4],[37,3,37,4],[38,3,38,4]]}
[]
[null,"Issues Identified",null,null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Issue Identified"]
[{"$nulls":16382},"Health promotion, protection and improvement"]
[{"$nulls":16382},"Dignified Care"]
[{"$nulls":16382},"Patient Information"]
[{"$nulls":16382},"Communicating effectively"]
[{"$nulls":16382},"Timely Access"]
[{"$nulls":16382},"Planning Care to promote independence"]
[{"$nulls":16382},"Peoples rights"]
[{"$nulls":16382},"Listening and Learning from feedback"]
[]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"Standard","Issue Identified"]
[]
[{"$nulls":16382},"Managing risk and promoting health and safety"]
[{"$nulls":16382},"Infection Prevention and Control (IPC) and Decontamination"]
[{"$nulls":16382},"Medicines Management "]
[{"$nulls":16382},"Safeguarding children and adults at risk"]
[{"$nulls":16382},"Medical devices, equipment and diagnostic systems"]
[{"$nulls":16382},"Safe and Clinically Effective care"]
[{"$nulls":16382},"Quality improvement, research and innovation"]
[{"$nulls":16382},"Information governance and communications technology"]
[{"$nulls":16382},"Record keeping"]
[null,null,"Quality of Leadership and Management"]
[null,null,"Standard","Issue Identified"]
[null,null,"Workforce","06/09/22 - conversation with XX (HCSW) working on RAU. XX indicated that she was feeling stressed and the unit was short staffed. XX disclosed that she had 'broken down' during today's shift. XX confirmed has escalated to unit manager. XX confirmed action taken with ward manager who confirmed XX's account and has referred to well-being service. Is also monitoring situation and recommending that XX does not accept overtime currently. "]
[{"$nulls":16382},"Governance, leadership and accountability"]
[{"$nulls":16382},"Workforce"]

{"sheet":"Good Practice","index":20,"n_rows":32,"n_cols":16382,"rows_kept":32,"merged":[[3,2,3,3],[15,2,15,3],[27,2,27,3]]}
[]
[null,"Good Practice",null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Good Practice Identified"]
[{"$nulls":16381},"Health promotion, protection and improvement"]
[{"$nulls":16381},"Dignified Care"]
[{"$nulls":16381},"Patient Information"]
[{"$nulls":16381},"Communicating effectively"]
[{"$nulls":16381},"Timely Access"]
[{"$nulls":16381},"Planning Care to promote independence"]
[{"$nulls":16381},"Peoples rights"]
[{"$nulls":16381},"Listening and Learning from feedback"]
[]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"Standard","Good Practice Identified"]
[]
[{"$nulls":16381},"Managing risk and promoting health and safety"]
[{"$nulls":16381},"Infection Prevention and Control (IPC) and Decontamination"]
[{"$nulls":16381},"Medicines Management "]
[{"$nulls":16381},"Safeguarding children and adults at risk"]
[{"$nulls":16381},"Medical devices, equipment and diagnostic systems"]
[{"$nulls":16381},"Safe and Clinically Effective care"]
[{"$nulls":16381},"Quality improvement, research and innovation"]
[{"$nulls":16381},"Information governance and communications technology"]
[{"$nulls":16381},"Record keeping"]
[null,null,"Quality of Leadership and Management"]
[null,null,"Standard","Good Practice Identified"]
[]
[{"$nulls":16381},"Governance, leadership and accountability"]
[{"$nulls":16381},"Workforce"]

{"sheet":"Feedback meeting notes","index":21,"n_rows":27,"n_cols":5,"rows_kept":27,"merged":[[1,1,1,4],[10,1,10,4],[12,1,12,2],[12,3,12,4],[13,1,13,2],[13,3,13,4],[14,1,14,2],[14,3,14,4],[15,1,15,2],[15,3,15,4],[16,1,21,2],[26,1,26,2],[27,1,27,2],[28,1,28,2],[29,1,29,2],[30,1,30,2],[31,1,31,2],[32,1,32,2],[33,1,33,2],[34,1,34,2],[35,1,35,2],[36,1,36,2],[37,1,37,2],[38,1,38,2]]}
[{"$nulls":4},"Back to Summary"]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
{"$rows_empty":8}
[null,"INSPECTION FEEDBACK MEETING NOTES"]
[]
[null,"Inspection reference number / setting name"]
[null,"Name of person leading the feedback meeting "]
[null,"Date"]
[null,"Time"]
[null,"Attendees"]
{"$rows_empty":7}
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Immediate Assurance Issues",null,"Noteworthy practice ","Areas for improvement"]

{"sheet":"Discussions Crib Sheet","index":22,"n_rows":90,"n_cols":7,"rows_kept":90,"merged":[[3,2,4,2],[3,3,4,3],[3,4,4,4],[3,5,4,5],[3,6,4,6],[5,2,5,6],[6,3,10,3],[6,4,10,4],[6,5,10,5],[6,6,10,6],[11,3,12,3],[11,4,12,4],[11,5,12,5],[11,6,12,6],[13,3,18,3],[13,4,18,4],[13,5,18,5],[13,6,18,6],[19,3,22,3],[19,4,22,4],[19,5,22,5],[19,6,22,6],[23,2,23,6],[24,3,26,3],[24,4,26,4],[24,5,26,5],[24,6,26,6],[27,2,27,6],[28,3,29,3],[28,4,29,4],[28,5,29,5],[28,6,29,6],[30,3,32,3],[30,4,32,4],[30,5,32,5],[30,6,32,6],[33,3,34,3],[33,4,34,4],[33,5,34,5],[33,6,34,6],[35,3,37,3],[35,4,37,4],[35,5,37,5],[35,6,37,6],[38,3,39,3],[38,4,39,4],[38,5,39,5],[38,6,39,6],[40,2,40,6],[41,3,43,3],[41,4,43,4],[41,5,43,5],[41,6,43,6],[44,3,49,3],[44,4,49,4],[44,5,49,5],[44,6,49,6],[50,3,53,3],[50,4,53,4],[50,5,53,5],[50,6,53,6],[54,3,55,3],[54,4,55,4],[54,5,55,5],[54,6,55,6],[56,3,58,3],[56,4,58,4],[56,5,58,5],[56,6,58,6],[59,2,59,6],[60,3,61,3],[60,4,61,4],[60,5,61,5],[60,6,61,6],[62,3,64,3],[62,4,64,4],[62,5,64,5],[62,6,64,6],[65,3,66,3],[65,4,66,4],[65,5,66,5],[65,6,66,6],[67,2,67,6],[68,3,71,3],[68,4,71,4],[68,5,71,5],[68,6,71,6],[72,3,76,3],[72,4,76,4],[72,5,76,5],[72,6,76,6],[77,3,79,3],[77,4,79,4],[77,5,79,5],[77,6,79,6],[80,3,81,3],[80,4,81,4],[80,5,81,5],[80,6,81,6],[82,2,82,6],[83,3,84,3],[83,4,84,4],[83,5,84,5],[83,6,84,6],[85,2,85,6],[86,3,89,3],[86,4,89,4],[86,5,89,5],[86,6,89,6]]}
[]
[null,"Staff Discussions Crib Sheet",{"$nulls":4},"Back to Summary"]
[]
[null,null,"Areas to cover","Senior managers","RN’s","Healthcare support workers","House-keeping staff"]
[]
[null,null,"Standard 7.1 - Workforce"]
[null,null,"Number and skill mix of staff"]
[null,null,"·       Do you feel the number of staff on the ward is appropriate for the patients?"]
[null,null,"·       Do you feel the skill mix of staff appropriate to meet patient’s needs?"]
[null,null,"·       Is acuity considered and arrangements for 1:1 nursing?"]
[null,null,"·       Do you have enough time to give patients the care they need?"]
[null,null,"Turnover/sickness/vacancies"]
[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,"Support/management arrangements"]
[null,null,"·       Is there regular supervision and appraisals?"]
[null,null,"·       Are there regular staff/management meetings?"]
[null,null,"·       Is there sharing of learning such as from incidents and of good practice?"]
[null,null,"·       What do you feel is the culture on the ward?"]
[null,null,"·       Do you feel able to report concerns? How are these dealt with and responded to?"]
[null,null,"Training access"]
[null,null,"·       Do you have access to training and development opportunities to support you in your role?"]
[null,null,"·       How do senior managers track whether mandatory training has been undertaken?"]
[null,null,"·       For students, is there a learning audit with the University? What are the supervisory arrangements?"]
[null,null,"Governance, leadership and accountability"]
[null,null,"·       What are the governance arrangements in place?"]
[null,null,"·       Do senior managers visit the ward and engage with staff on a regular basis?"]
[null,null,"·       How is info shared from management to staff/ from staff to management?"]
[null,null,"Standard 2.1 - Managing risk and health and safety"]
[null,null,"Significant incidents"]
[null,null,"·       (discuss any significant incidents from intelligence)"]
[null,null,"Incident reporting "]
[null,null,"·       How are risks and incidents reported? i.e. DATIX. "]
[null,null,"·       Where does this information go?"]
[null,null,"Dealing with incidents"]
[null,null,"·       How are incidents dealt with? "]
[null,null,"Sharing learning from incidents"]
[null,null,"·       What is done to ensure lessons are learned following incidents?"]
[null,null,"·       How is information on incidents shared with staff at ward level?"]
[null,null,"Quality audits/risk assessments"]
[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,"Standard 2.4 Infection control (IPC)"]
[null,null,"Infection rates"]
[null,null,"·       What are the current infection rates and does this fit within organisational process?"]
[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,"IPC training"]
[null,null,"·       What are the IPC training compliance levels? i.e. "]
[null,null,"-       Are C4C scores are greater than 95%?"]
[null,null,"-       Are hand hygiene scores greater than 95% "]
[null,null,"-       Are there cleaning records and schedules?"]
[null,null,"-       Are IPC training scores greater than 95%? E.g.  induction, level 1, 2 and Aseptic non touch technique"]
[null,null,"Infection control policies and responsibilities"]
[null,null,"·       Are there adequate IPC policies and procedures in place and do staff have access to them? Including:"]
[null,null,"-       Policy on decontamination of medical devices/equipment"]
[null,null,"-       Policy on water management"]
[null,null,"Ongoing audits for IPC "]
[null,null,"·       Is there an ongoing audit programme for IPC compliance and arrangements for feeding back the results?"]
[null,null,"Occupational health support"]
[null,null,"·       What support/access is there to occupational health for staff?"]
[null,null,"·       Are there records on staff immunisation status?"]
[null,null,"Standard 6.3 Listening and Learning from feedback "]
[null,null,"Concerns/complaints received "]
[null,null,"·       Are you aware of any recent/current complaints?"]
[null,null,"Complaint records"]
[null,null,"·       How are verbal/informal concerns (complaints) captured?"]
[null,null,"·       Is there evidence that common themes emerging from complaints are checked and addressed?"]
[null,null,"Sharing learning "]
[null,null,"·       How is information from complaints shared with staff and is there sharing of learning across ward and health board?"]
[null,null,"Standard 2.7 - Safeguarding children and adults at risk"]
[null,null,"Current POVAs and DOLS"]
[null,null,"·       Is there anyone on the ward who is subject to DOLS and what’s your understanding of this?"]
[null,null,"·       Are there any current or recent POVA’s? If so, who reported these?"]
[null,null,"·       What has been the outcome of POVA/DOLS referrals?"]
[null,null,"POVA/DOLS training "]
[null,null,"·       Do staff have training updates in safeguarding?"]
[null,null,"·       Are you aware of the recent changes to safeguarding legislation and the implications for staff? "]
[null,null,"·       How do you decide whether deprivation of liberty is or may be necessary? – Who makes this decision?"]
[null,null,"·       Are less restrictive options considered to avoid DOLS? (ask for details on these)"]
[null,null,"Reporting concerns"]
[null,null,"·       Do you know what to do if you have a safeguarding concern? Who would you report this to?"]
[null,null,"·       Are you aware of the organisations policies and procedure for safeguarding children and vulnerable adults?"]
[null,null,"Advocacy arrangements"]
[null,null,"·       For patients who lack mental capacity are there advocacy arrangements in place?"]
[null,null,"3.3 Quality Improvement, Research and Innovation"]
[null,null,"·       What quality improvement activities take place?"]
[null,null,"·       What good practice/initiatives and development plans are in place/being developed? "]
[null,null,"3.1 Safe and Clinically Effective care"]
[null,null,"Sepsis"]
[null,null,"·       What training is available to staff?"]
[null,null,"·       How does the health board ensure staff are up to date with guidelines?"]
[null,null,"·       What policy or guidelines are in place in relation to managing sepsis?"]

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[null,null,"Health promotion, protection and improvement",{"$nulls":4},"Managing risk and promoting health and safety"]
[null,null,"Dignified Care",{"$nulls":4},"Infection Prevention and Control (IPC) and Decontamination"]
[null,null,"Patient Information",{"$nulls":4},"Medicines Management "]
[null,null,"Communicating effectively",{"$nulls":4},"Safeguarding children and adults at risk"]
[null,null,"Timely Access",{"$nulls":4},"Medical devices, equipment and diagnostic systems"]
[null,null,"Planning Care to promote independence",{"$nulls":4},"Safe and Clinically Effective care"]
[null,null,"Peoples rights",{"$nulls":4},"Quality improvement, research and innovation"]
[null,null,"Listening and Learning from feedback",{"$nulls":4},"Information governance and communications technology"]
[{"$nulls":7},"Record keeping"]
[]
[]
[null,null,"Governance, leadership and accountability"]
[null,null,"Workforce"]

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[]
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[null,null,"Health promotion, protection and improvement",{"$nulls":6},"Managing risk and promoting health and safety"]
[null,null,"Dignified Care",{"$nulls":6},"Infection Prevention and Control (IPC) and Decontamination"]
[null,null,"Patient Information",{"$nulls":6},"Medicines Management "]
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[null,null,"Timely Access",{"$nulls":6},"Medical devices, equipment and diagnostic systems"]
[null,null,"Planning Care to promote independence",{"$nulls":6},"Safe and Clinically Effective care"]
[null,null,"Peoples rights",{"$nulls":6},"Quality improvement, research and innovation"]
[null,null,"Listening and Learning from feedback",{"$nulls":6},"Information governance and communications technology"]
[{"$nulls":9},"Record keeping"]
[]
[]
[]
[null,null,"Governance, leadership and accountability"]
[null,null,"Workforce"]

{"sheet":"Do not delete","index":25,"n_rows":22,"n_cols":3,"rows_kept":22,"hidden":true}
[]
[]
[]
[null,null,"Patient information and consent & Records management"]
[null,null,"Communicating effectively"]
[null,null,"Citizen engagement & feedback"]
[null,null,"Equality, diversity, dignity and respect"]
[]
[]
[]
[null,null,"Medical devices, equipment and diagnostic systems"]
[null,null,"Safeguarding children and adults at risk"]
[null,null,"Infection prevention and control & Decontamination"]
[null,null,"Environment & Risk management"]
[]
[]
[]
[null,null,"Governance and accountability framework & Participating in Quality Improvement activities "]
[null,null,"Concerns"]
[null,null,"Information Management and communication technology & Records management"]
[null,null,"Workforce recruitment and employment practices"]
[null,null,"Workforce Planning, Training and Organisational Development"]

{"sheet":"Sheet2 (2)","index":26,"n_rows":15,"n_cols":8,"rows_kept":15,"hidden":true}
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[null,null,"Health promotion, protection and improvement",{"$nulls":4},"Managing risk and promoting health and safety"]
[null,null,"Dignified Care",{"$nulls":4},"Infection Prevention and Control (IPC) and Decontamination"]
[null,null,"Patient Information",{"$nulls":4},"Medicines Management "]
[null,null,"Communicating effectively",{"$nulls":4},"Safeguarding children and adults at risk"]
[null,null,"Timely Access",{"$nulls":4},"Medical devices, equipment and diagnostic systems"]
[null,null,"Planning Care to promote independence",{"$nulls":4},"Safe and Clinically Effective care"]
[null,null,"Peoples rights",{"$nulls":4},"Quality improvement, research and innovation"]
[null,null,"Listening and Learning from feedback",{"$nulls":4},"Information governance and communications technology"]
[{"$nulls":7},"Record keeping"]
[]
[]
[null,null,"Governance, leadership and accountability"]
[null,null,"Workforce"]