{"text_format":"3","workbook":"xlsx","n_sheets":24,"sheets":["Guidance","Inspection Details","Arrival and Tour","Summary","Dignified Care (2)","Health PPI","Dignified Care","Communication and patient info","Timely access","People's Rights","Feedback","Risk & IPC","Nutrition","Safe care","Evidence capture form","Evidence capture form (2)","Evidence capture form (3)","Evidence capture form (4)","Issues Identified","Good Practice","Sheet2","Sheet1","Do not delete","Sheet2 (2)"],"not_rendered":{"images":8},"read":"whole","date_system":"1900"}

{"sheet":"Guidance","index":0,"n_rows":67,"n_cols":6,"rows_kept":67,"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],[13,2,13,4],[14,2,14,4],[15,2,15,4],[16,2,16,4],[17,2,17,4],[18,2,18,4],[19,2,19,3],[20,2,21,2],[20,3,21,3],[20,4,21,4],[20,5,21,5],[22,2,43,2],[23,3,25,3],[23,5,25,5],[27,3,28,3],[27,5,28,5],[29,3,30,3],[29,5,30,5],[31,3,33,3],[31,5,33,5],[37,3,38,3],[37,5,38,5],[40,3,43,3],[40,5,43,5],[44,2,62,2],[52,3,53,3],[52,5,53,5],[54,3,55,3],[54,5,55,5],[57,3,58,3],[57,5,58,5],[61,3,62,3],[61,5,62,5],[63,2,66,2],[63,3,64,3],[63,5,64,5],[69,2,69,3]]}
[]
[]
[null,"Tool Guidance"]
[]
[]
[null,null,"GUIDANCE FOR LAY REVIEWER"]
[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,"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,"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,"This workbook aims to guide you as to the areas you should consider when assessing whether a ward/unit meets the standards. 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. 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,"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,"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"]
[{"$nulls":3},"6.1 Planning Care to promote independence","Patients should be supported to look after their own health and well-being","PR"]
[{"$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","LR"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time"]
[{"$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 "]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it"]
[{"$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"]

{"sheet":"Inspection Details","index":1,"n_rows":39,"n_cols":5,"rows_kept":39,"merged":[[0,4,0,5],[5,3,5,5],[9,3,9,5],[13,3,13,5],[17,3,17,5],[21,3,21,5],[23,3,23,5],[27,3,27,5],[31,3,31,5],[35,4,35,5],[36,4,36,5],[37,4,37,5],[38,4,38,5]]}
[]
[]
[null,"Inspection Details"]
[]
[]
[null,null,"Reference number",21073]
[]
[]
[]
[null,null,"Inspection Type","ED"]
[]
[]
[]
[null,null,"Health Board ","Cardiff & Vale"]
[]
[]
[]
[null,null,"Name of setting","Emergency Department "]
[]
[]
[]
[null,null,"Date inspection started","2022-06-20"]
[]
[null,null,"Date inspection completed","2022-06-22"]
[]
[]
[]
[null,null,"Name of Lead HIW Inspector","XXXXX XXXXXXXX"]
[]
[]
[]
[null,null,"Name of Supporting HIW Inspector","XXXXXXXX XXXXXX"]
[]
[]
[]
[null,null,"Inspection team","Peer 1:","XXX XXXXX"]
[{"$nulls":3},"Peer 2:","XXXXXX XXXXX"]
[{"$nulls":3},"Peer 3:","XXXXXXX XXXXXX XXXXXXX"]
[{"$nulls":3},"Patient Experience:","XXXXXXX XXXXX"]

{"sheet":"Arrival and Tour","index":2,"n_rows":12,"n_cols":4,"rows_kept":12,"merged":[[0,4,0,5],[6,3,6,5],[11,3,11,5]]}
[]
[]
[null,"Arrival and Initial Discussions"]
[]
[]
[]
[null,null,"General observations from discussion with person in charge\nThings to think about: Make a note of any areas/patients that staff have said to avoid. Are they busier than normal with patients?\n","Arrived at a very busy Department on the evening of the 20 June 2022.  Nurse In Charge declared the Department was at Escalation Level 4:16.  "]
[]
[]
[]
[]
[null,null,"General observations of areas and environment\nVisit all areas of the ED including the waiting area, triage, majors, minors, resuscitation, clinical decision unit, paediatric.\nThings to think about:  What does each area feel like, how busy is it, how noisy is it?  Are the furniture, decorations, equipment in a good state of repair? Are bathrooms, showers, kitchen, and telephones in working order? Is the environment clean and tidy? Are there any obvious hazards to patient safety, such as tripping hazards? \n","Walked into a very busy Department.  There were four ambulances waiting outside to off load.  Crowds of patients waiting outside smoking. In walking into the waiting area, there was a patient lying on the floor inside the entrance being sick.  All seats were taken and patients were either standing or sitting on the floor.  Leftover food and discarded coffee cups left on top of an overflowing bin in waiting area.  Sharps bins were open and overflowing in the Unit. All areas felt overcrowded, cluttered and chaotic.  Environment was dirty and untidy with many trip hazards.  Damaged and old furniture and equipment still being used.  Inca pad on floor to soak up water from leaking water cooler. Patient medication charts left out on reception unattended.  Witnessed elderly naked patient in Assessment Unit walking around with just a gown covering his front.  Male and female toilets available, female toilet in waiting area was not lockable.  All toilets viewed were dirty, unflushed with tissue paper and discarded cotton wool balls on the floor.  Environment, furniture and equipment in poor state of repair. "]

{"sheet":"Summary","index":3,"n_rows":26,"n_cols":7,"rows_kept":26,"merged":[[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[22,2,22,4],[23,2,23,4],[24,2,24,4],[25,2,25,4]]}
[]
[]
[null,"Summary",null,null,"Issues Identified",null,"Good Practice"]
[]
[]
[]
[null,null,"Quality of Patient Experience","Significant improvement needed"]
[null,null,"1.1 Health PPI",null,null,{"$f":"'Health PPI'!D4","v":"Yes"},{"$f":"'Health PPI'!D5","v":"Significant improvement needed"}]
[null,null,"4.1 Dignified care",null,null,{"$f":"'Dignified Care'!D4","v":"Yes"},{"$f":"'Dignified Care'!D5","v":"Some improvement needed"}]
[null,null,"3.2 and 4.2 - Communicating effectively and patient information",null,null,{"$f":"'Communication and patient info'!D4","v":"Yes"},{"$f":"'Communication and patient info'!D5","v":"Significant improvement needed"}]
[null,null,"5.1 Timely Access",null,null,{"$f":"'Timely access'!D4","v":"Yes"},{"$f":"'Timely access'!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":"Standards met"}]
[null,null,"6.3 Listening and Learning from Feedback",null,null,{"$f":"Feedback!D4","v":"Yes"},{"$f":"Feedback!D5","v":"Some improvement needed"}]
[]
[]
[null,null,"Delivery of Safe and Effective Care","Significant improvement needed"]
[null,null,"2.2 - Managing Risk and Promoting Health and Safety & 2.4 IPC and Decontamination",null,null,{"$f":"'Risk & IPC'!D4","v":"Yes"},{"$f":"'Risk & IPC'!D5","v":"Significant improvement needed"}]
[null,null,"2.5 - Nutrition and Hydration",null,null,{"$f":"Nutrition!D4","v":"Yes"},{"$f":"Nutrition!D5","v":"Some improvement needed"}]
[null,null,"3.1 Safe and Clinically Effective care",null,null,{"$f":"'Safe care'!D4","v":"Yes"},{"$f":"'Safe care'!D5","v":"Some improvement needed"}]
[]
[]
[]
[null,null,"Evidence capture form"]
[null,null,"Evidence capture form(2)"]
[null,null,"Evidence capture form(3)"]
[null,null,"Evidence capture form(4)"]

{"sheet":"Dignified Care (2)","index":4,"n_rows":24,"n_cols":8,"rows_kept":24,"hidden":true,"merged":[[5,2,5,3],[6,2,6,3],[11,2,11,4],[11,5,11,6],[11,7,11,8],[12,2,12,3],[12,5,15,6],[12,7,15,7],[13,2,13,3],[14,2,14,3],[15,2,15,3],[16,2,16,3],[16,5,19,6],[16,7,19,7],[17,2,17,3],[18,2,18,3],[19,2,19,3],[20,2,20,3],[20,5,20,6],[21,2,21,3],[21,5,21,6],[22,2,22,3],[22,5,22,6],[24,2,30,6]]}
[]
[null,"Quality of Patient Experience - Standard 4.1 - Dignified Care"]
[{"$nulls":6},"Back to Summary"]
[]
[null,null,"Link with peer to consider the following jointly",null,null,"Completed","Outcome"]
[null,null,"Text written in purple = Could be used as staff discussion prompts, as well as key lines of enquiry.",null,null,"No","Significant improvement needed"]
[null,null,"Text blue and underlined = Hyperlink to applicable section of the workbook/guidance/legislation/standards.",{"$nulls":3},"Improvement required"]
[{"$nulls":6},"Good Practice identified"]
[null,null,"Key Document Section"]
[]
[]
[{"$nulls":5},"Findings/Evidence",null,"Improvements required"]
[null,null,"Do staff treat people with respect and kindness? ",{"$nulls":4},"Not Completed"]
[null,null,"• How do staff speak to patients?"]
[null,null,"• Do staff introduce themselves and address patients courteously?",null,"No"]
[null,null,"• Are staff kind to patients who may be wandering or shouting out?",null,"No"]
[null,null,"Do staff respect people’s privacy and dignity? For example:",{"$nulls":4},"Not Completed"]
[null,null,"• Are staff discreet and sensitive when speaking to patients and when speaking about patients to other staff? e.g. so they can’t be easily overheard",null,"No"]
[null,null,"• Do staff respect patient’s privacy when giving personal care so that other people can’t see? ",null,"No"]
[null,null,"• If there are patients on trolleys in corridors how do staff maintain patient dignity?",null,"No"]
[null,null,"Are there any issues with the environment which could affect patient dignity? \nE.g. are locks on toilet doors in working order? ",null,"No",null,null,"Not Completed"]
[null,null,"Do patients appear well cared for? ",null,"No",null,null,"Not Completed"]
[null,null,"Are patients’ warm and offered warm blankets?",null,"No",null,null,"Not Completed"]
[null,null,"Summary/Conclusion"]

{"sheet":"Health PPI","index":5,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,4],[11,6,11,7],[13,2,13,4],[13,6,13,7],[14,2,14,3],[17,2,17,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 1.1 - Health promotion, protection and improvement"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Patients spoken to were understanding and praised the staff in challenging circumstances.  We're happy with the care overall.",null,"No"]
[null,null,"Is smoking cessation advice available and are people encouraged not to smoke?  ",null,null,"Yes","No cessation advice posters anywhere in the Department.  Sign outside main entrance stating \"smoking prohibited\" but patients/carers were outside smoking.  Pathway littered with cigarette butts and rubbish.",null,"Yes"]
[null,null,"Is there information displayed highlighting the appropriate use of the ED and signposting to other services?",null,null,"Yes","Very little in the way of signage for other services.  No information displayed highlighting appropriate use of ED.  No way of patients knowing what current wait times are unless they ask a member of staff.  ",null,"Yes"]
[]
[null,null,"What did patients tell you about how they were helped to look after themselves and their health?",null,null,"No","Posters displayed advising patients to stay hydrated.  However, there was no water dispenser available in the ED main waiting area.  Question not discussed with patients spoken to as not appropriate at the time of speaking to them.",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"The patients spoken to were either waiting to be seen or were in one of the assessment bays.  Patients were notified of a 10 hour wait and although they were fed up with waiting understood the pressures on staff.  All the patients I spoke to had been triaged within the 1 hour timeframe.  Patients were not aware of what the pathway was for their care or when they were likely to be able to go home.  There were however large posters highlighting what patients can expect as part of their journey on display in the cubicles in Majors Unit. "]

{"sheet":"Dignified Care","index":6,"n_rows":22,"n_cols":9,"rows_kept":22,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[9,8,12,8],[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],[14,2,14,4],[14,6,14,7],[15,2,15,4],[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],[21,2,21,8]]}
[]
[null,"Quality of Patient Experience - Standard 4.1 - Dignified Care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Do staff treat people with respect and kindness? ",null,null,"Yes","Observed with some staff.  Witnessed a member of staff in Majors aggressively shouting at elderly patient because he would not turn on the trolley.  Patient was visibly distressed and unwell.",null,"Yes"]
[null,null,"• How do staff speak to patients?",null,null,"Yes","Pleasant enough."]
[null,null,"• Do staff introduce themselves and address patients courteously?",null,null,"Yes","Not observed in ED."]
[null,null,"• Are staff kind to patients who may be wandering or shouting out?",null,null,"Yes","Witnessed a patient wrapped in a blanket wandering around the unit, looked confused.  Patient was ignored by staff."]
[null,null,"Do staff respect people’s privacy and dignity? For example:"]
[null,null,"Are staff discreet and sensitive when speaking to patients and when speaking about patients to other staff? e.g. so they can’t be easily overheard",null,null,"Yes","Various staff conversations about patients overheard whilst in the ED. ",null,"Yes"]
[null,null,"Are there any issues with the environment which could affect patient dignity?  e.g. are locks on toilet doors in working order? ",null,null,"Yes","Female toilet in ED minors waiting area, lock was broken.",null,"Yes"]
[null,null,"Do patients appear well cared for? ",null,null,"Yes","On observations from walking around care was inconsistent.  Observed evidence of good care being given and instances where prints were ignored.",null,"Yes"]
[null,null,"Are patients’ warm and offered warm blankets?",null,null,"Not applicable","Very hot in the department on the days inspected.",null,"No"]
[null,null,"What did patients/carers tell you about how they were treated? i.e. Are staff kind and treat patients with dignity and respect?",null,null,"Yes","Patients spoken to were complimentary about the staff.",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Patient observed in Minors assessment unit lying on dirty and crumpled sheets.  Was not covered with a blanket.  Patient observed in assessment unit north trying to walk with the aid of a meal trolley around the department, patient was naked apart from incontinence pants and  had a gown covering his front but leaving his back exposed.  Patient walked around for several minutes before being approached by a member of staff.  Observed member of staff removing a patient's cannula on reception desk in Minors assessment.  Observed patient wrapped in blanket wandering around the assessment unit, was ignored by staff. Witnessed a member of staff in Majors aggressively shouting at elderly patient because he would not turn on the trolley.  Patient was visibly distressed and unwell."]

{"sheet":"Communication and patient info","index":7,"n_rows":33,"n_cols":9,"rows_kept":33,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[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],[17,2,17,4],[17,6,17,7],[19,2,19,4],[20,2,20,4],[20,6,20,7],[21,2,21,4],[21,6,21,7],[22,2,22,4],[22,6,22,7],[23,2,23,4],[23,6,23,7],[24,2,24,4],[24,6,24,7],[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],[32,2,38,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 3.2 and 4.2 - Communicating effectively and patient information"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department communicate current waiting times?",null,null,"Yes","Patients are told on arrival what the current waiting time is to be seen. For updates, patients have to ask staff where they are in the queue and when they are likely to be seen. ",null,"Yes"]
[null,null,"Is there clear information for patients and relatives? I.e. clear signs/directions to and from the department. ",null,null,"Yes","The ED is going through a period,of change and therefore there is no clear signage to and from the Department.  The different areas of the Department are not clearly signposted.",null,"Yes"]
[null,null,"Is information available for patients/carers to help them understand their care and journey through the department?",null,null,"Yes","No information available.",null,"Yes"]
[null,null,"Is information available in different formats and languages (not just in Welsh and English)?",null,null,"Yes","Predominantly, literature and posters are in English with only a few in Welsh.  No other formats or languages were visible.",null,"Yes"]
[null,null,"Is information available in Welsh?",null,null,"Yes","Information leaflets displayed and reviewed were all in English.",null,"Yes"]
[null,null,"Is there information displayed about the staff working in the department i.e. a ‘who’s who’ board?",null,null,"Yes","No staff board on display.  Some staff not wearing name badges or ID.",null,"Yes"]
[null,null,"Is information displayed and/or material available for patients to take away in relation to sepsis?",null,null,"Yes","No information displayed in relation to sepsis.",null,"Yes"]
[]
[null,null,"What did patients/carers tell you about how staff communicated with them? i.e. Did they listen and take time to explain about their care?",null,null,"Yes","Patients felt they were not regularly updated with what was happening.",null,"Yes"]
[]
[null,null,"Welsh language"]
[null,null,"Have staff asked what your preferred language is?",null,null,"No",null,null,"Not Completed"]
[null,null,"If it’s your choice, have you been able to speak in Welsh to staff, and do they speak Welsh to you?",null,null,"No",null,null,"Not Completed"]
[null,null,"Have you had the opportunity to use translation services if you have wanted/needed to?",null,null,"No",null,null,"Not Completed"]
[null,null,"Do staff speak to you in Welsh, even if it’s just a few words?",null,null,"No",null,null,"Not Completed"]
[null,null,"How do you know if staff are able to speak Welsh? (e.g. do they wear a ‘iaith gwaith’ badge highlighting they speak Welsh / have they introduced themselves as a Welsh speaker?)",null,null,"No",null,null,"Not Completed"]
[null,null,"Have staff spoken with your visitors in Welsh if they have wanted/needed to?",null,null,"No",null,null,"Not Completed"]
[null,null,"What difference has it made to patients to speak in Welsh with staff if they have wanted and been able to? ",null,null,"No",null,null,"Not Completed"]
[null,null,"Are there bilingual signs, posters, reading material available?",null,null,"Yes","Some bilingual signs and posters but no bilingual information leaflets displayed.",null,"Yes"]
[null,null,"Do staff wear a ‘iaith gwaith’ badge, or other visual prompts to indicate they speak Welsh?",null,null,"Yes","Not observed.",null,"Yes"]
[null,null,"Have you observed patients and staff / staff with staff speaking Welsh to each other?",null,null,"Yes","Not observed.",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"There is no system in place to keep patients informed on waiting times.  On arrival on the morning 21st June the current wait time was at 10.5 hours.  There is no information available to patients advising on their journey through the Department or what to expect.  Majority of posters on display were in English, very few in Welsh.  No other formats or languages available or observed.  No who's who board and patients were not aware of who was in charge or who were the staff on duty.  No sepsis information on display. No bilingual information leaflets.  No visual prompts to indicate staff who are Welsh speakers.  Did not observe anyone speaking Welsh.  Paramedics confirmed communication between WAST and UHW was good.  "]

{"sheet":"Timely access","index":8,"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],[13,2,13,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 5.1 Timely care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Majority of patients spoken to fed up about the wait to see a doctor but were grateful to be seen eventually.  ",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"On arrival at ED patients were notified of a 10.5 hour wait to be seen.  Some had been trying to get through to their GP for help but unable to so come to ED as last resort.  Patients grateful to get help but did feel their assessment had not been thorough enough and felt patched up and sent on their way.  Patients spoken to had been triaged within the one hour timeframe.  Evidenced via patient discussion that following triage patients are prioritised according to their injury/condition.  On discussion with Paramedic, they had been waiting 3.5 hours to off load their patient.  There is no treatment given on board, obs done every 15 minutes, deteriorating patients would be escalated to unit staff. "]

{"sheet":"People's Rights","index":9,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,3],[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],[14,2,14,4],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Quality of Patient Experience - 6.2 People's Rights"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Standards met"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there specific and suitable places for patients to meet with family and friends in private? e.g. relatives room",null,null,"Yes","Relatives room available but not in ED.  Accessed through Radiology. Room felt calm, comfortable and private.",null,"No"]
[null,null,"Is the relatives’ room conducive to breaking bad news?",null,null,"Yes","Yes.",null,"No"]
[null,null,"Is there a dedicated viewing room for bereaved relatives?",null,null,"Yes","Yes.  Within the hospital.",null,"No"]
[null,null,"Is this a multi faith or non-denominational area?",null,null,"Yes","Multi-faith Chaplains available in The Sanctuary. ",null,"No"]
[]
[null,null,"What did patients/carers tell you about the involvement of friends and family in their care? Did they know how to make a complaint?",null,null,"Yes","Patients are allowed to be accompanied by one person only whilst in the ED.  Majority of patients in attendance on their own due to the waiting times.  Observed a few posters on how to raise concern within the ED. ",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"The hospital has good facilities for relatives and has several family rooms through the building. "]

{"sheet":"Feedback","index":10,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[8,2,8,7],[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],[14,2,14,4],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Quality of Patient Experience - 6.3 Listening and Learning from Feedback"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"How does the department ensure that they listen and learn from feedback?"]
[{"$nulls":5},"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","Paediatric Consultant confirmed feedback is gathered via questionnaires and actioned as part of service improvement plans.",null,"No"]
[null,null,"Is there information displayed around the department about how patients and families are able to provide feedback about their care? Is this easily visible?",null,null,"Yes","Nothing visible.",null,"Yes"]
[null,null,"Are patients provided with Community Health Council details for assistance to raise concerns if they should need too?",null,null,"Yes","Poster on display in reception area of minors ED.",null,"No"]
[null,null,"Is there information on how the health board has learned and improved based on feedback received? ",null,null,"Yes","Nothing visible.",null,"Yes"]
[null,null,"Is Putting Things Right displayed?",null,null,"Yes","Two posters observed at the entrance to minors ED.",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Various posters randomly placed around all areas.  No information available of lessons learnt from patient feedback.  During meeting with paediatric consultant, stated that paediatric patients/family asked to complete questionnaires on care received and feedback used to improve service. "]

{"sheet":"Risk & IPC","index":11,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,3],[8,6,8,7],[9,2,9,4],[9,6,9,7],[9,8,12,8],[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],[17,2,17,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 2.2 - Managing Risk and Promoting Health and Safety & 2.4 Infection Prevention and Control (IPC) and Decontamination"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"Is the environment:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"• Accessible? Are the areas easy to navigate/ is there disabled access / are there facilities for people with mobility difficulties? Is signage appropriate and adequate for movement within the department, i.e. from waiting room to triage or minors?",null,null,"Yes","No clear signage on patients move through the department.   ",null,"Yes"]
[null,null,"• Well maintained? i.e. is the environment clean and in a good state of repair, including furniture, fixtures and fittings etc.",null,null,"Yes","Minors in poor state of repair, Majors is slightly better."]
[null,null,"• Fit for purpose? Is the environment suitable for the way it’s used? Are there enough trolleys and facilities?",null,null,"Yes","Due to the high level of patients going through the department would benefit from additional equipment and facilities."]
[null,null,"• Safe and secure? i.e.  Are there hazards in the environment such as blocked corridors, clutter and tripping hazards? Think about the type of patients in the area i.e. elderly, children and relatives who may be visiting them – can they do so safely?",null,null,"Yes","Observed that the department was cluttered.  Observed patients sitting on bins in the corridor of the waiting area in Minors."]
[null,null,"What changes can you see that have been made due to COVID-19 e.g. information on COVID-19 displayed on posters, social distance marking on the floor or chairs taped over / removed in the waiting room to help maintain social distancing between patients.",null,null,"Yes","Hand gel visibly available at entrance of Majors, wall hand gel at the entrance to Minors.  Plastic sheets still in existence to separate patients in Majors waiting area, all chairs in Minors waiting area in use.  No social distancing observed in any of the areas.  Some staff wearing masks. ",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"ED Minors in poor condition, missing and stained ceiling tiles, rusty bins which were overflowing.  Floors and walls marked and dirty, some chairs were worn and ripped.  Noticed empty cups and food wrappers left on floor in paediatric unit. Sharps bins overflowing and used to dispose of gloves.  Sluice room cluttered and dirty.  The department is wheelchair accessible but may struggle along some of the narrower corridors due to treatment trollies and bins being in he way.  Toilets in Minors waiting area were dirty with toilet paper left on floor.  Toilets in Majors waiting area, two out of the five were out of order and the cleaner highlighted that she found it difficult to keep on top of cleaning the remaining three as they were in constant use.  Environment in Majors unit looked cleaner and more organised.  Some of the hand gel dispensers were either missing, broken or empty.  Toilets in paediatric waiting area dirty, toilet tissue and used cotton wool balls left on the floor.  Staff room in paediatric waiting room open and staff personal belongings left unattended.  Child's hand gel dispenser too high for a child to reach.  Examination cubicles in paediatric unit, cleaning schedules had not been updated.  Books and toys available to play with."]

{"sheet":"Nutrition","index":12,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[8,2,8,4],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[12,2,12,4],[12,6,12,7],[12,8,14,8],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[20,2,20,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 2.5 - Nutrition and Hydration"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"If possible (on a ward environment), watch a meal time and look at how staff give patients their meals. This may not be possible in all areas (such as A&E). Speak to your inspection manager if you’re not sure about this.  "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Does water look like it is in easy reach of patients?",null,null,"Yes","Observations on walking around Department.  There was no water cooler in the ED waiting area.",null,"Yes"]
[null,null,"If patients are given meals – consider the following:"]
[null,null,"·       Are patients sat up and can they easily manage their meal in a trolley? Are patients offered hand wipes/washing prior to their meals?",null,null,"Yes","Observed patients who were on trolleys being offered food.  Staff confirmed patients in the waiting area were regularly offered tea and biscuits by Red Cross. Did not observe patients being offered wipes.",null,"Yes"]
[null,null,"·       Are meals served hot or is there a delay in serving meals ",null,null,"Yes","Did not observe hot meals being served."]
[null,null,"Does the food look appetising? ",null,null,"Yes","Only observed patients being given cereal and package sandwiches."]
[]
[null,null,"What did patients/carers tell you about the food and drinks? I.e. where they were staying longer in the department, were they given food options and helped with eating and drinking if they needed it?",null,null,"Yes","The patients/carers spoken to had been offered hot drinks.",null,"No"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","We're grateful to receive help but complained about the length of time they had to wait and lack of facilities.",null,"Yes"]
[]
[null,null,"Summary / Conclusion"]
[null,null,"There was no access to water in the main waiting area and the vending machine was out of order and empty.  Staff confirmed that the Red Cross offered patients tea and biscuits regularly during their wait.  Senior Staff confirmed that there is a Dietetic on duty during the day and a new satellite kitchen had been set up to serve meals three times a day.  There were several water coolers in the rest of the Department with bottles of squash on offer.  Observed patients being given cereal and packaged sandwiches.  Patients on board ambulances are offered tea and biscuits by Red Cross."]

{"sheet":"Safe care","index":13,"n_rows":13,"n_cols":9,"rows_kept":13,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,6,8,7],[12,2,12,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 3.1 Safe and clinically effective care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Discussions with patients.",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"On arrival at ED patients were notified of a 10.5 hour wait to be seen.  Some had been trying to get through to their GP for help but unable to so come to ED as last resort.  Patients grateful to get help but did feel their assessment had not been thorough enough and felt patched up and sent on their way."]

{"sheet":"Evidence capture form","index":14,"n_rows":28,"n_cols":13,"rows_kept":28,"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",{"$nulls":4},21073]
[null,"Setting name",{"$nulls":4},"Emergency Department, UHW Cardiff and Vale"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"Tour"]
[null,"About you"]
[null,"Name ",{"$nulls":4},"XXXXXXXX XXXXX"]
[null,"Team role (e.g. inspection manager peer reviewer)",{"$nulls":4},"Patient Experience Reviewer"]
[null,"Date",{"$nulls":4},"20-22 June 2022"]
[null,"Time",{"$nulls":4},"Various times"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"Tour of ED Minors Unit, Majors Unit, Paediatric Unit"]

{"sheet":"Evidence capture form (2)","index":15,"n_rows":28,"n_cols":13,"rows_kept":28,"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",{"$nulls":4},21073]
[null,"Setting name",{"$nulls":4},"Emergency Department, UHW Cardiff and Vale Hospital"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"Interviews with Patients"]
[null,"About you"]
[null,"Name ",{"$nulls":4},"XXXXXXXX XXXXX"]
[null,"Team role (e.g. inspection manager peer reviewer)",{"$nulls":4},"Patient Experience Reviewer"]
[null,"Date",{"$nulls":4},"20-22 June 2022"]
[null,"Time",{"$nulls":4},"Various times"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"Spending time in ED Minors and Paediatric Unit, conversations with patients and carers."]

{"sheet":"Evidence capture form (3)","index":16,"n_rows":29,"n_cols":13,"rows_kept":29,"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",{"$nulls":4},21073]
[null,"Setting name",{"$nulls":4},"Emergency Department, UHW Cardiff and Vale Hospital"]
[null,"Activity (e.g. tour, interview, staff discussion)",{"$nulls":4},"Staff discussion"]
[null,"About you"]
[null,"Name ",{"$nulls":4},"XXXXXXXX XXXXX"]
[null,"Team role (e.g. inspection manager peer reviewer)",{"$nulls":4},"Patient Experience Reviewer"]
[null,"Date",{"$nulls":4},"2022-06-22"]
[null,"Time",{"$nulls":4},"11am"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]
[null,"Conversations with paramedics"]
[null,"Conversations with nursing staff"]

{"sheet":"Evidence capture form (4)","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"]

{"sheet":"Issues Identified","index":18,"n_rows":27,"n_cols":16383,"rows_kept":27,"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]]}
[]
[null,"Issues Identified",null,null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Issue Identified"]
[null,null,"Health PPI","Waiting times to be seen; no information available on patients journey through the department or care pathway.",{"$nulls":16378},"Health promotion, protection and improvement"]
[null,null,"Dignified care","Patient being treated not covered up appropriately; patient lying on dirty sheets; patient's cannula removed by staff in reception area; female toilet in waiting area not lockable.   Witnessed a member of staff in Majors aggressively shouting at elderly patient because he would not turn on the trolley.  Patient was visibly distressed and unwell.",{"$nulls":16378},"Dignified Care"]
[null,null,"Comms and patient info","No system in place to keep patients informed and updated of waiting times.  Limited posters in Welsh and no information leaflets in Welsh.  No other formats or languages noted.  No information on display showing nurse in charge or staff on duty.  No bilingual information although staff stated they are able to access interpreter.",{"$nulls":16378},"Patient Information"]
[null,null,"timely access","Long waiting times to be seen in the unit and on board ambulances.",{"$nulls":16378},"Communicating effectively"]
[null,null,"feedback","No information available of lessons learnt from patient feedback.",{"$nulls":16378},"Timely Access"]
[{"$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"]
[null,null,"Risk and IPC","General environment in poor condition.  Overflowing bins; rubbish and leftover food on top of bins and on floors.  Areas cluttered and disorganised.  Poor cleanliness of toilet facilities."]
[null,null,"Nutrition","No water cooler available in main waiting area.",{"$nulls":16378},"Managing risk and promoting health and safety"]
[null,null,"Safe care","Long waiting times to be seen.",{"$nulls":16378},"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"]

{"sheet":"Good Practice","index":19,"n_rows":27,"n_cols":16382,"rows_kept":27,"merged":[[3,2,3,3],[15,2,15,3]]}
[]
[null,"Good Practice",null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Good Practice Identified"]
[null,null,"people's rights","The hospital has good facilities for relatives and has several family rooms through the building.",{"$nulls":16377},"Health promotion, protection and improvement"]
[{"$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"]
[null,null,"Safe care","Patients attending Emergency Department are being triaged within one hour and prioritised according to severity of injury/condition."]
[{"$nulls":16381},"Managing risk and promoting health and safety"]
[{"$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"]

{"sheet":"Sheet2","index":20,"n_rows":15,"n_cols":8,"rows_kept":15,"hidden":true}
[]
[]
[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"]

{"sheet":"Sheet1","index":21,"n_rows":17,"n_cols":10,"rows_kept":17,"hidden":true}
[]
[]
[]
[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",{"$nulls":6},"Medicines Management "]
[null,null,"Communicating effectively",{"$nulls":6},"Safeguarding children and adults at risk"]
[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":22,"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":23,"n_rows":15,"n_cols":8,"rows_kept":15,"hidden":true}
[]
[]
[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"]