{"text_format":"3","workbook":"xlsx","n_sheets":36,"sheets":["Guidance","Inspection Details","Arrival and Tour","Summary","Key Documents","Dignified Care","Communicating","Timely Care","Independence","People's Rights","Managing risk ","Infection Control","Nutrition","Medicines management","Safeguarding ","Blood Management","Pressure damage","Falls Prevention","Medical devices","Safe Care","Improvement","Governance","Workforce ","Case Tracking Part 1","Case Tracking Part 2","Record Keeping","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":9},"read":"whole","date_system":"1900"}

{"sheet":"Guidance","index":0,"n_rows":70,"n_cols":6,"rows_kept":70,"merged":[[4,2,4,5],[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],[19,2,19,4],[21,2,22,2],[21,3,22,3],[21,4,22,4],[21,5,22,5],[23,2,44,2],[24,3,26,3],[24,5,26,5],[28,3,29,3],[28,5,29,5],[30,3,31,3],[30,5,31,5],[32,3,34,3],[32,5,34,5],[38,3,39,3],[38,5,39,5],[41,3,44,3],[41,5,44,5],[45,2,63,2],[53,3,54,3],[53,5,54,5],[55,3,56,3],[55,5,56,5],[58,3,59,3],[58,5,59,5],[62,3,63,3],[62,5,63,5],[64,2,67,2],[64,3,65,3],[64,5,65,5],[69,2,69,5],[70,2,70,5]]}
[]
[null,"Tool Guidance"]
[]
[]
[null,null,"GUIDANCE FOR PEER 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,"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"]
[{"$nulls":3},"1.1 Health promotion, protection and improvement","Patients should be supported to look after their own health and well-being"]
[{"$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"]
[{"$nulls":3},"4.1 Dignified Care","Patients should be treated with dignity, respect and kindness","PR"]
[{"$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"]
[{"$nulls":3},"3.2 Communicating effectively","Patients should have their communication needs met","PR"]
[{"$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"]
[{"$nulls":3},"5.1 Timely access","Patients should have the right care at the right time in the right place with the right staff","IM"]
[{"$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"]
[{"$nulls":3},"6.2 Peoples rights","All health services must understand and support equality and human rights for everyone","IM"]
[{"$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"]
[{"$nulls":4},"Health services should know what is working well and what is not working well"]
[{"$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"]
[{"$nulls":3},"2.4 Infection Prevention and Control (IPC) and Decontamination","Health services should involve everyone in helping to control and stop infections so that people do not get ill","IM / PR"]
[{"$nulls":3},"2.5 Nutrition and Hydration","Patients should be supported to eat and drink so that they can get better quicker"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time"]
[{"$nulls":3},"2.7 Safeguarding children and adults at risk","Health services must support and protect all children and any adults who are vulnerable or at risk","IM"]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it"]
[{"$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"]
[{"$nulls":4},"Health services should know the best ways to care and support patients"]
[{"$nulls":3},"3.3 Quality Improvement, Research and Innovation","Health services should look at different ways to make services better based on good research","IM"]
[{"$nulls":3},"3.4 Information Governance and Communications Technology","Health services should have the right information and make sure this information is shared safely"]
[{"$nulls":3},"3.5 Record keeping","It is very important that health services keep good records to make sure patients get the right care"]
[{"$nulls":4},"Health services must follow the rules about how to record information and keep it safe"]
[null,null,"Quality of Management and Leadership","Governance, Leadership and Accountability","All health services should be person centred. They should focus on patient’s needs and listen to them"]
[{"$nulls":4},"Health services should do the right things well, know how well they are doing, be open and honest in everything they do, be caring and kind and work hard"]
[{"$nulls":3},"Staff and Resources"]
[{"$nulls":3},"7.1 Workforce","Health services should have enough staff with the right skills and training to be able to give patients the best care"]
[]
[null,null,"* If standard(s) have not been asssessed, please record the reason(s) for this below:"]

{"sheet":"Inspection Details","index":1,"n_rows":25,"n_cols":4,"rows_kept":25,"merged":[[0,4,0,5],[5,3,5,5],[7,3,7,5],[9,3,9,5],[11,3,11,5],[13,3,13,5],[15,3,15,5],[17,3,17,5],[19,3,19,5],[21,4,21,5],[22,4,22,5],[23,4,23,5],[24,4,24,5]]}
[]
[]
[null,"Inspection Details"]
[]
[]
[null,null,"Reference number 21073"]
[]
[null,null,"Inspection Type unannounced ED","NHS Emergency Department (ED)"]
[]
[null,null,"Health Board "]
[null,null,"Cardiff and vale"]
[null,null,"Name of setting EU and Mau"]
[]
[null,null,"Date inspection started 20.6.22"]
[]
[null,null,"Date inspection completed 22.6.22"]
[]
[null,null,"Name of Lead HIW Inspector ChristopherRoderick"]
[]
[null,null,"Name of Supporting HIW Inspector Huw Jones"]
[]
[null,null,"Inspection team","Peer 1:"]
[{"$nulls":3},"Peer 2:"]
[{"$nulls":3},"Peer 3:"]
[{"$nulls":3},"Patient Experience:"]

{"sheet":"Arrival and Tour","index":2,"n_rows":81,"n_cols":5,"rows_kept":81,"merged":[[0,4,0,5],[4,2,4,5],[7,3,7,5],[11,3,11,5],[15,3,15,5],[19,4,19,5],[20,4,20,5],[21,4,21,5],[22,4,22,5],[23,4,23,5],[27,3,27,5],[31,3,31,5],[32,3,32,5],[33,3,33,5],[34,3,34,5],[39,3,39,5],[43,3,43,5],[47,3,47,5],[51,3,51,5],[55,3,55,5],[59,3,59,5],[63,3,63,5],[68,3,68,5],[72,3,72,5],[76,3,76,5],[80,3,80,5]]}
[]
[]
[null,"Arrival and Initial Discussions"]
[]
[null,null,"The inspection manager will lead on asking the below; this section allows you to note down anything of clinical significance from that discussion that you may want to follow up on. "]
[]
[]
[null,null,"Time of Arrival ","20.6.22 19.30"]
[]
[]
[]
[null,null,"Who is the person in overall charge of the hospital? ","XXX XXXXX XXXXXX XXXXXXX, XXXXX XXXXXXX XXXX XX XXXXXX"]
[]
[]
[]
[null,null,"Who is Gold/Silver/Bronze on call out of hours?","Don't use this"]
[]
[]
[]
[null,null,"Number of Beds (in each ED area):","Majors:","110 patients overall in ED not including the MAU, SDEC or Speciality hub "]
[{"$nulls":3},"Minors:"]
[{"$nulls":3},"Resuscitation:",8]
[{"$nulls":3},"Clinical Decision Unit (if applicable):"]
[{"$nulls":3},"Other areas:","Mau North 21 beds, MAU south 8 trolleys 10 chairs, speciality hub had 50 patients, paeds area "]
[]
[]
[]
[null,null,"Number of Patients"]
[]
[]
[]
[null,null,"Staffing and skill mix in relation to the acuity (which areas are staff allocated to, e.g. resus, triage etc.).","Tonight skill mix and staffing is described as good with senior band 6s in each clinical area to support staff.  3x Paediatric nurses (4 is their aim)."]
[null,null,"Number of permanent/agency/bank staff","22 Registered nurses on shift. 9 are substantive and 13 are agency staff. 5 substantive hoses and 3 leads nurses"]
[null,null,"Staffing levels at time of inspection and any new/supernumerary staff"]
[null,null,"No. of ENPs","None from around midnight"]
[null,null,"(check if the above is normal level of staffing)"]
[]
[]
[]
[null,null,"Are there any patients with safeguarding concerns?","No"]
[]
[]
[]
[null,null,"Are there any patients with any cognitive impairment, e.g. dementia?\n\nIf so, what is the system to ensure these patients are identified?","Yes. The unit uses a \"snowflake icon\" which alerts staff to patients Dementia status. For patients who may need extra support they use a \"booklet part b' to identify patients in need of 1:1 care "]
[]
[]
[]
[null,null,"Are there any patients with mental health needs in the department at present?","Yes"]
[]
[]
[]
[null,null,"Is the department in escalation?","No however  escalation 4:16 which is a higher level of acuity"]
[]
[]
[]
[null,null,"Are there any 4 hour breaches?","Yes"]
[]
[]
[]
[null,null,"General observations following discussion with person in charge","The department was extremely busy. Patients appeared to be overflowing in the unit.  The XXXXX XX XXXXXX says this is very busy time but a typical Monday. They had experienced an exceptional amount of Resus patients whereby there had not been a spare bed in resus all afternoon/evening"]
[]
[]
[]
[null,null,"General observations of ward and environment\n\nPrompts: Observe the clinical area e.g. general ambience, how busy, noise levels etc. \nAre 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? \nIs the environment clean and tidy? \nAre there any obvious hazards to patient safety, such as tripping hazards? \nWhat signage/posters are on display?","All areas were cluttered and filled with mess. There were many areas with meds not locked away and 1 area had a broken drug cupboard door completely off it's hinges"]
[]
[]
[]
[]
[null,null,"Do you have any concerns about the operation of the department at the moment?  \n\nPrompts: Capacity of staff, overcrowding, high levels of agency staff, environmental risk. Are there any historical issues?","The area appears to be extremely busy with high levels of resus patients. The NIC does not appear overly concerned however."]
[]
[]
[]
[null,null,"General observations of department and environment   \n\nPrompts: Observe the clinical areas e.g. general ambience, how busy, noise levels etc. Are the furnishings and fittings in good state of repair and working order, bathrooms and showers, telephones, any areas that require maintenance or present any risks to patients and staff? ","The department is cluttered and feels dirty. There are high levels of patients with patients sat on the floor and rubbish inside and outside the department."]
[]
[]
[]
[null,null,"What system is used to identify patient status to staff e.g. Are patient status at a glance boards used? \n\nPrompts: Discuss with peer reviewers whether these are up-to-date, include relevant information and if there is information on patients who may be subject to DOLS and POVA"]
[]
[]
[]
[null,null,"Is there clear leadership evident on the ward e.g. is there a registered nurse in charge and are they visible?","There is a NIC who is visible and also during office hours there is a visible senior nurse presence on the floor. Senior nurses also provide on calls for staffing issues"]

{"sheet":"Summary","index":3,"n_rows":39,"n_cols":7,"rows_kept":39,"merged":[[6,2,6,4],[6,6,6,7],[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[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],[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],[22,6,22,7],[23,2,23,4],[23,6,23,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[30,2,30,4],[30,6,30,7],[31,2,31,4],[31,6,31,7],[32,2,32,4],[32,6,32,7],[35,2,35,4],[36,2,36,4],[37,2,37,4],[38,2,38,4]]}
[]
[]
[null,"Summary",null,"Key Documents","Issues Identified",null,"Good Practice"]
[]
[]
[null,null,"Quality of Patient Experience","Select outcome statement"]
[null,null,"4.1 Dignified Care",null,null,"No",{"$f":"'Dignified Care'!D5","v":"Select outcome statement"}]
[null,null,"3.2 Communicating Effectively",null,null,"Yes",{"$f":"Communicating!D5","v":"Select outcome statement"}]
[null,null,"5.1 Timely Care",null,null,{"$f":"'Timely Care'!D4","v":"Yes"},{"$f":"'Timely Care'!D5","v":"Select outcome statement"}]
[null,null,"6.1 Planning care to promote independence",null,null,"No",{"$f":"Independence!D5","v":"Select outcome statement"}]
[null,null,"6.2 Peoples rights",null,null,{"$f":"'People''s Rights'!D4","v":"Yes"},{"$f":"'People''s Rights'!D5","v":"Select outcome statement"}]
[]
[null,null,"Delivery of Safe and Effective Care","Select outcome statement"]
[null,null,"2.1 Managing risk and promoting health and safety",null,null,{"$f":"'Managing risk '!D4","v":"No"},{"$f":"'Managing risk '!D5","v":"Select outcome statement"}]
[null,null,"2.4 Infection Prevention and Control (IPC) and Decontamination",null,null,{"$f":"'Infection Control'!D4","v":"No"},{"$f":"'Infection Control'!D5","v":"Select outcome statement"}]
[null,null,"2.5 Nutrition and Hydration",null,null,{"$f":"Nutrition!D4","v":"Yes"},{"$f":"Nutrition!D5","v":"Select outcome statement"}]
[null,null,"2.6 Medicines management",null,null,{"$f":"'Medicines management'!D4","v":"Yes"},{"$f":"'Medicines management'!D5","v":"Select outcome statement"}]
[null,null,"2.7 Safeguarding",null,null,{"$f":"'Safeguarding '!D4","v":"Yes"},{"$f":"'Safeguarding '!D5","v":"Select outcome statement"}]
[null,null,"2.8 – Blood Management",null,null,{"$f":"'Blood Management'!D4","v":"No"},{"$f":"'Blood Management'!D5","v":"Select outcome statement"}]
[null,null,"2.2 - Preventing pressure and tissue damage",null,null,{"$f":"'Pressure damage'!D4","v":"No"},{"$f":"'Pressure damage'!D5","v":"Select outcome statement"}]
[null,null,"2.3 Falls Prevention",null,null,{"$f":"'Falls Prevention'!D4","v":"Yes"},{"$f":"'Falls Prevention'!D5","v":"Select outcome statement"}]
[null,null,"2.9 - Medical devices, equipment and diagnostic systems",null,null,"Yes",{"$f":"'Medical devices'!D5","v":"Select outcome statement"}]
[null,null,"3.1 - Safe and Clinically Effective care",null,null,"Yes",{"$f":"'Safe Care'!D5","v":"Select outcome statement"}]
[null,null,"3.3 Quality Improvement, Research and Innovation",null,null,"Yes",{"$f":"Improvement!D5","v":"Select outcome statement"}]
[]
[null,null,"Quality of Leadership and Management","Select outcome statement"]
[null,null,"Governance, leadership and accountability",null,null,"Yes",{"$f":"Governance!D5","v":"Select outcome statement"}]
[null,null,"7.1 – Workforce",null,null,"Yes",{"$f":"'Workforce '!D5","v":"Select outcome statement"}]
[]
[null,null,"Case Tracking","Select outcome statement"]
[null,null,"Part 1: Review of patient records",null,null,{"$f":"'Case Tracking Part 1'!D4","v":"Yes"},{"$f":"'Case Tracking Part 1'!D5","v":"Select outcome statement"}]
[null,null,"Part 2: How do patient records compare to practice?",null,null,{"$f":"'Case Tracking Part 2'!D4","v":"Yes"},{"$f":"'Case Tracking Part 2'!D5","v":"Select outcome statement"}]
[null,null,"Record Keeping",null,null,{"$f":"'Record Keeping'!D4","v":"Yes"},{"$f":"'Record Keeping'!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)"]

{"sheet":"Key Documents","index":4,"n_rows":24,"n_cols":8,"rows_kept":24,"merged":[[6,5,6,6],[7,2,7,3],[7,5,7,6],[8,2,8,3],[8,5,8,6],[9,2,9,3],[9,5,9,6],[10,5,10,6],[13,5,13,6],[14,5,14,6],[15,5,15,6],[16,5,16,6],[17,5,17,6],[18,5,18,6],[19,5,19,6],[23,5,23,6]]}
[]
[null,"Key Document Checking"]
[{"$nulls":7},"Back to Summary"]
[]
[null,null,"Key documents required to complete this section:"]
[]
[null,null,"Quality of Patient Experience",null,"Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"• Triage documents",null,"Sufficient",null,null,"No"]
[null,null,"• Any incidents/complaints relating to patient handover in the last 6 – 12 months",null,"Not Checked",null,null,"No"]
[null,null,"• Any policies or documents relating to patient flow",null,"Not Checked",null,null,"No"]
[null,null,"• Cas Cards – from initial triage to discharge or admission",null,"Needs Improvement",null,null,"No"]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"• Escalation policy",null,"Sufficient","The escalation plans and SDEC areas all sound like they could improve quality and patient safety",null,"No"]
[null,null,"• Records of Escalation policy being used in last 6 months",null,"Not Checked",null,null,"No"]
[null,null,"• Ligature risk assessment",null,"Not Checked",null,null,"No"]
[null,null,"• Health and Safety policy; Health and safety audit and action plans",null,"Not Checked",null,null,"No"]
[null,null,"• Management of Skin integrity",null,"Needs Improvement",null,null,"No"]
[null,null,"• Medication charts; Cas cards",null,"Needs Improvement",null,null,"No"]
[null,null,"• Safeguarding policies for children and vulnerable adults",null,"Sufficient","The violence and vulnerability lead nurses are a great resource for ED staff, patients and families and provide a valuable link between all services",null,"No"]
[]
[]
[null,null,"Quality of Management and Leadership"]
[null,null,"• Any policies/documents relating to staffing and on call arrangements.",null,"Not Checked",null,null,"No"]

{"sheet":"Dignified Care","index":5,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[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],[12,2,12,3],[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],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[20,2,20,8]]}
[]
[null,"Quality of Patient Experience - 4.1 Dignified Care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that people are treated as individuals and that their needs are met with dignity, compassion and respect?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Do staff speak to patients in a discreet, sensitive and courteous manner, taking into account the individual needs of the patient? ",null,null,"No",null,null,"Not Completed"]
[null,null,"Are there any issues with the environment which impact on patient privacy and dignity? ",null,null,"Yes","The entire EU felt cluttered and dirty. Patients were crowding around waiting rooms and clinical areas so limited privacy and digniy",null,"Not Completed"]
[null,null,"Are staff discreet when administering personal care?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"If patients are being cared for in ‘holding areas’/corridors, how is patient dignity maintained?",null,null,"No",null,null,"Not Completed"]
[null,null,"How does the department ensure that despite what may be a busy environment, patients are able to rest comfortably when they need to? ",null,null,"No",null,null,"Not Completed"]
[null,null,"Are patients provided with appropriate pain relief in a timely manner? Do staff care for them and address this in a compassionate way.",null,null,"Not Completed","Limited evidence of a pain assessment ",null,"Not Completed"]
[null,null,"Have you identified any palliative patients/patients undergoing cancer treatment in the emergency department, and if so, how is their care and treatment being managed?",null,null,"No",null,null,"Not Completed"]
[null,null,"Is Bereavement support provided in a timely way and is it sensitively and compassionately delivered?",null,null,"Not applicable","2 relatives rooms on the unit. 1 has been used as the donning and doffing room  and so this needs to be redecorated. Liaison with 2 Wish ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"On arrival Monday evening the department was overcrowded with some patients sat on the floor of entranceways with vomit bowls.  Each waiting area was littered with dirty cups, soiled blankets and an abandoned patient property bag was found outside the ED front door for 2 days. The entrance door was smashed and had not been fixed.  Patients were observed laid on trolleys some in a state of undress with no sheets or blankets and no curtain around them.  Conversations were loud and not confidential. Patients faced long waits with little in terms of privacy while in the waiting rooms. There were a number of toilets out of action during the inspection. Each area was cluttered and there was lots of equipment, trolleys and \"stuff\" around. There was also lots of packaging left on the sides or on top of trolleys. "]

{"sheet":"Communicating","index":6,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,4],[12,6,12,7],[15,2,15,8]]}
[]
[null,"Quality of Patient Experience - 3.2 Communicating Effectively"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that communication with patients and their carers is effective and discreet?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are staff aware of the need for discretion in communications about personal information with patients/ about patients? E.g. if observing a medical round, are doctors discreet?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are boards containing identifiable information in a discreet place?",null,null,"No",null,null,"Not Completed"]
[null,null,"Do staff speak with patients (and carers) about their care and treatment in a way that they understand?",null,null,"Yes","Mostly witnessed professional treatment of patients and relatives with regards to communication however 1 x staff nurse displayed very negative attitude to a patient relative requiring attention. The staff nurse said loudly that she was busy and she would have to wait. 20 minutes later the relative was still standing at the nursing station and commented \"obviously nobody wants to help me\" at this point I asked the nurse if there was anybody else who could help the relative and she replied angrily that she was too busy and \"she would have to wait\"",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Timely Care","index":7,"n_rows":42,"n_cols":9,"rows_kept":42,"merged":[[1,1,1,9],[8,2,8,3],[10,2,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,3],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,3],[17,6,17,7],[18,2,18,3],[18,6,18,7],[19,2,19,4],[19,6,19,7],[20,2,20,3],[20,6,20,7],[21,2,21,3],[21,6,21,7],[22,2,22,3],[22,6,22,7],[23,2,23,3],[23,6,23,7],[24,2,24,3],[24,6,24,7],[25,2,25,3],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,3],[27,6,27,7],[29,2,29,4],[29,6,29,7],[30,2,30,4],[30,6,30,7],[31,2,31,3],[31,6,31,7],[32,2,32,4],[32,6,32,7],[33,2,33,3],[33,6,33,7],[34,2,34,3],[34,6,34,7],[35,2,35,3],[35,6,35,7],[36,2,36,3],[36,6,36,7],[37,2,37,3],[37,6,37,7],[38,2,38,3],[38,6,38,7],[39,2,39,3],[39,6,39,7],[42,2,42,8]]}
[]
[null,"Quality of Patient Experience - 5.1 Timely Care "]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"Link with inspection manager to consider the following jointly"]
[]
[null,null,"How does WAST and the department ensure that patient handover times are appropriate and take place within agreed national timescales?"]
[null,null,"WAST / ED: Handover and triage",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What have been the average report of arrival times, handover times and off-loading times been over past 24-48hrs?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there presently any delays in offloading patients, if yes what are the causes of delays?",null,null,"Yes","No space in EU",null,"Not Completed"]
[null,null,"How long have you been waiting to offload?",null,null,"Yes","3.5hrs",null,"Not Completed"]
[null,null,"What is the patient’s category?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Has the patient been triaged by ED staff and categorised accordingly?",null,null,"Yes","\"Quick triage\"",null,"Not Completed"]
[null,null,"Who is ultimately responsible for the patient?",null,null,"Yes","Nursing however crew remains with patient",null,"Not Completed"]
[null,null,"What is the hospital policy on assessing patients unable to be offloaded? ",null,null,"Yes","Protocol for the care of patients who attend the emergency unit via ambulance.  Updated July 2021.  Patients who can not be offloaded into ambulatory care areas are assessed by the \"Majors Assessment Nurse\" (MAN).  Observations to be done every 15 mins by ambulance crew and deteriorating patients are to be highlighted to the MAN. if patients are still with a crew for over 1 hr then they will be offloaded into a triage room and assessed with observations by the MAN. Any dignity and toiletting should be performed in the unit with the crew assisting the patient.  Food and drink is available for patients in the assessment unit.",null,"Not Completed"]
[null,null,"What arrangements are in place to divert ambulances to alternate ED if appropriate /SOP/ transfer type (medical/surgical)?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have hospital Medical staff reviewed the patient while waiting to be offloaded?",null,null,"Not Completed","No",null,"Not Completed"]
[null,null,"If patient reviewed but no bed in hospital, who is ultimately responsible for the patient?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have basic needs been met, i.e. nutrition / elimination/ SKIN / Hydration / privacy?",null,null,"Yes","Crews to bring patients into the department to meet hygiene needs. Any patients with pressure area concerns to be highlighted early to the site team to prioritise for appropriate bed",null,"Not Completed"]
[null,null,"Who liaises between ambulance and hospital (provide updates)?",null,null,"Yes","MAN",null,"Not Completed"]
[null,null,"Do relevant ED staff attend hospital patient flow meeting?",null,null,"Yes","Senior nurse attend",null,"Not Completed"]
[null,null,"What arrangements are in place to receive a divert from other hospitals?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have there been occasions when delays in offloading have resulted in an inability to respond to other urgent calls? Have any such incidents resulted in patient harm?  What evidence is there of this (i.e. Datix report)?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are patients being received into the department from ambulances in a timely and effective way?",null,null,"No","Delays in offloading however it is evident that the escalation plans attempt to reduce ambulance waiting times.",null,"Not Completed"]
[]
[null,null,"WAST/ED: Patient flow and escalation",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What is the current capacity within the hospital – empty beds? \n(Could check this with Clinical Site Manager for example)",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What is the process and arrangements for patient flow?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there any processes in place to admit directly to wards (if safe to do so), i.e. direct admission to AMAU / SAU / ENT etc.",null,null,"Not Completed","SDEC Surgical and SDEC Trauma",null,"Not Completed"]
[null,null,"Do you / who attends the patient flow meetings and how often/times etc.?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What is the hospital’s policy and SOP for escalation status?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have any incidents relating to patient safety/harm been reported in the past twelve months?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have any complaints been received from patients or relatives?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there any concerns in relation to communication between WAST and hospital teams?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are patients kept in the corridors, if so who’s responsible? ",null,null,"No","We are told that patients are never nurse in coridors",null,"Not Completed"]
[null,null,"ENP – do they get involved with patients on ambulances?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Independence","index":8,"n_rows":15,"n_cols":9,"rows_kept":15,"merged":[[1,1,1,9],[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],[15,2,15,8]]}
[]
[null,"Quality of Patient Experience - 6.1 Planning care to promote independence"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department promote patients’ independence?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there initiatives such as ‘This is Me’ or the butterfly scheme being in place?",null,null,"No","Snowflake icon on workstation for patients with dementia",null,"Not Completed"]
[null,null,"Are there signs in place on toilet doors etc. to help assist patients with sensory problems or cognitive difficulties?",null,null,"No",null,null,"Not Completed"]
[null,null,"Are patients encouraged to be active and given equipment to help them walk, move, eat, hear, see etc.?",null,null,"No",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"People's Rights","index":9,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,4],[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],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[21,2,21,8]]}
[]
[null,"Quality of Patient Experience - 6.2 Peoples rights"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that the rights of individuals are respected and promoted when they receive care from the service?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are staff aware of individual needs and rights?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is there awareness of equality legislation and standards?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Have staff received training in human rights and equality?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are equality impact assessments carried out when policies are developed?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do staff address spiritual, religious and pastoral needs of patients in their care?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How are patient’s individual needs considered on the ward? i.e. spiritual, cultural",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are patients able to receive visitors within reasonable hours, sensitive to the needs of others? ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are patients’ family/carers able to provide assistance with and be involved in the patients care? ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"If a patient is critically ill, how are carers/relatives accommodated? ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Managing risk ","index":10,"n_rows":36,"n_cols":9,"rows_kept":36,"merged":[[1,1,1,9],[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],[12,2,12,3],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,4],[15,6,15,7],[16,2,16,4],[16,6,16,7],[17,2,17,3],[17,6,17,7],[18,6,18,7],[19,2,19,3],[19,6,19,7],[20,2,20,4],[20,6,20,7],[21,2,21,3],[21,6,21,7],[22,2,22,4],[22,6,22,7],[24,2,24,3],[24,6,24,7],[25,2,25,4],[25,6,25,7],[27,2,27,4],[27,6,27,7],[28,2,28,3],[28,6,28,7],[29,2,29,4],[29,6,29,7],[30,2,30,3],[30,6,30,7],[31,2,31,3],[31,6,31,7],[32,2,32,4],[32,6,32,7],[35,2,35,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.1 Managing risk and promoting 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","Back to Guidance"]
[]
[null,null,"How do the systems in place ensure that patients and other ED attendees (visitors, staff) are kept safe whilst in the department?  "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How is the environment maintained to ensure that patients, visitors and staff are kept safe from hazards? ",null,null,"No","There are multiple trip hazards throughout the unit.  Drug cupboards are not locked, cleaning materials are not locked away in sluice on Majors",null,"Not Completed"]
[null,null,"Do staff carry out regular health and safety audits, identifying any hazards and acting to minimise risks associated with their findings?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are risk assessments completed within areas of concern?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are ligature points identified and are there processes in place to ensure that patients at risk of self-harm are not cared for in these areas without supervision?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is the environment accessible and safe for people with mobility difficulties?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is the layout of the environment suitable for all the needs of patients attending the ED? (e.g. is it easy to get to scanning and x-ray facilities and is this signposted appropriately)",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are there processes in place to protect staff and other ED attendees from violence and aggression? ",null,null,"No",null,null,"Not Completed"]
[null,null,"How do staff deal with behaviours that challenge?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null," Is senior support available in these situations?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What protocols are in place for bringing prisoners into the department? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do staff respond to deterioration in health and wellbeing and what systems do they use to identify this?",null,null,"Yes","News scoring and sepsis bundles",null,"Not Completed"]
[null,null,"How are medical emergencies dealt with? Is there any difference in response out of hours?",null,null,"Yes","Same responses across day and night hours",null,"Not Completed"]
[null,null,"Are the waiting room and any other paediatric areas maintained in accordance with RCPCH Standards for children in ED’s? ",null,null,"Yes","Yes",null,"Not Completed"]
[]
[null,null,"WAST / ED:",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"Consideration to children on ambulances – is there a different policy/protocol/SOP for them?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"How does the Department ensure they maintain a safe service?",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"How is Escalation of the unit managed? ",null,null,"Not Completed","There ",null,"Not Completed"]
[null,null,"Are all staff clear about what they should do when the department is at or close to capacity?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What can unit managers tell you about escalation processes?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What do senior managers tell you about escalation processes?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What can Nurses and low grade medical staff tell you about escalation processes?  What should they do and is this knowledge in line with procedure?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"All resus trolleys in EU are inconsistently checked. 1 on minors has just 3 checks for the month of June.  IVF and drugs left in minors area in reach of patients, Surfaces in minors trolley area very dusty and filled with dirty cups and refuse.  Patient records left on printers and within site and reach of other patients..   medication area in Minors left unlocked and on investigation every drug cupboards and fridge within the room were also unlocked. Medications in the cupboard included Oramorph, antibiotics, anti-depressants amongst other. There was also a sharps box filled with strips of random medications.  Fridge temps are also not being consistently checked"]

{"sheet":"Infection Control","index":11,"n_rows":48,"n_cols":9,"rows_kept":48,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[14,6,14,7],[15,6,15,7],[16,6,16,7],[17,6,17,7],[18,6,18,7],[19,6,19,7],[21,2,21,4],[21,6,21,7],[22,2,22,3],[22,6,22,7],[23,2,23,3],[23,6,23,7],[24,2,24,3],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[30,2,30,4],[30,6,30,7],[31,2,31,3],[31,6,31,7],[32,2,32,3],[32,6,32,7],[33,2,33,3],[33,6,33,7],[35,2,35,3],[35,6,35,7],[36,2,36,4],[36,6,36,7],[37,2,37,4],[37,6,37,7],[38,2,38,4],[39,2,39,4],[39,6,39,7],[40,2,40,4],[41,2,41,4],[41,6,41,7],[42,2,42,4],[42,6,42,7],[43,2,43,4],[43,6,43,7],[44,2,44,4],[44,6,44,7],[45,2,45,4],[45,6,45,7],[48,2,48,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.4 Infection Prevention and Control (IPC) and Decontamination"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department ensure that infection prevention and control is managed carefully and appropriately?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Who is the IPC lead for the HB (who links into ED)?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are IPC audits undertaken regularly and acted on appropriately?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there IPC data on the walls highlighting good/poor statistics in compliance?",null,null,"No",null,null,"Not Completed"]
[null,null,"What changes have been made to the unit due to COVID-19 for example:"]
[null,null,"§  social distancing",null,null,"Not Completed","Covid measured have now been removed. Masks are no longer mandatory and there are no longer any Covid streams",null,"Not Completed"]
[null,null,"§  enhanced cleaning",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"§  PPE ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"§  COVID-19 training",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"§  Pre-screening for COVID-19",null,null,"Not Completed","Patients have screening and redirection at the entrance",null,"Not Completed"]
[null,null,"§  Screening before leaving ED to move patients onto wards",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Is there separate area for isolating patients with suspected or confirmed COVID-19?",null,null,"Not Completed","Majors area is all cubicles",null,"Not Completed"]
[null,null,"Are all staff aware of the standards they should follow?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is PPE available and do you see evidence of it in use?",null,null,"Not Completed","Poe is often found empty on the walls. Hand gels empty",null,"Not Completed"]
[null,null,"Is regular handwashing seen in between treatments, patients, etc?",null,null,"Not Completed","Hand washing is poor",null,"Not Completed"]
[null,null,"Are all staff adhering to ‘bare below the elbow’? This includes medical staff with ties/watches etc. Are lanyards used?",null,null,"Not Completed","Most staff are bare below the elbow. Drs wear scrubs",null,"Not Completed"]
[null,null,"How does the department handle the need for deep cleaning of areas / rooms after infectious patients?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How and where are Neutropenic patients cared for? Or other immunocompromised patients?",null,null,"Not Completed","In cubicles ",null,"Not Completed"]
[null,null,"Are there isolation rooms in the department/areas that can be used for isolation? ",null,null,"Not Completed","Yes ",null,"Not Completed"]
[null,null,"Is the route from ambulance bay to that room appropriate?",null,null,"Not Completed","Yes",null,"Not Completed"]
[null,null,"Role of cleaners in the department and the hours they cover. Who does daily cleaning? Who covers their role when they are not there?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Who does a deep clean if infection is suspected?  ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How is both normal waste and clinical waste managed? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do the condition of furnishings present any infection control hazards?",null,null,"Not Completed","Furnishings are tired and damaged in minors",null,"Not Completed"]
[]
[null,null,"WAST / ED:",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"Does transfer of potentially infectious cases from ambulance into the department get handled in any particular way?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Where highly contagious patients / potentially contaminated patients are present, what is the flow followed in relation to IPC and decontamination?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"COVID-19 outbreaks / Nosocomial transmission"]
[null,null,"How do you identify and effectively manage COVID-19 outbreaks / nosocomial transmission?  ",null,null,"Not Completed","Morning site meetings identify Covid pos patients in hospital site as a whole ",null,"Not Completed"]
[null,null,"If there have been any cases in the past three months:"]
[null,null,"How did you discuss this with all ward staff?",null,null,"Not Completed",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,"Summary/Conclusion"]

{"sheet":"Nutrition","index":12,"n_rows":22,"n_cols":9,"rows_kept":22,"merged":[[1,1,1,9],[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],[15,2,15,4],[15,6,15,7],[17,2,17,3],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[22,2,22,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.5 Nutrition and Hydration"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How does the department assess, support and manage the nutrition and hydration needs of patients?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are patients assessed to see if they need help to eat and drink and then given the support they need?",null,null,"Yes","Sometimes",null,"Not Completed"]
[null,null,"Is there a particular system in place to manage hydration and nutrition for patients who spend a long time in the department before admission or discharge?",null,null,"No","Sometimes",null,"Not Completed"]
[null,null,"Is there implementation of the All Wales nutrition pathway?",null,null,"Yes","Yes sometimes",null,"Not Completed"]
[null,null,"Is the department able to access a regular supply of food for patients and is there a system to ensure patients who are able, are provided with water and that supply is replenished?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are fluids, including IV fluids being monitored and recorded on the All Wales fluid balance charts?",null,null,"No",null,null,"Not Completed"]
[null,null,"Are nutrition charts also being completed for all fluid and food consumed?",null,null,"No",null,null,"Not Completed"]
[]
[null,null,"WAST / ED:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department manage the nutrition and hydration needs of patients waiting on ambulances?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Where is this recorded if the patient is given food or drink within the ambulance and is this appropriately handed over to the nursing team upon admission into ED?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Medicines management","index":13,"n_rows":30,"n_cols":9,"rows_kept":30,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,4],[14,6,14,7],[15,2,15,3],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[20,2,20,3],[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],[24,2,24,3],[24,6,24,7],[25,2,25,3],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,3],[27,6,27,7],[30,2,30,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.6 Medicines management"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"What systems are in place to ensure that medicines are managed safely, administered correctly and used safely?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are Casualty cards and All Wales Drug Charts completed correctly, including the prescription of oxygen and fluids?  ",null,null,"No",null,null,"Not Completed"]
[null,null,"Where oxygen is being given, has it been prescribed?",null,null,"No",null,null,"Not Completed"]
[null,null,"Does the department have a dedicated pharmacist? What hours can they access this support?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What are the arrangements for accessing medicines out of hours? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is medicine administration being recorded consistently and contemporaneously? ",null,null,"Yes","Mostly",null,"Not Completed"]
[null,null,"Is there a system for safe, calm administration of medicines?",null,null,"No",null,null,"Not Completed"]
[null,null,"How is discarded medication recorded?",null,null,"Not applicable",null,null,"Not Completed"]
[null,null,"Is pain relief being administered appropriately? \n(Pain relief sits under dignified care above, but please consider this as you review medicines as a whole)",null,null,"No","Rarely any pain score used",null,"Not Completed"]
[null,null,"Are all drugs, including controlled drugs, stored securely and administered safely?",null,null,"No","Multiple drug cupboards open. Mixed medicines in one box",null,"Not Completed"]
[null,null,"Are there standard operating procedures in place covering the whole process relating to supply / storage / administration / disposal of any controlled drugs? Does this follow through to what you see in practice? ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is a stock check carried out safely, in accordance with local procedure? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are fridge temperatures monitored consistently? I.e. daily and are these recorded?",null,null,"No","Evidence of limited fridge checks throughout the month",null,"Not Completed"]
[null,null,"What is the escalation process in place if a fridge temperature goes out of the specified ranges?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do all patients have identification bands? Are they checked? What about patients who lack capacity? \n(Check back with case tracking)",null,null,"No","Not consistently ",null,"Not Completed"]
[null,null,"Do staff stay with the patient to ensure medication is taken correctly?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is medication left unattended at any time? ",null,null,"Yes","In drug cupboards unlocked",null,"Not Completed"]
[null,null,"Are there arrangements for the safe disposal of unused medicines and sharps boxes? Are they stored in areas not accessible by patients? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How is medication dispensed to patients on discharge?",null,null,"Yes","Tth",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Safeguarding ","index":14,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[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 - 2.7 Safeguarding "]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"What systems and processes are in place to ensure that patients are safeguarded and kept safe from abuse?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What systems are in place to help staff understand the needs of patients with mental health conditions, learning disabilities, dementia, and autism?",null,null,"Yes","24hr psychiatric liaison who are very supportive. Not the same provision from CAMHS however ",null,"Not Completed"]
[null,null,"What is the understanding of staff around DOLS, mental capacity and safeguarding? Is there sufficient awareness to show they have completed recent training?",null,null,"Yes","Violence prevention nurses",null,"Not Completed"]
[null,null,"Does the department have a system for identifying children with injuries who may have been subject to physical abuse, or are at risk? ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Does the department have a system for identifying vulnerable adults?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are national guidelines on safeguarding children adhered to?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are there arrangements in place for safeguarding women and children who have undergone Female Genital Mutilation (FGM), or who are at risk of?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What systems are in place to identify and safeguard patients at risk of abuse, including domestic violence? ",null,null,"Yes","The vulnerable prevention nurses ",null,"Not Completed"]
[null,null,"Are any patients under constant supervision? If yes, are all necessary safeguards in place?",null,null,"Yes","They identify the need ",null,"Not Completed"]
[null,null,"How does the department protect patients assessed as at risk of self-harm and suicide? ",null,null,"Yes","Ligature risk assessment in place. CCTV cameras in psych room. Security staff able to withhold as part of common law. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"There are 2 x vulnerability and violence nurses employed within the unit. They are situated within the unit and accept referrals from all staff either via written, verbal or picked up via their own observations. These nurses are able to access other outside agencies who may be able to support the patient as well as being an integral part of the safeguarding team in Cardiff. The nurses act as support for family no staff members and are a source of information and from next week there will be the launch of the vulnerability hub which includes the nurses, Red Cross, domestic violence team, frequent attenders team. "]

{"sheet":"Blood Management","index":15,"n_rows":25,"n_cols":9,"rows_kept":25,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[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],[17,2,17,3],[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],[22,6,22,7],[25,2,25,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.8 – Blood Management"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"What systems and processes are in place to ensure that there is a safe system of blood management and transfusion?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department ensure that a safe system for blood transfusions is in place?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How does the department ensure that blood is stored and handled safely?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are all staff fully trained in blood administration and patient monitoring following the treatment?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is documentation correctly completed when blood is administered? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What systems do you have to identify potential risks and appropriate actions to ensure the safe sufficient supply of blood, blood components and blood products?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you ensure the minimum, appropriate use of blood, components and products?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What systems do you have in place to promote the use of alternatives and adjuncts to blood transfusion?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How are you assured that you have an adequate supply?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you monitor the safe and appropriate use of blood, components, and products?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What arrangements do you have to ensure all staff involved in the transfusion process are fully trained and competent?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you ensure that patient identification and blood component checks are established at all stages of the transfusion process?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What arrangements do you have for reporting events internally and to external bodies e.g. Serious Hazards of Transfusion (SHOT), Welsh Government?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you ensure robust investigation, implement corrective and preventative actions and share learning?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Pressure damage","index":16,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,12,7],[12,2,12,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[18,2,18,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.2 - Preventing pressure and tissue damage"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"How is pressure and tissue damage prevented in patients receiving care in the ED, or awaiting care from the ED?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are pressure risk assessments together with wound charts completed for patients and reviewed during their time in the ED?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is there evidence of pressure relieving equipment in use? What sort of aids are available and how do you access them?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Consider speaking with the Health Board’s Tissue Viability Team to gain clarity on the expectations of the ED, where needed. ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"WAST / ED:",{"$nulls":3},"Findings/Evidence",null,"Improvements required"]
[null,null,"Are risks to skin integrity associated with delay in ambulance transfer recognised and actively managed?",null,null,"Yes","In the policy it states that patients with risk of pressure area damage who are held on ambulances will be communicated to the site team in order to try and expedite offloading and admission. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Falls Prevention","index":17,"n_rows":19,"n_cols":9,"rows_kept":19,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[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],[15,2,15,4],[15,6,15,7],[16,2,16,3],[16,6,16,7],[19,2,19,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.3 Falls Prevention"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"How is the risk of falls managed within the department?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there moving and handling risk assessments completed in a timely and consistent manner for all appropriate patients?",null,null,"No","3/5 patients had a completed falls assessment",null,"Not Completed"]
[null,null,"Are falls risk assessments completed?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are patients encouraged to wear shoes or slippers when walking around the department?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are there sufficient staff to enable patients who require support to walk within the department to be supported to safely use the toilet facilities?",null,null,"No","Not always",null,"Not Completed"]
[null,null,"How do patients attract attention to get this support? Are there call bells and are they accessible?",null,null,"Not Completed","Call bells",null,"Not Completed"]
[null,null,"Are there any ancillary staff, such as Occupational Therapists or Physiotherapists used to support staff with patients assessed at risk of falling?",null,null,"Not Completed","Yes they get referred patients",null,"Not Completed"]
[null,null,"Are any falls within the department recorded? Reported via Datix? Any lessons learnt recorded and acted on appropriately?",null,null,"Yes","Inpatient falls are datixwhich goes to the NIC.  Health and safety then pick up the DATIX and contact the NIC to do an investigation if it warrants it. There is no falls review panel to pick up on these incidents which would be good practice",null,"Not Completed"]
[null,null,"Can staff advise if falls lessons learnt and actions are shared widely?",null,null,"No","There appears no shared learning from inpatient falls that cause harm",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Medical devices","index":18,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[11,2,11,3],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,4],[15,6,15,7],[18,2,18,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.9 - Medical devices, equipment and diagnostic systems"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"Is there appropriate equipment within the department that is accessed, stocked, used, maintained and, where necessary, disposed of, appropriately?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Does the department have the right equipment and medical devices to meet the needs of patients? I.e. hoists, monitoring equipment, slide sheets, commodes, walkers, pressure ulcer mattresses etc. ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What are the maintenance arrangements for equipment? i.e.:"]
[null,null,"• Who is responsible for maintaining equipment?",null,null,"Yes","Hoists are managed by health and safety due September 2022. Other equipment sent to clinical engineering",null,"Not Completed"]
[null,null,"• Are there labels showing when the equipment was last checked/serviced? Are these in date?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are there arrangements for reporting faults with equipment?",null,null,"Yes","Flow chart developed to show process",null,"Not Completed"]
[null,null,"Do all items of equipment appear to be in a good state of repair?",null,null,"Yes","Sluice master in minors broken since December",null,"Not Completed"]
[null,null,"What happens when equipment is taken out of circulation? E.g. are they clearly labelled/taken out of the department?",null,null,"Yes","Faulty sign put on or it is taken to clinical engineering. If it is life saving equipment it would be a direct swap",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Safe Care","index":19,"n_rows":38,"n_cols":9,"rows_kept":38,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,3],[14,6,14,7],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,3],[18,6,18,7],[19,2,19,4],[20,2,20,3],[20,6,20,7],[21,2,21,3],[21,6,21,7],[22,2,22,3],[22,6,22,7],[23,2,23,3],[23,6,23,7],[24,2,24,3],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[29,6,29,7],[30,2,30,4],[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],[35,2,35,3],[35,6,35,7],[38,2,38,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.1 - Safe and Clinically Effective care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"Does the care and treatment provided to patients reflect best practice guidelines, including out of hours?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Which patient pathways are in place? E.g. stroke, STEMI etc. How do they work? Are they effective? How are they audited?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"What are the out of hours options available?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you know how to access the relevant clinical policies and procedures?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Do you (Registered Nurses) know how to access the NMC Record Keeping Guidance for Nurses and Midwives?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are you aware of patient safety notices?",null,null,"Yes",null,null,"Not Completed"]
[]
[null,null,"How does the department ensure that practice is continually improving?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there evidence of audit activity being regularly undertaken? E.g. Are results of audits displayed? How are these acted upon? ",null,null,"Yes","Audits are undertaken for IP&C, hand hygiene etc",null,"Not Completed"]
[null,null,"Is there evidence risks are monitored?",null,null,"Yes","Health and care standards",null,"Not Completed"]
[null,null,"Suggested for senior managers:  Are there quality indicators/audits in use to monitor:"]
[null,null,"• Pressure areas",null,null,"Yes",null,null,"Not Completed"]
[null,null,"• Falls",null,null,"Yes",null,null,"Not Completed"]
[null,null,"• IPC i.e. monthly audits",null,null,"Yes",null,null,"Not Completed"]
[null,null,"• Hand washing?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is there internal audit and monitoring of records and record keeping audits?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"How do you ensure that all staff are aware of the clinical guidelines associated with their area of practice?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Are there any challenges around staffing levels/training which are affecting patient care?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"How does the department ensure that cases of sepsis are identified and managed in a safe and effective way?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department ensure possible cases of sepsis are identified as soon as possible (including both children and adults)? ",null,null,"Yes","News scoring and sepsis bundles followed. They also have a research nurse employed looking at sepsis",null,"Not Completed"]
[null,null,"What screening tools are used? (E.g. National Early Warning Score; ED/ AMU Sepsis Screening & Action Tool; Paediatric screening tool). Are these followed in practice?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"What training have staff completed to support them in identifying and managing sepsis? (Link with HIW Inspector re: staff training records).",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Speak with staff and check their awareness of sepsis and how they manage it, to triangulate evidence.",null,null,"Yes","Appears that staff understand about the recognition of sepsis",null,"Not Completed"]
[null,null,"How are cases of sepsis managed effectively and according to best practice guidelines? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there a sepsis pathway in place with associated Sepsis Six care bundle? How do staff ensure consistent, effective, clinical management of cases?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do staff ensure consistent, effective, clinical management of cases?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Improvement","index":20,"n_rows":16,"n_cols":9,"rows_kept":16,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,2,8,3],[8,5,12,5],[8,6,12,7],[8,8,12,8],[9,2,9,3],[10,2,10,3],[11,2,11,3],[12,2,12,3],[15,2,15,8]]}
[]
[null,"Delivery of Safe and Effective Care - 3.3 Quality Improvement, Research and Innovation"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[null,null,"Has the department implemented any innovative ways of working or ways of improving services?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Consider, for example, any:",null,null,"Yes",null,null,"Not Completed"]
[null,null,"• Best practice initiatives"]
[null,null,"• Winter pressure initiatives"]
[null,null,"• Links with community and third sector"]
[null,null,"• Use of volunteers"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"New development of the speciality hub and also the Trauma SDEC, Surgical SDEC and medical SDEC to try and improve flow within the department and ensure patients are being seen within a timely manner.  The vulnerability nurses are an excellent resource as well as the senior nursing visibility on the floor. Red Cross within the unit provides a valuable resource for nutrition and hydration. Patients are provided with food and drink regardless of the length of time they have been waiting."]

{"sheet":"Governance","index":21,"n_rows":14,"n_cols":9,"rows_kept":14,"merged":[[1,1,1,9],[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,7,13,9],[14,2,14,8]]}
[]
[null,"Quality of Management and Leadership - 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","Back to Guidance"]
[]
[null,null,"Is there an effective on call system in place?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What is the on call system? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you feel that this works effectively? Are you confident in using it? Do you feel that the response is helpful and appropriate?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Workforce ","index":22,"n_rows":22,"n_cols":9,"rows_kept":22,"merged":[[1,1,1,9],[9,2,9,3],[10,2,10,7],[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],[15,2,15,3],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[22,2,22,8]]}
[]
[null,"Quality of Management and Leadership - 7.1 - Workforce "]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[]
[null,null,"Link with HIW Inspector who will be looking at training records to come to conclusion."]
[null,null,"How does the department ensure there are sufficient numbers of appropriately trained staff for the provision of safe, effective patient care? "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"What is the acuity versus staffing levels at the point of inspection? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do staff feel there are sufficient numbers to meet clinical demand?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Do ward staff know and understand their responsibilities when escalation is necessary for staffing reasons?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Do members of the multidisciplinary team work well together?  ",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Do you feel you have enough time to provide care safely?",null,null,"No",null,null,"Not Completed"]
[null,null,"Do you feel that the number of staff in the department is appropriate to meet the needs of the patients?",null,null,"Yes",null,null,"Not Completed"]
[null,null,"Is there a Paediatric Emergency Medicine (PEM) consultant with dedicated session time allocated to paediatrics?",null,null,"Yes","Between 8am and 10pm",null,"Not Completed"]
[null,null,"In departments where children are treated, are there at least two registered children’s nurses?",null,null,"Yes",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Case Tracking Part 1","index":23,"n_rows":93,"n_cols":9,"rows_kept":93,"merged":[[0,8,0,9],[1,1,1,9],[6,2,10,9],[13,3,13,6],[14,3,14,6],[15,3,15,6],[16,3,16,6],[17,3,17,6],[18,3,18,6],[19,2,19,9],[20,8,20,9],[21,8,21,9],[22,2,22,9],[23,8,23,9],[24,8,24,9],[25,8,25,9],[26,8,26,9],[27,3,27,9],[28,2,28,9],[29,8,29,9],[30,8,30,9],[31,8,31,9],[32,8,32,9],[33,3,33,9],[34,2,34,9],[35,8,35,9],[36,8,36,9],[37,3,37,9],[38,2,38,9],[39,8,39,9],[40,8,40,9],[41,8,41,9],[42,8,42,9],[43,8,43,9],[44,8,44,9],[45,8,45,9],[46,3,46,9],[47,2,47,9],[48,8,48,9],[49,8,49,9],[50,8,50,9],[51,8,51,9],[52,3,52,9],[53,2,53,9],[54,8,54,9],[55,8,55,9],[56,3,56,9],[57,2,57,9],[58,8,58,9],[59,8,59,9],[60,8,60,9],[61,8,61,9],[62,8,62,9],[63,8,63,9],[64,3,64,9],[65,2,65,9],[66,8,66,9],[67,8,67,9],[68,8,68,9],[69,8,69,9],[70,8,70,9],[71,8,71,9],[72,8,72,9],[73,8,73,9],[74,3,74,9],[75,2,75,9],[76,8,76,9],[77,8,77,9],[78,3,78,9],[79,2,79,9],[80,8,80,9],[81,8,81,9],[82,8,82,9],[83,8,83,9],[84,3,84,9],[87,2,90,9]]}
[]
[null,"Case tracking – Part 1: Review of patient records"]
[]
[null,null,"Completed","Yes",null,"Back to Summary","Issues identified","Good Practice identified"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"The purpose of this case tracking exercise is to assess whether what is written in the care plan is translated into the care provided to the patient. You may need to speak to staff to assist you to understand patient records. Once you have reviewed the records, you will need to check this against what you find on the department. Please use the section ‘How do patient records compare to practice?’ to record your findings around this. \n\nSpeak to the inspection manager about how many records would be appropriate and for which patients. Particular patient records may be identified at the initial discussion on arrival, and should include some of the most vulnerable patients presenting to the department.\nThe case sample of 5-6 patients should include, where possible: \n• One paediatric patient\n• One patient with mental health needs\n• Two longer stay adults (any condition, patients who are going to be admitted)\n• One complex case or a patient who should be cared for elsewhere, e.g. cancer patient\n• One patient from minors (if the above sample doesn’t include a patient from this area)"]
[]
[]
[]
[]
[]
[]
[{"$nulls":3},"Patient Identifier"]
[null,null,"A","XXXXXXXX"]
[null,null,"B","XXXXXXXX"]
[null,null,"C","XXXXXXXX"]
[null,null,"D","XXXXXXXX"]
[null,null,"E","XXXXXXXX"]
[null,null,"Initial observations of patient records"]
[null,null,"Are notes clear and easy to navigate?\n\nWhat is the structure/layout like? \n\nHow have notes been organised? \n\nIf you were agency staff would you be able to look after the patient from their notes?","The notes are haphazard and not completely filled out.  Patient has been admitted for around 17 hours but no risk assessment booklet completed. Medication signed for on the MDT document however no times on.  Trauma proforma initiated however only partly filled in. Trauma dr plan in place. Very little nursing notes. No morning meds given.  Risk assessment booklet not completed at all.","The notes are clear, organised and easy to navigate","Yes the notes are clear and easy to navigate","Yes notes are organised and clear and easy to navigate","Yes the notes are clear and easy to navigate","A216096U"]
[null,null,"Areas to consider","A","B","C","D","E","F"]
[null,null,"Mental capacity and DOLS"]
[null,null,"Is there a record of findings that suggest that the person may lack capacity; and has a mental capacity assessment been carried out, if so?","No","Yes","No","No","No","No"]
[null,null,"Are there clear records on decisions around the patient’s mental capacity? \n\n(Also check staff’s understanding around capacity)","No","Yes","No","N/A","N/A","Na"]
[null,null,"Is a DOLS indicated and if so, has it been applied for? \n\n(This will only apply in certain circumstances, for example, possible in a Clinical Decisions Unit or Observation Ward)","No","N/A","N/A","N/A","N/A","Na"]
[null,null,"If a patient has a mental health problem that is diminishing their capacity, are they being assessed under the Mental Health Act? \n\n(More appropriate than MCA in this case)","N/A","No","N/A","N/A","N/A","NA"]
[null,null,"What is your overall assessment on records around DOLS and mental capacity? Why have you come to that conclusion?","1 in 5 patients had comments regarding mental capacity"]
[null,null,"Nutrition and hydration "]
[null,null,"Is a nutritional risk assessment being completed for patients on the basis of triage outcome/ frailty/ need?","N/A","Yes","Yes","No","No","No"]
[null,null,"Where appropriate, is food/fluid intake being monitored?","No","Yes","Yes","No","No","No"]
[null,null,"For longer-term ED patients:\n• Has a care plan been developed and a referral made to dietician or SALT if appropriate?\n• Is there an oral care plan in place? ","N/A","N/A","No","No","N/A","No"]
[null,null,"Where patients are NBM, has an assessment been made in relation to the duration of this and plans in place to maintain nutrition and hydration?","No","N/A","N/A","No","N/A","No"]
[null,null,"What is your overall assessment of how they have approached nutrition and hydration needs? Why have you come to that conclusion?","2 in 5 had appropriate nutrition and hydration assessment in majors"]
[]
[null,null,"Has sepsis screening taken place on arrival? ","No","No","No","No","No","No"]
[null,null,"Have appropriate actions been taken in relation to sepsis? Have they acted promptly and followed their local protocol?","N/A","N/A","N/A","No","N/A","No"]
[null,null,"What is your overall view around sepsis? Why have you come to that conclusion?","Observations are being completed and NEWS scoring in place there is also rapid Covid testing done on each patient. Minors patient was ?sepsis"]
[null,null,"Preventing pressure and tissue damage"]
[null,null,"Are patients assessed for pressure ulcer risk in a timely way, where required? \n(Consider length of time at home prior to ambulance; length of time awaiting in vehicles for off loading; length of time spent on trolleys)","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Is there evidence of appropriate skin assessment?","No","Yes","Yes","Yes","Yes","Yes"]
[null,null,"Is there an appropriate care plan developed and documented in line with risk assessment score?","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Is there evidence of frequent repositioning? Day and night? ","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Is there evidence of appropriate pressure relieving aids being used? \n(Consider situations such as people left on trolleys with injuries or conditions that reduce movement)","No","No","Yes","Yes","N/A","No"]
[null,null,"Is there ongoing monitoring of pressure areas?","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Has a referral been made to the tissue viability nurse if appropriate?","N/A","No","No","No","N/A","No"]
[null,null,"What is your overall view on pressure and tissue damage prevention and care?\nWhy have you come to that conclusion?","4 out of 5 patients had appropriate pressure area assessments in place including re-assessment"]
[null,null,"Falls prevention "]
[null,null,"Where a patient has been admitted or brought to the hospital as a result of a fall, has a falls risk assessment been completed and appropriate referral made? ","No","Yes","No","No","Yes","No"]
[null,null,"Is there a specialist falls service that the ED has access to? ","No","No","No","No","No","No"]
[null,null,"Where the patient is at risk of falls, is there an up-to-date plan of care, tailored to the patient (not generic) which is being implemented and evaluated?\nDoes this include how to reduce the risk of falling when the patient is out of sight? And on discharge?","No","Yes","No","No","Yes","No"]
[null,null,"Where applicable, is reassessment undertaken if an individual has fallen, been transferred to a new area or whose condition has changed?","N/A","N/A","No","No","N/A","No"]
[null,null,"What is your overall assessment on falls prevention?\nWhy have you come to that conclusion?","2 out of 5 patients had a falls risk assessment fully completed "]
[null,null,"Pain management "]
[null,null,"Is there documented evidence that pain is being measured, actioned and evaluated? ","No","Yes","No","No","No","No"]
[null,null,"Do patients have an up to date pain score?","No","Yes","No","No","No","No"]
[null,null,"What is your overall assessment on pain management?\nWhy have you come to that conclusion?","1 out of 5 patients had appropriate documentation of pain scoring"]
[null,null,"Assessment "]
[null,null,"Was the patient triaged within 15 minutes of arrival to ED?","No","Yes","Yes","No","Yes","No"]
[null,null,"Have relevant risk assessments been undertaken?","No","Yes","No","No","No","No"]
[null,null,"Do patient records reflect the risks identified and the actions required?","No","Yes","No","No","No","No"]
[null,null,"Has the patient’s language choice/preference been recorded as being asked?","No","No","No","No","No","No"]
[null,null,"Has the patient’s language choice/preference been recorded as a decision?","No","No","No","No","No","No"]
[null,null,"Is there evidence to show what action has been taken to address any language need?  e.g. translation service provided if needed or asked for","No","No","No","No","No","No"]
[null,null,"What is your overall assessment?\nWhy have you come to that conclusion?","3 out of 5 patients were triaged with 15 minutes of arrival"]
[null,null,"Planning care to promote independence "]
[null,null,"Is all the care/treatment given documented in the patients care plan/records?","Yes","Yes","Yes","Yes","Yes","Yes"]
[null,null,"Are important decisions such as Do Not Attempt to Resuscitate (DNACPR) being documented?","N/A","Yes","Yes","N/A","N/A","Na"]
[null,null,"Where patients attend ED with DNACPR already in place, where is this documented?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Are assessments/ treatment plans/ records based on individualised patient need?","N/A","Yes","Yes","No","N/A","Yes"]
[null,null,"Is there clear evidence of transfer of care/ discharge planning?","No","No","No","Yes","N/A","No"]
[null,null,"If a patient is about to be discharged – is there evidence of appropriate support in place? \nE.g. transport home, identification of who will support them (if required), packages in place, appropriate referral?","N/A","N/A","N/A","N/A","N/A","NA"]
[null,null,"Is it recorded when the patient is medically fit to be discharged?","N/A","N/A","No","N/A","N/A"]
[null,null,"Is care planned in a way that promotes independence?","No","Yes","Yes","No","N/A","Yes"]
[null,null,"What is your overall assessment on planning care to promote independence ?\nWhy have you come to that conclusion?","5 out of 5 patients had a clear plan of care by the doctors in majors"]
[null,null,"Delivery and effectiveness and evaluation"]
[null,null,"Is the effectiveness of care/treatment evaluated regularly?","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Are the patient’s records up to date and completed immediately after care and treatment?","No","Yes","Yes","Yes","N/A","No"]
[null,null,"What is your overall assessment on delivery and effectiveness and evaluation?\nWhy have you come to that conclusion?","3 out of 5 patients were re-evaluated for the effectiveness of their care and treatment in majors. Patient F is a minors patient who is withdrawing from alcohol and has not received treatment yet"]
[null,null,"Department management"]
[null,null,"Is the handwriting in patient records legible?","Yes","Yes","Yes","Yes","N/A","Yes"]
[null,null,"Are all entries signed, dated and the time of entry included?","No","No","No","No","N/A","No"]
[null,null,"Is there evidence of a written hand over?","No","Yes","Yes","Yes","N/A","No"]
[null,null,"Is there evidence that other members of the MDT team contribute to the patient’s treatment plan?\nIs this clear?","Yes","Yes","Yes","Yes","N/A","Yes"]
[null,null,"What is your overall assessment on department management?\nWhy have you come to that conclusion?","There appears to be an effective buy in of the MDT within the department.  I witnessed communication between members of the MDT and assessments of patients "]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Overall the documentation for majors patients sits between average and good. There is need for a consistent approach to completing all aspects of the risk assessment documents and proforma.  "]
[]
[]
[]
[]
[null,null,"Back to top"]

{"sheet":"Case Tracking Part 2","index":24,"n_rows":27,"n_cols":9,"rows_kept":27,"merged":[[0,8,0,9],[1,1,1,9],[6,2,10,9],[12,2,12,9],[13,3,13,7],[13,8,13,9],[14,3,14,7],[14,8,14,9],[15,3,15,7],[15,8,15,9],[16,3,16,7],[16,8,16,9],[17,3,17,7],[17,8,17,9],[18,3,18,7],[18,8,18,9],[21,2,24,9]]}
[]
[null,"Case tracking – Part 2: How do patient records compare to practice?"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement",null,"Back to Summary",null,"Issues identified","Good Practice identified"]
[]
[null,null,"The purpose of this case tracking exercise is to assess whether what is written in the care plan is translated into the care provided to the patient. You may need to speak to staff to assist you to understand patient records. Once you have reviewed the records, you will need to check this against what you find on the ward. Please use the section ‘How do patient records compare to practice?’ further below to record your findings around this. \n\nGuidance for choosing patient records – speak to the inspection manager about how many records would be appropriate and for which patients e.g. someone recently discharged if you are unsure. \n\nWhere aspects of the case tracking areas are not applicable – please clearly state this as N/A. Do not just leave the area blank.\n"]
[]
[]
[]
[]
[]
[null,null,"Check how the records correspond to what is actually happening with the patients you have patient on the ward. For example, if the records state that patients need a particular piece of equipment is this in place?"]
[{"$nulls":3},"Finding\nPrompts: Include any good practice, suggestions and areas for improvement",{"$nulls":4},"What is the evidence to support this?\nPrompts: Where did you see this?"]
[null,null,"A",{"$nulls":5},"Majors"]
[null,null,"B",{"$nulls":5},"Majors"]
[null,null,"C",{"$nulls":5},"Majors"]
[null,null,"D",{"$nulls":5},"Majors"]
[null,null,"E",{"$nulls":5},"Majors"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Summary as previous page. There is some concerted efforts observed to complete the risk assessment booklets however for some patients they aren't completed regularly or in their entirety.  Previous complaints within the unit are around property and communication. There is a property sheet which again is not always filled in by staff.  This could prevent loss of property and also prevent patients claiming they had property with them. It would be beneficial to have a communication log to log conversations with family members and NOK.  These patients were all from the Majors side and so these patients are likely to be in the unit for longer periods of time."]
[]
[]
[]
[]
[null,null,"Back to top"]

{"sheet":"Record Keeping","index":25,"n_rows":16,"n_cols":8,"rows_kept":16,"merged":[[1,1,1,8],[8,2,8,4],[8,5,8,6],[9,2,9,4],[9,5,9,6],[10,2,10,4],[10,5,10,6],[11,2,11,4],[11,5,11,6],[12,2,12,4],[12,5,12,6],[13,2,13,4],[13,5,13,6],[16,2,16,7]]}
[]
[null,"General observations on record keeping"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified","Good Practice identified"]
[]
[null,null,"What is the overall quality of patient records? Consider the following:",null,null,"Findings/Evidence",null,"Improvements required"]
[null,null,"Clear accountability and evidence of how decisions relating to patient care were made",null,null,"All notes assessed appeared to have a clear medical plan for the patient",null,"Not Completed"]
[null,null,"Good quality in terms of accuracy, being up to date, complete, understandable and contemporaneous",null,null,"Most notes appeared contemporaneousnderstandable however areas of improvement are for all notes to be signed, dated and timed as well as printed name and designation",null,"Not Completed"]
[null,null,"Easy access for people when requested and appropriate disposal of records?",null,null,"The notes in majors are kept outside patient rooms ",null,"Not Completed"]
[null,null,"Secure storage and compliance with Data Protection Act 1998 / General Data Protection Regulations (2016) (GDPR)",null,null,"The notes are not kept locked ",null,"Not Completed"]
[null,null,"Effective records management system, including IT system?",null,null,"All notes are paper versions.  There appears to be multiple proforma and avenues for documentation which can be confusing since some parts of each booklet are usually filled in but not one booklet in its entirety",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Evidence capture form","index":26,"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":27,"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":28,"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 (4)","index":29,"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":30,"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"]
[{"$nulls":3},"Low compliance of PILS qualified nurses as well as low compliance of EPALS.  this affects the quality and safety of paediatric patients within the department RCPCH recommendations are that ALL paeds EU staff are PILS trained and that at least one staff member on every shift is EPALS trained.",{"$nulls":16378},"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"]
[]
[{"$nulls":16382},"Governance, leadership and accountability"]
[{"$nulls":16382},"Workforce"]

{"sheet":"Good Practice","index":31,"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"]
[{"$nulls":3},"Snowflake icon on clinical workstation to identify patients with dementia",{"$nulls":16377},"Health promotion, protection and improvement"]
[{"$nulls":3},"Vulnerability and violence nurses and soon to be vulnerability hub",{"$nulls":16377},"Dignified Care"]
[{"$nulls":3},"Paeds area use timers to remind staff when patient observations need checking",{"$nulls":16377},"Patient Information"]
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