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

{"sheet":"Guidance","index":0,"n_rows":67,"n_cols":6,"rows_kept":67,"merged":[[5,2,5,4],[6,2,6,4],[7,2,7,4],[8,2,8,4],[9,2,9,4],[10,2,10,4],[11,2,11,4],[12,2,12,4],[13,2,13,4],[14,2,14,4],[15,2,15,4],[16,2,16,4],[17,2,17,4],[18,2,18,4],[19,2,19,3],[20,2,21,2],[20,3,21,3],[20,4,21,4],[20,5,21,5],[22,2,43,2],[23,3,25,3],[23,5,25,5],[27,3,28,3],[27,5,28,5],[29,3,30,3],[29,5,30,5],[31,3,33,3],[31,5,33,5],[37,3,38,3],[37,5,38,5],[40,3,43,3],[40,5,43,5],[44,2,62,2],[52,3,53,3],[52,5,53,5],[54,3,55,3],[54,5,55,5],[57,3,58,3],[57,5,58,5],[61,3,62,3],[61,5,62,5],[63,2,66,2],[63,3,64,3],[63,5,64,5],[69,2,69,3]]}
[]
[]
[null,"Tool Guidance"]
[]
[]
[null,null,"GUIDANCE FOR LAY REVIEWER"]
[null,null,"The Health and Care Standards (opposite) are at the core of HIW’s approach to inspections in NHS Wales. The seven themes are intended to work together. Collectively they describe how a service provides high quality, safe and reliable care centred on the person. The Standards are key to the judgements that we make about the quality, safety and effectiveness of services provided to patients "]
[null,null,"There is an expectation that inspection teams will consider all Health and Care Standards during an inspection. However, it may not be possible or necessary to review all standards in detail."]
[null,null,"HIW inspection teams include peer reviewers, lay reviewers and HIW inspectors. Each individual has different skills, and will therefore consider different standards. Some standards may be assessed by more than one person to examine the standard from different perspectives. All findings will be collated at the end of the inspection so that the inspection manager can draw comprehensive conclusions about how the service is meeting the standards overall. Guidance as to which role might examine which standard is included in the table on the following page. HIW inspection managers should assign standards and record on the table which person has examined which standard. When you are conducting the inspection and making findings, bare in mind how you triangulate evidence, i.e. not just relying on one piece of evidence from records, but checking this against observations and staff/patient discussions."]
[null,null,"In the table below there is a list of all Health and Care Standards. To aid consistency in report writing, these have been mapped to the core HIW reporting themes of:"]
[null,null,"·       Patient Experience"]
[null,null,"·       Delivery of Safe and Effective Care"]
[null,null,"·       Quality of Management and Leadership."]
[null,null,"HIW Inspection Managers must record which standards have been assessed. Where it has been decided that standards will not be assessed, record the reason for this. "]
[null,null,"This workbook aims to guide you as to the areas you should consider when assessing whether a ward/unit meets the standards. It is important that all aspects of the workbook are completed so that HIW has a comprehensive audit trail for any recommendations made in our inspection reports. When you are conducting the inspection and making findings, bare in mind how you triangulate evidence, i.e. not just relying on one piece of evidence from records, but checking this against observations and staff/patient discussions."]
[null,null,"REMEMBER, all members of the inspection team must record the evidence source for their findings. Where the evidence source is a staff interview, you must record the time and date of that conversation. All evidence must be recorded in official HIW workbooks. When making notes, reviewers and inspection managers must be aware of and adhere to Data Protection principles. Notes recorded within this workbook (including any additional pages) and any prescribed inspection tools/checklists may be used should HIW decide to take further action. Therefore, it is important that you record all findings as clearly as you can. "]
[null,null,"Completing the workbook"]
[null,null,"Text blue and underlined = Hyperlink to applicable section of the workbook/guidance/legislation/standards."]
[null,null,"Text written in purple = Could be used as staff discussion prompts, as well as key lines of enquiry."]
[]
[null,null,"HIW Theme","Health and Care Standard","What are we looking for?","Which workbook?"]
[]
[null,null,"Patient Experience","Staying Healthy"]
[{"$nulls":3},"1.1 Health promotion, protection and improvement","Patients should be supported to look after their own health and well-being","LR"]
[{"$nulls":4},"Patients should know what care and support services there are to help them"]
[{"$nulls":4},"Patients should be supported to make choices about their own health and wellbeing"]
[{"$nulls":3},"Dignified Care"]
[{"$nulls":3},"4.1 Dignified Care","Patients should be treated with dignity, respect and kindness","PR / LR"]
[{"$nulls":4},"Patients should have their needs are met whatever your religion, language, culture or feelings"]
[{"$nulls":3},"4.2 Patient Information (including consent)","Patients should have good information about their care that is easy to understand"]
[{"$nulls":4},"Patients should be supported to make choices about their care"]
[{"$nulls":3},"3.2 Communicating effectively","Patients should have their communication needs met","PR / LR"]
[{"$nulls":4},"Patients should be able to understand information about their care and health"]
[{"$nulls":4},"Patients are able to tell health services about what they need or what they think"]
[{"$nulls":3},"Timely Care"]
[{"$nulls":3},"5.1 Timely access","Patients should have the right care at the right time in the right place with the right staff","IM / LR"]
[{"$nulls":3},"Individual Care"]
[{"$nulls":3},"6.1 Planning Care to promote independence","Patients should be supported to look after their own health and well-being","PR"]
[{"$nulls":4},"Patients should be able to make choices about their care"]
[{"$nulls":3},"6.2 Peoples rights","All health services must understand and support equality and human rights for everyone","IM / LR"]
[{"$nulls":3},"6.3 Listening and Learning from feedback","Patients and their families should be able to tell health services about the care they get from health services","IM / LR"]
[{"$nulls":4},"Health services should know what is working well and what is not working well"]
[{"$nulls":4},"Health services should be open and honest with patients when they tell them that something has gone wrong"]
[{"$nulls":4},"Health services should learn from what patients tell them and make services better"]
[null,null,"Delivery of Safe and Effective Care","Safe Care"]
[{"$nulls":3},"2.1 Managing risk and promoting health and safety","Health services must look after patient’s health and safety and make sure that any risks are managed as well as they can","IM / PR / LR"]
[{"$nulls":3},"2.4 Infection Prevention and Control (IPC) and Decontamination","Health services should involve everyone in helping to control and stop infections so that people do not get ill","IM / PR / LR"]
[{"$nulls":3},"2.5 Nutrition and Hydration","Patients should be supported to eat and drink so that they can get better quicker","LR"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time"]
[{"$nulls":3},"2.7 Safeguarding children and adults at risk","Health services must support and protect all children and any adults who are vulnerable or at risk","IM "]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it"]
[{"$nulls":3},"Effective Care"]
[{"$nulls":3},"2.2 Preventing pressure and tissue damage","Patients should be helped to look after their skin","PR"]
[{"$nulls":4},"Health services should make sure that patients do not get sore skin from sitting or lying down for too long"]
[{"$nulls":3},"2.3 Falls Prevention","Health services should check if patients are likely to fall","PR"]
[{"$nulls":4},"Health services should do everything they can to stop people from falling and hurting themselves"]
[{"$nulls":3},"2.9 Medical devices, equipment and diagnostic systems","Health services must make sure that all the equipment they use is safe and works well","PR"]
[{"$nulls":3},"3.1 Safe and Clinically Effective care","Patients should get the right care and support for their needs","IM / LR"]
[{"$nulls":4},"Health services should know the best ways to care and support patients"]
[{"$nulls":3},"3.3 Quality Improvement, Research and Innovation","Health services should look at different ways to make services better based on good research","IM"]
[{"$nulls":3},"3.4 Information Governance and Communications Technology","Health services should have the right information and make sure this information is shared safely"]
[{"$nulls":3},"3.5 Record keeping","It is very important that health services keep good records to make sure patients get the right care"]
[{"$nulls":4},"Health services must follow the rules about how to record information and keep it safe"]
[null,null,"Quality of Management and Leadership","Governance, Leadership and Accountability","All health services should be person centred. They should focus on patient’s needs and listen to them"]
[{"$nulls":4},"Health services should do the right things well, know how well they are doing, be open and honest in everything they do, be caring and kind and work hard"]
[{"$nulls":3},"Staff and Resources"]
[{"$nulls":3},"7.1 Workforce","Health services should have enough staff with the right skills and training to be able to give patients the best care"]

{"sheet":"Inspection Details","index":1,"n_rows":39,"n_cols":4,"rows_kept":39,"merged":[[0,4,0,5],[5,3,5,5],[9,3,9,5],[13,3,13,5],[17,3,17,5],[21,3,21,5],[23,3,23,5],[27,3,27,5],[31,3,31,5],[35,4,35,5],[36,4,36,5],[37,4,37,5],[38,4,38,5]]}
[]
[]
[null,"Inspection Details"]
[]
[]
[null,null,"Reference number",3129]
[]
[]
[]
[null,null,"Inspection Type","ED"]
[]
[]
[]
[null,null,"Health Board ","Swansea Bay"]
[]
[]
[]
[null,null,"Name of setting","Morriston Hospital"]
[]
[]
[]
[null,null,"Date inspection started","2022-09-05"]
[]
[null,null,"Date inspection completed"]
[]
[]
[]
[null,null,"Name of Lead HIW Inspector","xxxxxxx xxxxxxx"]
[]
[]
[]
[null,null,"Name of Supporting HIW Inspector","xxxxxxxxxx    xxxxxx"]
[]
[]
[]
[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":12,"n_cols":4,"rows_kept":12,"merged":[[0,4,0,5],[6,3,6,5],[11,3,11,5]]}
[]
[]
[null,"Arrival and Initial Discussions"]
[]
[]
[]
[null,null,"General observations from discussion with person in charge\nThings to think about: Make a note of any areas/patients that staff have said to avoid. Are they busier than normal with patients?\n","Very busy unit, senior staff keen to introduce themselves. Patient flow obviously problematic from discussions and as a result the ED has evolved into different areas, some with longer patient stay durations. "]
[]
[]
[]
[]
[null,null,"General observations of areas and environment\nVisit all areas of the ED including the waiting area, triage, majors, minors, resuscitation, clinical decision unit, paediatric.\nThings to think about:  What does each area feel like, how busy is it, how noisy is it?  Are the furniture, decorations, equipment in a good state of repair? Are bathrooms, showers, kitchen, and telephones in working order? Is the environment clean and tidy? Are there any obvious hazards to patient safety, such as tripping hazards? \n","Offices situated in old run down buildings. First room - bed meeting/disaster planning - no natural light, ceilings shabby and in poor repair. Room very small for number of people involved in discussions. General area poorly signposted. Corridors busy with lines of trolleys. May be as a result of early morning and proximity to main hospital linen room. Second room - board room bigger with good natural light. Ceilings stained and shabby. "]

{"sheet":"Summary","index":3,"n_rows":26,"n_cols":7,"rows_kept":26,"merged":[[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[22,2,22,4],[23,2,23,4],[24,2,24,4],[25,2,25,4]]}
[]
[]
[null,"Summary",null,null,"Issues Identified",null,"Good Practice"]
[]
[]
[]
[null,null,"Quality of Patient Experience","Significant improvement needed"]
[null,null,"1.1 Health PPI",null,null,{"$f":"'Health PPI'!D4","v":"Yes"},{"$f":"'Health PPI'!D5","v":"Some improvement needed"}]
[null,null,"4.1 Dignified care",null,null,{"$f":"'Dignified Care'!D4","v":"Yes"},{"$f":"'Dignified Care'!D5","v":"Significant improvement needed"}]
[null,null,"3.2 and 4.2 - Communicating effectively and patient information",null,null,{"$f":"'Communication and patient info'!D4","v":"Yes"},{"$f":"'Communication and patient info'!D5","v":"Some improvement needed"}]
[null,null,"5.1 Timely Access",null,null,{"$f":"'Timely access'!D4","v":"Yes"},{"$f":"'Timely access'!D5","v":"Significant improvement needed"}]
[null,null,"6.2. People's Rights",null,null,{"$f":"'People''s Rights'!D4","v":"Yes"},{"$f":"'People''s Rights'!D5","v":"Some improvement needed"}]
[null,null,"6.3 Listening and Learning from Feedback",null,null,{"$f":"Feedback!D4","v":"Yes"},{"$f":"Feedback!D5","v":"Some improvement needed"}]
[]
[]
[null,null,"Delivery of Safe and Effective Care","Select outcome statement"]
[null,null,"2.2 - Managing Risk and Promoting Health and Safety & 2.4 IPC and Decontamination",null,null,{"$f":"'Risk & IPC'!D4","v":"Yes"},{"$f":"'Risk & IPC'!D5","v":"Some improvement needed"}]
[null,null,"2.5 - Nutrition and Hydration",null,null,{"$f":"Nutrition!D4","v":"Yes"},{"$f":"Nutrition!D5","v":"Significant improvement needed"}]
[null,null,"3.1 Safe and Clinically Effective care",null,null,{"$f":"'Safe care'!D4","v":"Yes"},{"$f":"'Safe care'!D5","v":"Some improvement needed"}]
[]
[]
[]
[null,null,"Evidence capture form"]
[null,null,"Evidence capture form(2)"]
[null,null,"Evidence capture form(3)"]
[null,null,"Evidence capture form(4)"]

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

{"sheet":"Health PPI","index":5,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,4],[11,6,11,7],[13,2,13,4],[13,6,13,7],[14,2,14,3],[17,2,17,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 1.1 - Health promotion, protection and improvement"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Mostly patients feel staff are trying to provide good care but sometimes there is not enough time. Some patients feel more time is required to discuss care. Staff are busy and do not always have time to explain things in detail. A patient in RAU felt staff often did not allow enough time for him to process information given to him. A patient in SDMU had been asked to go home initially from ED whilst his scan was awaited. However, his pain increased significantly overnight and he was unable to manage. On return his notes were unavailable and so there were delays in referral requests being made. He felt this had extended his hospital stay.  ",null,"Yes"]
[null,null,"Is smoking cessation advice available and are people encouraged not to smoke?  ",null,null,"Yes","No evidence of smoking information. Very little health promotion information in any areas.",null,"Yes"]
[null,null,"Is there information displayed highlighting the appropriate use of the ED and signposting to other services?",null,null,"Yes","Opposite ED reception there is a poster advising of minor injury service at Neath hospital for alternative service provision. There is also information for care services in the community. Little else observed.",null,"Yes"]
[]
[null,null,"What did patients tell you about how they were helped to look after themselves and their health?",null,null,"Yes","No significant information offered regarding health care advice",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"There is little evidence of general health promotion. There is little information generally regarding falls prevention, exercise management, recommended alcohol consumption or mental health support groups etc. "]

{"sheet":"Dignified Care","index":6,"n_rows":22,"n_cols":9,"rows_kept":22,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[9,8,12,8],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[16,2,16,3],[16,6,16,7],[17,2,17,3],[17,6,17,7],[18,2,18,4],[18,6,18,7],[21,2,21,8]]}
[]
[null,"Quality of Patient Experience - Standard 4.1 - Dignified Care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Do staff treat people with respect and kindness? ",null,null,"Yes","Glad to help. All the best now ' -heard as patient leaving. Conversation overheard. Mostly patients feel staff are kind. One patient felt very strongly that she had not been listened to in ED, which resulted in increased stress, pain and heightened emotional state. The patient felt the approach had changed when she was transferred to RAU and communication was much better. Whilst in attendance nurse administered IV drugs - explanations and reassurance were given throughout procedure. Patient feedback forms indicate some patients do not feel listened to and staff do not accommodate special needs sensitively.",null,"Yes"]
[null,null,"• How do staff speak to patients?",null,null,"Yes","P1 - in ambulance, has been in ambulance for approximately 14hrs. Very tired, staff have been out to assess but communication limited, not sure what is going on. One patient in RAU, who has known memory and processing issues felt staff talked to him and provided information but he did not have time to process it and identify his questions before they left the area. A patient in SDMU wanted to commend the communication skill of the HCSW, especially 'xxxx' who he felt had lifted the morale of the whole bay on one occasion. "]
[null,null,"• Do staff introduce themselves and address patients courteously?",null,null,"Yes","Staff in both ED and RAU appeared to speak respectfully to patients and introduce themselves. Staff in SDMU appeared to approach patients with respect."]
[null,null,"• Are staff kind to patients who may be wandering or shouting out?",null,null,"Yes","How are you feeling now, sorry you have had to wait' - witnessed conversation. Limited observation of patients displaying wandering or challenging behaviours. Some patients had familiar carers with them in waiting areas in ED which helped to reassure."]
[null,null,"Do staff respect people’s privacy and dignity? For example:"]
[null,null,"Are staff discreet and sensitive when speaking to patients and when speaking about patients to other staff? e.g. so they can’t be easily overheard",null,null,"Yes","Relatives are directed to specific relative rooms in ED, one patient's relative said her family had been offered privacy and had been grateful for the sensitivity shown by staff. However, rooms are very small to accommodate families. Another patient felt she had not been updated whilst in ED.",null,"Yes"]
[null,null,"Are there any issues with the environment which could affect patient dignity?  e.g. are locks on toilet doors in working order? ",null,null,"Yes","RAU has extended stays, one lady has been in for 2 weeks. Bays have curtains but beds are male and female occupancy side by side which is not usual for longer periods. This is the same in SDMU. However, duration of stay seems to be only a few days on average. Showers on SDMU were easy access and clean",null,"Yes"]
[null,null,"Do patients appear well cared for? ",null,null,"Yes","P1 -in ambulance for 14hrs. States very tired, trolley not comfortable. Ambulance crew helping her when needed. One patient in RAU stated that whilst in ED her stress levels were very high and she had not felt understood or listened to. One elderly patient was hungry in the ED waiting area. One patient was offered inappropriate food for her needs with no alternative.",null,"Yes"]
[null,null,"Are patients’ warm and offered warm blankets?",null,null,"Yes","An elderly lady in the corridor awaiting ED care was cold, thirsty and hungry. Staff provided hot tea and reassurance until results of X-ray known to progress plan. Most patients appeared to be warm.",null,"No"]
[null,null,"What did patients/carers tell you about how they were treated? i.e. Are staff kind and treat patients with dignity and respect?",null,null,"Yes","Most patients felt staff were trying hard but there were some frustrations evident linked to waiting times in ED and contact checks. One lady on RAU had found the time in ED very distressing, she had been in pain and was very anxious but was not seen for very several hours. A patient on RAU felt he had been waiting for scan all day and still didn't know if the scan was happening at 4pm. ",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"P1 has been laying on a trolley in an ambulance for approximately 14hrs. Ambulance crew providing water but no food available. Crew support with toileting needs, taking patient into department when needed. Hospital staff have assessed, blood tests performed, X-ray and CT scan performed. Occupational health assessed and patient able to walk with Zimmer frame so may be discharged home. Same patient viewed 3hrs later accompanied by ambulance crew in department. Another patient was seen laying on a bed in the middle of the department as all bays full. No screens around patient. Two patients interviewed made reference to a lack of time from staff and that they either didn't feel heard or did not understand the information given. This increased their anxiety."]

{"sheet":"Communication and patient info","index":7,"n_rows":33,"n_cols":9,"rows_kept":33,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[15,2,15,3],[15,6,15,7],[17,2,17,4],[17,6,17,7],[19,2,19,4],[20,2,20,4],[20,6,20,7],[21,2,21,4],[21,6,21,7],[22,2,22,4],[22,6,22,7],[23,2,23,4],[23,6,23,7],[24,2,24,4],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[28,2,28,4],[28,6,28,7],[29,2,29,4],[29,6,29,7],[32,2,38,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 3.2 and 4.2 - Communicating effectively and patient information"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department communicate current waiting times?",null,null,"Yes","Waiting times were not clearly evident in ED",null,"Yes"]
[null,null,"Is there clear information for patients and relatives? I.e. clear signs/directions to and from the department. ",null,null,"Yes","There is signage in both English and Welsh directing people to ED, RAU, SDMU and Paediatric ED. ",null,"No"]
[null,null,"Is information available for patients/carers to help them understand their care and journey through the department?",null,null,"Yes","In ED there is limited information boards seen. There is reference to Coronavirus and also contact details for Carers organisations. However, the leaflet rack is completely empty. there are illustrated displays outside the paediatric ED relating to hand washing and bullying.",null,"Yes"]
[null,null,"Is information available in different formats and languages (not just in Welsh and English)?",null,null,"Yes","In ED waiting room there is a communication  chart with visual cues to assist communication. There is also a similar display in the paediatric ward. One of the patients in RAU is Indian and does not speak English. There did not appear to be any translator provided. The patient's daughter was providing most translation and staff were exploring the use of communication charts. ",null,"No"]
[null,null,"Is information available in Welsh?",null,null,"Yes","There is evidence of some Welsh language signage throughout the units.",null,"No"]
[null,null,"Is there information displayed about the staff working in the department i.e. a ‘who’s who’ board?",null,null,"Yes","No obvious who's who board in ED. 'Who's who' board evident in RAU. RAU displays a 'Knowing how we are doing board' with actions of improvement identified. There is also information regarding Falls prevention and Falls champions. Advice regarding skin inspections and sepsis. 'Who's who' board and 'how did we do?' Board evident on entrance corridor of SDMU. Also complaints pathway with contacts evident.",null,"Yes"]
[null,null,"Is information displayed and/or material available for patients to take away in relation to sepsis?",null,null,"Yes","Sepsis information was displayed in ED and RAU. No leaflets available.",null,"Yes"]
[]
[null,null,"What did patients/carers tell you about how staff communicated with them? i.e. Did they listen and take time to explain about their care?",null,null,"Yes","Not all patients felt communication was good. Many patients felt they had been involved in discussion and decision making but one patient felt she had been ignored, one patient felt he was not given enough time to discuss his concerns properly. One lady did not speak English, ward allowed her daughter to stay for extended periods to provide translation. Also starting to use communication visual chart. One patient felt the healthcare support workers were very reassuring and one working in SDMU was especially able to connect with the patients.",null,"Yes"]
[]
[null,null,"Welsh language"]
[null,null,"Have staff asked what your preferred language is?",null,null,"Yes"," No patients spoken to were Welsh speakers and none made any reference to Welsh language.",null,"No"]
[null,null,"If it’s your choice, have you been able to speak in Welsh to staff, and do they speak Welsh to you?",null,null,"Yes","No Welsh language needs identified.",null,"No"]
[null,null,"Have you had the opportunity to use translation services if you have wanted/needed to?",null,null,"Yes","Translation service available and translator specialist office noted. No translator use witnessed. One lady on RAU was unable to speak English, family were supporting.",null,"Yes"]
[null,null,"Do staff speak to you in Welsh, even if it’s just a few words?",null,null,"Yes","No Welsh language heard.",null,"No"]
[null,null,"How do you know if staff are able to speak Welsh? (e.g. do they wear a ‘iaith gwaith’ badge highlighting they speak Welsh / have they introduced themselves as a Welsh speaker?)",null,null,"Yes","No 'Iaith gwaith' badges noted",null,"Yes"]
[null,null,"Have staff spoken with your visitors in Welsh if they have wanted/needed to?",null,null,"Yes","No need identified during this inspection",null,"No"]
[null,null,"What difference has it made to patients to speak in Welsh with staff if they have wanted and been able to? ",null,null,"Yes","Nil identified",null,"No"]
[null,null,"Are there bilingual signs, posters, reading material available?",null,null,"Yes","There is evidence of bilingual signage.",null,"No"]
[null,null,"Do staff wear a ‘iaith gwaith’ badge, or other visual prompts to indicate they speak Welsh?",null,null,"Yes","No 'iaith gwaith' badges observed",null,"Yes"]
[null,null,"Have you observed patients and staff / staff with staff speaking Welsh to each other?",null,null,"Yes","Not observed",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"  ED signage includes Sepsis signs in both English and Welsh. Lost property, MEWS, specialist palliative care referral line. South Wales trauma network - comprehensive list of pathways. There is a screen on the wall displaying a 'Let's beat the bugs' video.  Hand hygiene information displayed. Visiting guidance, liaison psychiatry contact numbers. Top tips for managing and understanding people with autism. Domestic abuse advice services. Stroke goals.Swansea community resource services contact. British Red Cross- useful sign posting numbers.ED infection control board - percentages for August on environmental audit,sharps,commode (33.3%). More information would be helpful relating to health promotion, waiting times, who is who etc in many areas. "]

{"sheet":"Timely access","index":8,"n_rows":14,"n_cols":9,"rows_kept":14,"merged":[[1,1,1,9],[7,2,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[13,2,13,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 5.1 Timely care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Many patients felt their care had been excellent. However, one patient referred to extended waits in ED. One patient spoke of a wait of 8hrs before seen, then collapsed, attended to but in ED for another 2 days before being moved to RAU. Felt very stressed during this time, sitting in chairs etc Most patients praised nursing staff but felt they were often very busy. One patient felt the care was very good but the system is failing in that his notes had been mislaid, he had been allocated to the wrong Consultant on SDMU and therefore had not been seen. Referral for scan was delayed and length of stay longer as a result. ",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Patient delayed in ambulance for 14hrs whilst awaiting admission. Assessment proess continued in ambulance. Another patient had waited 6hrs for an ambulance but was admitted directly into red resus on arrival at hospital.  Relatives allowed to visit in ED. Relative states 'nurses are great but appear very busy all the time, rushed off their feet', relative feels unit appears short staffed. Patients praise the nursing staff but are frustrated with the system which appears to cause delay and confusion at times. "]

{"sheet":"People's Rights","index":9,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[14,2,14,4],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Quality of Patient Experience - 6.2 People's Rights"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there specific and suitable places for patients to meet with family and friends in private? e.g. relatives room",null,null,"Yes","Meeting rooms are available in ED and reference to their use is made by patients. RAU did not appear to have specific meeting rooms but patients are nursed in bays with curtains for privacy.",null,"Yes"]
[null,null,"Is the relatives’ room conducive to breaking bad news?",null,null,"Yes","ED relatives room is very small, there is no natural light. One relative stated that they had been asked to discuss her father's condition here and it had helped to be separate from the unit even though it was small.",null,"Yes"]
[null,null,"Is there a dedicated viewing room for bereaved relatives?",null,null,"Yes","None observed",null,"Yes"]
[null,null,"Is this a multi faith or non-denominational area?",null,null,"Yes","No faith room identified or signposted",null,"Yes"]
[]
[null,null,"What did patients/carers tell you about the involvement of friends and family in their care? Did they know how to make a complaint?",null,null,"Yes","During the time in ED the Nurse in Charge was dealing with a telephone complaint. Patients mostly identified the nurse as first point of contact for registering a complaint. There were no obvious putting things right' posts or leaflets available identified other than on SDMU. ",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"ED - patient on trolley in middle of ward, no privacy. Advised by Charge nurse that in one area, React Blue, lighting is problematic as area used for longer stay patients and only bright lighting is available. No dimmer for night time. Some patients made reference to lack of nutrition, spending long periods in the unit with being offered food. One lady said she had been offered cake and custard but declined as she was diabetic. No alternative offered. One patient in ED waiting room said she was  very hungry and cold. Carer felt unable to leave her. There appears to be a lack of privacy and compromise to nutrition in ED.  "]

{"sheet":"Feedback","index":10,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[8,2,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Quality of Patient Experience - 6.3 Listening and Learning from Feedback"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"How does the department ensure that they listen and learn from feedback?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How does the department gather patients’/carers’ views and make changes as a result? Consider how departments gather views of children and their families also.",null,null,"Yes","No evidence of suggestion boxes or feedback forms",null,"Yes"]
[null,null,"Is there information displayed around the department about how patients and families are able to provide feedback about their care? Is this easily visible?",null,null,"Yes","SDMU has a poster displayed with a QR code for complaints management",null,"Yes"]
[null,null,"Are patients provided with Community Health Council details for assistance to raise concerns if they should need too?",null,null,"Yes","No route clearly identified.",null,"Yes"]
[null,null,"Is there information on how the health board has learned and improved based on feedback received? ",null,null,"Yes","RAU has a board with some reference to improvements put in place ",null,"Yes"]
[null,null,"Is Putting Things Right displayed?",null,null,"Yes","No 'putting things right' poster displayed in any of the areas but a complaints poster is displayed in SDMU and ED. Contact details are needed on ED poster. ",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"There does not appear to be information readily displayed on how patients can provide feedback or suggestions for improvement. Some information is displayed regarding how to make a complaint but contact details are not clearly evident."]

{"sheet":"Risk & IPC","index":11,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,3],[8,6,8,7],[9,2,9,4],[9,6,9,7],[9,8,12,8],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[17,2,17,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 2.2 - Managing Risk and Promoting Health and Safety & 2.4 Infection Prevention and Control (IPC) and Decontamination"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"Is the environment:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"• Accessible? Are the areas easy to navigate/ is there disabled access / are there facilities for people with mobility difficulties? Is signage appropriate and adequate for movement within the department, i.e. from waiting room to triage or minors?",null,null,"Yes","ED is quite cluttered with additional trolleys in the corridors. There are additional beds in open spaces that staff and others have to walk around. The ED waiting room is large but but patients in wheelchairs mean that some room space is occupied. One patient was sat in a wheelchair with a relative seated next to her blocking a door marked 'do not obstruct'.",null,"Yes"]
[null,null,"• Well maintained? i.e. is the environment clean and in a good state of repair, including furniture, fixtures and fittings etc.",null,null,"Yes","Ceilings in ED are shabby and in need of repair. Ceilings in RAU corridor are shabby and in need of repair. A broken notes trolley was noted in an open cupboard on SDMU. Floor in shower room is badly stained by metal foot of bin. "]
[null,null,"• Fit for purpose? Is the environment suitable for the way it’s used? Are there enough trolleys and facilities?",null,null,"Yes","RDU is a large open bay with both male and female patients, separated with curtains only. Some patients can stay for up to 2 weeks. Relative rooms on ED are very small and would appear congested if more than 2-3 people in situ. Waiting area in SDMU has a waiting area which is also used to store equipment etc and can feel uninviting."]
[null,null,"• Safe and secure? i.e.  Are there hazards in the environment such as blocked corridors, clutter and tripping hazards? Think about the type of patients in the area i.e. elderly, children and relatives who may be visiting them – can they do so safely?",null,null,"Yes"," There is evidence of additional trolleys etc in the corridor areas of ED and RAU. The sluice room in SMDU is jammed open with a bin. "]
[null,null,"What changes can you see that have been made due to COVID-19 e.g. information on COVID-19 displayed on posters, social distance marking on the floor or chairs taped over / removed in the waiting room to help maintain social distancing between patients.",null,null,"Yes","Mask wearing is evident on ED, RAU and SDMU. Covid 19 posters are displayed in areas. There is no evidence of social distancing. COVID positive patients are nursed in red areas and risk is identified. ",null,"Yes"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Some areas appear unfit for purpose, relative rooms are very small, some waiting areas appear cluttered. Corridors appear cluttered. Wheelchairs can sometimes block doors that require access. Some sluice room doors are jammed open. "]

{"sheet":"Nutrition","index":12,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[8,2,8,4],[9,2,9,4],[9,6,9,7],[10,2,10,3],[10,6,10,7],[11,2,11,3],[12,2,12,4],[12,6,12,7],[12,8,14,8],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[16,2,16,4],[16,6,16,7],[17,2,17,4],[17,6,17,7],[20,2,20,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 2.5 - Nutrition and Hydration"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Significant improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[]
[null,null,"If possible (on a ward environment), watch a meal time and look at how staff give patients their meals. This may not be possible in all areas (such as A&E). Speak to your inspection manager if you’re not sure about this.  "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Does water look like it is in easy reach of patients?",null,null,"Yes","There are trolleys with bottled water available in ED waiting areas and in ED. One patient had no jug on her bay table and no access to water. Son requested staff provide. Otherwise most patients appear to have access to water",null,"Yes"]
[null,null,"If patients are given meals – consider the following:"]
[null,null,"·       Are patients sat up and can they easily manage their meal in a trolley? Are patients offered hand wipes/washing prior to their meals?",null,null,"Yes","No evidence of hand wipes being offered. No hostess employed for ED, Red Cross providing hostess support over mealtimes. Red Cross representative note that insufficient soft meals are provided. Also, even though meals may be suffice for patients in ED patients in ambulances are not included in numbers. Therefore, if additional meals are needed for patients delayed in ambulances, there are insufficient meals to meet need.",null,"Yes"]
[null,null,"·       Are meals served hot or is there a delay in serving meals ",null,null,"Yes","Meals are served hot and most patients appeared to agree with this."]
[null,null,"Does the food look appetising? ",null,null,"Yes","Food presentation appeared adequate. One patient stated he had been surprised the food was so good. "]
[]
[null,null,"What did patients/carers tell you about the food and drinks? I.e. where they were staying longer in the department, were they given food options and helped with eating and drinking if they needed it?",null,null,"Yes","Patients in ED waiting area do not appear to be offered food. There is a sweet dispenser machine available if wanted. Several patients made reference to the fact they had not been offered food. One elderly patient stated she was hungry. Another patient stated she had been offered cake and custard but declined as she is diabetic, no alternative provided.",null,"Yes"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Yes","Views were mixed. Most patients praised the nursing staff stating they were' rushed off their feet', 'very busy'. One patient who was fully ambulant noted that nurses attended to people quickly to support to the bathroom for toileting needs if they had mobility issues. Most people expresssed frustration with the system, long delays in ambulance arrivals, then waits in ED with little communication. Some patients felt they did not understand what was going on or what would happen next. ",null,"Yes"]
[]
[null,null,"Summary / Conclusion"]
[null,null,"Food is often not sufficient for number of patients. Food is hot. No hostess available so Red Cross has paid role currently to serve meals. Number of patients very variable due to patients in ambulances, crew can come in to take meals out to patients on ambulances. Hostess trolley left on unit so tea, coffee or cold drink available throughout day. One patient had no water available on table. Patient had had breakfast but not eaten it. One patient noted the relevance of special dietary needs that she felt were overlooked."]

{"sheet":"Safe care","index":13,"n_rows":13,"n_cols":9,"rows_kept":13,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,6,8,7],[12,2,12,8]]}
[]
[null,"Delivery of Safe and Effective Care - Standard 3.1 Safe and clinically effective care"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Some improvement needed"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified",null,"Back to Guidance"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How did patients/carers feel about their care overall?",null,null,"Not Completed","In main ED waiting room there is a door stating ' Do not obstruct' which had 2 people seated on chairs outside. Falls signs evident with advice. P2 feels safe in the unit. Patient interviewed in SDMU felt safe. Patient had felt insecure going home from ED to await a scan and was re admitted overnight due to increased pain. Another patient had not felt listened to in ED and felt this had resulted in high levels of stress and a heightened emotional state.",null,"Not Completed"]
[]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Main corridor out of ED - ceiling in need of repair.sluice very small. Safe PPE poster. The ceilings in RAU are also shabby and in need of repair with some holes in the ceiling tiling evident. Some patients felt stressed in ED waiting room experiencing long delays with lack of contact and associated anxiety experienced. Some people reported episodes of hunger. Many patients wanted to praise the staff as felt they were trying to deliver to the best of their ability."]

{"sheet":"Evidence capture form","index":14,"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":15,"n_rows":27,"n_cols":13,"rows_kept":27,"merged":[[1,1,1,12],[10,1,10,12],[12,1,12,12],[13,1,13,5],[13,6,13,12],[14,1,14,5],[14,6,14,12],[15,1,15,5],[15,6,15,12],[16,1,16,12],[17,1,17,5],[17,6,17,12],[18,1,18,5],[18,6,18,12],[19,1,19,5],[19,6,19,12],[20,1,20,5],[20,6,20,12],[25,1,25,12],[26,1,26,12],[27,1,27,12],[28,1,28,12],[29,1,29,12],[30,1,30,12],[31,1,31,12]]}
[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]

{"sheet":"Evidence capture form (3)","index":16,"n_rows":27,"n_cols":13,"rows_kept":27,"merged":[[1,1,1,12],[10,1,10,12],[12,1,12,12],[13,1,13,5],[13,6,13,12],[14,1,14,5],[14,6,14,12],[15,1,15,5],[15,6,15,12],[16,1,16,12],[17,1,17,5],[17,6,17,12],[18,1,18,5],[18,6,18,12],[19,1,19,5],[19,6,19,12],[20,1,20,5],[20,6,20,12],[25,1,25,12],[26,1,26,12],[27,1,27,12],[28,1,28,12],[29,1,29,12],[30,1,30,12],[31,1,31,12]]}
[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]

{"sheet":"Evidence capture form (4)","index":17,"n_rows":27,"n_cols":13,"rows_kept":27,"merged":[[1,1,1,12],[10,1,10,12],[12,1,12,12],[13,1,13,5],[13,6,13,12],[14,1,14,5],[14,6,14,12],[15,1,15,5],[15,6,15,12],[16,1,16,12],[17,1,17,5],[17,6,17,12],[18,1,18,5],[18,6,18,12],[19,1,19,5],[19,6,19,12],[20,1,20,5],[20,6,20,12],[25,1,25,12],[26,1,26,12],[27,1,27,12],[28,1,28,12],[29,1,29,12],[30,1,30,12],[31,1,31,12]]}
[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[{"$nulls":12},"Back to Summary"]
{"$rows_empty":7}
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]

{"sheet":"Issues Identified","index":18,"n_rows":27,"n_cols":16383,"rows_kept":27,"merged":[[3,2,3,4],[4,3,4,4],[5,3,5,4],[6,3,6,4],[7,3,7,4],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,3,12,4],[13,3,13,4],[14,3,14,4],[15,2,15,4],[16,3,16,4],[17,3,17,4],[18,3,18,4],[19,3,19,4],[20,3,20,4],[21,3,21,4],[22,3,22,4],[23,3,23,4],[24,3,24,4],[25,3,25,4],[26,3,26,4]]}
[]
[null,"Issues Identified",null,null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Issue Identified"]
[{"$nulls":16382},"Health promotion, protection and improvement"]
[{"$nulls":16382},"Dignified Care"]
[{"$nulls":16382},"Patient Information"]
[{"$nulls":16382},"Communicating effectively"]
[{"$nulls":16382},"Timely Access"]
[{"$nulls":16382},"Planning Care to promote independence"]
[{"$nulls":16382},"Peoples rights"]
[{"$nulls":16382},"Listening and Learning from feedback"]
[]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"Standard","Issue Identified"]
[]
[{"$nulls":16382},"Managing risk and promoting health and safety"]
[{"$nulls":16382},"Infection Prevention and Control (IPC) and Decontamination"]
[{"$nulls":16382},"Medicines Management "]
[{"$nulls":16382},"Safeguarding children and adults at risk"]
[{"$nulls":16382},"Medical devices, equipment and diagnostic systems"]
[{"$nulls":16382},"Safe and Clinically Effective care"]
[{"$nulls":16382},"Quality improvement, research and innovation"]
[{"$nulls":16382},"Information governance and communications technology"]
[{"$nulls":16382},"Record keeping"]

{"sheet":"Good Practice","index":19,"n_rows":27,"n_cols":16382,"rows_kept":27,"merged":[[3,2,3,3],[15,2,15,3]]}
[]
[null,"Good Practice",null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Good Practice Identified"]
[{"$nulls":16381},"Health promotion, protection and improvement"]
[{"$nulls":16381},"Dignified Care"]
[{"$nulls":16381},"Patient Information"]
[{"$nulls":16381},"Communicating effectively"]
[{"$nulls":16381},"Timely Access"]
[{"$nulls":16381},"Planning Care to promote independence"]
[{"$nulls":16381},"Peoples rights"]
[{"$nulls":16381},"Listening and Learning from feedback"]
[]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"Standard","Good Practice Identified"]
[]
[{"$nulls":16381},"Managing risk and promoting health and safety"]
[{"$nulls":16381},"Infection Prevention and Control (IPC) and Decontamination"]
[{"$nulls":16381},"Medicines Management "]
[{"$nulls":16381},"Safeguarding children and adults at risk"]
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