{"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"]
[]
[null,null,"Inspection Type","NHS Emergency Department (ED)"]
[]
[null,null,"Health Board ","Swansea Bay "]
[]
[null,null,"Name of setting"]
[]
[null,null,"Date inspection started"]
[]
[null,null,"Date inspection completed"]
[]
[null,null,"Name of Lead HIW Inspector"]
[]
[null,null,"Name of Supporting HIW Inspector"]
[]
[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":4,"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 "]
[]
[]
[]
[null,null,"Who is the person in overall charge of the hospital? "]
[]
[]
[]
[null,null,"Who is Gold/Silver/Bronze on call out of hours?"]
[]
[]
[]
[null,null,"Number of Beds (in each ED area):","Majors:"]
[{"$nulls":3},"Minors:"]
[{"$nulls":3},"Resuscitation:"]
[{"$nulls":3},"Clinical Decision Unit (if applicable):"]
[{"$nulls":3},"Other areas:"]
[]
[]
[]
[null,null,"Number of Patients"]
[]
[]
[]
[null,null,"Staffing and skill mix in relation to the acuity (which areas are staff allocated to, e.g. resus, triage etc.)."]
[null,null,"Number of permanent/agency/bank staff"]
[null,null,"Staffing levels at time of inspection and any new/supernumerary staff"]
[null,null,"No. of ENPs"]
[null,null,"(check if the above is normal level of staffing)"]
[]
[]
[]
[null,null,"Are there any patients with safeguarding concerns?"]
[]
[]
[]
[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?"]
[]
[]
[]
[null,null,"Are there any patients with mental health needs in the department at present?"]
[]
[]
[]
[null,null,"Is the department in escalation?"]
[]
[]
[]
[null,null,"Are there any 4 hour breaches?"]
[]
[]
[]
[null,null,"General observations following discussion with person in charge"]
[]
[]
[]
[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?"]
[]
[]
[]
[]
[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?"]
[]
[]
[]
[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? "]
[]
[]
[]
[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?"]

{"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,{"$f":"'Dignified Care'!D4","v":"No"},{"$f":"'Dignified Care'!D5","v":"Select outcome statement"}]
[null,null,"3.2 Communicating Effectively",null,null,{"$f":"Communicating!D4","v":"No"},{"$f":"Communicating!D5","v":"Select outcome statement"}]
[null,null,"5.1 Timely Care",null,null,{"$f":"'Timely Care'!D4","v":"No"},{"$f":"'Timely Care'!D5","v":"Select outcome statement"}]
[null,null,"6.1 Planning care to promote independence",null,null,{"$f":"Independence!D4","v":"No"},{"$f":"Independence!D5","v":"Select outcome statement"}]
[null,null,"6.2 Peoples rights",null,null,{"$f":"'People''s Rights'!D4","v":"No"},{"$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,{"$f":"Nutrition!D4","v":"No"},{"$f":"Nutrition!D5","v":"Select outcome statement"}]
[null,null,"2.6 Medicines management",null,null,{"$f":"'Medicines management'!D4","v":"No"},{"$f":"'Medicines management'!D5","v":"Select outcome statement"}]
[null,null,"2.7 Safeguarding",null,null,{"$f":"'Safeguarding '!D4","v":"No"},{"$f":"'Safeguarding '!D5","v":"Select outcome statement"}]
[null,null,"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,{"$f":"'Falls Prevention'!D4","v":"No"},{"$f":"'Falls Prevention'!D5","v":"Select outcome statement"}]
[null,null,"2.9 - Medical devices, equipment and diagnostic systems",null,null,{"$f":"'Medical devices'!D4","v":"No"},{"$f":"'Medical devices'!D5","v":"Select outcome statement"}]
[null,null,"3.1 - Safe and Clinically Effective care",null,null,{"$f":"'Safe Care'!D4","v":"No"},{"$f":"'Safe Care'!D5","v":"Select outcome statement"}]
[null,null,"3.3 Quality Improvement, Research and Innovation",null,null,{"$f":"Improvement!D4","v":"No"},{"$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,{"$f":"Governance!D4","v":"No"},{"$f":"Governance!D5","v":"Select outcome statement"}]
[null,null,"7.1 – Workforce",null,null,{"$f":"'Workforce '!D4","v":"No"},{"$f":"'Workforce '!D5","v":"Select outcome statement"}]
[]
[null,null,"Case Tracking","Select outcome statement"]
[null,null,"Part 1: Review of patient records",null,null,{"$f":"'Case Tracking Part 1'!D4","v":"No"},{"$f":"'Case Tracking Part 1'!D5","v":"Select outcome statement"}]
[null,null,"Part 2: How do patient records compare to practice?",null,null,{"$f":"'Case Tracking Part 2'!D4","v":"No"},{"$f":"'Case Tracking Part 2'!D5","v":"Select outcome statement"}]
[null,null,"Record Keeping",null,null,{"$f":"'Record Keeping'!D4","v":"No"},{"$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,"Not Checked",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,"Not Checked",null,null,"No"]
[]
[null,null,"Delivery of Safe and Effective Care"]
[null,null,"• Escalation policy",null,"Not Checked",null,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,"Not Checked",null,null,"No"]
[null,null,"• Medication charts; Cas cards",null,"Not Checked",null,null,"No"]
[null,null,"• Safeguarding policies for children and vulnerable adults",null,"Not Checked",null,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":20,"n_cols":9,"rows_kept":20,"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","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 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,"Yes","Very difficult for discrete care delivery when communicating as the department is very busy. The trolley bays are very close together with curtains in between some bays have shoulder height screens instead.",null,"Not Completed"]
[null,null,"Are there any issues with the environment which impact on patient privacy and dignity? ",null,null,"Yes","There are relatives rooms away from the clinical area where staff may speak to relatives in a quiet and private environment. Speaking to relatives at the bedside is never going to be discrete because of the layout and business of the department.",null,"Not Completed"]
[null,null,"Are staff discreet when administering personal care?",null,null,"Yes","Not always, because of the environment conversations can be overheard clearly",null,"Not Completed"]
[null,null,"If patients are being cared for in ‘holding areas’/corridors, how is patient dignity maintained?",null,null,"Yes","Mobile screens are available however on Day 2 a patient was positioned in a central location of the Majors bay due to flow. This patient was in full view and should the need arise they would have had to have created a full 360 screen to allow private care to be delivered. This was not witnessed ",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,"Yes","Many patients were seen to be sleeping on trolleys Many had been there overnight.",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,"Yes","Pain relief witnessed. However, patients held in ambulances not so much. Paramedics are expected to raise alarm if their patient deteriorates and they require pain relief or additional review, they are not regularly checked on.",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,"Yes","Not seen",null,"Not Completed"]
[null,null,"Is Bereavement support provided in a timely way and is it sensitively and compassionately delivered?",null,null,"Yes","Need to check with xxxxx xxxxxx",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Communicating","index":6,"n_rows":16,"n_cols":9,"rows_kept":16,"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","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 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","Although attempts made to be discrete it's very difficult within the department layout and as very busy to not have a conversation which is not overheard. Even in the waiting area patients are aware of each other's issues",null,"Not Completed"]
[null,null,"Are boards containing identifiable information in a discreet place?",null,null,"Yes","Patient information is not on display to the general public.",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","Those who have been observed to be spoken to professionally were done so in a kind and professional way which promoted dignity and respect whilst checking that the patient understood. In some circumstances esp bereavement families are given additional support including after they have left the hospital.",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Very difficult under the circumstances to provide a discrete consultation. However, consultations in the rear of an ambulance has also been witnessed and found to be professional and dignified- all doors closed."]

{"sheet":"Timely Care","index":7,"n_rows":43,"n_cols":9,"rows_kept":43,"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],[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","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,"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,"Yes","No average available. However, on arrival evening day 1 a patient had been outside unable to decant for 10 hours. Day 2. Various waiting times 11hrs-6hrs varying degree of presenting problems of which 2 should not have been kept outside in an ideal situation. One a spinal injury with neuro deficit and one abdominal obstruction",null,"Not Completed"]
[null,null,"Are there presently any delays in offloading patients, if yes what are the causes of delays?",null,null,"Yes","Flow.",null,"Not Completed"]
[null,null,"How long have you been waiting to offload?",null,null,"Yes","Multiple delays offloading patients. 9 vehicles present, 2 had managed to offload walking. One was a MH patient unable to access the unit due to being disruptive currently waiting 16 hrs and requires a blood transfusion which could be delivered elsewhere however it was considered now he's here he should stay. One spinal injury currently waiting 12 hours-6 hours on a spinal board unable to clear via CT scan but board removed but not cleared. Another elderly patient waiting 8 hrs suspected abdominal obstruction seen by surgeons awaiting bed, may need IV fluids in the meantime and pain relief.",null,"Not Completed"]
[null,null,"What is the patient’s category?",null,null,"Yes","Amber",null,"Not Completed"]
[null,null,"Has the patient been triaged by ED staff and categorised accordingly?",null,null,"Yes","Yes triaged and some investigations performed some conclusive and some inconclusive.",null,"Not Completed"]
[null,null,"Who is ultimately responsible for the patient?",null,null,"Yes","Predominately ED staff with some specialty input from surgery.",null,"Not Completed"]
[null,null,"What is the hospital policy on assessing patients unable to be offloaded? ",null,null,"Yes","Policy is to support and liaise with WAST staff and ED. WAST will NEWS score and report accordingly to ED staff. Patients held in vehicles would not have their clinical interventions delayed e.g. CT and bloods. Patients will also be provided with food and drink if appropriate however on the days of inspection this was not seen. WAST crew have water on board but no food.",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,"Yes","There is a SOP to address this issue however rarely used as other ED departments close by would face similar circumstances. However there is a SOP in place to rapid release vehicles should the need arise.",null,"Not Completed"]
[null,null,"Have hospital Medical staff reviewed the patient while waiting to be offloaded?",null,null,"Yes","Yes. All patients have been reviewed a min of once. If there is a change in condition then the patient is subject to an additional review. This can be requested by the WAST team.",null,"Not Completed"]
[null,null,"If patient reviewed but no bed in hospital, who is ultimately responsible for the patient?",null,null,"Yes","Responsibilities lie with ED with WAST support.",null,"Not Completed"]
[null,null,"Have basic needs been met, i.e. nutrition / elimination/ SKIN / Hydration / privacy?",null,null,"Yes","Not in a timely manner. Food not offered to those reviewed. Patient left on spinal board for over 6 hours without being checked. An elderly patient also complained at being uncomfortable and WAST staff made every effort to reposition and make the patient comfortable however fundeme talks of care are not met.",null,"Not Completed"]
[null,null,"Who liaises between ambulance and hospital (provide updates)?",null,null,"Yes","There is a member of staff with dedicated responsibilities however this role is not 24/7 and is currently person dependent. In their absence the triage nursewill provide updates- this role is held by a Band 7.",null,"Not Completed"]
[null,null,"Do relevant ED staff attend hospital patient flow meeting?",null,null,"Yes","Where possible the senior nurse for ED attends",null,"Not Completed"]
[null,null,"What arrangements are in place to receive a divert from other hospitals?",null,null,"Yes","Policy/SOP",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,"Yes","No evidence anecdotally, however, the rapid release SOP is used but not always accepted and accessed by WAST. There appears to be a lack of understanding by all as to who authorises/chooses which vehicle should be released. ",null,"Not Completed"]
[null,null,"Are patients being received into the department from ambulances in a timely and effective way?",null,null,"Yes","Not always. During our visit there was a constant delay in vehicles outside. At no time was their no delay.",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,"Yes","Poor flow generally through the hospital and a low expectation of being able to offload a patient swiftly.",null,"Not Completed"]
[null,null,"Are there any processes in place to admit directly to wards (if safe to do so), i.e. direct admission to AMAU / SAU / ENT etc.",null,null,"Yes","It is rarely an ability to offload to a specific area. ",null,"Not Completed"]
[null,null,"Do you / who attends the patient flow meetings and how often/times etc.?",null,null,"Yes","Attended by xxxxx",null,"Not Completed"]
[null,null,"What is the hospital’s policy and SOP for escalation status?",null,null,"Yes","xxxxx",null,"Not Completed"]
[null,null,"Have any incidents relating to patient safety/harm been reported in the past twelve months?",null,null,"Yes","Yes. Trend is leaning towards violence and aggression mainly and they have a work in progress of addressing this and hopefully reduce numbers. This is in good practice",null,"Not Completed"]
[null,null,"Have any complaints been received from patients or relatives?",null,null,"Yes","As per report",null,"Not Completed"]
[null,null,"Are there any concerns in relation to communication between WAST and hospital teams?",null,null,"Yes","Yes in particular in relation to patient care whilst out in the vehicle awaiting entry to the department ",null,"Not Completed"]
[null,null,"Are patients kept in the corridors, if so who’s responsible? ",null,null,"Yes","Not in corridors but areas created within the department without screening therefore dignity and respect are missed therefore screens are erected if the patient needs privacy.",null,"Not Completed"]
[null,null,"ENP – do they get involved with patients on ambulances?",null,null,"Yes","Supportive when required",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"There is a constant delay in patients being seen whether it be walking wounded or trolley. Although are findings are for 3 days only I am assured by patients that this is the normal. Many had been admitted previously and discharged with advice to return which they had done. See case tracking."]

{"sheet":"Independence","index":8,"n_rows":16,"n_cols":9,"rows_kept":16,"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","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 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,"Yes","Not seen. Whe questioned staff were vague but could refer me to the nurse champion. ",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,"Yes","Yes, however the pictures are quite small on some of the signage and some may have difficulty deciphering what the sign is e.g. waiting area. All signage appears to be bilingual which is refreshing.",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,"Yes","Difficult to assess as most patients were trolley bound and appeared to have been on their bed/trolley for a time. Their nursing dependency was high with a low clinical dependency. ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Difficult to make a clinical assessment as majority of patients were trolley/bed fast with low NEWS score which would suggest their need was not ED but a more definitive clinical area."]

{"sheet":"People's Rights","index":9,"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],[10,2,10,3],[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","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 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,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there awareness of equality legislation and standards?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Have staff received training in human rights and equality?",null,null,"Not Completed",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,"Yes","Good insight demonstrated in spiritual beliefs in particular by the bereavement lead for the ED. Information was shared according to beliefs with respect.",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","Yes. One family member can be present in the waiting area providing there is capacity. When in the clinical area due to capacity there is no visitors however if the patient is unwell and not expected to survive allowances are made",null,"Not Completed"]
[null,null,"Are patients’ family/carers able to provide assistance with and be involved in the patients care? ",null,null,"Yes","Yes if there is cognitive impairment and in the patients best interest then allowances are made.",null,"Not Completed"]
[null,null,"If a patient is critically ill, how are carers/relatives accommodated? ",null,null,"Yes","There is accommodation for families, it is small but a provision is made.",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"The staff are aware of human rights and needs but we're not questioned in depth. The department despite being under duress did provide compassionate and considerate care."]

{"sheet":"Managing risk ","index":10,"n_rows":35,"n_cols":9,"rows_kept":35,"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,"Yes","Clean environment. Housekeeping/domestic appear to be very careful and respectful in the clinical and waiting area.",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","Some audits undertaken but not necessarily retailing to riskd hazards. The department in some areas appeared cluttered however it can be appreciated that due to the overwhelming traffic at times that this is inevitable but also there is a need to declutter.",null,"Not Completed"]
[null,null,"Are risk assessments completed within areas of concern?",null,null,"Not Completed","I am told risk assessments are undertaken evidence of such not seen.",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","Yes there are bed spaces which are ligature negative",null,"Not Completed"]
[null,null,"Is the environment accessible and safe for people with mobility difficulties?",null,null,"Yes","Can be quite crowded however they are able to accommodate those who require.",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,"Not Completed","NOT SURE CHECK",null,"Not Completed"]
[null,null,"Are there processes in place to protect staff and other ED attendees from violence and aggression? ",null,null,"Yes","Yes dedicated security staff",null,"Not Completed"]
[null,null,"How do staff deal with behaviours that challenge?",null,null,"Yes","Staff training and use of security staff when appropriate ",null,"Not Completed"]
[null,null," Is senior support available in these situations?",null,null,"Not Completed",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,"Not Completed",null,null,"Not Completed"]
[null,null,"How are medical emergencies dealt with? Is there any difference in response out of hours?",null,null,"Yes","All dealt with in the same way 24/7",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,"Not Completed",null,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",null,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,"Yes","Department is regularly at capacity and as a result all members are well versed of protocol",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"]

{"sheet":"Infection Control","index":11,"n_rows":49,"n_cols":9,"rows_kept":49,"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,"Yes","xxxxxx xxxxxx is the Lead There are 10 trained nurses within the team across the HB and 3 HCSW. By comparison this is well staffed.",null,"Not Completed"]
[null,null,"Are IPC audits undertaken regularly and acted on appropriately?",null,null,"Yes","Monthly audits undertaken. Some undertaken by IPC , some joint with staff and ED staff. Feedback is shared amongst many disciplines.",null,"Not Completed"]
[null,null,"Is there IPC data on the walls highlighting good/poor statistics in compliance?",null,null,"Yes","By their own admission the data results for IPC audits is questionable being 100%. Their intention is to revisit and review training and support but feel since COVID some slippage in practice has crept and this needs to be addressed",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","All parameters which were brought in at the onset of Covid are still current. There are some witnessed observations where staff may have adjusted their practice from guidance",null,"Not Completed"]
[null,null,"§  enhanced cleaning",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"§  PPE ",null,null,"Yes","Variances in PPE usage. Poor practice with use of gloves discussed at length as poor practice witnessed by nursing and medical staff. Witnessed over 2 days. Staff not changing gloves in between patients. Gloves being used for clinical and non clinical use. Full PPE donned , patient examined and team leaving the patient to use the telephone and computer in full PPE/gloves on. Visibly noticeable staff not washing their hands. ",null,"Not Completed"]
[null,null,"§  COVID-19 training",null,null,"Yes","Updates noted but little training given since the initial onset and predominately 2nd wave.",null,"Not Completed"]
[null,null,"§  Pre-screening for COVID-19",null,null,"Yes","Covid screening at the door by reception staff. ",null,"Not Completed"]
[null,null,"§  Screening before leaving ED to move patients onto wards",null,null,"Yes","Only if symptomatic This policy is changing this week by Welsh Health Circular.",null,"Not Completed"]
[]
[null,null,"Is there separate area for isolating patients with suspected or confirmed COVID-19?",null,null,"Yes","Not always. Some isolation facilities available however patients are mainly cared for in the main bays and staff apply appropriate use of PPE",null,"Not Completed"]
[null,null,"Are all staff aware of the standards they should follow?",null,null,"Yes","All staff spoken to are aware, however not always practiced.",null,"Not Completed"]
[null,null,"Is PPE available and do you see evidence of it in use?",null,null,"Yes","Yes in all areas",null,"Not Completed"]
[null,null,"Is regular handwashing seen in between treatments, patients, etc?",null,null,"Yes","Reviewer stood next to the washbasin for 30 min speaking to a tracked patient nobody used the sink in that time or was any hand washing witnessed. ",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,"Yes","Staff do practice bare below elbow.",null,"Not Completed"]
[null,null,"How does the department handle the need for deep cleaning of areas / rooms after infectious patients?",null,null,"Yes","Used of 4Ds policy however this is not monitored or are areas de cluttered therefore not practiced in full.",null,"Not Completed"]
[null,null,"How and where are Neutropenic patients cared for? Or other immunocompromised patients?",null,null,"Yes","Attempts always made to accommodate such patients in isolation for their own protection.",null,"Not Completed"]
[null,null,"Are there isolation rooms in the department/areas that can be used for isolation? ",null,null,"Yes","At a push there is a room with an airflow lock however they prefer to only use as an emergency",null,"Not Completed"]
[null,null,"Is the route from ambulance bay to that room appropriate?",null,null,"Yes","Yes easily accessed",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,"Yes","Domestic staff spoken to and all areas appeared clean",null,"Not Completed"]
[null,null,"Who does a deep clean if infection is suspected?  ",null,null,"Yes","Staff present",null,"Not Completed"]
[null,null,"How is both normal waste and clinical waste managed? ",null,null,"Yes","All waste managed appropriately ",null,"Not Completed"]
[null,null,"Do the condition of furnishings present any infection control hazards?",null,null,"Yes","This is managed at source and not via IPC",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,"Yes","Yes they have their own SOP which works well alongside ED procedures They also have onsite facilities to decontaminate their vehicle.",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,"Yes",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,"Yes","IPC lead is confident that all outbreaks are managed appropriately and that learning from such events is shared",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,"Yes","IPC are confident that under new executive  leadership any weaknesses that have been between medical staff and IPC that this will be dispelled . Currently there is little opportunity to have an audience with medical staff to discuss",null,"Not Completed"]
[null,null,"Did you follow your Health Board’s policy?",null,null,"Yes","Yes and is soon to change",null,"Not Completed"]
[null,null,"Were you able to identify the root cause? ",null,null,"Yes","Sometimes difficult to determine root cause when multi factorial sources involved.",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,"Yes","Difficult to share with medical staff at present but all other multi professionals are included in the learning fro estates, porters and nurses.",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Hand hygiene and use of gloves needs to be addressed with immediate effect. This was discussed with IPC lead and is of no surprise.There is much hope pinned on a new appointment for medical staff to make inroads within medical teams-this would be advantageous and a need to ensure further risk is reduced."]

{"sheet":"Nutrition","index":12,"n_rows":23,"n_cols":9,"rows_kept":23,"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","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 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","No. Food is not regularly delivered to the department. The Red Cross volunteers have a responsibility for providing and sourcing snacks and drinks for patients who have a prolonged stay within the department. Patients are offered breakfast bars in the walking wounded waiting area-some have been there for several hours.",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,"Yes","No.",null,"Not Completed"]
[null,null,"Is there implementation of the All Wales nutrition pathway?",null,null,"Yes","No",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","There is a Laissez Faire attitude to hydration and nutrition not much emphasis is put on it. Considering patients are within the department for lengthy periods as they are held there awaiting a bed a more robust system to ensure adequate food and drink is provided and not left to a voluntary service. It is an expectation of every nurse from their governing body that this is a basic requirement",null,"Not Completed"]
[null,null,"Are fluids, including IV fluids being monitored and recorded on the All Wales fluid balance charts?",null,null,"Yes","IV fluids are being administered within the department and in the rear of ambulance vehicles. Charting is completed in full. Ambulance staff use their own electronic record keeping which is transferred once the patient has gained entry.",null,"Not Completed"]
[null,null,"Are nutrition charts also being completed for all fluid and food consumed?",null,null,"Yes","No.",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","WAST staff do their best to access food for their patients but usually are only able to get water.",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,"Yes","If appropriate ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Hydration needs are not assessed if oral. There is a dependency on either the patient asking or attention given if the patient required IV fluids."]

{"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","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 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,"Not Completed",null,null,"Not Completed"]
[null,null,"Where oxygen is being given, has it been prescribed?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Does the department have a dedicated pharmacist? What hours can they access this support?",null,null,"Not Completed",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,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there a system for safe, calm administration of medicines?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How is discarded medication recorded?",null,null,"Not Completed",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,"Not Completed",null,null,"Not Completed"]
[null,null,"Are all drugs, including controlled drugs, stored securely and administered safely?",null,null,"Not Completed",null,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,"Not Completed",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,"Not Completed",null,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,"Not Completed",null,null,"Not Completed"]
[null,null,"Do staff stay with the patient to ensure medication is taken correctly?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is medication left unattended at any time? ",null,null,"Not Completed",null,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,"Not Completed",null,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","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 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,"Not Completed",null,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,"Not Completed",null,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,"Not Completed",null,null,"Not Completed"]
[null,null,"Does the department have a system for identifying vulnerable adults?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Are national guidelines on safeguarding children adhered to?",null,null,"Not Completed",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,"Not Completed",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,"Not Completed",null,null,"Not Completed"]
[null,null,"Are any patients under constant supervision? If yes, are all necessary safeguards in place?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How does the department protect patients assessed as at risk of self-harm and suicide? ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Safeguarding is led by a specific band 7 who also deals with frequently flyers therefore captured in good practice."]

{"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?"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are pressure risk assessments together with wound charts completed for patients and reviewed during their time in the ED?",null,null,"Yes","Yes. Is an issue when patients are in the back of an ambulance as they state this is not their role.",null,"Not Completed"]
[null,null,"Is there evidence of pressure relieving equipment in use? What sort of aids are available and how do you access them?",null,null,"Yes","Yes. Repose mattresses on all trolleys and some purchased for ambulance. However , WAST have declined to allow their staff to use the mattresses in fear that this becomes a norm. However the patient is at risk of developing pressure issues.",null,"Not Completed"]
[null,null,"Consider speaking with the Health Board’s Tissue Viability Team to gain clarity on the expectations of the ED, where needed. ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"WAST / ED:",{"$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","NO",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","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 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,"Yes","OPAS are totally dedicated to the falls service and are able to pinpoint admissions and pull them out of ED and address directly with the intention of avoiding a hospital admission",null,"Not Completed"]
[null,null,"Are falls risk assessments completed?",null,null,"Yes","Yes. Comprehensive ",null,"Not Completed"]
[null,null,"Are patients encouraged to wear shoes or slippers when walking around the department?",null,null,"Not applicable",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,"Yes","Yes",null,"Not Completed"]
[null,null,"How do patients attract attention to get this support? Are there call bells and are they accessible?",null,null,"Yes","Call bells but mainly staff close by",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,"Yes","Not always",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,"Not applicable",null,null,"Not Completed"]
[null,null,"Can staff advise if falls lessons learnt and actions are shared widely?",null,null,"Yes","Often shared and reported via OPAS",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]

{"sheet":"Medical devices","index":18,"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],[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","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 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","Yes quite cluttered storage areas",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","Dedicated staff",null,"Not Completed"]
[null,null,"• Are there labels showing when the equipment was last checked/serviced? Are these in date?",null,null,"Yes","Yes all found to be in date",null,"Not Completed"]
[null,null,"Are there arrangements for reporting faults with equipment?",null,null,"Yes","Yes-witnessed",null,"Not Completed"]
[null,null,"Do all items of equipment appear to be in a good state of repair?",null,null,"Yes","Yes but as previous cluttered as if quickly discared after a previous use. No indication of decontamination.",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,"Not applicable",null,null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Large storage areas shared for disposables and equipment. Could be arranged slightly better time permitting"]

{"sheet":"Safe Care","index":19,"n_rows":39,"n_cols":9,"rows_kept":39,"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","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,"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","Due to overwhelming numbers attending the department those with conditions who should expect immediate attention do not. Those attending with chest pain stroke and spinal injuries with neuro deficit do not get seen within the recommended time e.g. chest pain-4hours. See case tracking for evidence ",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","Staff did know how to access policies but on questioning admitted they had not accessed such documents for some time unless they required certain information.",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","Yes",null,"Not Completed"]
[null,null,"Are you aware of patient safety notices?",null,null,"Yes","Those questioned not aware of any recent PSN",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","New matron in post and a lot of expectation is at her feet. Band 7 staff are encouraged to look at improvement projects that would help the department and many are pursuing such ideas. E.g. bereavement",null,"Not Completed"]
[null,null,"Is there evidence risks are monitored?",null,null,"Yes","Verbal nothing noted",null,"Not Completed"]
[null,null,"Suggested for senior managers:  Are there quality indicators/audits in use to monitor:"]
[null,null,"• Pressure areas",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"• Falls",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"• IPC i.e. monthly audits",null,null,"Yes","Monthly audits for all",null,"Not Completed"]
[null,null,"• Hand washing?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there internal audit and monitoring of records and record keeping audits?",null,null,"Yes","Central audit which goes to senior nurse management ",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,"Not Completed",null,null,"Not Completed"]
[null,null,"Are there any challenges around staffing levels/training which are affecting patient care?",null,null,"Yes","Difficult to allocate education training days due to work pressures however there are monthly training days for staff updates.",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","Cases are identified based on vital signs, presentation and history prior to blood results being returned to confirm diagnosis.",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,"Yes","NEWS witnessed sepsis screening also witnessed",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,"Yes","Ongoing staff training ",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","Staff spoken to were well versed with sepsis, chain of treatment and expected timely outcomes",null,"Not Completed"]
[null,null,"How are cases of sepsis managed effectively and according to best practice guidelines? ",null,null,"Yes","Safe and appropriate ",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,"Yes","Case seen was treated appropriately and timely and a decision was also then made to keep patient comfortable as further treatment would be futile ",null,"Not Completed"]
[null,null,"How do staff ensure consistent, effective, clinical management of cases?",null,null,"Yes","Staff are confident.",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"No problems identified."]

{"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","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,"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,"Bereavement; Department sees approx 200-300 sudden deaths per annum. All staff are trained and supported to deal with sudden death within the department this is mandatory training. The department has developed links with the bereavement support organisation Cruiseand will refer families on to them. They have developed a service which means that within the first 48hrs the bereaved family will receive a phone call from staff for a well being check. The family are also sent a card within the fist few weeks offering additional telephone numbers with support /cruise. They are also offered a return visit to the hospital should they wish. Frequent Flyers: this piece of work is exceptional and has been developed since 2016. The lead is a band 7 for ED and dedicates 15 hrs per week to this service in addition to being a department sister. The service is linked to the following; the police MH liaison officer GP surgeries, Alcohol Dependency team, Community resource team and latterly the OPAS in particular when it relates to Falls. The role also embraces Safeguarding as many aspect interlink with the clientele they have. The role also addresses violence and aggression within the department and supports staff who may have been subject to aggressive behaviour from patients. As a result education is in place and staff are encouraged to report all such incidents to the police either via 101 or to use a specific email address. The staff are then supported as much as they require sometimes from the police if appropriate. Both of these initiatives show insight into the treatment of staff and patients"]

{"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","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,"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,"Not Completed",null,null,"Not Completed"]
[null,null,"Do ward staff know and understand their responsibilities when escalation is necessary for staffing reasons?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do members of the multidisciplinary team work well together?  ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Do you feel you have enough time to provide care safely?",null,null,"Not Completed",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,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there a Paediatric Emergency Medicine (PEM) consultant with dedicated session time allocated to paediatrics?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"In departments where children are treated, are there at least two registered children’s nurses?",null,null,"Not Completed",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","No",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","xxxxx"]
[null,null,"B","xxxxx"]
[null,null,"C"]
[null,null,"D"]
[null,null,"E"]
[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?","YES. SHORT NOTES","Yes"]
[null,null,"Areas to consider","A","B","C","D","E","Comments"]
[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?","N/A","Yes","N/A","N/A","N/A"]
[null,null,"Are there clear records on decisions around the patient’s mental capacity? \n\n(Also check staff’s understanding around capacity)","N/A","Yes","N/A","N/A","N/A"]
[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)","N/A","N/A","N/A","N/A","N/A"]
[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","Yes","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on records around DOLS and mental capacity? Why have you come to that conclusion?","B. Gongenital cognitive impairment "]
[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","No","N/A","N/A","N/A"]
[null,null,"Where appropriate, is food/fluid intake being monitored?","N/A","Yes","N/A","N/A","N/A"]
[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","N/A","N/A","N/A"]
[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?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"What is your overall assessment of how they have approached nutrition and hydration needs? Why have you come to that conclusion?","B. Patient taking oral fluids"]
[null,null,"Sepsis"]
[null,null,"Has sepsis screening taken place on arrival? ","N/A","N/A","N/A","N/A","N/A"]
[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","N/A","N/A"]
[null,null,"What is your overall view around sepsis? Why have you come to that conclusion?"]
[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)","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there evidence of appropriate skin assessment?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there an appropriate care plan developed and documented in line with risk assessment score?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there evidence of frequent repositioning? Day and night? ","N/A","N/A","N/A","N/A","N/A"]
[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)","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there ongoing monitoring of pressure areas?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Has a referral been made to the tissue viability nurse if appropriate?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"What is your overall view on pressure and tissue damage prevention and care?\nWhy have you come to that conclusion?","B. Patient is young and is able to move freely"]
[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? ","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there a specialist falls service that the ED has access to? ","N/A","N/A","N/A","N/A","N/A"]
[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?","N/A","N/A","N/A","N/A","N/A"]
[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","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on falls prevention?\nWhy have you come to that conclusion?"]
[null,null,"Pain management "]
[null,null,"Is there documented evidence that pain is being measured, actioned and evaluated? ","No","Yes","N/A","N/A","N/A"]
[null,null,"Do patients have an up to date pain score?","No","Yes","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on pain management?\nWhy have you come to that conclusion?","A. Patient  ADMITTED WITH CHEST PAIN THERFORE REQUIRES AN ASSESSMENT AND NOT UNDERTAKEN B. Chest pain and central back pain therefore pain relief given"]
[null,null,"Assessment "]
[null,null,"Was the patient triaged within 15 minutes of arrival to ED?","No","No","N/A","N/A","N/A"]
[null,null,"Have relevant risk assessments been undertaken?","No","Yes","N/A","N/A","N/A"]
[null,null,"Do patient records reflect the risks identified and the actions required?","No","Yes","N/A","N/A","N/A"]
[null,null,"Has the patient’s language choice/preference been recorded as being asked?","No","No","N/A","N/A","N/A"]
[null,null,"Has the patient’s language choice/preference been recorded as a decision?","No","No","N/A","N/A","N/A"]
[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","N/A","N/A","N/A"]
[null,null,"What is your overall assessment?\nWhy have you come to that conclusion?","A. very little documented. B. Little documented despite being in the ambulance for 12 hours however, has been to CT scan etc"]
[null,null,"Planning care to promote independence "]
[null,null,"Is all the care/treatment given documented in the patients care plan/records?","No","Yes","N/A","N/A","N/A"]
[null,null,"Are important decisions such as Do Not Attempt to Resuscitate (DNACPR) being documented?","N/A","N/A","N/A","N/A","N/A"]
[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?","No","N/A","N/A","N/A","N/A"]
[null,null,"Is there clear evidence of transfer of care/ discharge planning?","Yes","N/A","N/A","N/A","N/A"]
[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"]
[null,null,"Is it recorded when the patient is medically fit to be discharged?","Yes","N/A","N/A","N/A","N/A"]
[null,null,"Is care planned in a way that promotes independence?","No","N/A","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on planning care to promote independence ?\nWhy have you come to that conclusion?","A. Very little documented"]
[null,null,"Delivery and effectiveness and evaluation"]
[null,null,"Is the effectiveness of care/treatment evaluated regularly?","No","Yes","N/A","N/A","N/A"]
[null,null,"Are the patient’s records up to date and completed immediately after care and treatment?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on delivery and effectiveness and evaluation?\nWhy have you come to that conclusion?","A. Very little documented which does not reflect on the care and intervention given. B. Good note keeping considering "]
[null,null,"Department management"]
[null,null,"Is the handwriting in patient records legible?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Are all entries signed, dated and the time of entry included?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there evidence of a written hand over?","Yes","N/A","N/A","N/A","N/A"]
[null,null,"Is there evidence that other members of the MDT team contribute to the patient’s treatment plan?\nIs this clear?","N/A","Yes","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on department management?\nWhy have you come to that conclusion?","A. Busy but could have been dealt with more swiftly. B. Has received the expected care within the ambulance."]
[]
[null,null,"Summary/Conclusion"]
[]
[]
[]
[]
[]
[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","No"]
[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"]
[null,null,"B"]
[null,null,"C"]
[null,null,"D"]
[null,null,"E"]
[]
[null,null,"Summary/Conclusion"]
[]
[]
[]
[]
[]
[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","No"]
[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",{"$nulls":4},"Not Completed"]
[null,null,"Good quality in terms of accuracy, being up to date, complete, understandable and contemporaneous",{"$nulls":4},"Not Completed"]
[null,null,"Easy access for people when requested and appropriate disposal of records?",{"$nulls":4},"Not Completed"]
[null,null,"Secure storage and compliance with Data Protection Act 1998 / General Data Protection Regulations (2016) (GDPR)",{"$nulls":4},"Not Completed"]
[null,null,"Effective records management system, including IT system?",{"$nulls":4},"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"]

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