{"text_format":"3","workbook":"xlsx","n_sheets":30,"sheets":["Guidance","Inspection Details","Arrival and Tour","Summary","Key Documents","Communication","Managing Risk ","Nutrition and hydration","Meds Management","Safeguarding","Blood","Medical Devices","Safe Care","Dignified Care","Planning care ","Peoples Rights","IPC","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":69,"n_cols":6,"rows_kept":69,"merged":[[5,2,5,5],[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],[14,2,14,5],[15,2,15,5],[16,2,16,3],[16,4,16,5],[17,2,17,5],[18,2,18,5],[19,2,19,5],[20,2,20,5],[22,2,23,2],[22,3,23,3],[22,4,23,4],[22,5,23,5],[24,2,45,2],[25,3,27,3],[25,5,27,5],[29,3,30,3],[29,5,30,5],[31,3,32,3],[31,5,32,5],[33,3,35,3],[33,5,35,5],[39,3,40,3],[39,5,40,5],[42,3,45,3],[42,5,45,5],[46,2,64,2],[54,3,55,3],[54,5,55,5],[56,3,57,3],[56,5,57,5],[59,3,60,3],[59,5,60,5],[63,3,64,3],[63,5,64,5],[65,2,68,2],[65,3,66,3],[65,5,66,5]]}
[]
[]
[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"]
[{"$nulls":3},"1.1 Health promotion, protection and improvement","Patients should be supported to look after their own health and well-being","LR"]
[{"$nulls":4},"Patients should know what care and support services there are to help them"]
[{"$nulls":4},"Patients should be supported to make choices about their own health and wellbeing"]
[{"$nulls":3},"Dignified Care"]
[{"$nulls":3},"4.1 Dignified Care","Patients should be treated with dignity, respect and kindness","LR"]
[{"$nulls":4},"Patients should have their needs are met whatever your religion, language, culture or feelings"]
[{"$nulls":3},"4.2 Patient Information (including consent)","Patients should have good information about their care that is easy to understand"]
[{"$nulls":4},"Patients should be supported to make choices about their care"]
[{"$nulls":3},"3.2 Communicating effectively","Patients should have their communication needs met","PR / LR"]
[{"$nulls":4},"Patients should be able to understand information about their care and health"]
[{"$nulls":4},"Patients are able to tell health services about what they need or what they think"]
[{"$nulls":3},"Timely Care"]
[{"$nulls":3},"5.1 Timely access","Patients should have the right care at the right time in the right place with the right staff","LR"]
[{"$nulls":3},"Individual Care"]
[{"$nulls":3},"6.1 Planning Care to promote independence","Patients should be supported to look after their own health and well-being"]
[{"$nulls":4},"Patients should be able to make choices about their care"]
[{"$nulls":3},"6.2 Peoples rights","All health services must understand and support equality and human rights for everyone","IM / LR"]
[{"$nulls":3},"6.3 Listening and Learning from feedback","Patients and their families should be able to tell health services about the care they get from health services","IM / LR"]
[{"$nulls":4},"Health services should know what is working well and what is not working well"]
[{"$nulls":4},"Health services should be open and honest with patients when they tell them that something has gone wrong"]
[{"$nulls":4},"Health services should learn from what patients tell them and make services better"]
[null,null,"Delivery of Safe and Effective Care","Safe Care"]
[{"$nulls":3},"2.1 Managing risk and promoting health and safety","Health services must look after patient’s health and safety and make sure that any risks are managed as well as they can","IM / PR / LR"]
[{"$nulls":3},"2.4 Infection Prevention and Control (IPC) and Decontamination","Health services should involve everyone in helping to control and stop infections so that people do not get ill","IM / PR / LR"]
[{"$nulls":3},"2.5 Nutrition and Hydration","Patients should be supported to eat and drink so that they can get better quicker","PR / LR"]
[{"$nulls":3},"2.6 Medicines Management ","Patients should get the right medicine at the right time","PR"]
[{"$nulls":3},"2.7 Safeguarding children and adults at risk","Health services must support and protect all children and any adults who are vulnerable or at risk","IM / PR / LR"]
[{"$nulls":3},"2.8 Blood management","Patients should be able to get blood when they need it","PR"]
[{"$nulls":3},"Effective Care"]
[{"$nulls":3},"2.2 Preventing pressure and tissue damage","Patients should be helped to look after their skin"]
[{"$nulls":4},"Health services should make sure that patients do not get sore skin from sitting or lying down for too long"]
[{"$nulls":3},"2.3 Falls Prevention","Health services should check if patients are likely to fall"]
[{"$nulls":4},"Health services should do everything they can to stop people from falling and hurting themselves"]
[{"$nulls":3},"2.9 Medical devices, equipment and diagnostic systems","Health services must make sure that all the equipment they use is safe and works well"]
[{"$nulls":3},"3.1 Safe and Clinically Effective care","Patients should get the right care and support for their needs","IM / PR / LR"]
[{"$nulls":4},"Health services should know the best ways to care and support patients"]
[{"$nulls":3},"3.3 Quality Improvement, Research and Innovation","Health services should look at different ways to make services better based on good research","IM"]
[{"$nulls":3},"3.4 Information Governance and Communications Technology","Health services should have the right information and make sure this information is shared safely"]
[{"$nulls":3},"3.5 Record keeping","It is very important that health services keep good records to make sure patients get the right care","PR"]
[{"$nulls":4},"Health services must follow the rules about how to record information and keep it safe"]
[null,null,"Quality of Management and Leadership","Governance, Leadership and Accountability","All health services should be person centred. They should focus on patient’s needs and listen to them","IM"]
[{"$nulls":4},"Health services should do the right things well, know how well they are doing, be open and honest in everything they do, be caring and kind and work hard"]
[{"$nulls":3},"Staff and Resources"]
[{"$nulls":3},"7.1 Workforce","Health services should have enough staff with the right skills and training to be able to give patients the best care","IM"]

{"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 Hospital"]
[]
[null,null,"Health Board "]
[]
[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":9,"n_cols":3,"rows_kept":9,"merged":[[0,4,0,5],[6,3,6,5],[8,3,8,5]]}
[]
[]
[null,"Arrival and Initial Discussions"]
[]
[]
[]
[null,null,"General observations from discussion with person in charge\n"]
[]
[null,null,"General observations of ward/area and environment\n\nPrompts: Observe the clinical area e.g. general ambience, how busy, noise levels etc. Are the furnishings and fittings in good state of repair and working order, bathrooms and showers, kitchen, telephones, any areas that require maintenance or present any risks to patients and staff? Is the environment clean and tidy? Are there any obvious hazards to patient safety, such as tripping hazards?"]

{"sheet":"Summary","index":3,"n_rows":34,"n_cols":7,"rows_kept":34,"merged":[[7,2,7,4],[7,6,7,7],[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],[15,6,15,7],[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],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[30,2,30,4],[31,2,31,4],[32,2,32,4],[33,2,33,4]]}
[]
[]
[null,"Summary",null,"Key Documents","Issues Identified",null,"Good Practice"]
[]
[]
[null,null,"Quality of Patient Experience","Select outcome statement"]
[]
[null,null,"Standard 3.2 and 4.2 - Communicating effectively ",null,null,{"$f":"Communication!D4","v":"No"},{"$f":"Communication!D5","v":"Select outcome statement"}]
[]
[null,null,"Delivery of Safe and Effective Care","Select outcome statement"]
[]
[null,null,"Standard 2.1 – Managing risk and health and safety ",null,null,{"$f":"'Managing Risk '!D4","v":"No"},{"$f":"'Managing Risk '!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.5 - Nutrition and Hydration",null,null,{"$f":"'Nutrition and hydration'!D4","v":"Yes"},{"$f":"'Nutrition and hydration'!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.6 - Medicines Management",null,null,{"$f":"'Meds Management'!D4","v":"No"},{"$f":"'Meds Management'!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.7 - Safeguarding children and adults at risk",null,null,{"$f":"Safeguarding!D4","v":"Yes"},{"$f":"Safeguarding!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.8 - Blood Management ",null,null,{"$f":"Blood!D4","v":"No"},{"$f":"Blood!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.9 - Medical Devices, Equipment and Diagnostic Systems",null,null,{"$f":"'Medical Devices'!D4","v":"Yes"},{"$f":"'Medical Devices'!D5","v":"Select outcome statement"}]
[null,null,"Standard 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,"Standard 4.1 - Dignified Care",null,null,{"$f":"'Dignified Care'!D4","v":"No"},{"$f":"'Dignified Care'!D5","v":"Select outcome statement"}]
[null,null,"Standard 6.1 - Planning care to promote independence",null,null,{"$f":"'Planning care '!D4","v":"No"},{"$f":"'Planning care '!D5","v":"Select outcome statement"}]
[null,null,"Standard 6.2 - People’s Rights ",null,null,{"$f":"'Peoples Rights'!D4","v":"No"},{"$f":"'Peoples Rights'!D5","v":"Select outcome statement"}]
[null,null,"Standard 2.4 - Infection Prevention and Control (IPC) and Decontamination",null,null,{"$f":"IPC!D4","v":"No"},{"$f":"IPC!D5","v":"Select outcome statement"}]
[]
[null,null,"Case Tracking","Select outcome statement"]
[]
[null,null,"Case tracking – 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,"Case tracking – 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":23,"n_cols":8,"rows_kept":23,"merged":[[5,2,5,7],[8,5,8,6],[9,5,9,6],[10,5,10,6],[11,5,11,6],[12,5,12,6],[13,5,13,6],[16,5,16,6],[17,5,17,6],[18,5,18,6],[19,5,19,6],[20,5,20,6],[21,5,21,6],[22,5,22,6]]}
[]
[null,"Key Document Checking"]
[{"$nulls":7},"Back to Summary"]
[]
[]
[null,null,"As part of our inspection we will need to review the following documents. Please locate these and create copies were requested. In addition to the below, the inspections manager will advise you if any further documentation is required for the inspection. "]
[]
[null,null,"Please create copies of the following documents:"]
[null,null,"Key documents required to complete this section:","Comments:","Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"Local staff training records (if available), staff training matrix","At a minimum this should include mandatory training","Not Checked",null,null,"No"]
[null,null,"Staff rotas (including bank and agency staff use)","For the last 3 months","Not Checked",null,null,"No"]
[null,null,"Staff induction programme","e.g. new staff, agency/bank staff, students","Not Checked",null,null,"No"]
[null,null,"Copies of relevant audits (if not displayed)","e.g. Patient falls, infection control, pressure ulcers, hand hygiene","Not Checked",null,null,"No"]
[null,null,"Relevant organisational management structure (organisation chart)",null,"Not Checked",null,null,"No"]
[]
[null,null,"Please locate the following documents for HIW to review onsite:"]
[null,null,"Key documents required to complete this section:","Comments:","Checked","Findings/Evidence",null,"Improvements required"]
[null,null,"Patients records (including assessment, care, monitoring and medication records)","We will need to see a sample of patient care records/notes (discuss the sample required with the inspection team peer reviewer)","Not Checked",null,null,"No"]
[null,null,"Complaints policy/procedure\nSame of complaints records ","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Sample of incident records","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Sample of staff files, including appraisals, recruitment and pre-employment checks in accordance with Regulatory requirements","Please inform the inspection manager if these are not available for view","Not Checked",null,null,"No"]
[null,null,"Medicines management file/policy",null,"Not Checked",null,null,"No"]
[null,null,"Evidence from staff meetings/shared learning","Please inform the inspection manager if records are not available for view","Not Checked",null,null,"No"]

{"sheet":"Communication","index":5,"n_rows":12,"n_cols":9,"rows_kept":12,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[11,2,11,8]]}
[]
[null,"Quality of Patient Experience -  3.2 Communicating effectively and 4.2 Patient information"]
[]
[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"]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"U",null,null,"Yes","All staff spoken to were aware of the importance of patient confidentiality when collating information during admission process and sharing with information with colleagues during handover. ",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"PSAG boards in SDMU in ward area displaying full patient names,assured consent is gained to display this and if objections raised initials are the put on board as opposed to full name.Difficult to maintain confidentiality in bays both areas owing to bays having 6 beds with only curtains around each bed space. Surgical consultant ward round observed , 2 patients were seen in one 6 bedded bay but curtains were not pulled around patients for their review.Quiet room available for patients and or relatives if breaking bad news. Nursing handover undertaken outside each bay, nurses mindful of where they were in relation to patients when handing over."]

{"sheet":"Managing Risk ","index":6,"n_rows":20,"n_cols":9,"rows_kept":20,"merged":[[1,1,1,9],[7,2,7,4],[8,2,8,3],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[16,2,16,4],[16,6,16,7],[19,2,19,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.1 Managing risk and health and safety "]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[null,null,"Is the environment:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"• Accessible? i.e. is the ward/area accessible for people with mobility difficulties? ",null,null,"Yes","Some clutter in corridors mainly RAU",null,"Yes"]
[null,null,"• Well maintained? i.e.  Are the living arrangements clean and the appliances and furniture well maintained and in good working order?",null,null,"Yes","Bedside tables and chairs in both areas clean and in good condition",null,"No"]
[null,null,"• Fit for purpose? Is the environment suitable for the way it’s used? Is the ward locked?",null,null,"Yes","Doors not locked for either SDMU or RAU areas",null,"Yes"]
[null,null,"• Safe and secure? i.e.  Are there any hazards to patient safety visible? Are the call bells for those who are in bed easy to reach?",null,null,"Yes","Several bed areas with property on floor in SDMU, not evident in RAU.Patients in both areas had call bells at hand",null,"Yes"]
[]
[null,null,"Does the environment protect patient privacy? i.e. Are there areas where staff can speak to patients where they cannot be overheard by others?",null,null,"Yes","SDMU- quiet room available if patients clinically well enough to go to",null,"No"]
[null,null,"Have environmental hazards been considered?",null,null,"Yes","Equipment stored in SDMU waiting room",null,"Yes"]
[null,null,"Are cleaners cupboards and any chemicals been locked to prevent unauthorised access?",null,null,"Yes","Utility rooms have keypad access but both doors open",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"RAU had some clutter in corridors, notes trolley , bedside table and plastic chair situated directly outside the 6 bedded bay causing potential hazard for patients leaving the ward for toilet purposes. Neither area have locked entrances. Staff highlighted an incident yesterday when a patient was fortunately seen trying to leave the ward and escorted back to their bedside.Patients kept in overnight in SDMU triage area had property strewn on floor causing a potential trip hazard. Keypad access on both utility room doors but neither locked"]

{"sheet":"Nutrition and hydration","index":7,"n_rows":17,"n_cols":9,"rows_kept":17,"merged":[[1,1,1,9],[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],[16,2,16,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.5 Nutrition and hydration "]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[]
[null,null,"If possible, watch a meal time on the ward (this may be applicable depending on the area i.e. speak to your inspection manager about this if you are unsure) and consider the following:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Is there a system in place to identify patients who need assistance to eat? e.g. red tray or patient status at a glance board",null,null,"Yes","Staff aware of red tray system but not evidently in use, psag boards highlighting nil by mouth but no special dietary needs on display",null,"Yes"]
[null,null,"Are patients given the help they need to eat and drink?",null,null,"Yes","No patients identified as requiring assistance but assured that nursing staff would be available to assist if required",null,"No"]
[null,null,"Is there implementation of the All Wales nutrition pathway?",null,null,"Yes","All wales nutrition pathway in use",null,"No"]
[null,null,"Are meals served to patients in a timely way once the food trolley arrives? \n• Timing of meals throughout the day (not too close together or far apart)\n• How long are patients waiting to be served their meals?\n• Do they also need to wait for assistance to eat their meal?",null,null,"Yes","Can be delays as limited hostess service",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Patients are offered meals 3 times a day.SDMU have hostess to give out breakfast and lunch, nursing staff have to administer tea. This can cause delays depending on unit activity at that time. RAU have no ward hostess and all meals have to be given out by nursing staff. If several patients require assistance there are inevitable delays for some patients. Relatives encouraged to help with feeding. Sandwiches available for patients presenting out of hours to SDMU. Patients on the whole are happy with meals although there appears to be significant amount of leftover food "]

{"sheet":"Meds Management","index":8,"n_rows":53,"n_cols":9,"rows_kept":53,"merged":[[1,1,1,9],[8,2,8,8],[10,2,10,3],[10,6,10,7],[11,2,11,3],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[16,2,16,3],[16,6,16,7],[17,2,17,3],[17,6,17,7],[18,2,18,3],[18,6,18,7],[19,2,19,3],[19,6,19,7],[20,2,20,4],[20,6,20,7],[21,2,21,4],[21,6,21,7],[22,2,22,3],[22,6,22,7],[23,2,23,3],[23,6,23,7],[25,2,25,3],[26,2,26,3],[26,6,26,7],[27,2,27,3],[27,6,27,7],[29,2,29,8],[30,6,30,7],[31,2,31,3],[32,2,32,3],[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],[40,2,40,4],[40,6,40,7],[41,2,41,4],[41,6,41,7],[42,2,42,4],[42,6,42,7],[43,6,43,7],[44,2,44,4],[44,6,44,7],[45,2,45,4],[45,6,45,7],[46,2,46,4],[46,6,46,7],[47,2,47,4],[47,6,47,7],[48,2,48,4],[48,6,48,7],[52,2,52,8]]}
[]
[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,"When you consider the medicines management documentation and records, consider looking at the same patients as in the case tracking. You may need to speak to staff to assist you with understanding and reviewing this information."]
[]
[null,null,"Are the All Wales Drug Charts completed correctly? Including:",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"• Are they consistently signed and dated when prescribed and administered?",null,null,"Yes","All dated and signed",null,"No"]
[null,null,"• Are patient names/ID recorded throughout?",null,null,"Yes","Demographics insitu",null,"No"]
[null,null,"• Is it clear what has been administered – including any self administered medication?",null,null,"Yes","All medication administered is signed for. Disclaimer signed by patients in patient care record if own medications brought into hospital and are being used. ",null,"No"]
[null,null,"• If prescribed medication is not administered, is a reason clearly recorded?",null,null,"Yes","Codes in use for any omitted medications",null,"No"]
[]
[null,null,"Does the ward have a dedicated pharmacist?",null,null,"Yes","Ward based pharmacists in both areas",null,"No"]
[null,null,"What are the arrangements for accessing medicines out of hours",null,null,"Yes","Both areas have access to emergency drug cupboard within the hospital and are able to contact on call pharmicist if essential medication not available",null,"No"]
[null,null,"Is all administered oxygen prescribed on the All Wales Drugs Chart?",null,null,"Yes","Oxygen section and saturation levels filled in on 6 out of 8 drug charts seen",null,"Yes"]
[null,null,"Is the administration of oxygen being monitored and recorded?",null,null,"Yes","Patient in SDMU overnight on oxygen. Handover plan to wean oxygen. No documentation in nursing notes about oxygen requirements and saturations but recorded on news chart.",null,"Yes"]
[null,null,"Are intravenous fluids being prescribed on the All Wales Medication Administration Record?",null,null,"Yes",null,null,"No"]
[null,null,"Are IV fluids being monitored and recorded on the All Wales fluid balance charts?",null,null,"Yes","Fluid balance charts not completely filled in, gaps evident",null,"Yes"]
[null,null,"Is medicine administration being recorded consistently and contemporaneously? ",null,null,"Yes","No nursing documentation to state medication administered . Only evidence is signed drug chart",null,"Yes"]
[null,null,"Where is the medicines management policy/ medicines manage file stored?",null,null,"Yes","Sisters office to treatment room",null,"No"]
[]
[null,null,"Is the following information readily available for staff either on paper or electronically?:"]
[null,null,"• Self administration of meds",null,null,"Yes","All accessed via intanet",null,"No"]
[null,null,"• Safe storage, prescription, administration and dispensing of drugs",null,null,"Yes","All accessed via intranet",null,"No"]
[]
[null,null,"Ask staff to gain access to the medicines area/room (NB - you should not be left unattended in the medicines room) and speak to a nurse regarding medicines management. Consider the following:"]
[]
[null,null,"Are all drugs, including controlled drugs, stored securely?:"]
[null,null,"• Locked cupboards?",null,null,"Yes","SDMU - drug cupboards not locked , outer door to drug room has kep pad access. At time of visit outer door open and drug cupboards unlocked",null,"Yes"]
[null,null,"• Locked and secured medicines trolleys?",null,null,"Not applicable","Medication trollies not in use.medications dispensed from cupboards in locked drug room ",null,"No"]
[null,null,"• Locked fridges?",null,null,"Yes",null,null,"No"]
[null,null,"• Bedside lockers?",null,null,"Yes","No medication stored in bedside lockers as no locks",null,"No"]
[null,null,"Are controlled drugs recorded and signed for correctly?",null,null,"Yes","CD book completed in full by two nurses for each drug administration",null,"No"]
[null,null,"Is there a regular stock check of controlled drugs against the logbook?",null,null,"Yes","CD drugs checked every night and recorded on sheets at back of CD book. Pharmacy carry out ad his audits of same",null,"No"]
[null,null,"Are fridge temperatures monitored consistently? i.e. daily",null,null,"Yes","Checked every night and recorded alongside CD checks",null,"No"]
[]
[null,null,"Watch a medicines round on the ward and consider the following:"]
[null,null,"Do all patients have identification bands? Are they checked? (check back with case tracking)",null,null,"Yes","All patients in both areas had name bands insitu",null,"No"]
[null,null,"Are children and young people weighed so that medication is correctly titrated to their body size?",null,null,"Not applicable","Adult assessment areas",null,"No"]
[null,null,"Are medicines checked and administered to patients appropriately?",null,null,"Yes",null,null,"No"]
[null,null,"Do patients receive support where necessary to take their medication?",null,null,"Yes",null,null,"No"]
[null,null,"Are parents, carers and guardians supported to understand the medications being given so that they can continue with any administration necessary after discharge from the ward?",null,null,"Yes",null,null,"No"]
[null,null,"Are drugs trolleys left unattended at any time during the medicines round?",null,null,"Not applicable","No drug trollies in use",null,"No"]
[null,null,"Is there a system for safe, calm administration of medicines? E.g. red tabards",null,null,"No","No protected drug administration time",null,"Yes"]
[null,null,"Is medication left on patient lockers?",null,null,"Yes","Nil observed at time of audit",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[]
[null,null,"Some gaps in completion of oxygen prescription and target saturations section on drug charts,one patient observed to be on oxygen but no evidence of this in nursing documentation. Gaps in fluid balance chart, all intravenous fluids prescribed and signed for. Medications administered were all signed for but no entries in nursing documentation around medication medications given and response to same I.e analgesia. No protected drug administration time, some nurses not familiar with red tabard system. Drug. Up boards on SDMU unlocked for 'ease of access' , outer door had keypad access but unfortunately this was also open at time of visit. Staff. Loses door on highlighting concern. "]

{"sheet":"Safeguarding","index":9,"n_rows":16,"n_cols":9,"rows_kept":16,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,3],[9,6,9,7],[10,2,10,3],[10,6,11,7],[11,2,11,3],[12,2,12,4],[12,6,12,7],[15,2,15,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.7 Safeguarding children and adults at risk"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Are there locked doors to the ward/area and is there anything preventing patients from leaving?",null,null,"Yes","Neither area has locked access",null,"Yes"]
[null,null,"Are any patients under constant supervision?",null,null,"Yes","2 patients on RAU requiring enhanced care but no additional nursing support and DOLS had not been initiated",null,"No"]
[null,null,"If yes to the above, have staff considered DOLS?",null,null,"Yes",null,null,"Yes"]
[null,null,"What is the understanding of staff around DOLS, mental capacity and safeguarding? Is there sufficient awareness to show they have completed recent training?",null,null,"Yes","Staff spoken to are familiar with Dols but would need some support to complete paperwork as used infrequently",null,"Yes"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Staff spoken to were aware of Dols and safeguarding but felt they would need support in completing paperwork. One patient on RAU had been seen attempting to leave the unit, escorted back to bed but no DOLS or enhanced care paperwork in place .The two at risk patients were known to all staff but no formal documentation initiated. Staff would like more training on DOLS and safeguarding."]

{"sheet":"Blood","index":10,"n_rows":21,"n_cols":9,"rows_kept":21,"merged":[[1,1,1,9],[8,2,8,8],[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],[14,2,14,3],[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,"Delivery of Safe and Effective Care - 2.8 - Blood Management (only if applicable- check with your inspection manager)"]
[]
[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,"Speak to senior staff including the ward sister, if available. Depending on their availability, you may need to join the inspection manager for discussions with senior staff. Check this with your inspection manager if you are unsure. "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[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,"Any additional comments:"]

{"sheet":"Medical Devices","index":11,"n_rows":17,"n_cols":9,"rows_kept":17,"merged":[[1,1,1,9],[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],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[16,2,16,8]]}
[]
[null,"Delivery of Safe and Effective Care - 2.9 Medical Devices, Equipment and Diagnostic Systems"]
[]
[null,null,"Completed","Yes"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Does the ward have the right equipment and medical devices to meet the needs of patients? i.e. hoists,  monitoring equipment, commodes, walkers, pressure ulcer mattresses etc.",null,null,"Yes","Both areas report good supply of monitoring equipment. Pressure ulcer mattresses in use both areas. Sit down weighing scales needed for SDMU",null,"Yes"]
[null,null,"What are the maintenance arrangements for equipment? i.e.:"]
[null,null,"• Who is responsible for maintaining equipment?",null,null,"Yes","Reported to medical electronics",null,"No"]
[null,null,"• Are there labels showing when the equipment was last checked/services? Are these in date?",null,null,"Yes","All devices labelled with date maintenance check next due",null,"No"]
[null,null,"Are there arrangements for reporting faults with equipment?",null,null,"Yes","Staff inform ward manager and receptionist asked to report to medical electronics. Equipment then stored aside until maintenance/repair undertaken. ",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Both areas felt they had enough manual handling equipment, infusion devices and access to pressure relieving mattresses. RAU expressed concerns around lack of blood pressure machines and tympanics, SDMU highlighted need for sit down weighing scales particularly for their vascular patients who usually have mobility problems and find it difficult to be weighed for weight dependent medication prescription.Good reporting system for faulty equipment, same stored in rooms off corridor to avoid clutter. All equipment had clear labelling for maintenance due checks ."]

{"sheet":"Safe Care","index":12,"n_rows":47,"n_cols":9,"rows_kept":47,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,3],[12,6,12,7],[13,2,13,3],[13,6,13,7],[14,2,14,3],[14,6,14,7],[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],[20,6,20,7],[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],[25,6,25,7],[26,6,26,7],[27,6,27,7],[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],[34,2,34,4],[34,6,34,7],[35,2,35,3],[35,6,35,7],[36,2,36,3],[36,6,36,7],[37,2,37,4],[37,6,37,7],[38,2,38,3],[38,6,38,7],[39,2,39,3],[39,6,39,7],[40,2,40,4],[40,6,41,7],[41,2,41,4],[46,2,46,8]]}
[]
[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,"How does the ward 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 ward ensure possible cases of sepsis are identified as soon as possible (including both children and adults)? ",null,null,"Yes","Staff trained in sepsis recognition and sepsis care bundle. SDMU aim to triage their patients within 15 minutes in order to have early recognition of sepsis. ",null,"No"]
[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","Sepsis care bundle and news scoring in use",null,"No"]
[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","Initial training but no regular updates",null,"No"]
[null,null,"How are cases of sepsis managed effectively and according to best practice guidelines? ",null,null,"Yes","Both areas have medical/surgical doctors based on ward so no problem getting antibiotics prescribed with the one hour target.Patients in SDMU are triaged within 15 minutes which ensures early recognition of sepsis",null,"No"]
[null,null,"Is there a sepsis pathway in place with associated Sepsis Six care bundle? ",null,null,"Yes","Sepsis bundle and sepsis trollies in use both areas",null,"No"]
[null,null,"How do staff ensure consistent, effective, clinical management of cases?",null,null,"Yes","Early recognition of sepsis and commencement of treatment within a timely manner",null,"No"]
[null,null,"Ward Staff"]
[null,null,"Do you feel you have enough time to provide care safely?",null,null,"Yes","Some days are more difficult than others. As activity in both areas is unpredictable in terms of admissions and patient flow there is a tendency to 'get things done as quickly as possible'  ",null,"No"]
[null,null,"Do you feel that the number of staff on the ward is appropriate to meet the needs of the patients?",null,null,"Yes","Heavy reliance on agency staff in both areas. Ther are days when full staffing compliment but most days ther are staffing deficits which impact on patient care.Not always additional staff available for enhanced care patients",null,"Yes"]
[null,null,"Do you know how to access the relevant clinical policies and procedures?",null,null,"Yes","All policies accessible on intranet",null,"No"]
[null,null,"Do you (Registered Nurses) know how to access the NMC Record Keeping Guidance for Nurses and Midwives?",null,null,"Yes",null,null,"No"]
[null,null,"Are you aware of patient safety notices?",null,null,"Yes",null,null,"No"]
[null,null,"Does the ward have a system to ensure patients receive routine, safe, effective and systematic care? E.g. intentional rounding",null,null,"Yes","Intentional rounding not evident in either area",null,"Yes"]
[null,null,"What is staff’s understanding/awareness of sepsis and how they would manage sepsis cases?",null,null,"Yes","Discussion with 3rd year student nurse. Aware of sepsis 6, triggers for initiating bundle",null,"No"]
[null,null,"Senior Manager Discussions"]
[null,null,"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,"Not Completed",null,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,"Not Completed",null,null,"Not Completed"]
[null,null,"Are all staff 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,"Not Completed",null,null,"Not Completed"]
[]
[]
[null,null,"NURSE STAFFING LEVELS (WALES) ACT\nRELATES TO : Acute Medical Inpatient, or Acute Surgical Inpatient wards."]
[null,null,"What is the agreed level for this ward? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Can senior staff confirm that it is being adhered to today?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[null,null,"Is there a system for patient status? e.g. Are patient status at a glance boards used?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"If yes, are these up-to-date, accurate, and include all relevant information?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"Is there evidence of participation in national Quality Improvement programmes – Epilepsy 12 and National Diabetes Quality Programme in Paediatric Care?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"• If yes, are staff aware of these and do they consider that this contributes to improved quality in their work? ",null,null,"Not Completed",null,null,"Not Completed"]
[]
[]
[]
[null,null,"Summary / Conclusion"]
[null,null,"All staff spoken to were aware of the sepsis six and sepsis care bundle. Aware that early recognition is key and treatment needs to be started in a timely manner. Nurses on SDMU have PGD directive and are able to administer first line analgesia . Medical and surgical staff are based on each unit respectively and are amenable to prescribing early antibiotics as per sepsis bundle.Staff on the whole felt constantly working below their safe staffing levels was having an impact on patient care and well being of staff. Heavy reliance on agency nurses although both areas had regular agency staff which made things easier. Staff aware audits were regularly undertaken but did not always get feedback on how the audit went. Limited audit results visible on notice boards in both areas. Some staff felt they did not have enough time to complete mandatory and statutory training and were reluctant to do it in their own time or on days off. Staff aware of how to access policies but had very little time to read them and usually only access policies when something arises relating to that issue."]

{"sheet":"Dignified Care","index":13,"n_rows":18,"n_cols":9,"rows_kept":18,"merged":[[1,1,1,9],[8,2,8,4],[8,6,8,7],[9,2,9,4],[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],[14,2,14,3],[14,6,14,7],[17,2,17,8]]}
[]
[null,"Delivery of Safe and Effective Care - 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"]
[]
[{"$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","Yes",null,"No"]
[null,null,"What arrangements are in place to ensure Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) discussion and decision making is undertaken appropriately and sensitively?",null,null,"Yes","Medical/surgical teams act in patients best interest and will involve patients (if able) and relatives in decision making",null,"No"]
[null,null,"Are there any issues with the ward environment which impact on patient dignity and respect?",null,null,"Yes","Mixed sex bays",null,"Yes"]
[null,null,"Are staff discreet when administering personal care?",null,null,"Yes","Curtains pulled but difficult to maintain complete privacy and dignity",null,"Yes"]
[null,null,"Have patients continence needs been assessed?",null,null,"Yes","Completed as part of admission paperwork",null,"No"]
[null,null,"Are patients given appropriate help with continence needs?",null,null,"Yes","Continence products available in both areas",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Mixed sex beds in both areas. Patients are not informed prior to admission to the ward. Most patients accept this but if concerns raised attempts are made to relocate or move patients around.Difficulty in maintaining privacy and dignity when only curtains separate male and female beds "]

{"sheet":"Planning care ","index":14,"n_rows":14,"n_cols":9,"rows_kept":14,"merged":[[1,1,1,9],[7,2,7,4],[7,6,7,7],[8,2,8,4],[8,6,8,7],[9,2,9,4],[9,6,9,7],[10,2,10,4],[10,6,10,7],[13,2,13,8]]}
[]
[null,"Delivery of Safe and Effective Care - 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"]
[{"$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","SDMU encourage use of this is me booklet and use if butterfly on psag board. RAU staff x 2 not familiar with butterfly system and no evidence it is being utilised.",null,"Yes"]
[null,null,"Are there signs in place on toilet doors etc. to help assist patients with sensory problems or cognitive difficulties?",null,null,"No","No signage visualised",null,"Yes"]
[null,null,"Are patients encouraged to be active and given equipment to help them walk, move, eat, hear, see etc.?",null,null,"Yes","Steady transfer aid to assist with patient transfer, physio provide sticks/zimmer frames if required following assessment. Staff assured me if patients are unable to maintain their independence because of lack of equipment then assistance is given ",null,"No"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Some staff aware of butterfly symbol but nothing visualised on psag boards despite dementia patients being in ward.Very limited signage to aid people with cognitive/sensory deficits "]

{"sheet":"Peoples Rights","index":15,"n_rows":19,"n_cols":9,"rows_kept":19,"merged":[[1,1,1,9],[9,2,9,9],[10,6,10,7],[11,2,11,4],[11,6,11,7],[12,2,12,4],[12,6,12,7],[13,2,13,4],[13,6,13,7],[14,2,14,4],[14,6,14,7],[18,2,18,8]]}
[]
[null,"Delivery of Safe and Effective Care - 6.2 People’s Rights "]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Key Document Section","Issues identified",null,"Good Practice identified","Back to Guidance"]
[]
[]
[null,null,"You may need to speak to one or staff members to cover the below, depending on their availability. Consider speaking to healthcare support workers as well as registered nurses. Please note the role and initials of each staff member you speak to. "]
[{"$nulls":5},"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"How are patient’s individual needs considered on the ward? i.e. spiritual, cultural",null,null,"Yes","Staff address patients vidual needs and provide care and dietary requirements wher possible",null,"No"]
[null,null,"Are patients able to receive visitors within reasonable hours, sensitive to the needs of others?",null,null,"Yes","Visiting permitted during designated hours but dependent on patients needs can be flexible and other patients in that bay will be considered. Staff on SDMU highlighted an issue whereby relatives of a patient turne up at 03;45 this morning to visit their mum who had been to theatre earlier despite being reassured by telephone that she was doing well and no recovering as expected",null,"No"]
[null,null,"Are patients, family/carers able to provide assistance with and be involved in the patients care? ",null,null,"Yes","Visitors in both areas observed assistaing their relatives with hydration and snacks",null,"No"]
[null,null,"If a patient is critically ill, can relatives or carers stay overnight?",null,null,"Yes","Where possible patients would be nursed in a cubicle if very unwell and relatives would be able to stay overnight. This is not always achievable and there have been 2 instances recently wher patients have died in a six bedded bay with families present.",null,"No"]
[]
[]
[null,null,"Any additional comments:"]
[null,null,"Where possible staff will go above and beyond to facilitate patients spiritual,  cultural and individual needs,but this is very often hampered by restrictions within the environment "]

{"sheet":"IPC","index":16,"n_rows":57,"n_cols":9,"rows_kept":57,"merged":[[1,1,1,9],[8,6,8,7],[9,6,9,7],[10,6,10,7],[11,6,11,7],[13,2,13,4],[14,2,14,4],[14,6,14,7],[15,2,15,4],[15,6,15,7],[17,2,17,4],[17,6,17,7],[18,2,18,4],[18,6,18,7],[19,2,19,4],[19,6,19,7],[21,2,21,4],[21,6,21,7],[23,6,23,7],[24,2,24,4],[24,6,24,7],[25,2,25,4],[25,6,25,7],[26,2,26,4],[26,6,26,7],[27,2,27,4],[27,6,27,7],[29,2,29,4],[29,6,29,7],[31,2,31,4],[32,2,32,4],[32,6,32,7],[33,2,33,4],[33,6,33,7],[34,6,34,7],[35,6,35,7],[36,2,36,4],[36,6,36,7],[37,2,37,4],[37,6,37,7],[40,2,40,3],[40,6,40,7],[41,2,41,4],[41,6,41,7],[42,2,42,3],[42,6,42,7],[45,2,45,4],[45,6,45,7],[46,2,46,4],[46,6,46,7],[47,2,47,4],[48,2,48,4],[48,6,48,7],[49,2,49,4],[49,6,49,7],[50,2,50,4],[50,6,50,7],[51,2,51,4],[51,6,51,7],[52,2,52,4],[52,6,52,7],[55,2,55,4],[56,2,56,8]]}
[]
[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,"Is PPE used appropriately?",null,null,"Question answered?","Findings/Evidence",null,"Improvements required"]
[null,null,"Accessible, stored and in stock",null,null,"Yes",null,null,"No"]
[null,null,"Changed between each task/patient",null,null,"Yes",null,null,"No"]
[null,null,"Correct donning/removal to minimise transmission of infection",null,null,"Yes","Gloves not always removed prior to going onto next task",null,"No"]
[]
[null,null,"Is hand hygiene (HH) is appropriate and effective?"]
[null,null,"Do staff conduct HH between task/patient appropriately?",null,null,"Yes","Some missed opportunities for hand washing",null,"Yes"]
[null,null,"Are HH facilities/products accessible, stored and stocked appropriately?",null,null,"Yes",null,null,"No"]
[]
[null,null,"Does the environment appear visibly clean and free from clutter?",null,null,"Yes",null,null,"No"]
[null,null,"Are high/low levels are free from dust/dirt e.g. Bed base, curtain rail, corners?",null,null,"Yes",null,null,"No"]
[null,null,"Is equipment, sluice and cleaners cupboards stored and organised appropriately, with segregation of cleaning equipment?",null,null,"Yes",null,null,"No"]
[]
[null,null,"Is shared equipment and reusable medical devices decontaminated appropriately? e.g. IV pump, commode, mattress, BP cuff, handling devices ",null,null,"No","no cuffs not wiped down between patients",null,"Yes"]
[]
[null,null,"Does the environment enable effective infection control?",null,null,"Yes",null,null,"No"]
[null,null,"Is it in a good state of repair to enable effective cleaning? E.g. Walls/ceilings/floors intact, free from defect",null,null,"Yes",null,null,"No"]
[null,null,"Is there adequate provision of single and/or isolation room?  E.g. All known and suspected infectious patients can be isolated in a timely manner, single/isolation rooms facilitates IPC",null,null,"Yes","Constant struggle and juggling of beds to create cubicle capacity",null,"Yes"]
[null,null,"Safer sharp devices used",null,null,"Yes",null,null,"No"]
[null,null,"Sharps and bins are used/disposed of safely",null,null,"Yes","All sharps bins signed and dated post assembly and closure",null,"No"]
[]
[null,null,"Is there information on infection rates shared with staff/public/patients? E.g. Display boards, info leaflets, reports",null,null,"Yes","Results of audits not updated on boards",null,"Yes"]
[]
[null,null,"Speak to ward staff (registered nurses, healthcare support workers and housekeeping staff) about infection control. Consider the following:"]
[null,null,"What’s your understanding of infection control and your role?",null,null,"Yes","Patient and staff safety and well being is paramount and poor adherence to infection control principles canincrease patients length of stay and delay recovery ",null,"No"]
[null,null,"How would you access the infection control policy?",null,null,"Yes","Intranet or contact infection control",null,"No"]
[null,null,"Can you describe your hand hygiene regime? ",null,null,"Yes","Bare below the elbow, wash hands at every opportunity, between patient contact. Wears gloves for procedures/personal care of patients (HCSW)",null,"No"]
[null,null,"Do you know what to do following needle stick injury?",null,null,"Yes","Run under col water, squeezing blood from puncture wound. Inform nurse in charge, attend occupational health or a &e , dating, blood taken form injured person and patient following consent.(RN)",null,"No"]
[null,null,"How do you decontaminate shared equipment and reusable medical devices? E.g. how often, what do you use, what’s high/low risk",null,null,"Yes","Should be wiped down with clitellum wipe or soap and water after each patient contact but it's not always done (HCSW)",null,"No"]
[null,null,"Are there any current outstanding IPC estates requests? E.g. painting, repair, replacement",null,null,"Yes","Several works requests for general maintenance outstanding",null,"Yes"]
[]
[null,null,"Speak to housekeeping staff about the following:"]
[null,null,"What’s your role?",null,null,"Yes","Giving out meals,replenishing water and helping domestic staff. Sores ordering and unpacking of stores, reporting faulty equipment, raising works requests",null,"No"]
[null,null,"What are cleaning schedules for the ward e.g. deep cleaning areas and procedures for outbreak etc.?",null,null,"Yes","No cleaning audits visible but assured they are completed daily and entered onto monthly health care standards. Matrix signed daily and visibly displayed",null,"Yes"]
[null,null,"Do you have the right equipment?",null,null,"Yes","Mostly",null,"No"]
[]
[null,null,"COVID-19 "]
[null,null,"What changes were made due to COVID-19 e.g. social distancing, cleaning, PPE, specific COVID-19 training, pre-screening for COVID-19, patient visiting, risk assessments, COVID-19 testing",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"How do you identify and effectively manage COVID-19 outbreaks / nosocomial transmission?  ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"If there have been any cases in the past three months:"]
[null,null,"a. How did you discuss this with all ward staff?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"b. Did you follow your Health Board’s policy?",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"c. Were you able to identify the root cause? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"d. Were action plans created and implemented? ",null,null,"Not Completed",null,null,"Not Completed"]
[null,null,"e. How did you share lessons learnt?",null,null,"Not Completed",null,null,"Not Completed"]
[]
[]
[null,null,"Any additional comments:"]
[null,null,"Some missed opportunities with hand washing and removal of gloves and aprons between patients. Good supply of PPE evident. Shared medical devices I.e BP machines not iPad down between patients despite staff knowing this should be done"]

{"sheet":"Case Tracking Part 1","index":17,"n_rows":89,"n_cols":9,"rows_kept":89,"merged":[[0,8,0,9],[1,1,1,9],[10,2,10,6],[11,2,11,6],[12,2,12,6],[14,3,14,6],[15,3,15,6],[16,3,16,6],[17,3,17,6],[18,3,18,6],[19,3,19,6],[20,2,20,9],[21,2,21,9],[22,8,22,9],[23,8,23,9],[24,2,24,9],[25,8,25,9],[26,8,26,9],[27,8,27,9],[28,8,28,9],[29,3,29,9],[30,2,30,9],[31,8,31,9],[32,8,32,9],[33,8,33,9],[34,8,34,9],[35,8,35,9],[36,3,36,9],[37,2,37,9],[38,8,38,9],[39,8,39,9],[40,8,40,9],[41,3,41,9],[42,2,42,9],[43,8,43,9],[44,8,44,9],[45,8,45,9],[46,8,46,9],[47,8,47,9],[48,8,48,9],[49,3,49,9],[50,2,50,9],[51,8,51,9],[52,8,52,9],[53,8,53,9],[54,8,54,9],[55,3,55,9],[56,2,56,9],[57,8,57,9],[58,8,58,9],[59,8,59,9],[60,3,60,9],[61,2,61,9],[62,8,62,9],[63,8,63,9],[64,8,64,9],[65,8,65,9],[66,8,66,9],[67,8,67,9],[68,2,68,9],[69,8,69,9],[70,8,70,9],[71,8,71,9],[72,8,72,9],[73,8,73,9],[74,8,74,9],[75,8,75,9],[76,2,76,9],[77,8,77,9],[78,8,78,9],[79,2,79,9],[80,8,80,9],[81,8,81,9],[82,8,82,9],[83,8,83,9],[86,2,86,9]]}
[]
[null,"Case tracking – Part 1: Review of patient records"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified"]
[]
[]
[null,null,"Case Tracking guidance"]
[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. "]
[null,null,"Guidance 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. "]
[null,null,"Where aspects of the case tracking areas are not applicable – please clearly state this as N/A. Do not just leave the area blank."]
[]
[{"$nulls":3},"Patient Identifier"]
[null,null,"A","XXX"]
[null,null,"B","XXX"]
[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?                                  What is the structure / layout like?                  How have notes been organised? \nIf you were an agency staff – would you be able to look after the patient from their notes?","Notes not always filed and loose in case note folder but being assessment area no clerk overnight this may well be acceptable until clerk comes on duty in the morning"]
[null,null,"Areas to consider","A","B","C","D","E","Comments"]
[null,null,"Safeguarding – Mental capacity and DOLS*"]
[null,null,"Are there mental capacity assessments in place on admission?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Are there clear records on decisions around patient’s mental capacity and any DOLS authorisations?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Are the DOLS authorisations valid and up-to-date?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"What recommendations have been made on DOLS authorisations and are these in place?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on safeguarding and records around DOLS and mental capacity? Why have you come to that conclusion?","Patient care record"]
[null,null,"Nutrition and hydration "]
[null,null,"Is a nutritional risk assessment being completed for all patients within 24 hour of admission? ","Yes","Yes","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,"Has a care plan been developed and a referral been made to dietician or SALT if appropriate?","N/A","No","N/A","N/A","N/A"]
[null,null,"Is there an oral care plan in place?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Are patients who are nil by mouth being assessed appropriately?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"What is your overall assessment of nutrition and hydration? Why have you come to that conclusion?","All Wales care nutrition pathway in use "]
[null,null,"Sepsis"]
[null,null,"Where appropriate has sepsis been considered? Has screening been carried out where appropriate (e.g. National Early Warning Score; Inpatient screening and action tool)?","Yes","N/A","N/A","N/A","N/A"]
[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?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Have appropriate actions been taken in relation to sepsis? Have staff acted promptly and followed their local protocol? (Where applicable).","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?","Staff very familiar with sepsis recognition and treament"]
[null,null,"Preventing pressure and tissue damage"]
[null,null,"Are patients assessed for pressure ulcer risk on admission?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there evidence of appropriate skin assessment?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there an appropriate care plan developed and documented in line with risk assessment score?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there evidence of frequent repositioning day and night? i.e. SKIN Bundle, Repositioning, Turning charts, Carer's Log etc.?","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Is there ongoing monitoring of pressure areas?","Yes","Yes","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?","Good documentation and completion of risk assessment and skin bundles"]
[null,null,"Falls prevention "]
[null,null,"Have initial falls risk assessments been documented for any patient in hospital with intention to assess or admit for greater than 6 hours?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there a specialist falls service? ","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Where the patient is at risk of falls, is there up-to-date plan of care, tailored to the patient (not generic) which is being implemented and evaluated?","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?\n","Lots of information around falls in both areas, risk assessments completed and updated"]
[null,null,"Pain management "]
[null,null,"Is there evidence that pain is being measured, actioned and evaluated? E.g. are pain assessment tools in place, actioned and reviewed/evaluated?","Yes","No","N/A","N/A","N/A"]
[null,null,"Do patients have an up to date pain score?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Are pain scores being managed? E.g. use of suitable analgesic and administered on a regular basis as opposed to 'as required' (PRN)","Yes","Yes","N/A","N/A","N/A"]
[null,null,"What is your overall assessment on pain management?\nWhy have you come to that conclusion?","Discussions with patients confirm good pain management"]
[null,null,"Assessment "]
[null,null,"Do patients have their needs promptly assessed on admission?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Have other relevant risk assessments been undertaken?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Do patient records reflect the risks identified and the actions required?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Has the patient’s language choice/preference been recorded as being asked?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Has the patient’s language choice/preference been recorded as a decision?","Yes","Yes","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","N/A","N/A","N/A","N/A","N/A"]
[null,null,"Planning care to promote independence "]
[null,null,"Is all the care given documented in the patients care plan/records?","No","No","N/A","N/A","N/A"]
[null,null,"Are decisions being documented such as Do Not Attempt to Resuscitate (DNAR)?","No","N/A","N/A","N/A","N/A"]
[null,null,"Are care plans based on individualised patient need?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is there clear evidence of transfer of care/ discharge planning?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"If a patient is about to be discharged – is there evidence of appropriate packages in place, e.g. district nurse referral?","Yes","N/A","N/A","N/A","N/A"]
[null,null,"Is it recorded that the patient is medically fit to be discharged?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Is care planned in a way that promotes independence?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Delivery and effectiveness and evaluation"]
[null,null,"Is the effectiveness of care evaluated regularly?","Yes","Yes","N/A","N/A","N/A"]
[null,null,"Are the patients’ records up to date and completed immediately after care and treatment?","No","No","N/A","N/A","N/A"]
[null,null,"Ward 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","Yes","N/A","N/A","N/A"]
[null,null,"Is there evidence that other members of the MDT team contribute to the patients care plan?\nIs this clear?","Yes","Yes","N/A","N/A","N/A"]
[]
[null,null,"Summary/Conclusion"]
[]
[]
[null,null,"Back to top"]

{"sheet":"Case Tracking Part 2","index":18,"n_rows":21,"n_cols":8,"rows_kept":21,"merged":[[0,7,0,8],[1,1,1,8],[9,2,9,8],[10,3,10,6],[10,7,10,8],[11,3,11,6],[11,7,11,8],[12,3,12,6],[12,7,12,8],[13,3,13,6],[13,7,13,8],[14,3,14,6],[14,7,14,8],[15,3,15,6],[15,7,15,8],[18,2,18,8]]}
[]
[null,"Case tracking – Part 2: How do patient records compare to practice?"]
[]
[null,null,"Completed","No"]
[null,null,"Outcome","Select outcome statement"]
[]
[null,null,"Back to Summary","Issues identified","Good Practice identified","Case Tracking guidance"]
[]
[]
[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":3},"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":19,"n_rows":18,"n_cols":8,"rows_kept":18,"merged":[[1,1,1,8],[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],[14,2,14,4],[14,5,14,6],[17,2,17,7]]}
[]
[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",null,null," Clear medical plans based on clinical assessment, pathology and radiological findings. Evidence of discussions with patients regarding treatment and management plan ",null,"Not Completed"]
[null,null,"Good quality in terms of accuracy, being up to date, complete, understandable and contemporaneous",null,null,"Entries by nursing and medical staff signed and dated. Most entries clear and legible",null,"Not Completed"]
[null,null,"Easy access for people when requested and appropriate disposal of records?",null,null,"Notes readily available on request, delays with tracking notes after 19.30 as no receptionist/clerk",null,"Not Completed"]
[null,null,"Secure storage and compliance with Data Protection Act 1998 / General Data Protection Regulations (2016) (GDPR)",null,null,"Notes trolleys visible and evidence of notes left on work surfaces. ",null,"Not Completed"]
[null,null,"Effective records management system, including IT system?",null,null,"Notes requested on admission, delays with accessing notes out of hours ",null,"Not Completed"]
[]
[null,null,"Summary/Conclusion"]
[null,null,"Record keeping good, integrated notes used. All entries dated , signed and on the whole legible. Clear medical/surgical plans in place. News charts in use for patient observations, psag boards used to indicate news score. Unable to ascertain from boards when observations were recorded and what time next observations were due. Example patient :- news score 3, obs repeated 13 hours later, news then 7, obs repeated 90 minutes later when news score back to 4 , obs not then repeated for 10 hours. patients full names visible on psag boards, discussion with ward manager around Caldicott principles but assured patient consent gained for name to be displayed and initials used if any concerns raised. Intentional rounding not evident from nursing notes, general record keeping one entry per day unless clinical change or anything specific to note. No communication page at a glance for discussions with patients and or relatives. "]

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[]
[null,"OFFICIAL SENSITIVE WHEN COMPLETED"]
[]
[{"$nulls":12},"Back to Summary"]
[]
[]
[]
[]
[]
[]
[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":21,"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"]
[]
[]
[]
[]
[]
[]
[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":22,"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"]
[]
[]
[]
[]
[]
[]
[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":23,"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"]
[]
[]
[]
[]
[]
[]
[null,"INSPECTION EVIDENCE CAPTURE FORM"]
[]
[null,"About the inspection"]
[null,"Inspection reference number"]
[null,"Setting name"]
[null,"Activity (e.g. tour, interview, staff discussion)"]
[null,"About you"]
[null,"Name "]
[null,"Team role (e.g. inspection manager peer reviewer)"]
[null,"Date"]
[null,"Time"]
[]
[]
[null,"All evidence must be recorded in official HIW workbooks"]
[]
[null,"Notes "]
[null,"Please record source of evidence"]

{"sheet":"Issues Identified","index":24,"n_rows":32,"n_cols":16383,"rows_kept":32,"merged":[[3,2,3,4],[4,3,4,4],[5,3,5,4],[6,3,6,4],[7,3,7,4],[8,3,8,4],[9,3,9,4],[10,3,10,4],[11,3,11,4],[12,3,12,4],[13,3,13,4],[14,3,14,4],[15,2,15,4],[16,3,16,4],[17,3,17,4],[18,3,18,4],[19,3,19,4],[20,3,20,4],[21,3,21,4],[22,3,22,4],[23,3,23,4],[24,3,24,4],[25,3,25,4],[26,3,26,4],[27,2,27,4],[28,3,28,4],[29,3,29,4],[30,3,30,4],[31,3,31,4],[32,3,32,4],[33,3,33,4],[34,3,34,4],[35,3,35,4],[36,3,36,4],[37,3,37,4],[38,3,38,4]]}
[]
[null,"Issues Identified",null,null,"Back to Summary"]
[]
[null,null,"Quality of Patient Experience"]
[null,null,"Standard","Issue Identified"]
[{"$nulls":16382},"Health promotion, protection and improvement"]
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