One of the recommendations of the Free to Lead, Free to Care, Empowering Ward Sisters/Charge Nurses Ministerial Task and Finish Group: was that

Transcription

1 INTRODUCTION One of the recommendations of the Free to Lead, Free to Care, Empowering Ward Sisters/Charge Nurses Ministerial Task and Finish Group: was that All ward sister/charge nurses should have access to an All Wales Audit Tool which should be developed to measure standards against the Fundamentals of Care Standards published in Reports arising from use of this Audit Tool should be distributed to the NHS Board and the Chief Nursing Officer, Wales. The NHS within Wales is constantly changing and adapting using both Government and Professional frameworks and standards to meet the continuing demand for health care. This is a challenge and we have tried to maintain the founding principles as we evolve. Here, fairness, effectiveness, efficiency, responsiveness, integration, accountability and flexibility, are but a few ways that we will need to measure the standards of our service, whilst working in partnership with patients. It can be argued that quality depends as much on people as it does on systems and techniques; it is with this in mind that the All Wales Fundamentals of Care Audit tool is designed. The Fundamentals of Care document directs that all standards are to be met and compliance systematically monitored. It is the responsibility of the organisation providing that care and the staff they employ to implement, evaluate and audit these standards. It is important that this is not seen as a paper exercise, it is an opportunity to recognise good practice and to identify areas where work can be undertaken to develop or alter service provision, in order to improve the patient experience. Fundamentals of Care is a Health and Social Care document which aims to improve the quality of fundamental aspects of care for users who are acutely or chronically ill, frail or disabled regardless of where or why they need this care. The initiative grew out of concern about the following: Inconsistency of standards across service settings and areas Emphasis, until recently, on service efficiency and cost, rather than quality of care Common themes in complaints and compliments All Wales Fundamentals of Care Audit Tool 1

2 Increasing expectations of service users Lack of clarity for service users Increasing focus on regulation and performance ALL WALES FUNDAMENTALS OF CARE AUDIT TOOL In recognition of the fact that the process of care is as important to the patient experience as the outcome of that care, this document lists 12 aspects of care pertinent to adults. Communication and Information Respecting people Ensuring Safety Promoting Independence Relationships Sleep, rest and activity Ensuring comfort, alleviating pain Personal Hygiene and appearance Eating and Drinking Oral Health and hygiene Toilet needs Preventing pressure sores THE AUDIT TOOL It is intended that the ward sister/charge nurse has ownership and responsibility of this audit tool. Each section of the audit tool states the principle for that aspect of care, as written in the Fundamentals of Care document. Within a box, there is a brief summary of the STANDARDS FOR HEALTH SERVICES for Wales and relevant national guidance. Data collated from completion of this audit tool will be used by the Director of Nursing to measure compliance with the standards of the Fundamentals of Care throughout the organisation. The audit results will be presented by the Director of Nursing to the organisational board in October of each year and an Action Plan addressing the areas for improvement forwarded to the Chief Nursing Office for Wales by November of each year. This audit package is simple to use, yet comprehensive and measures the real essentials of care and care delivery. The tool is refreshing in that it has a practical approach which covers consumer elements as well as professional aspects. A prime focus of audit is effective care. However, it is also essential to measure appropriateness and acceptability, this tool goes some way to achieving this. All Wales Fundamentals of Care Audit Tool 2

3 The audit data will be collated electronically via the HOWIS web site. The audit tool can be completed electronically at ward site with for those with access to wireless computers. A paper copy of the audit tool can be downloaded and data entered following completion of the audit. FUNCTIONAL REQUIREMENTS Security A username and password protected system will be provided with unlimited password availability. Only nominated individuals within NHS organisations and WAG will be provided with passwords that will enable them to enter data into the system and to view assessments. The following levels of access will be available: o Assessor read/write: can update assessments for a Ward. o Ward Sister/Charge Nurse read/write: can update assessments and create action plans for a Ward o Divisional Nurse read only: sees information, summaries and action plans from all Wards within their Trust, and can add comments o Director of Nursing read only: sees information, summaries and action plans from all Wards within their Trust and can add and amend comments o WAG user read only: sees submitted information and summaries from all Trusts, but not action plans o Super User (WAG, HSW) performs administration functions. Users will have the facility to change their password to one of their own choosing once they have logged on to the system. The system will time-out after 60 minutes of inactivity. The system will include an audit trail that records any changes. DATA ENTRY Each section of the audit tool contains a series of corporate, operational and user questions. All Wales Fundamentals of Care Audit Tool 3

4 Corporate questions help assess the resources and facilities available within the ward/service area that enable employees to deliver the standard of healthcare and service required, for example Policy, Education and Training, staff and patient information, equipment and furnishings etc Operational questions measure the level of compliance with the required standard User questions establish if we are delivering the standard of care/service we perceive we are delivering. In areas where patients are unable to answer user questions please ask next of kin, family or patients carer, for example Mental Health, Learning Disabilities or EMI patients To aid completion of these standards, it will be possible to print paper-based versions of these forms, for completion in Wards where no computer is readily available. The assessor at Ward level checks every audit item in the standard and notes whether the item fails or meets the standard, and answers Yes, No or Not Applicable. Text boxes exist for the assessor to enter qualitative information such as issues identified, areas of improvement and examples of good practice. NB: if the No box is checked then the comments and action boxes are mandatory. If the Yes box is checked then the good practice box is mandatory. A summary sheet is created from the responses given, with additional text boxes for issues of concern and areas of good practice not identified in the questionnaire. One point will be awarded for every standard achieved and no points will be awarded for non-compliance of the standard. Where staff and users are consulted in answering the questions one point is awarded only if all staff and patients confirm the standard has been achieved. No points will be awarded if one or more staff or patients give a negative response. A rating is calculated as follows: Possible Score: Add the number of Applicable questions in each standard section together Actual Score: Add the number of YES answers in each standard section together Rating: Total number of YES answers Total number of Applicable questions x 100 The rating will be converted to a 1-5 score to match the STANDARDS FOR HEALTH SERVICES rating system. Each question contributes equally to the final score; there is no system of weighting particular questions. All Wales Fundamentals of Care Audit Tool 4

5 Ward Sisters/Charge Nurses will be able to collate this information to create an Action Plan. Against each issue identified in the assessment, the Ward Sister/Charge Nurse will propose an action, and assign it to a lead person with a review date. Question Number Issues Identified Proposed Action Lead Person Review Date The data entry process occurs annually with final submissions to be carried out in June/July, although the tool will be flexible enough to cope with irregular assessment periods. Organisations may also wish to complete the assessment process more frequently. Reporting Ward Sisters/Charge Nurses will be able to summarise all assessments for their Ward in a number of ways, filtered by the following criteria: View all Yes answers across all standards View all No answers across all standards Collated summary sheets across all standards View Audit scores across all standards Quantitative reports can also be filtered by type of question, e.g. Corporate/Operational/User. Divisional Nurses and Directors of Nursing will be able to view a similar range of reports, collated by organisation, with the ability to drill down to view data at ward and assessment level. WAG users will be able to view collated data and Divisional Nurse reports only. Benchmarking graphs will also be available, showing anonymised graphs by standard. All Wales Fundamentals of Care Audit Tool 5

6 General Advice Each question in the audit gives guidance on how to gather the information to answer. E.g. Check 5 documents /ask 5 members of staff. You will also need to select 5 patients for each standard and give them a questionnaire. They need not necessarily be the same 5 patients for each standard. In order for the results of this audit to be unbiased, it is important that patients and data are selected at random. Some examples of how this might be done include; If you have 20 patients on the ward select every 4 th one for inclusion or, If you have 30 patients, select every 6 th etc. or, Select a patient from in the first bed from each bay. Thus is to ensure unbiased patient selection. Remember, the frail, elderly and vulnerable patients are the very ones whose experience we need to capture do not avoid including this type of patient. Where patients are unable to complete the questionnaires a relative, carer or advocate may do this. All Wales Fundamentals of Care Audit Tool 6

7 FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION & INFORMATION Principle: You will receive full information about your care in a language and manner sensitive to your needs The Health & Social Care Guide for Wales (2002) Nursing & Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002) METHOD QUESTION YES NO N/ A Are the patients demographic details clearly recorded on the patient s documentation? STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS Issues identified Improvements to be Good Practice 1 Check 5 Documents Patients name, address, date of birth and identification number (n.h.s. number / hospital number) must be recorded on every sheet of paper within the patients nursing and medical record. 2 Check 5 Documents 3 Check 5 Documents Standards for Health Services: 20c Has each patient been fully assessed on admission in respect of their communication needs? Each patient should have an initial assessment on admission recording their communication needs. Fundamentals of Care Standard:- 1.1, 3.3, 8.1 Standards for Health Services: 18e Is the patient s preferred language clearly Indicated in the patients nursing records? The patients preferred language and method of communication should be recorded in patients records Fundamentals of Care Standard: 1.3 Standards for Health Services: 18e Does each patient have an individual care All Wales Fundamentals of Care Audit Tool 7

8 FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION & INFORMATION Principle: You will receive full information about your care in a language and manner sensitive to your needs The Health & Social Care Guide for Wales (2002) Nursing & Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002) METHOD QUESTION YES NO N/ A 4 plan? STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS Issues identified Improvements to be Good Practice Check 5 Documents There should be an individual Care Plan designed specifically for the needs of each patient. 5 Check 5 Documents Ask staff 6 Check 5 Documents 7 Ask 5 staff Fundamentals of Care Standard:- 1.1, 3.7, 4.2, 8.1 Standards for Health Services: 8 Is there documented evidence Care Plans are discussed and agreed with patients? Care plan documents should b readily available to patients. Fundamentals of Care Standard:- 1.4 Standards for Health Services: 9b Are contact details regarding next of kin clearly recorded in patient s documentation? Contact details of next of kin must be recorded in patients documentation Standards for Health Services: 18b Are there systems in place to obtain patients and carers views with regard to the service receive? Patients and user should be provided with an opportunity to express their views and opinions on the service they receive. All Wales Fundamentals of Care Audit Tool 8

9 FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION & INFORMATION Principle: You will receive full information about your care in a language and manner sensitive to your needs The Health & Social Care Guide for Wales (2002) Nursing & Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002) METHOD QUESTION YES NO N/ A STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS Issues identified Improvements to be Good Practice 8 Ask 5 staff Check Document 9 Check notice boards 10 Ask 5 Staff 11 Ask 5 staff Standards for Health Services: 5c Is there an available up to date list of interpreters that is easily acceptable? All wards/departments should have details of the availability of interpreters and how to contact them. Standards for Health Services: 18e Is there information clearly displayed within the ward on how to make a complaint? Information on how to make a complaint should be clearly displayed on the ward/department. Standards for Health Services: 18d (links to 23) Are there mechanisms/policy in place to defuse complaints? There should be an agreed organisational procedure/policy available on how to defuse a complaint. Standards for Health Services: 23 Do patients receive a general information booklet/leaflet/about the hospital /department/ward prior to admission or on arrival? All Wales Fundamentals of Care Audit Tool 9

10 FUNDAMENTALS OF CARE STANDARD 1: COMMUNICATION & INFORMATION Principle: You will receive full information about your care in a language and manner sensitive to your needs The Health & Social Care Guide for Wales (2002) Nursing & Midwifery Council Code of professional Conduct (2008) Welsh Assembly Government good practice in consent implementation guide: to consent to examination or treatment (2002) METHOD QUESTION YES NO N/ A All patients should receive information on the hospital/ward/department prior to or on admission. STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 2: EQUALITY DIVERSITY AND HUMAN RIGHTS STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 20: RECORDS MANAGEMENT STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS Issues identified Improvements to be Good Practice 12 Ask staff Standards for Health Services: 18d Is there a policy for the use of mobile phones? Guidelines should be available on the use of mobile phones within the organisation. Standards for Health Services: 18 All Wales Fundamentals of Care Audit Tool 10

11 Please ask 5 patients the following questions. Tick the appropriate box to record the demographic details. Q1: Who has answered these questions Yes Q2: Is the patient Yes Q3: Age of patient Yes Patient Male Under 16 Relative/Carer Female Other e.g. advocate Other Over 85 Patients Questions QUESTION YES NO N/A General Comments Patient number Patient Comment Ward Managers Comment Were you able to speak to staff in a 13 language of your choice? Standards for Health Services: 2, 18, 5b If you have a communication disability (hearing, verbal or sight) were your 14 needs met? Standards for Health Services: 2, 18e, 5b Were you given an opportunity to ask 15 questions about your care? Standards for Health Services: 9b,5b Were your questions answered in a way that you could clearly 16 understand? Standards for Health Services: 9a, 5b Were you able to contact your family 17 by telephone when necessary? Standards for Health Services: 18e, 5b Are there any things you would 18 change? Standards for Health Services: 5b, 5c All Wales Fundamentals of Care Audit Tool 11

12 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A Has the patient s dignity and respect needs been assessed and documented on admission? 1 All patient areas should offer privacy or be screened. Check 5 Documents 2 Check 5 Documents 3 Fundamentals of Care Standard: 2.4, 8.3 Standards for Health Services: 10 Do patients identified with privacy and dignity needs have care plans to address these needs? The patients plan of care should reflect identified needs Fundamentals of Care Section : 2 Standards for Health Services: 8a Is there documented evidence that a plan of care has been agreed with the patient? STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice Check 5 Documents 4 Check 5 Fundamentals of Care Standard: 1.1 Standards for Health Services: 8a and 9a Does the patient documentation indicate the patients preferred name? All Wales Fundamentals of Care Audit Tool 12

13 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A Documents Patients preferred name should be documented in nursing/medical records. Patients will be addressed by their preferred name. STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice Fundamentals of Care Section: 2.4 Standards for Health Services: 18e Are Care Plans available for the patient to see? 5 Ask staff 6 Check 5 documents 7 Care plan documents should be readily available to patients. Fundamentals of Care Standard: 1.4 Standards for Health Services: 8a and 9a Has a carer s needs assessment been completed? The carer s needs should be documented in nursing record. Fundamentals of Care Standard: 5 Standards for Health Services: 18b Is there documented evidence stating the patients cultural and spiritual needs? Check 5 Documents Patient s documentation should include written comments regarding the patients cultural and spiritual needs All Wales Fundamentals of Care Audit Tool 13

14 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice 8 Ask staff Fundamentals of Care Standard: 1.1, 3.7, 11.1 Standards for Health Services: 10 Are staff aware of Data Protection (Caldicott) requirements and patient confidentiality All staff should be aware of Data Protection requirements and confidentiality Fundamentals of Care Section: 1.5 Standards for Health Services: 19a Is patient information securely stored to ensure confidentiality? 9 Check 10 Patient records should be stored in accordance with Caldicott guidelines. (Secure trolley within the ward or department ) Fundamentals of Care Standard: 1.5 Standards for Health Services: 19a Is there written evidence in the patients nursing/medical profile to indicate that sharing of information has been discussed. Check 5 Documents Patient documentation should state if information can be shared with a third party and with whom it can be shared with. All Wales Fundamentals of Care Audit Tool 14

15 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice Fundamentals of Care Section: 2 Standards for Health Services: 18c Is each patient area individually screened to ensure privacy? 11 Check 12 Ask staff 13 Ask staff All patient areas should be screened or offer privacy Fundamentals of Care Standard:- 2.4, 8.3 Standards for Health Services: 12e Are efforts to ensure that privacy is respected during intimate procedures e.g. washing, dressing, toileting & clinical interventions (e.g. promotion of a culture where no one walks behind closed screens without asking permission and laminated signs are used to promote this?) Standards for Health Service: 10 When needed, are hospital gowns and night attire for patient use easily accessible? Gowns and night attire should be accessible for patients if required. Standards for Health Services: Do these gowns promote patient dignity? All Wales Fundamentals of Care Audit Tool 15

16 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice Ask staff 15 ask staff 16 Ask staff 17 Ask staff Check 18 Ask staff Are they of appropriate size and fit, do they fasten adequately? Standards for Health Services 10 Is there a facility for patients to talk in confidence to staff (e.g. quiet room/office) Fundamentals of care standard: 5 Standards for Health Services 9, 12c Is there a comfortable and quiet seating area available for patients to spend time with their visitors away from the bedside? Fundamentals of care standard: 5.2 Standards for Health Services: 12e Are there facilities available for close relatives / friends to stay over night if necessary? Appropriate facilities will be available for relatives and friends to stay over night if necessary Fundamentals of Care Standard: 5.5 Standards for Health Services: 12c Where necessary, are visiting hours flexible and adjusted according to the needs of the patient? All Wales Fundamentals of Care Audit Tool 16

17 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A People are able to receive visitors within reasonable hours, sensitive to the needs of others. STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice Fundamentals of Care Standard: 5.1 Standards for Health Services: 10 Is a Registered Nurse available to speak to relatives at visiting time? 19 Ask staff Always be welcoming in your approach to visitors, showing courtesy and patience at all time 20 Ask Staff check 21 Ask staff Fundamental of Care: 5 Standards for Health Services: 9b, 24a Can patients access information in an appropriate format for their needs? Information should be available in appropriate format. E.g. Braille, video, cassette, large print and languages Standards for Health Services: 9a, 18b Are patients able to access advice and support as needed? People are able to access free and independent advice so that they can make choices about their care and lifestyle e.g. counselling services, patient advocacy, All Wales Fundamentals of Care Audit Tool 17

18 FUNDAMENTALS OF CARE STANDARD 2: RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes STANDARD 5: RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes. METHOD QUESTION YES NO N/ A community health council etc STANDARDS FOR HEALTH SERVICES IN WALES STANDARD 8: CARE PLANNING AND PROVISION STANDARD 9: PATIENT INFORMATION AND CONSENT STANDARD 10: DIGNITY AND RESPECT STANDARD 12: ENVIRONMENT STANDARD 18: COMMUNICATING EFFECTIVELY STANDARD 19: INFORMATION MANAGEMENT AND COMMUNICATIONS TECHNOLOGY STANDARD 24: WORKFORCE PLANNING STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT Issues identified Improvements to be Good Practice 22 Ask staff Check for documented evidence 23 Ask staff Check 24 Ask staff check Fundamentals of Care Section: 2.2 Standards for Health Services: 23c Have all staff attended Diversity, Equality & Human Rights Training? All staff should attend training on Diversity & Equality and Human Rights. Fundamentals of Care Section: 2 Standards for Health Services: 2, 26b Have all staff attended Protection of Vulnerable Adults (POVA) training. Documented evidence should be available stating staff had attended POVA Training Standards for Health Services: 11c Is there single sex accommodation for sleeping, washing and toileting? Single sex accommodation should be available for patients when necessary Standards for Health Services: 12e All Wales Fundamentals of Care Audit Tool 18

19 Please ask 5 patients the following questions. Tick the appropriate box to record the demographic details. Q1. Who has answered Yes Q.2 Is the patient Yes Q3. Age of patient Yes these questions Number of Patient Number of Patient Number of Patient Patient Male Under 16 Relative/Carer Female Other e.g. advocate Other Over 85 Patients Questions QUESTION YES NO N/A General Comment Patient number Patients Comment Ward Managers Comment 25 Do you feel that you have been treated with respect and politeness during your episode of care? People are treated with respect, courtesy and politeness Fundamentals of Care: 2.1 Standards for Health Services: 5b, Has your privacy been respected during washing, dressing and toileting etc? Standards for Health Services: 5b, Did people use your correct/preferred name or title when speaking to you? Standards for Health Services: 5b, 10 All Wales Fundamentals of Care Audit Tool 19

20 QUESTION YES NO N/A General Comment Patient number Patients Comment Ward Managers Comment 28 Were you able to see and discuss your nursing care plans with a Registered/Qualified Nurse? Ward Sister/Staff Nurse Standards for Health Services: 5b, 9b 29 When discussing confidential or personal issues were you given sufficient privacy? Standards for Health Services: 5b, Were you asked about sharing personal information with others? Standards for Health Services: 5b, 18c 31 Could you understand the information that was given to you? (Written or verbal) Standards for Health Services:5b, 9 32 Were your relatives/carer s able to speak to a Nurse at visiting time if they wanted to? Standards for Health Services: 5b, 18b 33 Do you know the name of the doctor responsible for your treatment? Standards for Health Services: 5b, 9b All Wales Fundamentals of Care Audit Tool 20

21 QUESTION YES NO N/A General Comment Patient number Patients Comment Ward Managers Comment 34 Do you know the name of the Ward Sister or Nurse in charge of your care Standards for Health Services: 5b, 9b 35 Are there any things you would change? Standards for Health Services: 5b FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented All Wales Fundamentals of Care Audit Tool 21 STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be INFECTION CONTROL 1 Evidence of documentation Is there a programme of Infection Control Audit, which includes your ward? There should be regular programme of Infection Control Audits. Standards for Health Services: 6a, 13a Good Practice

22 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be 2 Ask 5 Staff Check Document Do staff have access to an Infection Control Policy? All wards & departments should have access to a Control of Infection Manual. Standards for Health Services: 13a Does the caring environment encourage compliance with hand decontamination? Good Practice 3 Check Ward/dept Resources Alcohol hand rub is sited in convenient locations. A hand washing poster indicating approved hand-washing method located near at least one hand wash basin. Clinical wash hand basins should be appropriately sited i.e. in / adjacent to each patient area. During audit hand decontamination to be observed being undertaken appropriately in at least two staff members. 4 Ask 5 Staff Check Document Fundamentals of Care Standard 3.1 & 3.6 Standards for Health Services: 13c Do you have a designated person or link nurse responsible for taking the lead in Infection Control Issues? Does the department have a designated link person for infection control? All Wales Fundamentals of Care Audit Tool 22

23 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be Good Practice 5 Check ward records for documented evidence 6 Ask 5 Staff 7 Ask 5 Staff Fundamentals of Care Standard: 3.6 Standards for Health Services: 13c Have all staff attended training relating to Infection Control within the last year? All staff should attend Infection Control Training and regular updates AS PER Health Board Policy. Fundamentals of Care 3.6 Standards for Health Services 13c, 26b Are staff aware of the correct procedure for source isolating patients? All staff should be aware of the correct procedure for source isolating patients. Fundamentals of Care 3.6 Standards for Health Services 13a Are staff aware of the MRSA Screening policy for their speciality? All staff should be aware of the MRSA screening policy. Standards for Health Services 13a Are sharps bins placed appropriately within All Wales Fundamentals of Care Audit Tool 23

24 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be 8 Check Observe the Department? Sharps bins should be placed out of the reach of children and away from public areas. Wall brackets should be used to secure sharps boxes. Good Practice 9 Ask 5 Staff 10 Check & Observe Fundamentals of Care Standard 3.1 & 3.2 Standards for Health Services 13d Are staff aware of the correct procedure for bagging and sending infected linen to the laundry? Standards for Health Services 13d Is clinical waste disposed of in the appropriate bin? Waste should be segregated and disposed of in the correct type of waste bin. A choice of clinical and domestic waste bins and sharp boxes should be available. Fundamentals of Care Standard 3.2 Standards for Health Services 13a, 13d MANUAL HANDLING 11 Check Document Is there a Health Board local policy for Minimal Manual handling? All Wales Fundamentals of Care Audit Tool 24

25 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be There should be a local policy for minimal manual handling. Fundamentals of Care Standard 3.6 Standards for Health Services 22b Are all employees aware of Health Board & Local Policies and know where they are located? Good Practice 12 Ask 5 Staff All employees should be aware of Health Board & Local Policies and where they can be located. 13 Check ward records 14 Check 5 patient Fundamentals of Care Standard 3.6 Standards for Health Services 22b Have all staff received training or an update in Moving & Handling procedures in the past year? All staff should have received training or up date in the past year. Fundamentals of Care Standard 3.6 Standards for Health Services 22b, 26b Have all patients had a manual handling risk All Wales Fundamentals of Care Audit Tool 25

26 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be records assessment completed? All patients should have a manual handling risk assessment completed. Good Practice 15 Check5 patients records 16 Check patient records 17 Check ward Fundamentals of Care Standard 3.3 & 12.4 Standards for Health Services 22a Are Manual Handling risk assessments regularly reviewed? All risk assessments should be reviewed as and when situations change. Fundamentals of Care Standard 3.3 Standards for Health Services 22a If found to be at risk, is a care plan initiated? All those found to be at risk should have a care plan initiated. Fundamentals of Care Standard 3.3 Standards for Health Services 22a Have all staff received training or an update in Display Screen Equipment Policy (DSE) DSE policies should be available for all staff. All Wales Fundamentals of Care Audit Tool 26

27 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be records Fundamentals of Care Standard 3.6 Standards for Health Services 22a, 26b Is there documented evidence that hoist slings and other manual handling aids are regularly checked for wear and tear? Good Practice 18 Check There should be documented evidence that hoist slings and manual handling aids are checked regularly. 19 Ask 5 Staff Check 7 & Observe Fundamentals of Care Standard 3.4 Standards for Health Services 22a, 16b Are appropriate and sufficient handling aids available for use in Wards/Departments? There should be appropriate and sufficient manual handling aids available for use. Fundamentals of Care Standard 3.4, 4.4 & 12 Standards for Health Services 22a, 16c HEALTH & SAFETY Is there documented evidence that all staff 20 receive statutory training in Health & Safety All Wales Fundamentals of Care Audit Tool 27

28 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be Check ward records Awareness? All staff should attend Health & Safety training. Fundamentals of Care Standard 3.6 Standards for Health Services 22b, 26b Is your ward/ department kept tidy and uncluttered? Good Practice 21 Observe 22 Check 23 All areas of the department should be clean and uncluttered. Fundamentals of Care Standard 3.3 Standards for Health Services12b, 22a Are entrances and exits clear and accessible? Entrances and exits should be assessable Fundamentals of Care Standard 3.3 Standards for Health Services 12a, 22a Are alternative lighting facilities available in the event of a mains power failure? All Wales Fundamentals of Care Audit Tool 28

29 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be Ask 5 Staff 24 Ask 5 Staff In the event of a power failure adequate emergency lighting facilities should be available e.g. generator, touch. Fundamentals of Care Standard 3.3 Standards for Health Services 4, 12f, 22a Is there adequate security available in the ward /department at night? Fundamentals of Care Standard 3.3 Standards for Health Services 12d, 22a, 22b FIRE PRECAUTIONS Are all fire exits clearly marked? Good Practice 25 Check Fire exits should be clearly labelled, using standard signs. Fundamentals of Care Standard 3.3 Standards for Health Services 22a Are fire exits kept clear and accessible? 26 Check All fire exits should be fully accessible and not obstructed with equipment, both outside and inside. All Wales Fundamentals of Care Audit Tool 29

30 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be Fundamentals of Care Standard 3.3 Standards for Health Services 12a, 22a, 22b Are fire restraint doors kept closed? Good Practice 27 Check 28 Ask 5 Staff Fire restraint doors must be closed. Fundamentals of Care Standard 3.3 Standards for Health Services 12d, 22b Do staff know the location of fire alarms? Fundamentals of Care Standard 3.3 Standards for Health Services 22b Is there documented evidence staff have attended Fire Safety Training in the last year? 29 Check ward records All staff must be undated annual on fire safety training. Fundamentals of Care Standard 3.6 Standards for Health Services 22b, 26b Is there documented evidence that staff All Wales Fundamentals of Care Audit Tool 30

31 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be 30 Check ward records have attended Basic Life Support Training? All staff should have attended Basic Life Support Training. Fundamentals of Care Standard 3.6 Standards for Health Services 22b, 26b Is all medical/clinical equipment regularly maintained? Good Practice 31 Check Clinical / medical equipment should be maintain in accordance to equipment maintenance programme Fundamentals of Care Standard 3.4 Standards for Health Services 16b Are all staff given adequate training prior to using equipment? 32 Ask 5 Staff All staff should receive appropriate training prior to using equipment Fundamentals of Care Standard 3.6 Standard for Health Services 16e Are staff aware of the Trust incidents reporting policy? All Wales Fundamentals of Care Audit Tool 31

32 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be 33 Ask 5 Staff Staff should be aware of the Health Board Incident Reporting Policy Good Practice Fundamentals of Care Standard 3.3 Standards for Health Services 23a Are all incidents/accidents fully investigated? 34 Ask 5 Staff 35 Ask 5 Staff All incidents /accidents involving staff contractors, patients, members of public clinical incidents, near misses and non clinical incidents must be recorded in the Incident Report Book. Fundamentals of Care Standard 3.3 Standards for Health Services 23b Are Action Plans agreed to prevent reoccurrence of reported incident? Action Plans should be agreed to prevent reoccurrence of reported incident. Fundamentals of Care Standard 3.3 Standards for Health Services 23e All Wales Fundamentals of Care Audit Tool 32

33 FUNDAMENTALS OF CARE STANDARD 3: ENSURING SAFETY STANDARDS FOR HEALTH SERVICES IN WALES Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and where possible, reduced or prevented STANDARD 4: CIVIL CONTINGENCY AND EMERGENCY PLANNING ARRANGEMENTS STANDARD 12: ENVIRONMENT STANDARD 13: INFECTION PREVENTION AND CONTROL (IPC) and DECONTAMINATION STANDARD 16: MEDICAL DEVICES, EQUIPMENT, AND DIAGNOSTIC SYSTEMS STANDARD 22: MANAGING RISK AND HEALTH AND SAFETY STANDARD 23: DEALING WITH CONCERNS AND MANAGING INCIDENTS STANDARD 26: WORKFORCE TRAINING AND ORGANISATIONAL DEVELOPMENT METHOD QUESTION YES NO N/A Issues identified Improvements to be C.O.S.H.H. Are C.O.S.H.H. regulations adhered too? Good Practice 36 Check A C.O.S.H.H. manual should be available in all wards/departments. Fundamentals of Care Standard 3 Standards for Health Services 22b, 22c All Wales Fundamentals of Care Audit Tool 33