DELIVERING THE FUNDAMENTALS OF CARE. Director of Nursing. Deputy Director of Nursing

DELIVERING THE FUNDAMENTALS OF CARE AGENDA ITEM 3.2 23 October 2009 Report of Director of Nursing Paper prepared by Purpose of Paper Action/Decision required Link to Health Care Standards: Link to Health Board s Strategic Direction and Corporate Objectives Deputy Director of Nursing To provide the Board with the outcome of the Fundamentals of Care audit and identify areas for action. To note and endorse the actions proposed The Fundamentals of Care have been mapped to the Health Care Standards. The specific healthcare standards are: 4,5,6,7,8,9,11,12,14,16 This report aligns with the quality and patient safety and patient experience agendas. Acronyms and abbreviations Fundamentals of Care FOC Welsh Assembly Government WAG University Health Board - UHB Delivering the FOC Page 1 of 9 Board Meeting 23 October 2009

FOR INFORMATION Executive Summary Delivering the Fundamentals of Care In June 2008 the Minister for Health and Social Services issued the report Free to Lead Free to Care. The report contained 35 recommendations across five themes: Fundamentals of Care The Ward Environment Cleaning An All Wales Nursing Uniform Education, Development and Support This paper focuses on the recommendations contained within the theme entitled Fundamentals of Care (recommendations 2 and 3) and outlines the national and local action taken to achieve the requirements of the recommendations. The recommendations have been provided in Appendix 1 for ease of reference. An overview of the findings of the first baseline audit of the Fundamentals of Care (FOC), within ward areas across Cardiff and Vale NHS Trust, now known as Cardiff and Vale University Health Board (UHB), is also provided together with the actions identified to support improvement in standards of patient care. Following the issuing of Free to Lead Free to Care Welsh Assembly Government (WAG) established a steering group to review the FOC standards and devise an all-wales audit tool. The All Wales Fundamentals of Care Audit Tool was introduced to all hospitals in NHS Wales in July 2009 with the expectation that each organisation would complete the audit by September 2009, present the findings to the UHB in October 2009 and submit the report to the Office of the Chief Nurse, WAG by November 2009. It is intended that the audit tool will be used as a vehicle for the monitoring of developments in improving overall patient experience. Despite the challenging timescale the audit was completed by all bed holding areas across the organisation and action plans have been developed by each Ward Sister in collaboration with their respective Delivering the FOC Page 2 of 9 Board Meeting 23 October 2009

FOR INFORMATION Senior Nurse. It should be noted that the audit tool is divided into Operational questions and User questions. The Operational questions focus on documentation and staff elements of care delivery whilst the User questions enable patients, their relative or advocate, to provide feedback on their experience of care. The overall findings from the audit have identified a variety of issues and themes requiring focussed attention during the coming year as well as highlighting areas of good practice. Based upon the overall audit results the key standards which will require attention include: Personal Hygiene, appearance and foot care (standard 8) Oral health and Hygiene (standard 10) Preventing Pressure areas/ulcers (standard 12) Many areas of good practice have been identified by individual wards and Directorates as a result of the audit process. Some of the specific areas of good practice which should be noted include implementation of protected meal-times in many areas, health and safety actions which promote patient and staff safety and adoption of safety actions in line with 1000 Lives campaign (safety briefings, hand hygiene). It should also be noted that patient feedback across the 12 standards has been in many instances more positive than the evidence obtained through the operational questions component of the audit. The timescale associated with the introduction and implementation of the new all-wales audit tool was challenging. There are a number of lessons which have been learnt following the completion of the audit process which will inform the arrangements required to support future sustainable implementation. These include issues associated with: training and tool administration timescale and frequency of auditing the linkage with overall quality monitoring the development of processes which support the independent gathering of patient feedback the monitoring of action plans Next steps include the need to establish a robust mechanism across the organisation for the implementation and sustainability of the FOC auditing process. Delivering the FOC Page 3 of 9 Board Meeting 23 October 2009

FOR INFORMATION Background In June 2008 the Minister for Health and Social Services issued the report Free to Lead Free to Care. The report contained 35 recommendations across five themes: Fundamentals of Care The Ward Environment Cleaning An All Wales Nursing Uniform Education, Development and Support Following release of the report the Welsh Assembly Government established a Steering Group to drive and monitor the delivery of the recommendations contained within Free to Lead Free to Care. Theme specific task and finish groups were also established to support the delivery of the recommendations within each theme with direct involvement of representatives from a wide variety of organisations. Whilst each task and finish group has provided progress reports and feedback to the overarching Steering Group, the Board of Cardiff and Vale NHS Trust has received updates on local implementation. It should be noted that the underpinning principle of the Free to Lead Free to Care report was to empower Ward Sisters/Charge Nurses with the aim of improving patient care and experience at ward level. The work of the Fundamental of Care (FOC) task and finish group has focused on recommendations 2 and 3 within Free to Lead Free to Care, Appendix 1. This has included a review of the 12 standards originally issued to health and social care services in 2003 as identified in Appendix 2 and the development of an all-wales audit tool for use by all wards within NHS Trusts (now Local Health Boards). The review of the 12 FOC standards identified that the principles outlined within each of the standards remained relevant and applicable to healthcare delivery today and for the foreseeable future. It was therefore agreed that the audit tool used to capture achievement against each of the standards should reflect the core principles of each standard as well as any more recent initiatives aimed at improving patient care and experience. Like all other NHS Trusts within Wales, Cardiff and Vale NHS Trust had developed local tools to support the monitoring of implementation of the standards. Unfortunately, through the development of individual, local, Delivering the FOC Page 4 of 9 Board Meeting 23 October 2009

FOR INFORMATION mostly paper-based tools, the opportunities for benchmarking within and between organisations was not able to be realised although individual wards and directorates have benefitted from being able to monitor compliance with the standards at a local level. The user/patient feedback component, now an integral component of the all-wales audit tool, had not been directly incorporated into local tools. Given the importance now placed on user/patient feedback it was recognised that this needed to form an essential element of the all-wales tool. As such the audit tool developed includes two parts: Operational questions and User/Patient questions, both of which must be completed for the audit to be considered complete. Prior to issuing the final draft version of the all-wales audit tool it was tested in clinical areas across Wales, refinements made and training in the use of the tool provided to identified leads in each organisation. The tool was issued formally to NHS Trusts in July 2009 with an instruction that an audit of all 12 FOC standards should be undertaken in bed holding areas using the on-line tool by September 2009. A number of areas were excluded from the audit process as it was considered that the new tool would not be fit for purpose within these areas: Accident and Emergency Departments Operating Theatres Community Paediatrics Out-patient Departments (including day hospitals) Organisations were advised that the findings of the audit should be reported to the new Local Health Boards in October ready for submission to the Office of the Chief Nurse (CNO) in WAG by November 2009. Appendix 3 provides the report required for submission to CNO and is provided for information to the Board. Audit Implementation and Findings Despite the challenging timescale imposed it is pleasing to report that all identified bed holding areas (essentially all wards) within the UHB have completed the audit within the required timescale. It should be noted that following internal discussion and review of the new tool it was decided that Child Health/Paediatrics would use the tool and complete the audit. To support this approach staff within the directorate were given advice in how to interpret the audit questions from a child s perspective, an approach which has provided rich and relevant information for use within Delivering the FOC Page 5 of 9 Board Meeting 23 October 2009

FOR INFORMATION the directorate. This approach will also be helpful in informing the development of an all-wales audit tool fit for use within paediatric areas. The audit findings have been entered onto the on-line tool by Ward Sisters/Charge Nurses and are available for individual ward areas, Senior Nurses and Heads of Nursing to view. The tool can also be accessed by the Corporate Nursing team. The development of action plans in response to the audit findings is being progressed in collaboration between individual Ward Sisters/Charge Nurses and the respective Senior Nurse. The findings which have emerged from the audit are varied although there does appear to be some common themes across directorates and Service Groups. These include issues associated with the following: Provision and standard of patient information The use of jargon by healthcare staff Access to and knowledge relating to interpreter services Space constraints within Ward areas impacting upon storage, privacy, achievement of cleaning standards Refurbishment (including upgrading and redecoration) of ward areas. Limitations in the provision/availability of therapy staffing, particularly physiotherapy and occupational therapy. Many of these issues can will be taken forward locally within ward and directorate areas led by the current Service Group Heads of Nursing. It is anticipated that responsibility for progression of identified actions in respect of these issues will sit within the remit of the Divisional Nurses once appointed. Based upon the overall audit findings of the audit the following standards will require further consideration and attention during the coming year: Personal Hygiene, appearance and foot care (standard 8) Oral health and Hygiene (standard 10) Preventing Pressure areas/ulcers (standard 12) The actions required to improve achievement against these standards will be led by the current Deputy Director of Nursing in collaboration with the Heads of Nursing and relevant corporate departments and leads. Delivering the FOC Page 6 of 9 Board Meeting 23 October 2009

FOR INFORMATION As well as areas requiring further attention during the coming year many areas of good practice have been highlighted. Some of the specific examples of good practice identified through the audit include: Protected mealtimes Use of the red tray system Development of Do Not Disturb signs for bed screens to promote dignity and respect Utilisation of the EIDO patient information system which supports good practice in relation to consent Effective roll-out of initiatives from the 1000 Lives campaign Development of a Dietary Assistant role to support improved nutrition Development of a Palliative Care Nurse for Mental Health (1 st in Wales) A key action, to be led by the Deputy Director of Nursing in collaboration with the Heads of Nursing and appropriate departments, will be the further dissemination of good practice across all wards within the Health Board. With regard to the actual audit tool an issues log has been created within the organisation to capture user feedback and inform further refinement and development of the tool for on-going implementation. The organisational lead for development and implementation of Fundamentals of Care has been the Deputy Nurse Director who will continue to represent the organisation at the all-wales task and finish group and provide advice regarding further development of the tool at an all-wales level. To support on-going implementation of the all-wales audit within the Health Board consideration will need to be given to a number of key issues: Administrative support for the system Training and advice support for staff expected to implement the audit process How the audit can be integrated into the overall quality and patient experience arrangements to avoid duplication of effort at ward, directorate and Divisional levels. Frequency of audit and on-going reporting arrangements Delivering the FOC Page 7 of 9 Board Meeting 23 October 2009

FOR INFORMATION A review of the reasons why such a high level of not applicable scores have been given during this baseline audit. It is thought that this may be linked to interpretation of the audit questions although this does need to be understood fully to inform future implementation. Arrangements which could be put in place to support the independent gathering of patient feedback (completion of the user/patient questions within the audit) These issues will be given further, more detailed consideration by the Corporate nursing team and briefing paper will be provided to up- date the Board on the arrangements that are considered necessary. CONCLUSION AND RECOMMENDATION Implementation of the all-wales FOC audit has been successfully undertaken within the UHB within the agreed timescale despite significant challenges in terms of timing, capacity to undertake the audit and limited time for staff to familiarise themselves with the electronic tool. It should be noted that findings of the audit represent a baseline from which Ward Sisters/Charge Nurses within the Health Board can work to improve patient care and overall patient experience. The Board is asked: to NOTE the issues highlighted within this paper. to NOTE the content of the report contained within attachment 3. IMPACT ASSESSMENT Health Improvement Improved quality outcomes for in-patients. Workforce Identification of training and development needs. Financial To be identified as part of the action plan. Legal Not Applicable Delivering the FOC Page 8 of 9 Board Meeting 23 October 2009

FOR INFORMATION Equality Ensuring equitable services for all. Environmental Identification of improvement and action required within clinical areas. RISK ASSESSMENT Clinical/Service Not applicable Financial To be identified Reputational Document will allow benchmarking across Wales. SOURCES OF INFORMATION & EVIDENCE Fundamentals of Care Guidance for Health and Social Care Staff Welsh Assembly Government 2003 Free to Lead, Free to Care Empowering ward sisters/charge nurses Welsh Assembly Government 2008 Delivering the FOC Page 9 of 9 Board Meeting 23 October 2009

Appendix 1 Recommendation 2 Fundamentals of Care Ward Sisters/Charge Nurses should play a significant part of the updating of Fundamentals of Care (2003) in line with subsequent policy developments, in particular the Health Care Standards 3 Fundamentals of Care All Ward Sisters/Charge Nurses should have access to an All Wales Audit Tool which should be developed to measure standards against the Fundamentals of Care. Reports arising from use of this Audit Tool should be distributed to the NHS Trust Board and Chief Nursing Officer, Wales. Responsible Body Welsh Assembly Government Welsh Assembly Government/NHS Trusts Timescale By end 2008 By end 2008

Appendix 2 Fundamentals of Care Standards & Principles Number Standards: Principles 1. Communication and Information People must receive full information about their care in a language and manner sensitive to their needs. 2. Respecting People Basic human rights to dignity, privacy and informed choice must be protected at all times, and the care provided must take account of the individual s needs, abilities and wishes. 3. Ensuring Safety People s health, safety and welfare must be actively promoted and protected. Risks must be identified, monitored and where possible reduced or prevented. 4. Promoting Independence The care provided must respect the person s choices in making the most of their ability and desire to care for themselves. 5. Relationships People must be encouraged to maintain their involvement with their family and friends and develop relationships with others, according to their wishes. 6. Rest and Sleep Consideration is given to people s environment and comfort so that they may rest and sleep. 7. Ensuring comfort, alleviating pain People must be helped to be as comfortable and pain free as their condition and circumstances allow. 8. Personal hygiene, appearance and foot care People must be supported to be as independent as possible in taking care of their personal hygiene, appearance and feet. 9. Eating and drinking People must be offered a choice of food and drink that meets their nutritional and personal requirements and provided with any assistance that they need to eat and drink. 10. Oral health and hygiene People must be supported to maintain healthy, comfortable mouths and pain free teeth and gums, enabling them to eat well and prevent related problems. 11. Toilet needs Appropriate, discreet and prompt assistance must be provided when necessary, taking into account any specific needs and privacy. 12. Preventing pressure sores People must be helped to look after their skin and every effort made to prevent them developing pressure sores. Taken from Fundamentals of Care (2003)

STANDARD 1: COMMUNICATION AND INFORMATION Range of Scores within Directorate Areas Operational Perspective 41.7% - 100% User Experience Perspective 80% - 100% 1. Summary of Issues/Key Themes Inadequate verbal communication with patients/families and the use of jargon by health professionals, particularly medical staff. Difficulties associated with timely access to information which enables care to be provided to patients by members of the multi-disciplinary team. Care plans are not always discussed with or developed in collaboration with patients/families. Lack of access to patient information in a variety of different languages relevant to local and transient population. Efforts are made to ensure that patient information is provided in Welsh and English. Information regarding access arrangements for interpreter services is not readily available at ward level despite information being available at directorate level. Nurses are not always recording in the records the caring/interventional activities provided to patients. Lack of public telephones on wards for patients/relatives to use impacting upon use of ward telephones, staff and inappropriate use of mobile telephones. 2. Good Practice Examples of 1-1 protected time for patients with named nurses (mental health) Patient satisfaction surveys and focus group activities taking place across Service Groups which enable patients, carers, families to influence care delivery. Examples of good written information on diseases, treatments, side-effects in some clinical areas. Implementation of EIDO patient information system (particularly within Surgery Services). Communication throughout patient pathway within Trauma & Orthopaedics. 3. Opportunities/Plans for Improvements A focused PPI audit is being put in place to review children s levels of understanding of what has been discussed with them by healthcare staff. The outcome of the audit will inform actions required across professional groups. Discussions are on-going with other agencies regarding improving access to interpreter services. Immediate practical steps are also being taken to improve access to information at ward level the ward telephone directory. Review of all patient information taking place. Steps are being taken to develop a database of patient information used across the organisation to support a robust review and updating process. Reinforcement of standards of documentation by nursing staff through professional forums and in-house nurse education programmes (particularly the Nurse Foundation Programme). October 2009 1

STANDARD 2&5: RESPECTING PEOPLE AND RELATIONSHIPS Range of Scores within Directorate Areas Operational Perspective 45.8% - 100% User Experience Perspective 66.7% - 100% 1. Summary of Issues/Key Themes Limited availability of rooms/space within ward and department areas for staff to undertake confidential/sensitive discussions with patients/their families regarding care, treatment etc. Lack of privacy re clinical discussion which takes place on ward rounds/at patient bedsides. Concerns expressed about dignity associated with the theatre/patient gowns used patients/parents feel that gowns can lead to inappropriate exposure. Staff failing to wear identification badges on occasions. 2. Good Practice Use of Do not Disturb signs on bed curtains to restrict interruptions and promote privacy. Health Care Support Worker (HCSW) Development Programme in place to support dignity and respect agenda- accessible to all HCSWs. Positive feedback from patients/families received re professional, respectful behaviour by staff. Identification of an area within some wards to enable the breaking of bad news (Surgery Service Group). 3. Opportunities/Plans for Improvements Roll out of RCN Dignity toolkit across the service. Implementation of bed screen Do Not Disturb signs across all ward areas. New builds to take into consideration for the need for space for confidential/sensitive discussions (examples include mental health new build and phase 2 Children s Hospital for Wales). Explore sourcing of alternative hospital gowns for patients via the Procurement team. October 2009 2

STANDARD 3: ENSURING SAFETY Range of Scores within Directorate Areas Operational Perspective 61.1%-100% User Experience Perspective 76%- 100% 1. Summary of Issues/Key Themes Availability of training places for staff on mandatory training programmes, especially manual handling training. Some clinical areas require refurbishment. Inadequate numbers of toilet and bathroom facilities (rehabilitation areas in particular) Inadequate storage facilities within ward areas leading to cluttered environments. Infection control audits are not always disseminated to wards. Lack of cubicles to support isolation of patients with suspected or actual infections. Limited timely access to ultra low beds. 2. Good Practice Robust security arrangements in place within Child Health. Effective roll out of 1000 Lives campaign, in particular uptake of safety briefings, hand hygiene Effective engagement in infection reduction target by hotspot wards realising a reduction in C.Difficile. Examples of clear escalation processes in place supporting the reporting and response to serious untoward incidents. De-cluttering activity taking place in collaboration with Waste Management/Hotel Services. 3. Opportunities/Plans for Improvements New Cleaning Standards/BICS process being implemented within the organisation (commencing in UHW) Access and location of alcohol gels reviewed and revisions agreed by Board. To be rolled out across the organisation. E-Learning approach for mandatory training being supported by Organisational Development and Training Department. Manual Handling training team to be enhanced through recruitment process an approach agreed by the Board. STANDARD 4: PROMOTING INDEPENDENCE Range of Scores within Directorate Areas Operational Perspective 40%- 100% User Experience Perspective 66%- 100% 1. Summary of Issues/Key Themes Inadequate bathroom facilities, particularly in respect of disabled patients (access, space) Very limited provision of en-suite facilities in ward areas. October 2009 3

Limited provision of therapy staff (Occupational therapy and physiotherapy staff) in a number of ward areas. This is impacting upon timeliness of discharge arrangements. Delays experienced in social work allocation. 2. Good Practice 24 hour physiotherapy cover in Child Health Outside agencies included in discharge planning (Child Health) Relapse prevention groups established in some wards (Mental Health) Risk assessment booklet developed and implemented (Medicine) Equality and Diversity training and advice readily available for staff. Outreach teams in place within a number of directorates supporting independent living. Ticket Home Trauma & Orthopaedics Directorate. Early mobilisation project Critical Care Directorate Carers Clinics- Trauma & Orthopaedics Directorate 3. Opportunities/Plans for Improvements Collaborative working with Social Services to trial discharging of patients considered to be higher risk (medicine Service Group). New build plans incorporate requirements of equality legislation. Discharge planning to be included as an integral part of the nursing assessment. October 2009 4

STANDARD 6: SLEEP, REST AND ACTIVITY Range of Scores within Directorate Areas Operational Perspective 53.8% - 100% User Experience Perspective 58.8% - 100% 1. Summary of Issues/Key Themes Background noise in shared environments (bays) leads to sleep disturbance. Lighting and noise identified as a reason for poor sleep by patients. Inadequate supply of linen and pillows reported in some clinical areas (stock levels not reflective of patient flow). Normal sleep pattern not recorded in documentation. 2. Good Practice Staff trained in relaxation techniques and Indian Head Massage (mental health) Patient s rest/quiet hour introduced in many areas across the organisation Parent/family accommodation made available in child health and maternity to promote comfort/reduce anxiety for family/patient. Play therapists available in child health to promote appropriate activity. Activity nurses available in Mental Health and several areas within Medicine/Rehab. Blood products are not transfused at night unless in an emergency. Noise study taking place to inform practice- Critical Care Quiet closing bins introduced in many areas. 3. Opportunities/Plans for Improvements Review of ward routine to ensure that night medication rounds do not disturb patients Implementation of All-Wales Uniform guidance when received from Welsh Assembly Government with attention paid to soft-soled shoes. Findings from the noise study currently taking place in Critical Care to be considered when made available so that lessons can be learnt. Explore the options associated with the introduction of earphones and earplugs. STANDARD 7: ENSURING COMFORT, ALLEVIATING PAIN Range of Scores within Directorate Areas Operational Perspective 30%-100% User Experience Perspective 60%-100% 1. Summary of Issues/Key Themes Patient feedback indicates a positive perspective on comfort and pain management although operational audit component indicated variation in practice across clinical areas. Inadequate provision of pillows in some clinical areas. Pain assessment tools not utilised consistently across clinical areas and evidence of incomplete pain assessments noted. October 2009 5

No designated pain team available in Child Health. Timeliness of access to syringe drivers in some clinical areas. Inconsistent approach to pain management across directorates (Surgery Services). Training in pain management and end of life care required in some areas. 2. Good Practice Good relationship with and effective referral mechanisms to pain team by ward staff. Provision and access to pain study days. Palliative Care nurse for Mental Health (first in Wales) Post operative pain assessment by patients (General Surgery, Urology and ENT) 3. Opportunities/Plans for Improvements Review provision of End of Life training for qualified staff to support staff in delivery of the End of Life Care pathway. Review provision of linen and pillows across service areas and promote appropriate and timely escalation of issues by ward sisters. Pain tools for children to be explored with a view to implementation within the service. Promote good practice re documentation to ensure that nursing activity is accurately reflected with patient records. October 2009 6

STANDARD 8: PERSONAL HYGIENE, APPEARANCE AND FOOT CARE Range of Scores within Directorate Areas Operational Perspective 35.7% - 100% User Experience Perspective 50%- 100% 1. Summary of Issues/Key Themes Lack of en-suite facilities in established facilities. Access to bathrooms/toilets can be problematic in some areas (linked to storage issues in many instances) Lack of mirrors, particularly at wheelchair height. No designated separate toilets/bathrooms in a number of directorates. Laundering of personal clothing an issue, including loss and damage (particularly in mental health, slow stream areas). Very limited and inconsistent arrangements for laundering of patient clothing at ward level. 2. Good Practice Use of inflatable hair washing trays to accommodate hair washing of the bed bound patient. Examples of good models of chiropody practice in some areas (chiropody clinics for mental health inpatients) Example of good practice re written information with regard to specific hygiene needs for haematology patients. Single use toiletry packs available for ward sisters to requisition to support patient hygiene. Positive feedback from patients regarding timing of personal hygiene opportunities and availability of nursing staff to assist patients with personal hygiene needs. Hand wipes (hygiene wipes) made available to patients after use of the commode. 3. Opportunities/Plans for Improvements Liaise with podiatry service re staff training in foot assessment/nail cutting Review bathroom mirrors and promote introduction of mirrors at standing and sitting heights. Toilet and bathroom facility issues within child health will be addressed as part of phase 2 Children s Hospital for Wales development. Review of current arrangements to be undertaken by Head of Nursing to identify interim measures to address single sex facilities. Explore the introduction of disposable washing bowls across the service. STANDARD 9: EATING AND DRINKING Range of Scores within Directorate Areas Operational Perspective 50%- 100% User Experience Perspective 58.3%- 100% 1. Summary of Issues/Key Themes Not all staff have completed the food hygiene course. October 2009 7

Choice of food by patients across the organisation has received varied response. Patients have reported ordering one meal and being served something different. Meal times are not always appropriate for some patient groups (e.g.child health) Limited provision of snacks for patients requiring supplementary intake/those with poor appetites. Patient feedback has indicated that food can sometimes be tasteless although this may be associated with clinical condition (e.g. haematology) Maintaining correct temperature of food at point of service can be problematic (last bay issue). Limited access to SALT provision, especially on weekends. Limited access to warm drinks throughout the day (water available and tea rounds undertaken) 2. Good Practice Evidence of effective implementation of protected mealtimes in a number of wards. Red tray system in place in many wards Evidence of good information provision to patients regarding dietary advice. Implementation of the Dietary Assistant role within rehabilitation/slow stream areas (Elizabeth Ward is noteworthy). Smoothie sessions implemented in a number of areas to support dietary/supplementary intake where required. Provision for Breast feeding mothers. Evidence of appropriate weighting of patients in accordance with individual care plans. 3. Opportunities/Plans for Improvements Continue the excellent working relationship with the dietetics department to further extend good practice across all clinical areas. Key role in rolling out the new All-Wales Food and Fluid intake charts/posters. Planned programme to be put in place to support attendance by staff at the food hygiene training sessions. Identify opportunities to develop/increase the number and role of the Dietetic Assistants across ward areas. Focused PPI audit will be used to inform choice/nutrition for children. Review frequency and nature of tea rounds Improve liaison with catering department and menu sub-group. October 2009 8

STANDARD 10: ORAL HEALTH AND HYGIENE Range of Scores within Directorate Areas Operational Perspective 33.3% - 100% User Experience Perspective 0% -100% 1. Summary of Issues/Key Themes Incomplete oral hygiene care plans Basic oral healthcare toiletries not routinely available at ward level(toothbrush/paste/mouthwash) Need to assess oral health and dental status not recognised in all areas. Oral health assessment is not incorporated into assessment booklet at this time. Feedback from patients/parents is overall more positive than operational components of the audit 2. Good Practice Evidence that in some areas patients are informed of the importance of mouth hygiene/care linked to treatment/side-effects. Access arrangements to dentist for identified patients (especially mental health and child health). Health promotion activity by play therapy staff within child health. Oral toilet trays are available for patients identified as Nil By Mouth (Surgery Services) 3. Opportunities/Plans for Improvements Explore procurement of dental hygiene pack for ward sisters to access based upon individual patient need. Put in place arrangements which promote the sharing of good practice across directorates/service Groups. Identify appropriate oral health/hygiene assessment tool for inclusion in assessment booklet. Work on going within Child Health to incorporate assessment with ADL to be progressed. STANDARD 11: TOILET NEEDS Range of Scores within Directorate Areas Operational Perspective 45.5% - 100% User Experience Perspective 65.8%-100% 1. Summary of Issues/Key Themes Limited availability of en-suite facilities. Some toilet facilities are undersized to accommodate/manoeuvre wheelchairs and patients with oxygen cylinders. Urinals and bedpans not always removed from patients/bed areas in a timely manner. Limited sluice facilities in some wards. Poor signage of toilet/bathroom facilities. Inadequate provision of toilets for visitors. October 2009 9

Ward staff unable to change/renew toilet rolls as they do not have access to the toilet roll holder key. 2. Good Practice Commode audit undertaken and standards monitored. Development of Commode cleaning protocol/poster supporting improved standard of cleanliness. Wipes available for patients to clean hands after commode usage. 3. Opportunities/Plans for Improvements Improve signage within ward areas. Explore opportunities with the Infection Control team and Estate department to improve sluice/bathroom and toilet facilities. Reinforce importance of removal of bedpans/urinals from patient bedsides in a timely manner (issue to be highlighted within relevant existing training programmes). Source keys for toilet roll holders so that ward staff can change/replenish toilet rolls as required. October 2009 10

STANDARD 12:PREVENTING PRESSURE SORES/ULCERS Range of Scores within Directorate Areas Operational Perspective 15.4% - 100% User Experience Perspective 42.9%-100% 1. Summary of Issues/Key Themes Limited evidence of provision of information to patients regarding pressure area care/prevention. Assessment tool available for children but not currently used and need for assessment is not triggered in ADL assessment. Limited use of incidence monitoring point prevalence currently used routinely. Limited numbers of wound healing specialist nurses within the service leading to difficulties in the provision of timely specialist advise to ward based staff. Access to bariatric beds with dynamic mattresses. 2. Good Practice Access arrangements for pressure relieving mattresses Example of good practice/reduction in incidence in Critical Care using safety cross (IHI/1000 Lives tool) Pressure area sticker used within Surgery Services to identify pressure area and promote use of appropriate procedure. 3. Opportunities/Plans for Improvements Review current arrangements for pressure ulcer/care monitoring in collaboration with wound healing department. Explore opportunities to roll out skin bundle and use of safety cross to support monitoring of pressure areas. Pressure ulcer management to be a key quality indicator within ward/directorate/corporate dashboard. Review information available for patients/carers regarding pressure ulcer prevention and care. Directorate Feedback re Audit Tool/Process of data collection/plans for implementation of ward/ directorate improvement plans The audit has been implemented across all bed holding areas within the required timescale. There are some further amendments required to the All-Wales audit tool to support robust implementation and make its use more user friendly. Enhancements to the filtering/report production component of the tool would further enable scrutiny of the findings of audits within directorates. Organisational approaches should be developed to facilitate independent gathering of information from patients/relatives/advocates to ensure rich feedback from patients who may feel vulnerable providing feedback at the time of receiving care. Support will need to be given to staff to develop action plan writing within the context of the tool/audit process although greater familiarity with the tool will lead to improved plans being developed by Ward Sisters/Charge Nurses in collaboration with Senior Nurses. Any Other Comments Further refinement of the All-Wales tool required with consideration being given to implementation of a October 2009 11

wireless and/or hand held system to support data capture. COMPLETED BY: Mandy Rayani DATE 07 October 2009 October 2009 12