Fundamentals of Care Annual Audit Report 2013

Fundamentals of Care Annual Audit Report 2013

INDEX Page 1. Executive Summary 3 2. Situation 3. Background 4. Assessment 4.1 Fundamentals of Care Standards - Review of Operational Questions and User Experience feedback 4.1.1 Overall Summary 4.1.2 Std 1 - Communication and information 4.1.3 Std 2 and 5 - Respecting people & relationships 4.1.4 Std 3 Ensuring safety 4.1.5 Std 4 Promoting independence 4.1.6 Std 6 Rest & sleep 4.1.7 Std 7 Ensuring comfort, alleviating pain 4.1.8 Std 8 Personal hygiene, appearance & foot care 4.1.9 Std 9 Eating and drinking 4.1.10 Std 10 Oral health & hygiene 4.1.11 Std 11 toileting needs 4.1.12 Std 12 preventing pressure sores 5 5 8 8 8 10 14 18 20 22 24 26 28 32 33 35 4.2 Fundamentals of Care Staff Survey 37 5. Recommendations 42 5.1 Actions for improvement 42 5.2 Monitoring and assurance 45 5.3 Conclusion 46 6. References 47 7. Appendix A - Quality Matrix compliance scores Appendix B - Local action plan PDSA model for improvement 49 51 2 Fundamentals of Care Annual Audit 2013 Welsh Government

1 Executive Summary Cwm Taf University Health Board Quality Strategy, Quality Delivery Plan and Patient Experience Plan embrace our philosophy of Cwm Taf Cares putting patients at the centre of everything we do to deliver safe and effective care, ensuring excellent patient (carer/user) experience and excellent staff experience. The Francis review (February 2013) of care delivered at Mid Staffordshire NHS Foundation Trust identified 5 key themes, underpinned by the requirement for a fundamental quality improvement culture and the adoption of common values across organisations focusing on: Fundamental standards Openness, transparency and candour Compassionate, caring and committed staff Strong, patient centred healthcare leadership Accurate, useful and relevant information The Fundamentals of Care (FOC) National Audit System has been redesigned during 2012 to ensure that it supports these values, providing quality assurance and identifying improvements where required within services, health boards and across NHS Wales. The 2013 NHS Wales FOC National Audit results provide assurance from the operational audit, patient survey and staff survey where compliance with the 12 standards and excellent experience is demonstrated. It identifies where we need to focus improvements where scores are reported below the 85% compliance rate. The detailed results of each question within the audit are presented in this report, the summary findings include: 1). Feedback from patients confirms the high standards of care provided across the Health Board and the need to focus improvement with: Standard 6 (Rest and Sleep) 2). The operational audit supports the findings in the patient survey and confirms standards for improvement: Standard 6 (Rest and sleep); Standard 7 (Ensuring comfort and alleviating pain); Standard 8 (Personal hygiene, appearance and foot care). 3). The staff survey results align with the findings of the 2013 NHS Wales staff survey and the actions for improvement are being taken forward with the UHB staff survey team focusing on health wellbeing, how we work and support staff, building trust and ownership and being part of an effective team. I would like to extend my gratitude to all the patients, carers and staff involved with the 2013 FOC audit process and assisting with providing assurance of where we are providing excellent standards with fundamentals 3 Fundamentals of Care Annual Audit 2013 Welsh Government

of care and identifying where we need to focus our continuous quality improvement. Mrs Lynda Williams Executive Director of Nursing and Midwifery 4 Fundamentals of Care Annual Audit 2013 Welsh Government

Situation The Fundamentals of Care (FOC) Standards have been developed and implemented to improve the quality of fundamental aspects of health and social care for patients and service users in Wales. The importance of the National annual FOC audit is emphasised from the findings from the Francis Enquiry (2013) and Keogh Report (2013). The FOC system complies with Safe Care, Compassionate Care (A National Governance Framework to enable high quality care in NHS Wales 2013) and with the NHS Wales National Clinical Audit and Outcome Review Plan (2013/14). The Fundamentals of Care audit system provides assurance to patients, the public, staff teams, Health Boards/Trusts and Welsh Government by measuring the operational compliance with the 12 FOC standards, user (patient/carer) experience and also staff experience. The Welsh Government requires all Welsh Health Boards/Trusts to measure their compliance against the standards by undertaking an annual national FOC audit and these results are published. It should also be noted that the FOC audit tools within the system can be utilised locally at any time throughout the year to measure compliance with the 12 FOC standards. The Welsh Government has commissioned a review of 12 FOC standards and the 26 Standards for Health Services in Wales commencing January 2014. 2 Background Review of the FOC system 2013 The FOC audit system has been completely reviewed prior to the 2013 National audit which was completed during October and November. The questions to inform the operational, patient and staff surveys were reviewed, scrutinised and developed to ensure elimination of duplication of data collection and to design an updated audit system that is fit for purpose. The entire review of the FOC audit system has been completed during 2013 to include: Full review of all operational audit questions Full review of the 2003 FOC document, with driver diagrams developed for each standard, and updating the wider multi professional/agency evidence base for each standard Design of sub-set audit questions for key specialities Partnership working with the All Wales User group to review/redesign the user questionnaire and involvement of the Welsh Government statistician to ensure a robust data collection process and validated system. Redesigning and development of the FOC action plan module to align with the Model for Improvement to inform quality improvements where non compliance is identified 5 Fundamentals of Care Annual Audit 2013 Welsh Government

The FOC system implementation was supported by the review of: The Best Practice Guidance for staff Patient/Carer/Staff information leaflets A training package to support the implementation of the new FOC system. And the development of: A Staff Survey, aligned with the All Wales NHS Staff Survey A Compliance Matrix and user guide (85% compliance measure required for each standard). The RAG red, amber, green scoring system has been used throughout this report to present the report, see appendix1. Purpose of the FOC system The results of the FOC audits provide patients, staff teams, Health Boards/Trusts and Welsh Government with rich data to identify: 1. What we are doing well 2. What we need to improve 3. How we can improve the experience of patients and staff The audit enables patients/carers: To share their views and experiences on what we do well and where we need to improve, which will be used to help improve the services we provide To have a voice in the quality of the care they receive It ensures an openness and transparency with the quality standards It empowers staff: To make a difference and ensures ownership of their practice To have a voice in the care that they provide and ensure the focus is on essential elements of care and caring. To identify areas of good practice and highlight issues for concern To develop action plans which enables them to monitor change It enables organisations: To have a mechanism to monitor/measure the quality of care To develop organisational policies and procedures To identify key themes for improvement The new FOC audit tool has been designed with teams across NHS Wales to ensure that the questions are specifically tailored to meet the needs of general wards, outpatient departments, operating theatres, endoscopy suites, 6 Fundamentals of Care Annual Audit 2013 Welsh Government

day patient units and Unscheduled Care (accident and emergency departments). The FOC National Audit Autumn 2013 The 2013 National FOC audit was completed during 1 st October 2013-30 th November 2013 using the: 1. Patient survey 2. Staff survey 3. Operational audit The FOC audit involved asking patients about their experiences of care; asking staff about their experience of working within the Health Board, and observing delivery of care and the assessment of the operational application of the 12 FOC standards. This included: Examination of patient records respectively to measure compliance against the standards and triangulation of information Observation of clinical practice Environmental assessment Guidance was obtained from the chief Statistician in the Welsh Government to provide assurance of the validity of the FOC system and data collection methodology, and part of the guidance provided was to undertake patient and staff surveys across Wales on the same date to ensure uniformity. It should be noted that the Action Planning module within the updated FOC system has been aligned with Improving Quality Together, using the Model for Improvement tools (SBAR situation, background, assessment, recommendations and PDSA cycles plan, do, study, act). This strengthens ownership of quality improvement locally within teams and across the Health Board. The FOC system is not used to compare organisations across NHS Wales. The FOC audit results generated are for local measurement to inform quality improvements, learning and to share and celebrate good practice. Learning and feedback from using the new FOC audit system in practice will inform an evaluation and future changes that may be required to continually enhance the national FOC system. During 2014 the All Wales FOC system will be designed specifically for a wider set of services: Mental Health, Paediatrics, Neonatal Care, Maternity, Community and Learning Disabilities, with the staff survey being expanded to all members of the multidisciplinary team. 7 Fundamentals of Care Annual Audit 2013 Welsh Government

4 Assessment 4.1 Fundamentals of Care Standards (Operational Questions and User Experience Feedback) 4.1.1 Overall Summary In light of the significant revisions made to the format, number and types of questions included in this year s audit, no direct comparison can be drawn between the 2013 and previous annual audits. It is also important to note that the operational, patient experience and staff survey questions have been reviewed independently and not combined as in previous audits. It is intended that the 2013 audit will form a baseline for the 2014 and subsequent audits. Operational Questions The 2013 audit results for the 59 clinical areas audited across Cwm Taf University Health Board (CTUHB) demonstrate that for the operational questions in 5 out of the 12 standards the organisation had met the All Wales fundamentals of care standards compliance of 85% and over. Seven areas were identified for improvement, but no areas were noted as a major concern. Table 1 Operational Question Overall Summary RAG % Std 1 Communication and Information 83% Std 2 & 5 Respecting people and Relationships 80% Std 3 Ensuring Safety 88% Std 4 Promoting Independence 88% Std 6 Rest & Sleep 65% Std 7 Ensuring Comfort & Alleviating pain 66% Std 8 Personal hygiene, appearance and foot care 71% Std 9 Eating and Drinking 86% Std 10 Oral Health & hygiene 91% Std 11 Toileting needs 71% Std 12 Preventing pressure sores 93% Overall Health Board Score 83% The action plan for improvement will focus particular attention on Standard 6 (Rest and sleep), Standard 7 (Ensuring comfort and alleviating pain) and Standard 8 (Personal hygiene, appearance and foot care). 8 Fundamentals of Care Annual Audit 2013 Welsh Government

User Experience The user experience surveys were undertaken on the 6 th November 2013 across all audit areas within the organisation and across all organisations in Wales, except within theatre departments. 437 patients/carers were surveyed across CTUHB. Graph 1 Overall User Experience Summary (All Questions) 100% 80% 60% 40% 20% 0% 77.63% 16.63% 4.64% 1.11% Always Usually Sometimes Never The combined results for all user experience survey questions demonstrates that the patients surveyed were satisfied with the standards of care that they received from CTUHB. When specifically asked to rate their overall satisfaction with the care provided to them and their families they gave the organisation a rating of 87% ensuring that Cwm Taf University Health Board achieved a RAG rating of green in accordance with the All Wales fundamentals of care audit criteria. 9 Fundamentals of Care Annual Audit 2013 Welsh Government

4.1.2 Standard 1 - Communication and Information Operational Questions Table 2 Standard 1 Operational Questions RAG % Q1 Are the patient's demographic details clearly recorded on all the patient's documentation? Q2 Is there documented evidence that the patient's ability to achieve effective communication has been assessed and discussed with the patient or advocate? Q3 Where the patient requires assistance to achieve effective communication, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q4 Is there documented evidence that each plan of care has been assessed and discussed with the patient or advocate? Q5 Are the contact details of the first point of contact recorded in the patient s documentation? Q6 Is there information clearly displayed regarding how patients/relatives/advocates can raise a formal or informal concern? Q7 Do all patients wear an identification band which states their first and last name, date of birth and NHS number? Q8 Is the patient's identity checked visually and verbally prior to giving medication or undertaking a procedure? 95% 92% 64% 69% 97% 83% 98% 99% Q9 Are all clinical staff wearing staff identification badges? 83% Q10 Are all clinical staff complying with the All Wales Dress Code? 95% Q11 For patients with no known diagnosis of dementia, delirium or other cognitive impairment at admission, there is documented evidence that within 72 hours of admission, the screening question been asked? Q12 For this episode of care, where the patient has an identified care need in respect of cognitive impairment, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q13 Are all medication charts completed clearly and is patient information complete? Q14 Is a nurse present during the contact between doctors/consultants/gps and patients? Q15 Are patients able to communicate in Welsh with nursing staff in the clinical area, if they wish to? 36% 55% 68% 91% 66% Overall Score 83% Medicines management CTUHB performed strongly in elements of this standard. Of particular note was the good practice observed with staff compliance to the CTUHB 10 Fundamentals of Care Annual Audit 2013 Welsh Government

guidance for the safe administration of medicines. 99% of staff observed checked patient identification verbally and visually prior to the administration of medicines and 98% of patients were wearing appropriately completed identification bands. All Wales dress code Compliance with the All Wales dress code was high but the numbers of clinical staff wearing identification badges needs to be improved. This has been reported in other forums where service users have said that they did not know the name of the nurse or doctor looking after them. As well as the use of appropriate identification badges this might also reflect the need for staff to introduce themselves to patients and carers on each contact. Care Planning Communication Communication is central to all activities provided in the care environment and all human interaction involves communication. When caring for patients, carer`s and service users who are often experiencing high emotions due to worry, fear and anxiety, clear, regular and consistent communication and information becomes even more vital. When patients have difficulty communicating or being communicated with this can significantly impact on well-being, and relationships. Communicating effectively needs to be recognized as a priority within the care planning activity. Only 64% of patients with identified communication problems had an up to date care plan which had been reviewed within the previous 24hours and only 69% showed documented evidence that the plan had been discussed with the patient or their carer. Cognition Screening Within Standard 1 the area in which CTUHB failed to reach an acceptable level of performance was in ensuring that the agreed cognition screening question had been asked at admission. This screening question does not currently form part of the CTUHB nursing documentation, but is being included within the review of nursing documentation for implementation from April 2014. Question 12 explored the availability of a care plan to manage cognitive impairment. At first glance it would appear to be an area in which performance is poor. However, there needs to be consideration of wider issues than cognition alone. All patients should have risk assessments completed within the first 6-24hours following admission to hospital within CTUHB. These assessments consider the patient s needs and risk in respect of falls and the use of cot sides; pressure ulcer formation; oral hygiene; nutrition; mobility; moving and handling and general hygiene. Care plans are then prepared to reflect the needs and risks and highlight the planned interventions to manage them. Even when a specific care plan to address the broad term cognitive impairment is absent, care plans will reflect the multi-faceted issues relevant to delivering safe care for patients 11 Fundamentals of Care Annual Audit 2013 Welsh Government

with different levels of cognitive ability such as delirium, learning difficulties, strokes, head injuries, acute confusional states and dementia. In all cases the care plans are based on identified nursing need and not the medical condition. CTUHB patient supervisory needs assessment tool and policy documents are currently in draft form. Once approved these will support the risk assessment and care planning processes further. Communicating in Welsh 66% of the clinical areas which responded to the audit question identified the availability of Welsh speaking staff. There is a register of Welsh speaking staff within CTUHB and a member of staff can be identified from another area if required to communicate with a patient if Welsh is their language of choice. In an effort to increase the number of Welsh speaking staff within the organisation the CTUHB Welsh Language Unit, in partnership with the University of South Wales, offers Welsh classes for beginners and at an intermediate level. Welsh speaking nurses are easily identifiable by the embroidered badge on their uniforms The staff population of CTUHB come from many cultures and countries around the world and speak many languages and dialects. They can be called upon to communicate with patients originating in their native country who do not speak English or Welsh. Additionally, a register of translators is available to utilise if we cannot meet the requirement from within the organisation. User Experience Question 99 Throughout your stay/attendance, how often did you feel that you and those that care for you were given full information about your care in a way that you could understand? Graph 2 100% 80% 60% 40% 20% 0% 73.09% 20.19% 6.26% 0.46% Always Usually Sometimes Never Findings Overall the vast majority of patients who responded were satisfied with the quality and frequency of information given and the manner in which it was 12 Fundamentals of Care Annual Audit 2013 Welsh Government

provided. 93% of patients felt that they were always or usually given full information about their care in a way they could understand. Commentary suggests that those patients who expressed dissatisfaction are mostly concerned with the lack of information prior to a planned hospital stay. For example:- What are the reasons for admission 24hours prior to surgery? How long can a person usually expect to be in hospital? Patient Comments The Doctors I saw explained medical matters very well and I felt confident in their abilities especially with Mr X and Mr F who were most kind. Doctors saying they would take 10 minutes to see me then took 2 hours. Did we have to come in day before op?. Is coming in so early on a Monday necessary for a Tuesday op?. Took a while for me to get my appointment then it was initially cancelled. Could have done with more information on what to expectto plan accordingly etc. 13 Fundamentals of Care Annual Audit 2013 Welsh Government

4.1.3 Standard 2 and 5 - Respecting people and Relationships Operational Questions Table 3 Standard 2 and 5 Operational Questions RAG % Q16 Does the patient's documentation capture their preferred name and/or title? Q17 Is there documented evidence that an assessment of the carers needs has been considered? Q18 Is there documented evidence that the patient's cultural needs has been assessed and discussed with the patient or advocate? Q19 Is there documented evidence that the patient's spiritual needs has been assessed and discussed with the patient or advocate? Q20 Is there evidence to demonstrate that patient identifiable information is treated in a confidential and secure manner? Q21 Is there written evidence in the patient's clinical notes that the patient's consent to the sharing of information with others has been obtained? Q22 Is there a facility for patients to talk in private to staff (e.g. a quiet room or office)? Q23 Is there a quiet room for patients to spend time with their visitors away from their bedside? 81% 55% 58% 58% 98% 62% 95% 60% Q24 Within the clinical area, are all the bays single sex bays? 83% Q25 Do all patients have access to single sex toilet and washing facilities? Q26 Is there a facility to preserve patient dignity by communicating to others that care is in progress? Q27 Can staff demonstrate they know the procedure if a safeguarding concern is identified? 85% 98% 98% Overall Score 80% Patient Privacy The audit information suggests that patient privacy and dignity is receiving the consideration expected by CTUHB. Good practice is demonstrated by the use of Care in Progress signs to promote privacy and reduce interruptions to the patient whilst receiving care. In 98% of cases staff demonstrated knowledge of the procedure to safeguard a vulnerable patient and 95% of areas have a quiet room that can be utilized for conversations between patients and staff to protect their privacy. However, of the 42 clinical areas that responded to the survey, only 25 (60%) had access to a quiet room for patients to spend time with their family away from the bedside. 14 Fundamentals of Care Annual Audit 2013 Welsh Government

Carers Needs In July 2013 the Carer`s Measure was launched in CTUHB in conjunction with Local Authority partners. A program of training and staff awareness raising was developed and is currently being rolled out across the UHB. An e-learning package has been established for staff to access and carer champions are being identified across the health board to cascade key learning and identify training needs. These individuals receive further Carer Awareness training and guidance to support colleagues with their own learning. There is more work to be completed to achieve the outcome of all staff having an awareness and understanding of the rights of carers. This program of work will continue across primary care, secondary care and community settings into 2014. Although a 55% score appears low for Question 17 the audit does not capture the percentage of patients who had informal carers, it only captures the percentage of notes scrutinized which confirmed documented evidence of carers needs being considered. This issue with be reviewed as part of the FOC system evaluation in readiness for the 2014 audit. Cultural and Spiritual Needs In almost half of the patient notes which were scrutinized there was little evidence to suggest that the patient s cultural or spiritual needs had been assessed or discussed with the patient or their advocate. Wales now has a multi-cultural, multi-faith society and this is reflected in the service user population. Spiritual and religious care has been shown to be important to patients and is acknowledged to have a significant and beneficial impact on patient outcomes. Everyone whether religious or not needs support and when confronting serious or life threatening illness or injury may have spiritual needs and welcome spiritual care as they seek to cope with suffering, loss, fear, loneliness, anxiety, uncertainty, impairment, despair, anger or guilt. Those associated with a faith community may derive help and comfort from their beliefs, from the rituals and ceremonies of their faith, and the ministry of its leaders. The NHS must offer both spiritual and religious care with equal skill and enthusiasm (Standard 1: Standards for Spiritual Care Services in the NHS in Wales, Welsh Government 2009) To ensure patient needs are met and the organization is compliant with the spiritual standards outlined by Welsh Government, greater emphasis will need to be placed on this area of assessment and discussion in the future. Security of Patient Information In November 2013 Welsh Government introduced legislation to ensure integrated assessment, planning and review for an older person takes place 15 Fundamentals of Care Annual Audit 2013 Welsh Government

between health and social services. To meet the requirements of the legislation a core data set was identified. Consent to share information with others is one of the key areas identified within the Integrated Assessment core data set. From April 2014 all patients (or their advocate) will be required to acknowledge and document consent to the inter agency sharing of information. Nursing documentation will be adjusted to accommodate this process. This adjustment will also accommodate the patient s nomination of a family member(s) with whom information can be shared. This change will considerably improve the 62% score for Question 21. User Experience Question 100 Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect? Graph 3 100% 80% 60% 40% 20% 0% 87.41% 10.76% 1.83% 0.00% Always Usually Sometimes Never Question 101 Throughout your stay/attendance, how often did you feel that you were given the privacy that you needed? Graph 4 100% 80% 60% 40% 20% 0% 84.14% 12.18% 3.45% 0.23% Always Usually Sometimes Never Findings Findings confirm that patients experience of a dignified care environment is very positive. 98% of patients surveyed reported that they were always or usually treated with dignity and respect. A copy of the CTUHB Dignity Pledge is available at every patient bedside throughout the Health Board. This informs the patient and their family of the standard of care they can expect and the behaviours and attitudes with which staff can be expected to deliver care. Alongside this is the Have Your 16 Fundamentals of Care Annual Audit 2013 Welsh Government

Say feedback form, which service users can use to communicate, anonymously if they wish, issues, concerns, compliments or suggestions to improve the service provided. These have been successfully used for example, by the Patient Experience manager to inform improvements in care environments and to address concerns such as standards of cleanliness. Patient Comments Patient commentary overwhelmingly reflects the patience, kindness and caring attitudes they have experienced from CTUHB staff. Examples include: Everyone is so helpful and friendly. They respected my dignity and treated me with respect. They were very reassuring when I was anxious about aspects of my treatment. Carer was allowed to come in and see to personal hygiene, which made me feel more comfortable. I have been treated with kindness and respect from every member of staff and have been most impressed with the love and care given to all patients. A very dedicated team of hard working people. How fortunate we are to have such an excellent NHS service. I have no complaints at all. Everyone does their best for their patients and in fact go out of their way to get anything that is required. 17 Fundamentals of Care Annual Audit 2013 Welsh Government

4.1.4 Standard 3 Ensuring Safety Operational Questions Table 4 Standard 3 Operational Questions RAG % Q28 Has the Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months? Q29 If an Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months, please enter the percentage compliance score. Q30 Has a Waste Management Audit been undertaken within the last 12 months? Q31 Has a Waste Management Audit been undertaken within the last 12 months. Please enter the compliance score as a percentage. Q32 Are staff able to give examples of the correct procedure for source isolating patients? Q33 For this episode of care, is there documented evidence that the patient has an up to date manual handling risk assessment? Q34 For this episode of care, where the patient has an identified manual handling risk, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours? Q35 Are any Manual Handling aids and slings regularly checked for wear and tear? Q36 Within the clinical area, are all fire restraint doors free from obstruction or closed if not automatic self closing? Q37 Is the equipment used in the clinical area up to date with maintenance and calibration? Q38 Are all drug cupboards/trolleys locked and secure as per local policy? 88% 90% 54% 68% 100% 82% 84% 96% 95% 99% 97% Overall Score 88% CTUHB Quality Strategy aims to improve safe and effective care and patient experience. Audit data confirms the excellent compliance in practice in key areas of this standard. Good practice Good practice is demonstrated in the safety checks carried out on moving and handling aids and the calibration and maintenance of equipment. 100% awareness was demonstrated when staff were questioned about the procedure for source isolation of patients. Waste management Safe management of healthcare waste (2013) requires that any clinic or practice that creates 5 tonnes or more of clinical waste in a year should undergo an annual waste management audit. 54% of the clinical areas 18 Fundamentals of Care Annual Audit 2013 Welsh Government

surveyed had undergone a waste management audit within the previous 12 months and had received an average score of 68%. The frequently each ward/department should be audited and whether, for example, the requirements on wards are the same as operating theatres will be reviewed and clarified with the waste management manager to ensure compliance in all areas is achieved. User Experience Question 103 Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy and not cluttered? Graph 5 100% 80% 60% 40% 20% 0% 82.80% 15.83% 0.92% 0.46% Question 108 Throughout your stay/attendance, how often did you feel that you were made to feel safe? Graph 6 Always Usually Sometimes Never 100% 80% 60% 40% 20% 0% 89.71% 8.37% 1.67% 0.24% Always Usually Sometimes Never 19 Fundamentals of Care Annual Audit 2013 Welsh Government

Findings 99% of patients who responded felt that the clinical area was always or usually clean, tidy and uncluttered. 98% of patients said that they were always or usually made to feel safe while in or attending CTUHB hospitals Patient Comments All staff showed they wanted to help, comfort and make one feel secure and safe. Everywhere nice and tidy and clean. Staff are very good Clinical area well presented. 4.1.5 Standard 4 - Promoting Independence Operational Questions Table 5 Standard 4 Operational Questions RAG % Q39 For this episode care, is there documented evidence that the patient s level of independence has been assessed and discussed with the patient or advocate? Q40 For this episode of care, where the patient has been identified as requiring support and/or assistance to maximise independence, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q41 For this episode of care, is there documented evidence the patient's mobility has been assessed and discussed with the patient or advocate? Q42 For this episode of care, where the patient has been identified as requiring support and/or assistance with mobility, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q43 For this episode of care, is there documented evidence the patient's risk of falls has been assessed and discussed? Q44 For this episode of care, where the patient has been identified as being at risk of falls, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q45 Where appropriate, do all patients have written evidence of a discharge assessment and plan? Q46 Where appropriate, is there written evidence that the patient's family/carer has been involved in discharge planning? Q47 Within the clinical area, are washing, bathing and toilet facilities suitable for the all service users? Q48 Does the clinical area allow patients to bring in personal items to assist with patient orientation/familiarity? 96% 89% 90% 87% 91% 85% 73% 79% 96% 95% Overall Score 88% 20 Fundamentals of Care Annual Audit 2013 Welsh Government

Good Practice Overall the audit data suggests good practice is being observed with the assessment of patient mobility and risk of falls. Care planning was undertaken and reviewed in the majority of records reviewed. Discharge Planning Two areas in which documentary evidence of robust practice is less evident relate to discharge assessment and planning and involvement of the patient s family. Anticipated date of discharge (ADD) is used across CTUHB as a guide to proactively plan the patient journey through the hospital system and reduce delays in ensuring all requirements for a safe discharge are anticipated and organized in advance of being medically fit to leave hospital. The audit results suggest that in more than 20% of cases there is no evidence of anticipatory plans being developed. The consequence of this could be unnecessary delays in discharge putting the patient more at risk of hospital acquired complications and avoidable pressures on hospital bed occupancy. Since this audit focused activity on improving patient flow has demonstrated considerable improvement and reduction in unnecessary delays in patient discharges. User Experience Question 102 Throughout your stay/attendance, how often did you feel that you were given help to be as independent as you can and wish to be? Graph 7 100% 80% 60% 40% 20% 0% 79.02% 17.32% 3.17% 0.49% Always Usually Sometimes Never Question 104 Throughout your stay/attendance, how often did you feel that when you called us that we responded in a timely manner? Graph 8 100% 80% 60% 40% 20% 0% 68.19% 26.02% 5.30% 0.48% Always Usually Sometimes Never 21 Fundamentals of Care Annual Audit 2013 Welsh Government

Findings More than 96% of patients expressed satisfaction that they were always or usually assisted to be as independent as they would want to be. Similarly, more than 94% of respondents were always or usually responded to in a timely manner. However, two patients out of the 437 audited reported that they were never responded to in a timely manner and this patient experience feedback is being further explored to determine actions for assurance with improvement. Patient Comments I did not feel that the fact I was partially sighted was taken fully into account in the assessment of my capabilities. The thing I would change is that I would like my night tablets earlier around 2100 hrs if possible. Improve experience: waiting in toilet when using a chair and being dependant. Nurses always came when called to help me. 4.1.6 Standard 6 - Rest & Sleep Operational Questions Table 6 Standard 6 Operational Questions RAG % Q49 For this episode of care, is there documented evidence that the patient's normal sleep pattern and needs have been assessed and discussed with the patient or advocate? Q50 For this episode of care, where the patient has an identified sleep issue or sleep has been recorded as poor/disrupted is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? 77% 49% Overall Score 65% Within Standard 6 there were only two operational questions asked. These were specifically focused on whether a sleep history was recorded and once needs were assessed whether an appropriate plan of care was formulated, reviewed and evaluated regularly. Although 77% of the notes examined showed evidence of an assessment being undertaken and discussed, only 49% of patients identified as having problems sleeping had a care plan which reflected the issues. For all patients admitted to hospital the environment is alien to their usual experience. Sharing a multi occupied room, unfamiliar noises, over stimulation; sleeping in a single bed with a very firm mattress; plastic coated pillows; room temperature; fear; pain; reduced activity; new medications; 2 hourly repositioning by nurses; daytime dozing are all 22 Fundamentals of Care Annual Audit 2013 Welsh Government

factors which might interfere with normal sleep patterns. Some wards, with appreciation of these issues have introduced rest periods during the day to help patients have protected time for their rest. Whilst these might be appreciated it is often difficult for patients to revert to their usual sleep patterns on discharge from hospital if new habits have been developed. Ideally, patients should be supported to maintain their usual rest and sleep patterns as far as possible and these should be reflected in the plan of care. Adequate sleep and rest is important for mental wellbeing and physical restoration and recovery. Acutely unwell patients deprived of sleep can become confused and agitated or lethargic and disinterested. Even patients who are reasonably healthy can become agitated and aggressive if their sleep is continuously disturbed. Focused work is required across CTUHB to highlight the importance of assessing a patient s need for sleep and rest and address their requirements in care planning. User Experience Question 109 Throughout your stay, how often did you feel that you were able to get enough rest and sleep? Graph 9 100% 80% 60% 40% 20% 0% 46.93% 31.01% 17.60% 4.47% Always Usually Sometimes Never Findings Of all twelve standards audited Sleep and Rest was the standard that service users reported most dissatisfaction. Patient feedback aligns with the operational audit findings. Less than 88% of patients agreed that they were always or usually able to get enough rest and sleep while in hospital. The factors which contribute to disturbances in sleep and rest across all sites needs to be further explored, to inform service and quality improvements and identify the factors to consider when formulating plans of care. 23 Fundamentals of Care Annual Audit 2013 Welsh Government

Patient Comments As a person that doesn't sleep much and shouts out a lot through the night I would have preferred a side room as not to disturb others. Not too warm on the ward and bed's uncomfortable. Very noisy at night not able to sleep properly. One patient kept calling throughout the day. This is not a complaint as I understand that wards have to look at lots of different patients. There were some noisy patients on the ward. Other patients kept me awake. 4.1.7 Standard 7 - Ensuring Comfort & Alleviating pain Operational Questions Table 7 Standard 7 Operational Questions RAG % Q51 For this episode of care, is there documented evidence that the patient's pain has been discussed and assessed using an appropriate pain assessment tool? Q52 For this episode of care, where the patient has an identified problem with pain is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? Q53 For this episode of care, is there documented evidence that the patient's concerns/anxieties or fears has been assessed and discussed with the patient or advocate? Q54 For this episode of care, where the patient has expressed concerns, anxieties or fears, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? 72% 75% 60% 57% Overall Score 66% Pain The National Early Warning System (NEWS) for early assessment of the deteriorating patient has been used within CTUHB for more than two years. This tool provides a scoring system aligned with the vital signs of the patient to provide early alerts to altered stability of the patient s physical condition. One of the elements included within the tool is a numerical pain score to capture a tangible measure of the patient s description of any pain they might be experiencing. When a patient confirms they have pain a baseline score should be recorded against which the effectiveness of any analgesia can be measured and adjusted if necessary. Three quarters of the patient notes scrutinized for this audit confirmed evidence and compliance with this requirement. 24 Fundamentals of Care Annual Audit 2013 Welsh Government

The commentary from the auditors identifies some confusion about the use of the pain scoring tool by staff and this will be addressed to ensure prompt, consistent application to achieve efficient and effective pain management. Anxiety & Fear There is less evidence that robust systems are in place to consider the concerns, anxieties and fears experienced by patients. Although patient comments identify that staff were kind, considerate and informally addressed many of the anxieties they experienced, tools such as the Hospital Anxiety and Depression Scale (HADS) are not universally used as a measure. As a consequence only 60% of patients had documented evidence that they had the opportunity to express concerns, anxieties and fears and only just over half of those who expressed a need had this considered in a plan of care. User Experience Question 110 Throughout your stay, how often did you feel that you were made to feel comfortable? Graph 10 100% 80% 60% 40% 20% 0% 76.92% 17.58% 4.40% 1.10% Always Usually Sometimes Never Question 111 Throughout your stay/attendance, how often did you feel that you were, as far as possible, kept free from pain? Graph 11 100% 80% 60% 40% 20% 0% Findings 73.24% 20.28% 6.20% 0.28% Always Usually Sometimes Never 94% of patients felt that they were always or usually made to feel comfortable and that as far as possible they were always or usually kept free from pain. 25 Fundamentals of Care Annual Audit 2013 Welsh Government

Patient Comments Pain relief regularly offered. Certain nurses physically could not do enough, they were fantastic. When visiting, insufficient seating available. More chairs for visitors Provide more chairs in the ward for visitors and patients. You haven t been able to find the cause of the problem but all the while you keep looking and kept the pain down and I was not sent home. Maybe given pain relief a bit quicker. I think the treatment I have had with all the staff has been excellent, they gave me great confidence before my operation which really helped. 4.1.8 Standard 8 - Personal hygiene, appearance & foot care Operational Questions Table 8 Standard 8 Operational Questions RAG % Q55 For this episode of care, is there documented evidence that the patient's hygiene needs have been assessed and discussed with the patient or advocate? Q56 For this episode of care, where the patient's hygiene needs have been identified is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours? Q57 Does the clinical area have access to mirrors for patients to use? Q58 For this episode of care, is there documented evidence that the patient's foot and nail condition has been assessed using a recognised, evidence based tool and discussed with the patient or advocate? Q59 For this episode of care, where the patient has an identified risk or requires assistance with foot or nail care, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours? Q60 Does the clinical area have supplies of toiletries for patients who have been admitted without them? 91% 94% 93% 15% 25% 89% Overall Score 71% Hygiene Data confirms evidence of good practice in the assessment and planning of patient hygiene needs. In 91% of cases reviewed there was written evidence that hygiene needs had been assessed and discussed with patients and 94% of patient records had documentary evidence of up to date care plans. 26 Fundamentals of Care Annual Audit 2013 Welsh Government

Foot care The audit findings confirm that the performance is less than satisfactory in the consideration of foot care needs. Nursing notes show very little evidence that foot and nail care is being considered when the nursing needs assessment is completed. Only 15% of notes showed any written evidence of pedal assessment and only 25% of those with an identified risk had evidence of an up to date care plan which had been reviewed in the previous 24 hours. To meet the requirements of Together for Health A Diabetes Delivery Plan (2013) all patients with diabetes will be expected to undergo a foot assessment on every contact with a health professional. This provides CTUHB with a timely opportunity to review the foot health assessment process for all patients and has been identified as a service improvement priority within Standard 8 of the Corporate Healthcare Standards for CTUHB (Care Planning and Provision). A proposal will be developed for a foot care training programme to support the implementation of the All Wales Foot Care Assessment tool when it is develop during 2014. Patient Supplies From commentary there appears to be some confusion regarding the availability of toiletries for patient use. Although 89% of ward areas reported toiletries were available for patient use, some auditors reported that toiletries are obtainable while others report that staff purchase toiletries from personal funds. As a measure to provide assurance with the correct process, a comprehensive list of all available toiletries along with product order codes and sources have been obtained from procurement and circulated to all senior nurses and ward managers. User Experience Question 112 Throughout your stay, how often did you feel that your personal hygiene needs were met? Graph 12 100% 80% 60% 40% 20% 0% 85.15% 10.91% 2.73% 1.21% Always Usually Sometimes Never Findings 96% of patients felt that their personal hygiene needs were always or usually met but one patient commented that access to foot care was limited. 27 Fundamentals of Care Annual Audit 2013 Welsh Government

Patient Comments Need better access to podiatry. I have tried really hard to think of one thing to change but I am happy to say no, mums care has been gold standard. 4.1.9 Standard 9 - Eating and Drinking Operational Questions Table 9 Standard 9 Operational Questions RAG % Q61 Is there evidence in the nursing documentation that those patients, who on admission have been assessed as requiring a swallowing assessment, have had this completed within 24 hours of their admission? Q62 Prior to meal times, are patients that require help assisted into a suitable position? Q63 Prior to meal service, are bed tables and communal areas cleared and tidied for the meal? 58% 100% 98% Q64 Are patients meals placed within easy reach? 98% Q65 Are all patients given the opportunity to wash or cleanse their hands with hand wipes prior to eating meals? Q66 Are patients given the opportunity to go to the toilet before meal time? Q67 Is there evidence that the systems in place to enable staff to identify patients with special requirements are being implemented and their effectiveness evaluated? 91% 98% 86% Q68 Are water jugs changed 3 times daily? 19% Q69 Is drinking water available for patients and where applicable, are drinking water jugs and glasses within the patient's reach? Q70 During a 24 hour period, how many beverage rounds are carried out within your clinical area? 98% 74% Q71 Does a Registered Nurse supervise every meal time? 84% Q72 Is there evidence that all members of the nursing team are engaged in the mealtime service? Q73 Does the clinical area have access to weighing scales and a height measurement stick in good working order? Q74 Is a range of snacks available for patients who have missed a meal or who are hungry between meals? Q75 For patients who require a food chart, is there evidence that they are being kept up to date and evaluated? Q76 For patients who require a fluid chart, is there evidence that they are kept up to date and evaluated? Q77 Is there a system in place to allow family/friends to assist with meal times? 89% 79% 98% 95% 92% 86% 28 Fundamentals of Care Annual Audit 2013 Welsh Government Overall Score 86%

Overall performance with this standard demonstrated high compliance however two areas for improvement were identified. Fluids The All Wales Nutrition and Catering Standards for Food and Fluid for Hospital Inpatients (Welsh Government 2012) provide technical guidance for caterers, dieticians and nursing staff responsible for meeting the nutritional needs of patients who are capable of eating and drinking. This was published in response to Welsh Audit Office 2012 Catering and Nutrition Review which identified that although good practice was demonstrated in some areas, there needed to be more consistent standards of quality and service delivery across Wales. Within the standards are the requirements that 7 8 beverage rounds take place per day offering hot and cold beverages and water in jugs should be changed three times a day. Data suggests that CTUHB is achieving seven or more beverage rounds in 74% of areas, but only 19% of areas currently comply with the requirement for replenishing fresh water jugs. These findings have been shared with the catering manager and are being addressed at the next CTUHB catering and nutrition audit meeting. E- Learning programme A national nutrition and food chart e-learning programme is available for staff. Current compliance with this e learning tool within the organisation is only 10%, but CTUHB has provided assurances to Welsh Government of intention to prioritise engagement and work towards achieving the target of 100% nursing staff compliance by July 2015. Classroom based sessions are being held for staff with limited computer skills and work is progressing with the University of South Wales to incorporate this e learning as part of undergraduate nurse training. Swallow Assessment The audit results identifies that 58% of records show documented evidence that patients with identified swallow problems were assessed within 24 hours of admission by a skilled professional. Some clinical areas are involved in the dysphagia friendly ward initiative which specifically engages specially trained nurses in assessing whether a patient has a safe swallow following a stroke. However, these nurses do not complete swallow assessments as this specialist assessment is carried out by a Speech and Language Therapist (SALT). The data does not specifically identify who completes the assessment nor offer specific guidance for the auditor. The precise figure might be lower than shown if auditors have included dysphagia friendly ward information as well as swallow assessment information. This issue will be fed back to the All Wales FOC steering group for clarity in guidance for future audit 29 Fundamentals of Care Annual Audit 2013 Welsh Government

Good Practice Data suggests that good practice is observed in the preparation of patients in readiness for eating to ensure their safety and a more enjoyable mealtime experience. Evidence that food and fluid record charts were being accurately maintained demonstrated excellent compliance with scores at 95% and 92% respectively. In addition to the annual FOC audit there is a requirement on all in patient areas to electronically report monthly monitoring data on a minimum of three FOC national indicators: this information populates the All Wales Nursing Dashboard (care indicators). The three indicators are: - hand hygiene, healthcare acquired pressure ulcer formation and numbers of patients having a nutritional score completed within 24 hours of admission. This provides an on-going measure of performance and a benchmark against the national position (Graph 13). Graph 13 Source: Nursing & Midwifery Dashboard for Wales, Welsh Government User Experience Question 105 Throughout your stay, how often did you feel that you were provided with nutritious food and snacks? Graph 14 100% 80% 60% 40% 20% 0% 74.58% 17.60% 6.98% 0.84% Always Usually Sometimes Never 30 Fundamentals of Care Annual Audit 2013 Welsh Government

Question 106 Throughout your stay/attendance, how often did you feel that you were provided with fresh drinking water and plenty of drinks when you need them? Graph 15 100% 80% 60% 40% 20% 0% 83.54% 12.04% 3.19% 1.23% Always Usually Sometimes Never Question 107 Throughout your stay, how often did you feel that you were given help with feeding and drinking if you needed this? Graph 16 100% 80% 60% 40% 20% 0% 82.01% 11.11% 3.17% 3.70% Always Usually Sometimes Never Findings Patient satisfaction with the availability and quality of food and drink appears to be high. 92% of patients felt that they were always or usually provided with nutritious food and snacks throughout their hospital stay 96% of patients acknowledged that they were always or usually provided with fresh drinking water and plenty of drinks when they needed them 93% agreed that they were always or usually helped with feeding and drinking if they needed it 31 Fundamentals of Care Annual Audit 2013 Welsh Government

Patient Comments The food menu could be changed. You have the same thing often and after a long stay you get fed up with it. I love the food. The food was terrible - no fault of the ward serving staff. Good meals. Good experience: food menu was good. Food cold and not enough choice for soft or puree. 4.1.10 Standard 10 - Oral Health & Hygiene Operational Questions Table 10 Standard 10 Operational Questions RAG % Q78 For this episode of care, is there documented evidence that the patient been assessed using the All Wales Oral Health tool with respect to their oral health needs? Q79 For this episode of care, where the patient has an identified risk or requires assistance with oral health, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours? 93% 88% Overall Score 91% The All Wales Oral Health Tool is currently in the process of being introduced across all health boards including CTUHB. This process is taking place in a partnership between nursing and community dental health colleagues. For many health boards it will be the introduction of a whole new process and oral health will be formally assessed using a validated tool for the first time. Within CTUHB an oral health assessment tool and prescribed nursing action plan has been used for more than two years. Our experience and awareness has informed the development of the national tool. For the purpose of this FOC audit the existence of the CTUHB assessment tool might have created some confusion. Roll out of the national tool is in the very early stages with only tester sites receiving training and new documentation. It would appear that auditors in this instance have collected data considering the established tool. While this might make an implementation progress comparison with other organisations difficult, findings reflect the good practice that is happening within CTUHB. Documented assessments were evident in 93% of the notes scrutinised with slightly fewer of those patients with identified risk (88%) having current, evaluated plans of care. In 2012 the Patient Safety Unit issued a notice from Welsh Government that the use of pink oral care sponges should stop immediately in all healthcare settings and any stock removed and returned to suppliers. This 32 Fundamentals of Care Annual Audit 2013 Welsh Government

created frustration amongst staff as no like for like alternative was provided. The recommendation was that a small headed toothbrush should be used, but this created concern about the risk of choking or aspiration for patients with altered levels of consciousness. The All Wales Tool will address this issue with training and a full list of products available for effective oral care, along with order codes and location, has been made available to all senior nurses and ward managers to ensure good practice continues. User Experience Question 114 Throughout your stay, how often did you feel that you were given help, if required, to make sure that your mouth, teeth and gums were kept clean and healthy? Graph 17 100% 80% 60% 40% 20% 0% 79.42% 15.23% 3.29% 2.06% Always Usually Sometimes Never Findings 95% of patients responded that they were always or usually given the help they needed to ensure their teeth and gums were kept healthy, which suggests high levels of satisfaction. No service users provided narrative comments about oral care. 4.1.11 Standard 11 - Toileting Needs Operational Questions Table 11 Standard 11 Operational Questions RAG % Q80 For this episode of care, is there documented evidence that the patient's toileting needs has been assessed and discussed with the patient or advocate? Q81 For this episode of care, where the patient has been identified as requiring assistance with their toileting needs, is there evidence that an appropriate assessment has taken place with an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours? 73% 69% Overall Score 71% 33 Fundamentals of Care Annual Audit 2013 Welsh Government

The data confirms the need to improve compliance with this standard in the assessment and planning of patient toileting requirements. Currently there is no universal assessment tool available across CTUHB. Some wards have developed local arrangements to assess and monitor continence management. These range from a narrative in the nursing notes to a symbol on the care at a glance magnetic white board to identify those patients who will need assistance to manage toileting needs. For some time the development of a tool has been work in progress on an All Wales level. This has now been concluded and produced for implementation in a bundles package. The plan for introduction has been developed within CTUHB and awareness sessions being held across the Health Board and to pre-registration students at the University of South Wales. The planned roll out of the bundles will be complete by March 2014. User Experience Question 113 Throughout your stay/attendance how often did you feel that if you needed help to use the toilet that we responded quickly and discreetly? Graph 18 100% 80% 76.11% 60% 40% 20% 0% 17.75% 5.46% 0.68% Always Usually Sometimes Never Findings 94% of patients surveyed agreed that their toilet needs were always or usually responded to quickly and discreetly. Patient Comments Question: was there anything particularly good about your experience that you would like to tell us about? Answer: Staff instant attendance when we utilized the alarm bell. Things that could be improved height of toilets, more blankets and pillows take note! 34 Fundamentals of Care Annual Audit 2013 Welsh Government

4.1.12 Standard 12 - Preventing Pressure Sores Operational Questions Table 12 Standard 12 Operational Questions RAG % Q83 For this episode of care, is there documented evidence that the patient's skin condition has been assessed and discussed with the patient or advocate? Q84 For this episode of care, where the patient has been identified as requiring assistance with looking after their skin, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours. 98% 86% Overall Score 93% The introduction of the NHS Wales skin bundle and daily assessment of a patient s skin state has ensured a more consistent approach to skin assessment and care planning. 98% of the 255 sets of patient notes reviewed provided documentary evidence that patients skin condition had been assessed and discussed with the patient or advocate. However, a lower proportion of patients who were identified to be at risk or needing assistance to maintain skin health (86%) had a care plan which had been reviewed in the previous 24 hours. Although this audit confirms high levels of compliance and performance in assessment of patients, there is need to remain vigilant and pro-active in ensuring all patients with identified need have an individualized management plan to ensure all members of the care team can contribute to minimize risk and maintain skin health. Good Practice A printed patient information leaflet is provided at every bedside in general adult services across CTUHB informing service users of appropriate skin care and how to minimize the risk of pressure ulcer formation. Healthcare acquired pressure ulcers are reported monthly into the National Nursing Dashboard (care indicators, see Graph 18). This provides a process for reporting, measurement and monitoring of incidents to inform targeted improvement. Additionally, any incidence of new skin damage/pressure ulcer development Grade 1 or above is reported via the Datix system as a clinical incident. The All Wales Pressure Ulcer Reporting and Investigation guidance will be implemented during 2014. Process mapping of reporting healthcare acquired pressure ulcers has been completed within CTUHB in November 2013 to streamline the process, reduce duplicate reporting and provide assurance with compliance with this standard. 35 Fundamentals of Care Annual Audit 2013 Welsh Government

Graph 19 Source: Nursing & Midwifery Dashboard for Wales, Welsh Government User Experience Question 115 Throughout your stay/attendance, how often did you feel that you were given help to look after your skin to prevent you from getting pressure sores? Graph 20 100% 80% 60% 40% 20% 0% 74.25% 17.54% 4.10% 4.10% Always Usually Sometimes Never Findings 92% of service users responded that they were always or usually given help to look after their skin to prevent the formation of pressure ulcers. No service users provided narrative comments about skincare. 36 Fundamentals of Care Annual Audit 2013 Welsh Government

4.2 Fundamentals of Care Staff Survey For the 2013 annual FOC audit, the staff survey component was reintroduced. The main focus was aimed at establishing how valued and supported staff felt by the organisation with their development and their feedback in relation to the care that they provide to patients and their families. As well as a number of specific questions to which the staff were asked to respond based on a choice between, always, usually, sometimes and never. Staff were also asked to give a score between 1 and 10, (where 1 is the lowest score and 10 is excellent) for how they would rate their overall satisfaction with the care that they provide to patients and their families. The summarised response to the survey is detailed in table 13. The average rating for their overall satisfaction with the care that they provide to patients and their families was 75%. 37 Fundamentals of Care Annual Audit 2013 Welsh Government

Table 13 Staff Survey Questions Always Usually Sometimes Never Q85 Our organisation aims to, make sure you are able to access up to date information in order to be able to do your job. For example, access to policies, clinical guidelines etc. Do we achieve this? Q86 Our organisation aims to, ensure that as an employee you are treated with dignity and respect. Do we achieve this? 57.00% 34.00% 8.17% 0.83% 23.12% 41.21% 32.83% 2.85% Q87 Our organisation aims to, make you feel safe at work. Do we achieve this? 26.75% 42.42% 28.45% 2.39% Q88 Our organisation aims to, make you feel you have a positive contribution to patient care. Do we achieve this? Q89 Our organisation aims to, provide you with sufficient equipment to do your job. Do we achieve this? Q90 Our organisation aims to, provide you with opportunities to enhance your skills and professional development. Do we achieve this? Q91 Our organisation aims to, provide you with feedback on the outcomes of any incidents/accidents that you report or that are reported within your clinical area? Do we achieve this? Q92 Our organisation aims to, provide you with opportunity to identify and learn from good practice to bring about improvements in care. Do we achieve this? Q93 Our organisation aims to, provide opportunities for you to raise any concerns that you have. Do we achieve this? Q94 Our organisation aims to, provide you with the opportunity to establish a work life balance. Do we achieve this? Q95 Our organisation aims to, make you feel a valued member of the organisation and have a sense of belonging. Do we achieve this? Q96 Our organisation aims to, make you feel proud to be a nurse. Do we achieve this? Q97 Our organisation aims to, ensure that you have the knowledge and skills to deliver a consistent standard in the fundamental aspects of compassionate care. Do we achieve this? 29.25% 39.12% 28.57% 3.06% 20.99% 47.27% 29.69% 2.05% 22.83% 35.09% 38.16% 3.92% 21.04% 27.34% 32.55% 19.06% 23.70% 37.88% 34.11% 4.31% 27.18% 38.29% 29.74% 4.79% 19.06% 41.48% 34.06% 5.40% 14.02% 30.91% 38.18% 16.89% 17.18% 30.76% 43.64% 8.42% 28.35% 45.33% 25.47% 0.85% 38 Fundamentals of Care Annual Audit 2013 Welsh Government

Staff Survey The FOC staff survey was carried out across Health Boards and Trusts in Wales on October 7 th 2013. All qualified nurses and clinical health care support workers (HCSW)/nursing assistants on duty in those clinical areas undertaking the annual FOC audit from 7am on that day to 7am on 8 th October were given the staff survey questionnaire at the start of their shift and asked to return the survey before they went off duty. Responses from 600 nurses from across CTUHB were uploaded into the FOC system. This was a greater response rate compared to the NHS Wales staff survey. In 2013 for the first time the FOC staff questions have been considered as a separate survey to the operational audit. In previous years staff questions were based around operational skills and opinions, but did not focus on the feelings and personal experiences of working within an organisation. The NHS Staff Survey (2013) revealed opportunities and frustrations for staff common to all NHS organisations. The FOC audit will build on those findings and the FOC staff survey is available to be used at more frequent intervals and be used as a barometer to continually measure outcomes from improvement work that has been initiated following the NHS Staff Survey and FOC staff survey. The NHS Staff Survey provided a census of all grades and professions of staff within CTUHB: the 2013 FOC audit considers responses from nurses and HCSWs only. The 2013 FOC audit will be considered alongside the NHS Staff Survey results analysis to add to the rich data already available. Resulting action plans will be aligned with current improvement work being led by the Workforce and Organisational Development Team. Many of the findings of the FOC staff survey reflect those of the NHS Staff Survey. There is a need for further investigation into all of the domains explored by the audit, however three priority areas for improvement (below 50% satisfaction) important to our staff relate to: 1. Feedback on incidents and accidents 2. Being a valued member of the organisation 3. Being proud to be a nurse 1. 48% of the nurses surveyed agreed that the organisation always or usually provide feedback on the outcome of an incident or accident that is reported within the clinical areas. 106 of the 556 nurses who responded (19%) said that they never receive feedback. This equates with the findings of the NHS Staff Survey and is a priority for improvement to learn from concerns and incidents to reduce risk of reoccurrence. 2. 45% of nurses reported that they were always or usually made to feel a valued member of the organisation and had a sense of belonging. 100 of the 592 nurses (17%) who responded to this question said that this never happened. Employees who receive regular feedback on how they are doing are more likely to be satisfied overall and are more likely to feel valued and feel they are able to have an influence on their area of 39 Fundamentals of Care Annual Audit 2013 Welsh Government

work. The need to promote regular feedback and the benefits will be communicated with all line managers. 3. 48% of the nurses reported that CTUHB always or usually made them feel proud to be a nurse. 8.5% reported that the organisation never made them feel proud to be a nurse. The NHS Staff Survey identified that those who have experienced an individual appraisal are more likely to hold positive views than those who have not. These measures include employees being able to judge their own performance and having a clear set of objectives. While they should not be the only form of providing feedback an appraisal process generates wider benefits The staff survey reported positively that CTUHB performed well was in the provision of information for staff. 91% of nurses responded that CTUHB always or usually made sure that staff were able to access up to date information such as policies and guidelines in order to be able to do their jobs. 74% of nurses agreed the organisation ensured that staff have the knowledge and skills to deliver a consistent standard in the fundamental aspects of compassionate care that this was always or usually the case and only 5 staff (0.85%) said this never happened. Commentary from staff frequently reflected concerns about current staffing levels, the reliance on bank nurses and impact on continuity of care and impact on team. Exhaustion experienced from caring for increasingly dependent patients with increasingly complex care needs was reported. The OD team has devised a set of health and well being indicators to be used as a Pulse Check (questionnaires) for staff across CTUHB. This tool considers many of these issues identified by staff and will aim to collect data targeted at specific issues to increase organisational awareness, target improvement and staff satisfaction with development work and outcome measures. Nursing staff expressed shared frustrations and difficulties in being able to deliver the quality of care they aspire to due to the intensity of demand on their time and lack of alternative resources. Two actions to support these issues currently being finalised are: The Nursing Establishment Review The National Acuity Tool (from April 2014) These measures aim to ensure that all clinical areas are staffed appropriately, and the acuity tool will enable senior nurses to adjust staffing according to the fluctuating acuity status of the patients being nursed. This reflects our philosophy of Cwm Taf Cares putting patients at the centre of everything we do to deliver safe and effective care, and ensure excellent patient (carer/user) experience and excellent staff experience. These are measures being taken forward by the organisation to support improvement in the staff and patient experience of care. There is also a need to constructively engage staff in identifying the factors that they feel would deliver positive outcomes. 40 Fundamentals of Care Annual Audit 2013 Welsh Government

Employee engagement strategies enable people to be the best they can at work, recognising that this can only happen if they feel respected, involved, heard, well led and valued by those they work for and with (BMG Research 2013). The OD team has supported staff at two of our community hospitals to look at the environment and culture of care. Staff have actively engaged and the work is progressing with enthusiasm. The Transforming Care team is working collaboratively to develop staff awareness of improvement methodology and process and will continue to support and guide staff in the areas they have identified for development. One initiative that has yielded positive outcomes for staff working in pressured environments has been the introduction of Schwartz Centre Rounding. These rounds provide a forum for staff from a range of disciplines to meet once a month to explore together some of the challenging psychosocial and emotional issues that arise from caring for patients. The OD team is making preparations to develop this initiative within CTUHB by developing a framework to determine the most effective way of introducing and utilising the model. The 2013 FOC audit provides evidence that nursing staff across CTUHB are caring, kind and willing to go the extra mile for their patients. With an enthusiasm to enhance that further the Director of Nursing is working with Heads of Nursing and Senior Nursing teams across CTUHB to foster continuous improvements with the professional code and standards by listening to staff with collaborative working to strengthen professionalism and pride and to celebrate the high standards of care provided by CTUHB nurses and the wider multidisciplinary team members. 41 Fundamentals of Care Annual Audit 2013 Welsh Government

5 Recommendations 5.1 Actions for Improvements (for all elements that scored less than 85% compliance rate) Standard (Where applicable) 1 Operational issue 1 Operational issue 1 Operational issue 2&5 Operational issue 2&5 Operational issue 2&5 Operational issue 3 Operational issue 3 Operational issue 4 Operational issue Action to be taken By whom By When Care plans should reflect any difficulties the patient experiences with communication and discussed with the patient/advocate Add memory screening question to initial patient assessment nursing documentation and monitor use Consideration of memory problems in the care planning process Continue to raise staff awareness of carers rights and ensure discussions are documented Work with pastoral leads and nurses to identify how best to capture the cultural and spiritual needs of the increasingly diverse patient population Plan to re-audit compliance with obtaining consent after Integrated Assessment documentation introduced Identify waste management audit requirement for all clinical areas and inform ward managers Work to improve compliance with moving and handling risk assessment Work with the Focus on Flow improvement project to improve compliance with discharge planning, documentation and anticipated date of discharge Senior nurses Documentation group Documentation group Carers measure team Pastoral leads FOC nurse FOC nurse FOC nurse Senior nurses Senior nurses June 2014 April 2014 April 2014 Ongoing March 2014 May 2014 Feb 2014 June 2014 Mar 2014 42 Fundamentals of Care Annual Audit 2013 Welsh Government

Standard (Where applicable) 4 Operational issue 6 Operational & patient issue 6 Operational & patient issue 7 Operational issue 7 Operational issue 7 Operational issue 8 Operational issue 8 Operational issue Action to be taken By whom By When Promote good practice in recording carer role and document any communication/involvement of family in discharge planning Investigate the causes of sleep disturbances for patients and actions for improvement Senior nurses FOC nurse Mar 2014 Mar 2014 Use results to inform prescribed nursing action plans FOC nurse April 2014 Provide laminated copies of visual pain assessment score charts for all clinical areas Promote audit findings in relation to consequences of poor pain management and the need for documented measures of pain and response to interventions Promote awareness of the consequences of anxiety and fear and the need for documented measures and response to interventions Develop foot care assessment tool during 2014 Develop foot care prescribed nursing action plan during 2014 FOC nurse Pain management team Wad sisters Diabetes podiatrist Practice development nurse Diabetes podiatrist Practice development nurse Feb 2014 June 2014 June 2014 June 2014 43 Fundamentals of Care Annual Audit 2013 Welsh Government

Standard (Where applicable) 9 Operational issue 9 Operational issue 9 Operational issue Action to be taken By whom By When Discuss audit findings with speech and language therapy lead to determine next steps to manage timely swallow assessments Discuss water and beverage frequency with catering manager and agenda for next nutrition and catering audit group meeting Continue to promote engagement of all staff in protected mealtime and the need for a registered nurse to supervise FOC nurse Speech therapist FOC nurse FOC nurse Senior nurses Feb 2014 Feb 2014 Ongoing 10 Operational issue Continue with plan for roll out of continence assessment and care planning bundles during 2014 Continence nurses Mar 2014 10 Operational issue Plan to re-audit Standards 6,7 & 10 to determine compliance and improvement FOC nurse June 2014 staff Identify appropriate feedback mechanism for staff relating to incidents reported HON Senior nurses Ward managers June 2014 staff Support OD with pulse check monitoring of staff well being HON Senior nurses Ward managers During 2014 Teams Support all areas to develop local FOC action plans using SBAR format & progress using improvement methodology HON Senior Nurses During 2014 Teams Encourage senior nurses to utilize FOC findings when identifying silver Improving Quality Together (IQT) improvement projects HON, Senior Nurses During 2014 44 Fundamentals of Care Annual Audit 2013 Welsh Government

5.1 Monitoring and Assurance The 2013 FOC CTUHB audit provides assurance to Board Members where compliance is reported as high and best practice can be shared as well as identifying the improvements to be made across all 12 standards, with a focus on three key priority standards:- Sleep and rest (Standard 6) Ensuring comfort and alleviating pain (Standard 7) Ensuring personal hygiene and foot care (Standard 8) Monitoring progress with implementation of the CTUHB FOC action plan for improvement will require: a. This report will be presented at the Directorate/Locality Integrated Governance groups to share the findings. b. Support will be provided to clinical teams in developing local action plans for improvement held locally at ward and Directorate/Locality level and ward/department managers will be accountable for progress of actions. c. Implementation of action plans will be monitored and supported by senior nurses and reported via Directorate/Locality integrated governance groups to ensure work is completed within an expected time frame or escalated for appropriate management. The FOC audit compliance scoring matrix provides a guide for the management and monitoring of actions. d. Improving Quality Together (IQT) model for improvement Bronze and Silver level will be applied to support improvement projects e. The CTUHB Patient Experience Plan requires the use of the FOC user survey in practice a minimum of twice a year in all FOC audit sites to measure the service user experience. In areas where the FOC audit tool is not yet designed for purpose, the All Wales Patient Questionnaire will be applied to continually monitor patient experience. f. The FOC audit supports the CTUHB Quality Strategy with assurance and informs the Annual Quality Delivery plan by informing our priorities for quality improvement. g. The CTUHB FOC action plan is reported and monitored through the Quality Steering Group. h. The FOC audit findings will also inform the CTUHB Annual Quality Statement to be published summer 2014. 45 Fundamentals of Care Annual Audit 2013 Welsh Government

5.2 Conclusion The National annual Fundamentals of Care audit 2013 has generated detailed information to measure the quality of fundamental aspects of health and social care delivered to our patients across CTUHB. The audit has engaged patients/carers/service users and staff and has identified compliance scores with operational standards, patient experience and staff feedback. The National FOC audit is reported to the Chief Nursing Officer in March 2014 however teams can continue to use the FOC system to monitor and measure standards and effects of improvement work taken forward in their local action plans. The FOC audit results provide us with an opportunity to celebrate the excellent care provided and the positive experiences reported by our patients and service users. It also enables us to prioritise our quality improvements and continued support and development to improve the experience of our staff. Patients have expressed high levels of satisfaction with the standards of care they have received from staff within CTUHB and we strive to continue to enhance their experiences. 46 Fundamentals of Care Annual Audit 2013 Welsh Government

6 References 1. 1000 Lives+ (2013) Improving Quality Together 2. Cwm Taf University Health Board (2013) Patient Experience Plan 3. Cwm Taf University Health Board (2013) Quality Strategy 4. Cwm Taf University Health Board Guidance for Safe Administration and Storage of Medicines 5. Francis, R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry 6. Informed Carers Cwm Taf Carers Information and Consultation Strategy (2013) 7. Keogh, B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England 8. NHS Institute for Innovation and Improvement (2008) Model for Improvement 9. NWIS (2012) Nursing Dashboard 10. Royal College of Physicians (2012) National Early Warning Score (NEWS) Standardising the assessment of acute illness severity in the NHS, RCP: London 11. Shared Services Partnership Facility Services (2013) WHTM 07-01 - Safe management of healthcare waste 12. WAG (2003) Fundamentals of Care. Guidance for Health and Social Care Staff. Improving the quality of fundamental aspects of health and social care for adults 13. Welsh Government (2010). Catering and Nutrition Review, Wales Audit Office, Wales 14. Welsh Government (2011). All Wales Nutrition & Catering Standards for Food and Fluid Provision for Hospital Patients (http:/www.cymru.gov.uk) 15. Welsh Government (2013) NHS Wales National Clinical Audit and Outcome Review Plan 2013/14 47 Fundamentals of Care Annual Audit 2013 Welsh Government

16. Welsh Government (2013) NHS Wales Staff Survey Report: Cwm Taf Health Board 17. Welsh Government (2013) Safe Care, Compassionate Care. A National Governance Framework to enable high quality care in NHS Wales 18. Welsh Government (2013) Together for Health: A Diabetes Delivery Plan a. WG: Wales 19. WAG (2010) Doing Well, Doing Better. Standards for Health Services in Wales a. http:www.nhswalesgovernance.com 20. Zigmond, AS. & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6): 361-370 48 Fundamentals of Care Annual Audit 2013 Welsh Government

7 Appendix A: Fundamentals of Care Audit - Compliance Scoring Matrix 49 Fundamentals of Care Annual Audit 2013 Welsh Government

Step approach to Triangulation - a framework for data t riangulat ion Planning for Triangulation Conducting Triangulation Step 1. Identify key issue/s to be explored Step 2. Identify data sources and gather background information Step 3. Gather data/reports Step 4.Make observations from each data set. Hint: Consider FoC, Care Metrics, Datix etc. Step 8. Summarise findings and draw conclusions Step 7. If necessary identify additional data and return to STEP 3 Step 6. Check [corroborate, refute, modify] theory/suggestions Step 5. Note trends across data sets and formulate theory/suggestions Communicating Triangulation Step 9. Communicate results and recommendations Step 10. Outline Ac tion Plan based on f indings. 50 Fundamentals of Care Annual Audit 2013 Welsh Government

Appendix B Local action plan PDSA Model for Improvement Ward / Clinic / Department: Site: S Situation B Background A St. No. Quest No. Assessment Include issues identifiedd in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA 51 Fundamentals of Care Annual Audit 2013 Welsh Government

Appendix B Local action plan PDSA Model for Improvement A St. No. Quest No. Assessment Include issues identifiedd in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA 52 Fundamentals of Care Annual Audit 2013 Welsh Government

Appendix B Local action plan PDSA Model for Improvement Fundamentals of Care 2013 Annual Audit Ward / Clinic / Department: Site: PDSA Cycle No: Aim [what are you trying to accomplish]: Measures[how will you know that the change is an improvement]: Change Describe your test of change: Person / s Responsible Completion/Review Date PLAN List the tasks required to set up this test of change Person / s Responsible Completion/Review Date 53 Fundamentals of Care Annual Audit 2013 Welsh Government

Appendix B Local action plan PDSA Model for Improvement DO Describe what actually happened when you ran the test Fundamentals of Care 2013 Annual Audit STUDY Describe the measured results and how they compared to the predictions ACT Describe what modifications will be made to the plan for the next cycle 54 Fundamentals of Care Annual Audit 2013 Welsh Government