Care Assurance & Accreditation Standards
for Acute and GP Hospitals
2015
1
Contents
Introduction to Care Assurance & Accreditation Standards (CAAS) .................................................................................................................................... 3
Record of completion: .......................................................................................................................................................................................................... 5
Standard 1: Pressure Area Care .......................................................................................................................................................................................... 6
Standard 2: Falls .................................................................................................................................................................................................................. 8
Standard 3: Catheter Associated Urinary Tract Infection (including continence issues) ..................................................................................................... 10
Standard 4: Deteriorating Patient ....................................................................................................................................................................................... 12
Standard 5: Medicines Management .................................................................................................................................................................................. 14
Standard 6: Pain Control.................................................................................................................................................................................................... 16
Standard 7: Infection Prevention and Control ..................................................................................................................................................................... 18
Standard 8: Food Fluid & Nutritional Care.......................................................................................................................................................................... 20
Standard 9: Person Centred Health and Care .................................................................................................................................................................... 22
Standard 10: Older People in Acute Care & Adult Protection ............................................................................................................................................. 24
Standard 11: End of Life Care: ........................................................................................................................................................................................... 27
Standard 12: Effective Management of Resources & Staff Governance............................................................................................................................. 30
Standard 13: Working Effectively in the Multidisciplinary Team .......................................................................................................................................... 32
2
Introduction to Care Assurance & Accreditation Standards (CAAS)
Delivering safe, effective, quality care to patients is at the heart of our business in healthcare. In being responsible and accountable for the quality of safe,
effective and person centred care delivered to patient that care should be evidence based and appropriate to the needs of each individual 1. However
measuring and assuring the quality and standard of nursing care delivered by individuals and teams is not easy. There is currently no formal system in place
that enables us to consistently ensure and assure safe/effective and person centred care at ward/department/team level. To address this there is a
professional desire to develop and implement a “Care Assurance and Accreditation System”
This system is based on a model used within Salford Royal NHS Foundation Trust and each standard has been framed using the four domains within the
Leading Better Care Role Framework (2008).
Safe and effective patient care:
Leading, managing and developing the performance of the team:
Enhancing the patients experience of care:
Contributing to the organisations objectives
Whilst the CAAS aims to frame the standards using LBC it is also designed to encompass professional standards as well as the key components of the
following national and professional drivers:





NMC Code and Revalidation
Scottish Patient Safety Programme,
Person Centred Health and Care Collaborative,
Older People in Acute Hospital Care Settings,
Healthcare Environment Inspection and Healthcare Associated Infection
The Care Assurance and Accreditation System (CAAS) is designed to support nurses and the multiprofessional team in practice to understand how they
deliver care, identify what works well and where further improvements are needed. The overall responsibility and accountability for achieving and maintaining
the required standards lies with the Senior Charge Nurse (SCN) and the wider team. The role of the senior professional nursing staff, (ie senior nurses, lead
nurses or clinical nurse managers) and other specialist services (Practice Development, Quality Improvement support, Organisational Development etc) is to
support the SCN and the team to ensure continuous improvement within their departments.
1
Scottish Government (2010) The Healthcare Quality Strategy for NHS Scotland. Available from www.scotland.gov.uk Accessed on 20.10.14
3
Assessment Process – being tested at present
Further information on the Assessment Process can be found in the Assessment Framework Document
1. The CAAS lead will select a day to assess the ward, this will be unannounced.
2. The care assessment will cover the identified standards and will involve at a minimum, one third of patients and two thirds of staff.
 Observation of care given and patients documentation
 Discussion with patients and staff member
3. Each ward will have an assessment completed and will be accredited with a level 0 to 3. Reassessment will take place at a time interval dependent upon
the results:
BRONZE
SILVER
GOLD
PLATINUM
5 bronze standards or more in total
3 - 4 bronze standards in total
1- 2 bronze standards in total
3 consecutive gold WAAS assessments
PLATINUM competencies
PLATINUM Panel
PLATINUM Review Panels on a yearly basis
Level 0
Level 1
Level 2
Level 3
Reassess in 2 months
Reassess in 4 months
Reassess in 8 months
Reassess in 12 months
4
Care Assurance and Accreditation System 2014
Record of completion:
Date:
Ward and Specialty:
Senior Charge Nurse:
Lead Nurse Assessor:
Senior Nurse / Head of Nursing:
Service Manager:
Associate Director of Nursing / Chief of Nursing Services:
Overall Score
Bronze
Silver
Gold
PLATINUM Ward
Level 0
Level 1
Level 2
Level 3
Date action plan due:
5
Standard 1:
Pressure Area Care
Patient harm from pressure ulcers is prevented
1.1
1.1.1
1.1.2
1.1.3
1.1.4
1.1.5
1.2
1.2.1
1.2.2
1.2.3
1.3
1.3.1
Element: Safe and effective patient care
All patients are reliably risk assessed using an agreed
tool and there is evidence of ongoing assessment
SSKIN care bundle is reliably implemented for patients
with an identified risk
All patients with pressure area damage or those at high
risk have an appropriate plan of care recorded and if
grade 2-4 ulcer, a wound care plan in place
Pressure relieving equipment is used appropriately for
individual patients needs as per local guidance
Patients who are identified as being at risk and those
who have a diagnosed pressure ulcer are highlighted at
ward handovers/ safety briefs / huddles
Element: Enhancing the patients’ experience of
care
Evidence of patients and carers/relatives being
encouraged to actively participate in pressure area care
by maximising mobility
Patient/relatives and carers are fully informed of any
pressure damage that occurs
Patients and where appropriate carers/relatives
understand the plan of care and the importance of good
nutrition and hydration and the need to relieve pressure
areas regularly
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice , and there is evidence of
their effectiveness
Evidence Type
Care record, recognised risk
assessment tool
Care record, SSKIN
completion, intentional safety
rounds/active care rounds
Observation, wound care plan,
SSKIN bundle, datix, TVN
involvement
Observation, discuss with staff,
local guidance
Compliant
Comments
OPAH Outcome
8/ SPSP
OPAH Outcome
8/ SPSP
OPAH Outcome
8/ SPSP
Observe, discuss with staff
Evidence Type
SPSP
Compliant
Comments
Care plan, patient/carers
leaflets, discuss with patient/
relatives/carers
Care record, discuss with
patient/relatives/carers
Information leaflets, discuss
with patient/relatives/carers,
care record.
Evidence Type
Folder, link nurse descriptor
monitored, discuss with SCN .
discuss with link nurse PU
improvement plan in place,
days between PU
Mapped to
OPAH Outcome
8 / SPSP
Mapped to
OPAH Outcome
8/ SPSP / PCHC
OPAH Outcome
8/ SPSP / PCHC
OPAH Outcome
8/ SPSP / PCHC
Compliant
Comments
Mapped to
OPAH Outcome
8/ SPSP / VoL
6
1.3.2
Staff have undertaken education and development
relating to pressure ulcer risk assessment, prevention
and management including the SSKIN bundle
Learning plans, training
records, discuss with link
nurse/SCN
OPAH Outcome
8/ SPSP
1.3.3
Staff are aware of how to access specialist pressure
relieving equipment both in and out of hours
Element: Contributing to the organisations
objectives
Mattress is checked for signs of damage in line with
organisational policy.
Patients who have a pressure ulcer are reported in line
with organisational policy / guidance including
discussion with family / carer
Monthly pressure ulcer information is displayed on the
ward performance board
Discuss with staff
OPAH Outcome
8/ SPSP
Mapped to
Equipment / stock is available to support the prevention
and treatment of pressure ulcers
Scores
Observe, discuss with SCN,
stock records
1.4
1.4.1
1.4.2
1.4.3
1.4.4
Evidence Type
Compliant
Comments
Mattress audits
OPAH Outcome
8/ SPSP / HEI
Datix
Lanqip, safety cross, ward
displays
OPAH Outcome
8/ SPSP
OPAH Outcome
8/ SPSP
Bronze
Silver
Gold
Best Practice/Comments
7
Standard 2:
Falls
Patient harm from falls is prevented
2.1
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.2
2.2.1
2.2.2
2.2.3
2.2.4
Element: Safe and effective patient care
All patients being reliably risk assessed for falls and
evidence of ongoing falls risk assessment
All elements of the falls safe care bundle is reliably
implemented for patients with an identified risk of
falling (i.e. blood pressure, footwear, mobility aids,
glasses, medication review etc)
Bed rail risk assessment is completed to minimise
risk of harm and plan of intervention recorded
Patients who have fallen or who have a high risk of
falls have a recorded plan of care in line with the level
of risk
Patients who are identified as high risk of falling and /
or who have had a fall are identified at the ward safety
brief/huddle and actions taken to minimise risk in line
with organisational policies
Following a patient fall actions are taken to examine
and minimise the risk of further falls, lessons learned
are shared across the team
Element: Enhancing the patients’ experience of
care
Patient, relatives/carers are provided with falls
prevention information at admission and during stay
on ward
Patients and relatives /carers are encouraged to
actively participate in minimising the risk of falls i.e.
appropriate foot wear / glasses sticks etc
Patients/relatives/carers are informed, at the earliest
opportunity, when a fall occurs, the outcome of the
patient falls and actions taken to minimise further risk
Patients feel safe and supported and are aware of
how to call for assistance when mobilising and
alternative systems are in place if patient is unable to
use call bell system
Evidence Type
Care record, falls risk
assessment tool
Care record, falls safe bundle
Compliant
Comments
Mapped to
OPAH Outcome 7
/ SPSP
OPAH Outcome 7
/ SPSP
OPAH Outcome 7
/ SPSP
Care record, audit tools
Care record
OPAH Outcome 7
/ SPSP
OPAH Outcome 7
/ SPSP
Observe, safety briefs,
intentional safety rounds/active
care rounds, red triangle
Debrief, discuss with staff, datix
Evidence Type
OPAH Outcome 7
/ SPSP
Compliant
Comments
Mapped to
Discuss with patient/relatives/
carers, information leaflet
OPAH Outcome 7
/ SPSP / PCHC
Discuss with patient/relatives/
carers, observe, care record
OPAH Outcome 7
/ SPSP / PCHC
Care record, discuss with
patient/relatives/carers
OPAH Outcome 7
/ PCHC
Discuss with patient/relatives/
carers, observe, falls audit tool
OPAH Outcome 7
/ SPSP / PCHC
8
2.3
Element :Leading, managing and developing the
performance of the team
Evidence Type
2.3.1
.
The link nurse ensures that staff are up to date with
their knowledge and practice, and there is evidence of
their effectiveness.
OPAH Outcome 7
/ SPSP
2.3.2
Staff have undergone education and development in
relation to falls risk assessment and falls risk
minimisation
Learning plans, discuss with
staff, discuss with SCN/ link
nurse, review falls data/ falls
improvement plan
Learning plan, training record,
discuss with staff
2.3.3
Staff are aware of how to contact specialist support
and advice in relation to falls (falls coordinator / physio
/ podiatry / moving & handling coordinator etc) in line
with organisational policy
Element: Contributing to the organisations
objectives
Monthly falls information is displayed on the ward
performance board
Patients who have a fall are reported in line with
organisational policy / guidance including discussion
with relatives/carers
Scores
Discuss with staff , review
referrals to specialist services,
discuss with specialist services
OPAH Outcome 7
/ SPSP
2.4
2.4.1
2.4.2
Evidence Type
Ward poster, safety cross,
lanqip
Datix, care record
Compliant
Comments
Mapped to
OPAH Outcome 7
/ SPSP
Compliant
Comments
Mapped to
OPAH Outcome 7
/ SPSP
OPAH Outcome 7
/ SPSP
Bronze
Silver
Gold
Best Practice/Comments
9
Standard 3:
Catheter Associated Urinary Tract Infection (including continence issues)
Patient harm from catheter associated urinary tract infection is prevented.
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.2
3.2.1
3.2.2
3.2.3
3.2.4
Element: Safe and effective patient care
All patients are reliably risk assessed with reference to
CAUTI
Rationale for insertion of a urinary catheter is
documented as well as date, time, type, size, batch
number, amount of water in the catheter balloon for
patients where catheterisation is required
The catheter insertion bundle is reliably implemented
for patients who require catheterisation
The catheter maintenance bundle is reliably
implemented for patients who have a catheter inserted
Accurate fluid balance recording is in place for
patients with indwelling urinary catheters in line with
organisational policy / guidance
Patients with an indwelling urinary catheter or who
have been identified as having continence issues are
highlighted at ward handovers / safety briefs / huddles
/intentional rounds
Element: Enhancing the patients’ experience of
care
Patients and where appropriate relatives / carers are
actively encouraged to be involved in their care
planning and continence management
Patients are fully assisted to use toilet facilities and
continence aids / devices to reduce the need for an
indwelling urinary catheter
Patients with an indwelling urinary catheter are
encourage to maintain oral fluid intake in line with
organisational policy / guidance
Patients/relatives/carers are notified at the earliest
opportunity when a CAUTI suspected and diagnosed
Evidence Type
Compliant
Comments
Mapped to
SPSP
Care record
Care record
SPSP
Care record
SPSP
Care record, specimens, lab
results
Care record, fluid balance chart
SPSP
Observe, handovers, intentional
safety rounds/active care rounds
SPSP
Evidence Type
SPSP
Compliant
Comments
Mapped to
Care records, discuss with
patient/relatives/carers
SPSP / PCHC
Observe, discuss with
patient/relatives/carers
SPSP / PCHC
Patient information leaflet,
discuss with
patient/relatives/carers
Care record, discuss with
patient/relatives/carers
SPSP/ PCHC
PCHC
10
3.3
3.3.1
3.3.2
3.3.3
3.4
3.4.1
3.4.2
3.4.3
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice, and there is evidence of
their effectiveness.
Staff have undergone education and development in
relation to continence management, catheter insertion
and indwelling catheter care.
Staff are aware of how to access specialist services in
relation for continence support and advice
Element: Contributing to the organisations
objectives
Monthly CAUTI information is displayed on the ward
performance board
Antimicrobial prescribing policy is followed in relation
to urinary catheter management and information
displayed
There is effective and efficient use of resources to
support both continence management and catheter
care within the clinical area ( e.g. stock rotation,
number and size of continence devices etc)
Scores
Evidence Type
Compliant
Comments
Mapped to
Learning plans, CAUTI
improvement plan, discuss with
SCN / link nurse, training
records
Learning plan
SPSP
Discuss with staff
SPSP
Evidence Type
Ward information board, lanqip,
safety cross
Prescribing information, discuss
with staff
Observe, review stock, discuss
top up with staff, discuss with
ward staff
SPSP
Compliant
Comments
Mapped to
SPSP
SPSP /
Antimicrobial
Stewardship
SPSP
Bronze
Silver
Gold
Best Practice/Comments
11
Standard 4:
Deteriorating Patient
Patient harm from unidentified deterioration, sepsis, and cardiac arrest is prevented.
4.1
4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.1.6
4.2
4.2.1
4.2.2
4.2.3
Element: Safe and effective patient care
Patients observations are reliably recorded at the
correct frequency and appropriate actions taken, using
the correct equipment
Staff identify patients who are deteriorating respond
effectively and record the plan of care
Emergency medical equipment is available and is
checked daily .
Sepsis 6 trolleys are cleaned and stock maintained,
reviewed and restocked after patient use (where in
use)
Where appropriate, DNACPR / Ceilings of Treatment
/Treatment Escalation Plans should be considered,
recorded including evidence of discussion with
patients / relatives / carers. This should be reviewed if
patient status changes
Patients who are identified as high risk / deteriorating
/ have sepsis are identified at the ward safety brief /
huddle and actions taken to minimise risk in line with
organisational policies
Element: Enhancing the patients’ experience of
care
When appropriate, patient who are identified of at risk
and their relatives /carers , have explained to them
what the plan of care and outcomes are in a
supportive and sensitive manner
Patients/relative/carers feel listened to and are as
involved as possible in the decisions regarding their
care (consideration of Daily Goals/ ACP / Ceilings of
Treatment taken into account)
Patients know what to expect and understand the
need and frequency of clinical observations to be
undertaken
Evidence Type
Care record, MEWS chart, audit
data
Compliant
Comments
Care record, discuss with staff
Mapped to
SPSP / SIGN
guideline 139
Observe, audit, trolley checklist
SPSP /SIGN
guideline 139
SPSP
Observe, checklist, audit
SPSP
Care record
SPSP / PCHC /
OPAH Outcome 2
/ SIGN guideline
139
Observe, safety brief, care
record, intentional safety
rounds/active care rounds
SPSP/ SIGN
guideline 139
Evidence Type
Discuss with staff / patient /
relatives/ carer
Care record, discuss with
patient/relatives/carers
Discuss with patient/
relatives/carers
Compliant
Comments
Mapped to
SPSP / PCHC /
OPAH Outcome
2/ SIGN guideline
139
SPSP / PCHC/
OPAH Outcome
2/ SIGN guideline
139
SPSP / PCHC/
SIGN guideline
139
12
4.2.4
Patients/relatives/carers are fully informed about any
deterioration in the patient’s condition at the earliest
opportunity
Discuss with patient/relatives/
carers
4.3
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice and there is evidence of
their effectiveness
Staff have access to equipment to monitor the patients
condition and can use it appropriately and correctly
Staff have undertaken education and development in
relation to the recognition of the deteriorating patient /
sick patient (including sepsis where appropriate)
Evidence Type
4.3.1
4.3.2
4.3.3
4.3.4
4.3.5
4.4
4.4.1
4.4.2
4.4.3
Staff are aware of how to contact specialist support
and advice in line with organisational policy (i.e. HECT
/ ERT/Dual Response etc)
Staff are up to date with Basic Life Support and if
required Intermediate or Advanced Life Support
Element: Contributing to the organisations
objectives
Cardiac arrest, sepsis and deteriorating patient
information is displayed on the ward performance
board
Staff are aware of organisational policy in relation to
the deteriorating patient and escalation of treatment
Where there has been a cardiac arrest event or
unidentified deterioration of a patient a case note
review is completed and lessons learned shared
Scores
Compliant
Comments
SPSP / PCHC/
OPAHOutcome 2/
SIGN guideline
139
Mapped to
Learning plans, improvement
plan, discuss with SCN / link
nurse, training records
Observe, discuss with staff,
training records
Training records, discuss with
staff/ link nurse / HECT / dual
response
Discuss with staff / HECT / dual
response
SIGN guideline
139
Training records, discuss with
link nurse / RTOs/ staff
Evidence Type
SPSP / SIGN
guideline 139
Mapped to
SPSP/ SIGN
guideline 139
SPSP/ SIGN
guideline 139
SPSP/ SIGN
Guideline 139
Compliant
Comments
Observe
SPSP
Discuss with staff, debriefs
SPSP / SIGN
Guideline 139
SPSP
Discuss with staff, cardiac
arrest debriefs, discuss with
RTO
Bronze
Silver
Gold
Best Practice/Comments
13
Standard 5:
Medicines Management
Patients medicines are stored and administered accurately and safely
5.1
5.1.1
5.1.2
5.1.3
Element: Safe and effective patient care
All medicines, including IV infusions, are stored in
accordance with organisational policy e.g. PODs,
locked trolley / cupboards, locked fridges, IV
preparation areas
Patient’s weight and allergy status are recorded on the
medicine prescription chart, all patients have an
accurately completed wristband in situ
Medicines reconciliation has been completed on
admission to hospital and transfer / discharge
Evidence Type
Observe
Prescription chart, transfer
summary, discharge summary,
care record
Prescription chart
Medicine prescription charts and discharge
prescriptions are legible and accurate
5.1.5
All medicines are administered in line with
organisational policy and best practice
Observe drug round,
audit of prescription charts
5.1.6
Patients with no medicines reconciliation completed or
requiring high risk medicines are highlighted at safety
briefs / handovers
Element: Enhancing the patients’ experience of
care
Measures are taken to minimise interruptions during
the medicines administration process
Review safety brief, review
documentation, ask staff
Patients/relatives/carers understand the medicines
being administered , reason for administration and
implications
If medicines are omitted this is recorded accurately,
including the reason for omission, and action is taken
Ask patient/relatives/carers
Medicines reconciliation on admission has taken place
which involves the patient / relatives and or carers
Review notes, ask
patient/relatives/carers
5.2.1
5.2.2
5.2.3
5.2.4
Comments
Care record, prescription chart,
observe patients
5.1.4
5.2
Compliant
Evidence Type
Coloured tabards, quiet zones observe
Review prescription charts
Compliant
Comments
Mapped to
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
Mapped to
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
NMC standards
medicines
management
14
5.2.5
Where patients require medicines for their discharge
home / transfer these have been explained to p/r/c
and to another care setting this is undertaken to
minimise delays
Element: Leading, managing and developing the
performance of the team
The link nurse/person ensures that staff are up to date
with their knowledge and practice and there is
evidence of their effectiveness
Staff have access to key sources of medicines
information whilst on the ward and know how to
access them e.g..eBNF, BNF , drug data sheets, IV
monographs, clinical guideline
Staff receive appropriate training relating to medicines
administration
Care record, observe, discharge
summary
Staff can access pharmacy support in relation to
medicines queries and administration.
Where IV drugs require administration staff are
appropriately trained, assessed and competent and
keep their skills up to date
Element: Contributing to the organisations
objectives
Controlled drugs are stored, administered and
checked in line with legal and organisational
requirements
Ask staff, discuss with pharmacy
5.4.2
All medication incidents are recorded and there is
evidence of appropriate learning shared
Datix
5.4.3
There is effective and efficient management of
medicines stock levels and spending, with evidence of
review processes
Scores
Review pharmacy order,
observe drug cupboards/trolleys
5.3
5.3.1
5.3.2
5.3.3
5.3.4
5.3.5
5.4
5.4.1
Evidence Type
NMC standards
medicines
management
Compliant
Comments
Mapped to
Review training records, speak
to link nurse/SCN
Ask staff, observe medicines
management
NMC standards
medicines
management
Review training records/PGD/
CPD
NMC standards
medicines
management
NMC standards
medicines
NMC standards
medicines
management
Mapped to
Review training records, ask
staff
Evidence Type
Review controlled drug book
Compliant
Comments
NMC standards
medicines
management /
Dangerous Drug Act
NMC standards
medicines
management
NMC standards
medicines
management
Bronze
Silver
Gold
Best Practice/Comments
15
Standard 6:
Pain control
Patients’ pain will be controlled to an acceptable level
6.1
6.1.1
6.1.2
6.1.3
6.2
6.2.1
6.2.2
6.3
6.3.1
6.3.2
6.3.3
Element: Safe and effective patient care
All patients have a pain assessment using a
recognised pain tool recorded on admission and
reassessment appropriate to patient status and
severity of pain
Analgesia is prescribed and administered in line with
patients severity of pain and organisational protocol
and are monitored for effectiveness
Patients who have high risk pain control therapy (such
as PCA , epidural, syringe driver) are highlighted at
safety briefs / handovers
Element: Enhancing the patients’ experience of
care
Pain relieving measures are taken promptly and the
effectiveness of the intervention to alleviate pain
reviewed. This may include comfort measures,
distraction therapy etc
Patients and where appropriate carers / relatives are
encouraged to actively participate in pain
management
Element: Leading, managing and developing the
performance of the team
The pain control link nurse ensures that staff are up to
date with their knowledge and practice , and there is
evidence of their effectiveness
Device managers ensure that staff are able and
competent to use appropriate devices to administer
pain relief.
Staff are aware of how to contact specialist service
relating to effective pain management
Evidence Type
Review case notes
Compliant
Comments
Review case notes/ pain charts
Observe safety brief, ask staff
Evidence Type
Compliant
Comments
Mapped to
SIGN guidance 136
SIGN guidance 106
OPAH Outcome 1
SIGN guidance 136
SIGN guidance 106
OPAH Outcome 1
SIGN guidance 136
SIGN guidance 106
OPAH Outcome 1
Mapped to
Review case notes/ pain chart,
ask patient/relatives/carers
SIGN guidance 136
SIGN guidance 106
Patient information leaflets
SIGN guidance 136
SIGN guidance 106
Evidence Type
Compliant
Comments
Mapped to
Review training records,
discuss with link nurse / SCN
SIGN guidance 136
SIGN guidance 106
Review training records
SIGN guidance 136
SIGN guidance 106
Ask staff , discuss with specialist
pain services
SIGN guidance 136
SIGN guidance 106
16
6.4
6.4.1
Element: Contributing to the organisations
objectives
Pain control and pain management guidelines are
available and reliably implemented , including
palliative care protocols, pain management for
patients with dementia
6.4.2 Devices are available, maintained and serviced in line
with agreed organisational processes.
Scores
1 ‘no’ in each element / 50% ‘no’ / 7 no’s
2 ‘no’s / less than 50% in total and the rest ‘yes’
1 ‘no’ in total and the rest ‘ yes’ / 100% ‘yes’
Best Practice/Comments
Evidence Type
Compliant
Comments
Mapped to
Review availability, ask staff
SIGN guidance 136
SIGN guidance 106
Ask staff, review any devices
available re maintenance check
SIGN guidance 136
SIGN guidance 106
Bronze
Silver
Gold
17
Standard 7:
Infection Prevention and Control
Patients receive care in a clean environment, where risks of Healthcare Acquired Infection are minimised
7.1
Element: Safe and effective patient care
Evidence Type
Compliant
7.1.1 Hand washing facilities or alcohol based hand rubs
SICPs audits, ward displays,
are available at the ward entrances and at point of
ask visitors, observe
care delivery and staff / visitors encouraged to use
them
7.1.2 The decontamination of commonly used equipment
SICPs audits, observe, review
i.e. commodes, I.V. stands, mattresses , bed spaces
cleaning records
is carried out in accordance with Standard Infection
Control Procedures (SICPs) and are labelled
appropriately. Records of regular cleaning are
maintained
7.1.3 All staff clean their hands appropriately in line with the SICPs audits
5 key moments for hand hygiene and the six steps.
7.1.4 Personal Protective Equipment (PPE) is worn in line
SICPs audits
with SICPs and is removed between patients and if
necessary between care delivery interventions with
the same patient and hands cleaned.
7.1.5 Patients with a suspected or known infection are
SICPs audits
isolated and cared for in line with Transmission Based
Precautions
7.1.6 The peripheral vascular catheter / central vascular
SICPs audits
catheter insertion and maintenance bundle is reliably
implemented for patients
7.1.7 Environmental Infection Control audit is completed
SICPs audits
every 6 months
7.2
Element: Enhancing the patients’ experience of
Evidence Type
Compliant
care
7.2.1 Patients and carers / relatives are encouraged to
Observe, ask patients/relatives
actively participate in assisting in reducing the risks of
HAI
7.2.2 Patients who require to be isolated feel safe and are
Ask patients/relatives/carers,
understand what is happening and how to get
observe, discuss with staff
assistance if required
Visitors are aware of their role in preventing further
infection
Comments
Mapped to
SICPS
HEI
SICPS
HEI
SICPS/ HEI
SICPs /HEI
SICPs / HEI
SICPs / HEI
SICPs /HEI
Comments
Mapped to
18
7.2.3
7.2.4
7.3
7.3.1
7.3.2
7.3.3
7.3.4
7.4
7.4.1
7.4.2
7.4.3
7.4.5
Patients who require isolation are risk assessed to
ensure other care needs are not compromised i.e risk
of falls, dementia, wellbeing
Patients/relatives/carers are informed, at the earliest
opportunity, there are any suspected or actual
infection control issues at the earliest opportunity
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice , and there is evidence
of their effectiveness
All staff have completed and are up to date with
compulsory infection control learning modules
Staff know how to access and follow organisational
policies in relation to infection control issues i.e
outbreak management, escalation procedures,
sickness absence management
Staff are aware of how to contact specialist support
relating to infection prevention and control issues
Element: Contributing to the organisations
objectives
The ward environment is clean, clutter free and in a
good state of repair and ward cleaning schedules are
available and monitored
Linen is appropriately bagged and tagged in line with
SICPs and organisational policy
Safe disposal of waste is undertaken in line with
organisational policy
Performance information relating to HAI (MRSA /
CDiff,SAB) is displayed in a meaningful way for both
patients and staff
Scores
Review case notes, discuss with
staff
HAI standards
Review case notes, ask
patient/relatives/carers
Evidence Type
Compliant
Comments
Mapped to
Discuss with link nurse/ SCN,
review folder
HAI standards
Review training records
HAI standards
Ask staff, discuss with infection
prevention and control team
HAI standards
SICPS
Ask staff, discuss with infection
prevention and control team
Evidence Type
SICPs
Compliant
Comments
Mapped to
Observation
Observation, ask staff
Observation, ask staff
Observation
Bronze
Silver
Gold
Best Practice/Comments
19
Standard 8:
Food Fluid & Nutritional care
Patients experience of eating and drinking enhances their health and well being
8.1
Element: Safe and effective patient care
Evidence Type
8.1.1
Patients nutritional status has been reliably assessed Review case notes
using a recognised screening tool and plan of care
clearly recorded
A clear process for identifying individual patient’s
nutritional requirements and support is in place (e.g.
white board, safety brief.)
8.1.3
Patients have the opportunity to clean their hands
before mealtimes
8.1.4
Patients are offered fresh, cold water at regular
intervals and encouraged to maintain oral intake as
appropriate.
8.1.5
Where required patients are positioned to allow them
to eat safely
8.1.6
Staff clearly identify patients who are fasting or NBM
and follow organisational guidelines for their
management
8.1.7
Staff clearly identify patients who require enteral or
parenteral feeding and follow organisational
guidelines for their management
8.1.8
All food and fluid charts are completed and monitored
regularly
8.1.9
Appropriate and timely referrals are made for patients
identified as being in need of specialist nutritional
support
8.1.10 Patients with swallowing difficulties are offered the
correct texture of food and fluids after assessment
8.2
Element: Enhancing the patients’ experience of
care
8.2.1
Patients who have been identified as requiring
support with eating and drinking are given assistance
as appropriate, in a dignified manner
8.2.2
Relatives, carers or volunteers are positively
encouraged to assist at meal times for appropriate
individuals
8.1.2
Compliant
Comments
Observation of whiteboard
/safety brief, ask staff, observe
mealtime
Observation, ask patients
Ask patients, observation
Mapped to
OPAH Outcome 1,6
FFN Standards
(2014) 2.1, 2.2, 2.3,
2.9
OPAH Outcome 6
FFN Standards
(2014) 4.1 (a)
FFN Standards
(2014) 4.8
OPAH Outcome 6
FFN Standards
(2014) 4.5
Observation, ask staff
Observation, ask staff
Review notes, ask staff
Review notes
FFN Standards
(2014) 4.1 (g)
Review notes, referral data from
specialty services.
Review notes, ask staff
Evidence Type
Compliant
Comments
FFN Standards
4.11
Mapped to
Meal time observation
FFN Standards
(2014) 4.1 (e), 4.6
Meal time observation, ask
patient/relatives
PCHC
20
8.2.3
8.2.4
8.3
8.3.1
8.3.2
8.3.4
8.3.5
8.3.6
8.4
8.4.1
Patients are given sufficient time to eat and drink at
their own pace
Patients are asked about likes and dislikes and this is
recorded and acted upon
Observation, ask patient
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice , and there is evidence
of their effectiveness
All staff have completed and are up to date with the
Food Hygiene LearnPro module.
A mealtime coordinator is identified every day on the
duty rota sheet
The number of staff involved is adequate to support
all the processes in the Standard Operating
Procedure for Mealtimes
Staff undertake a meal time sweep
Evidence Type
Element: Contributing to the organisations
objectives
All the principles of the Mealtime Bundle/ Protected
Mealtimes are embedded within the clinical area
Scores
Ask patient, observe, review
notes
Compliant
Comments
Review link nurse folder if
available, training records,
discuss with link nurse/SCN
Review training records
FFN Standards
(2014) 4.1.(d)
FFN Standards
(2014) 2.2 (c) 4.1
(d)
Mapped to
FFN Standard 6.3
Review duty rota, observe
Review rosters, observe
Meal time observation, discuss
with staff/patient/relatives/carers
Evidence Type
Observation
FFN Standards
(2014) 4.6
Compliant
Comments
Mapped to
FFN Standards 4.7
Bronze
Silver
Gold
Best Practice/Comments
21
Standard 9:
Person Centred Health and Care
Patients experience person centred care and feel safe and supported within the care environment
9.1
9.1.1
9.1.2
9.1.3
9.1.4
9.1.5
9.2
9.2.1
9.2.2
9.2.3
Element: Safe and effective patient care
Ward environment is clean, clutter free, calm and
noise kept to a minimum, particularly in respect of
those patients who experience cognitive impairment
Environmental and specific risks are taken into
consideration relevant to specific patient needs
There is evidence that patients needs are assessed
and addressed on an ongoing basis
Staff are able to access support for patient’s spiritual
needs
If patients have been transferred between wards the
reason for transfer is clearly documented and is
clinically appropriate.
Element: Enhancing the patients’ experience of
care
Patients, relatives and carers are orientated to the
environment on admission and ongoing. i.e how to call
for assistance, where toilets are, mealtimes, visiting
times etc
Patients, carers and relatives are encouraged to be
involved in decisions regarding the patients care and
take an active role in contributing to the plan of care
Patients are addressed by their preferred name
9.2.4
Patients are asked about “who and what matters most
to me..” and this is recorded and acted upon
9.2.5
Patients receive care which is dignified and respectful
i.e appropriate use of curtains, sensitivity regarding
going to toilet, ensuring patients dignity preserved
Corporate feedback tools are clearly visible and
accessible for patients and visitors (Care to Comment
Card, ‘our customer service – what do you think?)
9.2.6
Evidence Type
Observe
Compliant
Comments
Observe, care record, safety
brief, discuss with staff
Care record, observe
OPAH Outcome 1
OPAH Outcome
2,5,9
OPAH Outcome 1,5
Care record, discuss with
patient
Care record, transfer/handover
forms
Evidence Type
Mapped to
Compliant
Comments
Mapped to
Care record, ward information
sheet, discuss with patient/
relatives/ carers
OPAH Outcome 1
Care record, discuss with
patient/relatives/carers
OPAH Outcome
2,3,4,9
Observe, care record, discuss
with patient
Care record, Getting to Know
Me document, discuss with
patient/relatives/carers
Observe, discuss with patient
OPAH Outcome 2,
5,9
Observe, discuss with staff
PCHC
PCHC
22
9.2.7
9.3
9.3.1
9.3.2
9.4
9.4.1
9.4.2
9.4.3
Information leaflets appropriate to the care
environment are visible and easily accessible for
patients
Element: Leading, managing and developing the
performance of the team
The link nurse ensures that staff are up to date with
their knowledge and practice , and there is evidence
of their effectiveness
There is evidence that staff have undertaken some
learning and development relating to person centred
health and care
Element: Contributing to the organisations
objectives
There is a patient feedback board visible for staff and
relatives within the area that is clearly being used
All staff are aware of, and have access to, National
Care Standards
Customer Care / patient experience audits are carried
out at the designated intervals and appropriate action
plans put in place
Scores
Observe
Evidence Type
Compliant
Comments
Mapped to
Compliant
Comments
Mapped to
Review link nurse folder if
available, training records,
discuss with link nurse/SCN
Learning plan, PDP, discuss
with staff
Evidence Type
Observe
PCHC
Discuss with staff
National Care
Standards
National Care
Standards
Review of audits and action
plans
Bronze
Silver
Gold
Best Practice / comments
23
Standard 10: Older People in Acute Care & Adult Protection
Ensure older & vulnerable patients’ needs are met in the acute ward setting
10.1
Element: Safe and effective patient care
Evidence Type
10.1.1
Ward environment is welcoming, hazard free, with
correct signage that is appropriate for patients with
cognitive impairment clocks visible in each room,
colour scheme
10.1.2
Glasses, hearing aids, and dentures are accessible
to patients Walking aids are for individual patients
and kept within reach
10.1.3
Patient has been fully assessed for cognitive
impairment, ensuring that where there is cognitive
impairment, delirium is excluded.
10.1.4
Where cognitive impairment has been identified,
correct care bundles are in place and the correct
identifiers used. Where delirium has been identified
the TIME bundle is in place
10.1.5
Where cognitive impairment is identified an
assessment of capacity is undertaken within the AWI
legal framework
10.1.6
Staff are aware of how to access specialist help and
advice from Mental Health/Elderly Mental
Health/Learning Disability Team/Social Work
10.1.7
All patients assessed as having capacity issues have
an Adults with Incapacity Certificate and Treatment
Plan in place
10.1.8
All patients who have Power of Attorney have it
clearly identified in notes and copy of documentation
requested and retained
10.1.9
Stress/ distress managed in ward using Newcastle
Model ( recommended by NES) with as required
medication closely monitored and reviewed
10.1.10 Appropriate assessment of pain using tool suitable
based on need ( Abbey pain tool if unable to verbally
communicate pain)
Compliant
Comments
Mapped to
Observation
OPAH Commitment
10
Observation, review case notes
OPAH Commitment
10
Review case notes
OPAH 11.1, 11.2,
13.1,
Commitment 10
Commitment 10
OPAH 12.1, 12.3
Delirium
Guidelines.
OPAH 2.1, 2.3, 2.4,
12.6
Review case notes
Medical notes, AWI treatment
plan, record of carer
involvement
Audit, evidence of referrals With
specialist services, ask staff
OPAH Commitment
10
Review notes
OPAH Commitment
10
Review notes
OPAH Commitment
10
Drug kardex prescription audits,
review record for impact of
medication used
Review notes
OPAH Commitment
10
OPAH Commitment
10
24
Element: Enhancing the Patient’s experience of care
Full assessment of patient needs is completed on
admission to the ward.
10.2.2 All patients with cognitive impairment have a completed
Getting To Know Me document completed
Evidence Type
Review notes
10.2.3
Review notes
10.2
10.2.1
10.2.4
10.2.5
10.2.6
10.3
10.3.1
10.3.2
Accurate next of kin details are recorded at admission,
including details of legal guardianship/power of welfare
attorney
Staff respond appropriately and timeously to requests
for support with attending to basic hygiene and toilet
needs
All care is carried out in a discreet and respectful
manner
There is evidence that the patient and relatives / carers
participate in care and decision making
Element: Leading, managing and developing the
performance of the team
Audit of physical environment is carried out using the
dementia environment checklist
All staff have access to training in caring for patients
with cognitive impairment:



Comments
Review notes
Mapped to
OPAH 6.6, 9.6
Commitment 10
OPAH 3.1,
3.2,Commitment
10
OPAH
Commitment 10
Observation
OPAH
Commitment 10
Observation
OPAH
Commitment 10
OPAH
Commitment 10
Mapped to
Review case notes, discuss
with relatives/carers
Evidence Type
Observation, audit results
Review training records
Compliant
Comments
OPAH
Commitment 10
OPAH
Commitment 10
Informed/ skilled level Promoting Excellence
NES Delirium module
Stress/ Distress training
NES Think Capacity

OPAC/Dementia link nurse ensures that staff are up to
date with their knowledge and practice , and there is
evidence of their effectiveness
10.3.4 Guidelines are in place to support staff to maintain
patient safety with regard to risk assessment and
increased supervision of patients at risk
10.3.5 The ward has an identified Carers Champion/s and Staff
are aware of how to access the carers liaison service
and the advocacy service
10.3.3
Compliant
Review link nurse folder if
available, training records,
discuss with link nurse/SCN
Ask staff, review records
OPAH
Commitment 10
Ask staff
Commitment 10
OPAH
OPAH
Commitment 10
25
10.4
Element: Contributing to the organisations
objectives
10.4.1 Standards of care are measured on a regular basis to
ensure compliance with care bundles and organisational
values
Scores
Evidence Type
Audits, complaints, patient
feedback
Compliant
Comments
Mapped to
OPAH
Commitment 10
Bronze
Silver
Gold
Best practice / comments
26
Standard 11: End of Life Care:
Patients and their families / carers are supported effectively during End of Life Care
11.1
11.1.1
11.1.2
11.1.3
11.1.4
11.1.5
11.2
11.2.1
11.2.2
11.2.3
11.2.4
Element: Safe and effective patient care
Staff are able to identify patients who require End of
Life care and plan care appropriately
There are clearly documented records of discussions
relating to ceilings of treatment and DNACPR with
patients and families / cares where appropriate within
the clinical / care record
Where discussions have identified Preferred Place of
Death as home/care home, provide necessary
support to expedite transfer
Staff initiate and coordinate the rapid discharge of a
dying patient from hospital to home, if requested and
involve the discharge coordinator for assistance and
support
Staff are aware of and know how to seek advice on
areas of care such as nutrition, hydration and pain /
sedation management in End of Life care
Element: Enhancing the patients’ experience of
care
Staff are aware of the support available to
themselves and their patients, relatives and carers
through the spiritual care team
Relatives of a dying patient have access appropriate
information and facilities i.e. quiet space,
refreshments, telephone
Information for relatives following a bereavement (i.e
‘What to do After a Death’ or ‘Information and
Support for When Someone Dies’ ) and bereavement
support is made available
Staff are aware of verification of death policy( in care
settings without 24hour medical cover) and how
death or acute deterioration is communicated to
relatives who are present, or via telephone
Evidence Type
Review case notes, ask staff
Compliant
Comments
Review case notes
Mapped to
OPAH Outcome 3,
OPAH Outcome 4
OPAH Outcome 3,
OPAH Outcome 4
Review case notes, ask staff
OPAH Outcome 4
Ask staff re process, review
records
OPAH Outcome 4
Ask staff, review records
OPAH Outcome 3,
OPAH Outcome 4
Evidence Type
Compliant
Comments
Mapped to
Ask staff, review information
available on ward
OPAH Outcome 4
Observation, ask staff
OPAH Outcome 4
Review information available
OPAH Outcome 4
Ask staff
27
11.2.5
11.3
11.3.1
11.3.2
11.3.3
11.3.4
11.4
11.4.1
11.4.2
11.4.3
11.4.5
Staff undertake the last offices for the deceased
patient in a safe, respectful and dignified manner in
line with organisational policies.
Element: Managing and developing the
performance of the team
Staff are trained in end of life care and can
demonstrate principles of bereavement care and
support for patients, families and carers
The palliative care link nurse / bereavement care link
nurse ensures that staff are up to date with their
knowledge and practice , and there is evidence of
their effectiveness
Staff can access support in line with organisational
structures if required following a personal or patient
death (i.e employee counselling, HR, Spiritual Care
Team, Staff Care Team, Occupational Health)
Human Resources policies are adhered to in relation
to staff following a bereavement
Element: Contributing to the organisations
objectives
Staff are aware of the content of organisational
policies relating to End of Life and Bereavement care
Contact numbers for community support services ,
care teams , social work, palliative are services etc
are readily accessible for staff, patients / carers and
families
Staff follow organisational protocol relating to death
certification, procurator fiscal involvement and are
able to communicate this ins a supportive and
sensitive manner to bereaved relatives.
When a death is unexpected a case note review is
undertaken to identify any avoidable harm and,
where appropriate lessons learned shared.
Scores
Ask staff
Evidence Type
Compliant
Comments
Mapped to
Compliant
Comments
Mapped to
Ask staff
Review link nurse folder, staff
training records
Ask staff, review information
available for staff
Review rosters
Evidence Type
Ask staff
Review information available
Ask staff
Review debrief, learning from event
plan, discuss with staff
Bronze
Silver
Gold
28
Best Practice/Comments
29
Standard 12: Effective Management of Resources & Staff Governance
Ward systems and processes enhance safe, effective and person centred care
12.1
12.1.1
12.1.2
12.1.3
12.1.4
12.1.5
12.2
12.2.1
12.3
12.3.1
12.3.2
Element: Safe and effective patient care
Staff rosters comply with organisational policy and
national guidance
A nurse in charge / shift coordinator is identified on
every shift to ensure smooth and efficient care
delivery and can be identified
Nurse in charge / shift coordinator identifies and
escalates any gaps in staffing/ increase in shift
workload to ensure appropriate effective patient safety
and high standards of person centered care are
maintained.
Ward processes are designed, implemented and
reviewed to ensure the efficient delivery of safe,
effective and person centred care
Stock levels are maintained appropriately and within
agreed budget to deliver safe, effective and person
centred care.
Element: Enhancing the patients’ experience of
care
Feedback from a range of sources is used to inform
and improve practice including learners and students
Element: Leading, Managing and developing the
performance of the team
Predictable absence and supplementary staffing is
monitored and appropriate action taken to ensure
compliance with National workforce workload tools
and within budget
Link nurse / champions within the clinical area have
clearly defined roles and responsibilities and there is
evidence of their effectiveness
Evidence Type
Review rosters
Compliant
Comments
Mapped to
Evidence Type
Compliant
Comments
Mapped to
Practice placement audits,
discuss with ward mentors/PEF’s,
student feedback, patient
feedback/complaints
Evidence Type
Compliant
Comments
Mapped to
Review rosters/whiteboard
Review rosters, review datix in
relation to staffing issues
Named nurse, audit datix reports
and Riddors, review/observe
safety brief and patient care,
review ward dashboard if in place
Observe stock levels/ward, review
budgets
Review rosters
Review link nurse folder
30
12.3.3
Professional registration is monitored and staff are
aware of their roles and responsibilities including ,
revalidation and the application of the NMC Code.
12.3.4
There are appropriately selected, trained and
maintained mentors to effectively support learning and
assessment within the practice environment
All staff have a PDP in place and have PDP reviews
documented
All staff have undertaken compulsory and mandatory
training relevant to organisational policies
12.3.5
12.3.6
12.4
12.4.1
12.4.2
12.4.3
12.4.4
Element: Contributing to the organisations
objectives
Policies relating to organisational Human Resources
are reliably implemented
Health and safety legislation and policies are reliably
implemented and issues escalated in line with agreed
protocols
Ward budgets are maintained within agreed levels and
the SCN is aware of any financial exceptions
Equipment / other resources are available to support
safe and effective care delivery
Scores
Review record of professional
practice, audit local process in
place for monitoring/reporting,
NMC registration, discuss with
staff
Practice education mentor
database, review practice
placement audits, training records
Review PDP figures (eKSF)
Review training records, review
managers learnPro reviewer
reports
Evidence Type
OPAH Outcome 10
Compliant
Comments
Mapped to
Discuss with staff/ SCN/LN & HR
support managers/ Occupational
Health, review staff complaints,
promoting attendance records,
disciplinary hearings, complaints
Review ward datix reports, stress
risk assessments
Review budgets
Observation
Bronze
Silver
Gold
Best Practice/Comments
31
Standard 13: Working Effectively in the Multidisciplinary Team
Robust and effective communication & documentation enhances safe, effective and person centred care.
13.1
13.1.1
13.1.2
13.1.3
13.1.4
13.1.5
13.1.6
13.1.7
13.2
13.2.1
13.2.2
13.2.3
13.2.4
Element: Safe and effective patient care
Patient information boards are clean, up to date and
display relevant nursing / medical / AHP information
Registered nursing staff take an active role in the ward
round and contribute effectively to discussions relating
to safe, effective and person centred care, recording
the plan of care in the care record.
There is evidence of effective multidisciplinary team
working which promotes safe, effective and person
centred care
Staff take an active part in Safety Briefs / Safety
Huddles / Whiteboards / meetings at a local /
departmental level
Patients who are identified at risk are highlighted
Intentional Safety Rounding is reliably implemented
within the ward area
Staff record incidents (actual or near miss) on DATIX,
investigations occur and lessons learned are shared
There is evidence of action following informal or
formal debriefs, examining data for improvement,
from patient safety executive walk rounds, inspections
, and / or scrutiny visits
Element: Enhancing the patients’ experience of
care
Staff introduce themselves to patients and their
visitors in a friendly and professional manner at all
times
The nurse in charge is known to patients , relatives
and carers
Patient information leaflets are readily accessible to
patients / relatives and carers and staff answer
questions if required
Patient care is assessed, planned and recorded in line
with the nursing process and reviewed and updated
Evidence Type
Observation
Compliant
Comments
Mapped to
Compliant
Comments
Mapped to
Observe, ask staff, review
records
Case note review, discuss with
members of the MDT
Ask staff , review attendance,
observe
Audit patient records,
observation
Review datix and actions taken
As above
Evidence Type
Observation
Ask staff, observation
Observation
Review case notes
32
13.2.5
13.2.6
13.3
13.3.1
13.3.2
13.3.3
13.3.4
13.3.5
13.3.6
13.4
13.4.1
13.4.2
Staff are available/accessible when relatives /carers
visit to discuss the patients well being/progress and
care and this is recorded within the care record.
Patients / relative and carer feedback is used to inform
area for improvement
Element: Leading, managing and developing the
performance of the team
Clinical record keeping complies with legal and
professional standards and action taken to improve
record keeping standards at a personal / ward level
The SCN assures the quality of care within their
sphere of responsibility
There is evidence of robust communication across the
team i.e. handovers, team meetings, team
newsletters, team cascade discussions etc
Staff identify evidence to support Professional
Revalidation
There is a clearly identified learning plan within the
clinical area
All staff new to the clinical area receive relevant role
and departmental induction
Element: Contributing to the organisations
objectives
Organisational policy relating to IT systems is adhered
to
The Health and Safety Control Book is maintained and
is up to date and there is evidence of actions taken to
minimised identified health and safety issues
Scores
Review case notes
Review feedback and actions
Evidence Type
Compliant
Comments
Mapped to
PDP/eKSF, ward learning plan,
staff training records
Review ward learning plan with
staff/SCN
Local Induction plan, discuss
with staff/SCN/LN, review
training records
Evidence Type
Compliant
Comments
Mapped to
Review case notes
Quality performance data,
regular quality meetings
Review minutes from team
meetings, staff survey results
Review, observe practices
Review book
Bronze
Silver
Gold
Best Practice/Comments
33