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Fundamentals of Care Annual Audit Report 2013

2 Fundamentals of Care Annual Audit 2013 | Welsh Government

INDEX

Page

1. Executive Summary 3

2. Situation 5

3. Background 5

4. Assessment 8

4.1 Fundamentals of Care Standards - Review of Operational

Questions and User Experience feedback

8

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

8

10

13

17

19

21

23

25

27

31

32

33

4.2 Fundamentals of Care Staff Survey 35

5. Recommendations

40

5.1 Actions for improvement 40

5.2 Monitoring and assurance 44

5.3 Conclusion 45

6. References

7. Appendix A - Quality Matrix – compliance scores

Appendix B - Local action plan – PDSA model for improvement

46

48

50


1 Executive Summary

Abertawe Bro Morgannwg University Health Board Quality Strategy, Quality Delivery Plan and Patient Experience Plan embrace the philosophy of 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.

Nursing is the largest workforce within ABM Health Board. It is essential that every nurse at all levels knows what the expectations are of them and are equip to

deliver. We need to ensure that the Health Board nursing standards of care delivery are clearly outlined, that all staff are trained and competent to deliver these and

that the Senior Nurses are monitoring compliance with these by visible leadership

across all clinical services on a daily basis.

The Health Board will ensure that it abides by the NMC requirements and supports a professional clinical workforce with the appropriate skill and knowledge for the

role. The Dignity and Respect in Care Programme for Wales was launched by The Welsh Assembly Government in October 2007. ABMU Health Board and its

preceding organisations have been firmly committed to this programme The Dignity in Care Programme is clearly aligned to the Empowering Ward Sisters Programme

and progress is reported to ABMU Health Board’s Quality and Safety Committee. Treating others with dignity and respect is a core value of ABMU Health Board.

Dignified care of older people in both social and healthcare settings has been given a high priority in the strategic development of the Health Board and in the work of

the Western Bay Partnership between ABMU and its three Local Authorities.

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 around:

Standard 6 (Rest and Sleep). There were a number of general comments which included;

“Very nice staff from nurses to Doctors.

Nursing staff were professional kind and helpful”

2). The operational audit supports the findings in the patient survey and

confirms standards for improvement: Standard 6 (Rest and sleep),

Standard 10 which is the lowest at 61% (Oral health and hygiene), 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 Health Board workforce team focusing on 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

of care and identifying where we need to focus our continuous quality improvement.

Mrs Christine Williams Acting Director of Nursing


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


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,


day patient units and Unscheduled Care (accident and emergency departments).

The FOC National Audit Autumn 2013 The 2013 National FOC audit was completed during 1st October 2013- 30th

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.


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 89 clinical areas audited across Abertawe Bro Morgannwg University Health Board (ABMUHB) 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. Five 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 86%

Std 2 & 5 Respecting people and Relationships 81%

Std 3 Ensuring Safety 88%

Std 4 Promoting Independence 88%

Std 6 Rest & Sleep 75%

Std 7 Ensuring Comfort & Alleviating pain 80%

Std 8 Personal hygiene, appearance and foot care 73%

Std 9 Eating and Drinking 85%

Std 10 Oral Health & hygiene 61%

Std 11 Toileting needs 88%

Std 12 Preventing pressure sores 94%

Overall Health Board Score 84%


The action plan for improvement will focus particular attention on Standard 6 (Rest and sleep), Standard 8 (Personal hygiene, appearance and foot

care) Standard 10 (Oral health and hygiene), Standard 2&5 (Respecting people & relationships) and standard 7 (Ensuring comfort & alleviating

pain).

User Experience

The user experience surveys were undertaken on the 6th November 2013

across all audit areas within the organisation and across all organisations in Wales, except within theatre departments. 935 patients/carers were

surveyed across ABMU Health Board.

Graph 1

Overall User Experience Summary (All Questions)

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 ABMU Health Board.

When specifically asked to rate their overall satisfaction with the care

provided to them and their families they gave the organisation a rating of 89.77% ensuring that Abertawe Bro Morgannwg University Health Board

achieved a RAG rating of green in accordance with the All Wales fundamentals of care audit criteria.

75.62%

18.13% 4.26% 0.99%

0%

20%

40%

60%

80%

100%

Always Usually Sometimes Never


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? 93%

Q2 Is there documented evidence that the patient's ability to

achieve effective communication has been assessed and

discussed with the patient or advocate?

93%

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?

82%

Q4 Is there documented evidence that each plan of care has been

assessed and discussed with the patient or advocate? 75%

Q5 Are the contact details of the first point of contact recorded in

the patient’s documentation? 97%

Q6 Is there information clearly displayed regarding how

patients/relatives/advocates can raise a formal or informal

concern?

93%

Q7 Do all patients wear an identification band which states their

first and last name, date of birth and NHS number? 92%

Q8 Is the patient's identity checked visually and verbally prior to

giving medication or undertaking a procedure? 99%

Q9 Are all clinical staff wearing staff identification badges? 85%

Q10 Are all clinical staff complying with the All Wales Dress Code? 99%

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?

64%

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?

76%

Q13 Are all medication charts completed clearly and is patient

information complete? 76%

Q14 Is a nurse present during the contact between

doctors/consultants/GPs and patients? 86%

Q15 Are patients able to communicate in Welsh with nursing staff in

the clinical area, if they wish to? 68%

Overall Score 86%


Medicines management

ABMU Health Board performed strongly in elements of this standard. Of

particular note was the good practice observed with staff compliance to the ABMU Health Board guidance for the safe administration of medicines.

99% of staff observed checked patient identification verbally and visually prior to the administration of medicines and 92% of patients were wearing

appropriately completed identification bands.

All Wales dress code

Compliance with the All Wales dress code was high at 99%, but the

numbers of clinical staff wearing identification badges was only 85% which demonstrates a need for improvement. This has been reported in other

forums where service users have stated 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 24

hours and only 75% showed documented evidence that the plan had been discussed with the patient or their carer.

Cognition Screening

Within Standard 1 the area in which ABMU Health Board failed to reach an

acceptable level of performance was in ensuring that the agreed cognition screening question had been asked at admission or within 72 hours only

64% of patients were asked the question. As part of the Fundamentals of Care nursing Documentation patients are asked if they have any mental

Health issues or confusion as well as difficulties in communicating. Further work is needed in relation to this area.

Question 12 explored the availability of a care plan to manage cognitive

impairment. Only 75% of patients had an up to date care plan. Further work is required in this area.

The Learning Disability pathway has been implemented across ABMU Health Board. Work is also ongoing via the Dementia steering group to look

at piloting a pathway for Dementia patients who are admitted into the


acute Hospitals across ABMU Health Board. Key assessments are included in the pathway.

Communicating in Welsh

68% of the clinical areas which responded to the audit question identified the availability of Welsh speaking staff. Ward sisters/ Charge Nurses are

aware of the staff within their area who can speak. Welsh speaking nurses are easily identifiable by the embroidered badge on their uniforms. ABMU

Health Board has a regular Welsh Language Steering Group meeting, where concerns and initiatives are raised.

The staff population of ABMU Health Board come from many cultures and countries around the world and speak many languages and dialects. The

Health Board is signed up to use language line and encourage staff to use where necessary. Also utilising staff to translate if appropriate.

Good Practice

Preferred language is clearly requested on the front page of the nursing documentation.

Following the clinical meeting with Doctor Staff update patients/relatives with any changes.

Patients and relatives are fully involved with care planning and updating

where necessary.

Butterfly Scheme in Clinical areas for patients with a known diagnosed

Dementia or acute confusion

.

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

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

73.35%

21.90%

4.31% 0.43%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%



provided. 94% of patients felt that they were always or usually given full information about their care in a way they could understand.

Patient Comments

“The reassurance by the Doctors and nurses throughout the whole day has been very comforting”.

“I have a special diet and the staff were more than happy to ensure

diet was arranged”.

Standard 2 and 5 - Respecting people and Relationships


Table 3

Standard 2 and 5 Operational Questions RAG %

Q16 Does the patient's documentation capture their preferred name

and/or title? 87%

Q17 Is there documented evidence that an assessment of the carers

needs has been considered? 73%

Q18 Is there documented evidence that the patient's cultural needs

has been assessed and discussed with the patient or advocate? 74%

Q19 Is there documented evidence that the patient's spiritual needs

has been assessed and discussed with the patient or advocate? 69%

Q20 Is there evidence to demonstrate that patient identifiable

information is treated in a confidential and secure manner? 98%

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?

79%

Q22 Is there a facility for patients to talk in private to staff (e.g. a

quiet room or office)? 99%

Q23 Is there a quiet room for patients to spend time with their

visitors away from their bedside? 64%

Q24 Within the clinical area, are all the bays single sex bays? 72%

Q25 Do all patients have access to single sex toilet and washing

facilities? 76%

Q26 Is there a facility to preserve patient dignity by communicating

to others that care is in progress? 81%

Q27 Can staff demonstrate they know the procedure if a

safeguarding concern is identified? 96%

Overall Score 81%


Patient Privacy

The audit information suggests that patient privacy and dignity is receiving

consideration however further improvement is needed in this area. Good practice is demonstrated by the use of red pegs or signs to promote

privacy and reduce interruptions to the patient whilst receiving care. In 96% of cases staff demonstrated knowledge of the procedure to safeguard

a vulnerable patient and 99% of areas have a quiet room that can be utilized for conversations between patients and staff to protect their

privacy. Only 64% of areas have access to a quiet room for patients to spend time with their family away from the bedside.

Single Sex Toilets and Bays

Further reinforcement and compliance is required around this area. All staff are encouraged to utilize signage to ensure there is designated male and

female toilet facilities. Where clinical areas are being updated consideration is required to achieve single sex facilities.

Carers Needs

In July 2013 the Carer`s Measure was launched in ABMU Health Board in conjunction with Local Authority partners. This measure has been

highlighted to staff as part of sessions that have been undertaken with the roll out of nursing documentation and there is more work to be completed

to ensure all staff achieve the outcome in understanding the rights of carers. A score of 73% was achieved for this question.

Cultural and Spiritual Needs

The scores were only 74% and 69% for these questions, and therefore not much 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.

To ensure patient needs are met and the organization is compliant with the

spiritual standards, 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 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 has already been adjusted to accommodate this process. This area has been highlighted in many nursing


forums throughout the year and although compliance has improved to 79% further reinforcement will be needed to achieve full compliance.

Good Practice

A task and finish group has been set up to take forward the work in relation to the integrated assessment process, this group links closely with the

Health Board Nursing Documentation group.

There are clear signs in place to identify male and female toilet and

bathroom facilities in the majority of areas.

Experience

Question 100

Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect?

Graph 3

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.

Dignity and respect training is ongoing across ABMU Health Board the patient experience teams encourage patients/relatives/carers to provide

regular feedback in relation to this area. Clinical staff are encouraged to monitor their areas to make continuous improvements. Environmental

audits are part of the POINT Reviews (Patient Orientation to Nuture Teams) audits are carried out by senior nursing teams. Patient experience reports

are closely monitored by staff. Staff also encourage the completion of the

friends and family test and monitor feedback to improve practice.

Patient commentary overwhelmingly reflects the patience, kindness and caring attitudes they have experienced from ABMU Health Board staff.

Examples include:

“I was always treated with Dignity and Respect and witnessed other

patient’s dignity being maintained”.

“Friendly good humoured staff that were always helpful. I was

checked on regularly and made comfortable”.

87.27%

11.23% 1.50% 0.00%

0%

20%

40%

60%

80%

100%



Question 101

Throughout your stay/attendance, how often did you feel that you were

given the privacy that you needed?

Graph 4

Findings

96% of patients surveyed reported that they were always or usually given the privacy that they needed.

Patient Comments

“The door in the consultantation room can be shut for privacy”.

80.64%

15.83% 3.21% 0.32%

0%

20%

40%

60%

80%

100%



4.1.3 Standard 3 – Ensuring Safety Operational Questions

Table 4


Q28 Has the Infection Prevention & Control Audit (ICNA) been

undertaken within the last 12 months? 97%

Q29 If an Infection Prevention & Control Audit (ICNA) been undertaken within the last 12 months, please enter the percentage compliance score.

87%

Q30 Has a Waste Management Audit been undertaken within the last

12 months? 26%

Q31 Has a Waste Management Audit been undertaken within the last

12 months. Please enter the compliance score as a percentage. 55%

Q32 Are staff able to give examples of the correct procedure for

source isolating patients? 100%

Q33 For this episode of care, is there documented evidence that the patient has an up to date manual handling risk assessment?

97%

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?

89%

Q35 Are any Manual Handling aids and slings regularly checked for

wear and tear? 98%

Q36 Within the clinical area, are all fire restraint doors free from

obstruction or closed if not automatic self closing? 93%

Q37 Is the equipment used in the clinical area up to date with

maintenance and calibration? 98%

Q38 Are all drug cupboards/trolleys locked and secure as per local

policy? 97%

Overall Score 88%

ABMU Health Board 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.

Improvement in compliance around the locking of Drug cupboards. Audits

have been carried out in all ward areas across ABMU Health Board.


Waste management

Only 26% of the clinical areas surveyed had a waste management audit undertaken. There appeared to be lack of clarity and understanding around

this question. As a Health Board we have discussed this issue with the environmental officer, who suggests that the audits legally required are pre

acceptance audits, which are not scored on a ward by ward basis. However issues are ranked according to severity. The audits do not cover each ward

each year but are a representative sample as determined by the external

auditor. There are plans to audit Singleton, Morriston and Princess of Wales Hospital in march. This information will be feedback to the All Wales FOC

steering group.

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

Question 108

Throughout your stay/attendance, how often did you feel that you were made to feel safe?

Graph 6

Findings

98% 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 ABMU Health Board hospitals

80.69%

17.92%

1.29% 0.11% 0%

20%

40%

60%

80%

100%


88.03%

10.75% 1.11% 0.11%

0%

20%

40%

60%

80%

100%



Patient Comments

“Lovely clean ward all the time”.

“First impression very clean”.

“Very safe”.

“Cluttered due to lack of space”.

4.1.4 Standard 4 - Promoting Independence


Table 5


Q39 For this episode care, is there documented evidence that the

patient’s level of independence has been assessed and


94%

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


86%

Q41 For this episode of care, is there documented evidence the

patient's mobility has been assessed and discussed with the

patient or advocate?

97%


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?

86%

Q43 For this episode of care, is there documented evidence the

patient's risk of falls has been assessed and discussed? 91%


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?

91%

Q45 Where appropriate, do all patients have written evidence of a

discharge assessment and plan? 79%

Q46 Where appropriate, is there written evidence that the patient's

family/carer has been involved in discharge planning? 80%

Q47 Within the clinical area, are washing, bathing and toilet facilities

suitable for the all service users? 88%

Q48 Does the clinical area allow patients to bring in personal items

to assist with patient orientation/familiarity? 93%

Overall Score 88%

Good Practice

Overall the audit data suggests good practice is being observed with the assessment of patient mobility and risk of falls. Compliance is monitored


via POINT reviews and also as part of the FOC care indicators. Spot checks are also carried out via the senior nursing teams.

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. Estimated date of discharge (EDD) is used across ABMU Health Board 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 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. Evidence of discharge planning should be clearly visible in

documentation and also on the patient at a glance boards which have been implemented (PSAG) Board rounds are undertaken in a number of areas

and are being implemented across ABMU Health Board. A number of other improvement initiatives have also been implemented.

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

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

79.40%

16.91%

3.36% 0.34% 0%

20%

40%

60%

80%

100%


68.31%

26.54%

4.93% 0.22% 0%

20%

40%

60%

80%

100%



Findings

More than 96% of patients expressed satisfaction that they were always or

usually assisted to be as independent.

94% of respondents were always or usually responded to in a timely

manner.

Patient Comments

“I was always encouraged by all the team to promote independence”.

“Nurses busy at all times but did their best to respond”.

“Very happy with care”.

“Staff always busy but did their best”.

4.1.5 Standard 6 - Rest & Sleep Operational Questions

Table 6


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?

86%


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?

59%

Overall Score 75%

Findings

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 86% of the notes examined

showed evidence of an assessment being undertaken and discussed, only 59% 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; are all

factors which might interfere with normal sleep patterns.


Good Practice

Some wards, with appreciation of these issues have introduced rest periods during the day to help patients have protected time for their rest.

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.

User Experience

Question 109

Throughout your stay, how often did you feel that you were able to get enough rest and sleep?

Graph 9

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, 80% of patients agreed that they were always or usually able to get enough rest and sleep

while in hospital. The overall operational score was 75%

The factors which contribute to disturbances in sleep and rest across all

sites needs to be further explored. To identify the factors to consider when formulating plans of care. Each area will look at improvements wherever

possible

Patient Comments

“Very noisy ward”.

“Bins noisy”.

“Other patient’s noisy.”

“One patient very confused and noisy”.

50.21%

30.35% 16.60%

2.84% 0%

20%

40%

60%

80%

100%



4.1.6 Standard 7 - Ensuring Comfort & Alleviating pain Operational Questions

Table 7



patient's pain has been discussed and assessed using an

appropriate pain assessment tool?

88%


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?

87%


patient's concerns/anxieties or fears has been assessed and


76%

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?

67%

Overall Score 80%

Pain

The National Early Warning System (NEWS) for early assessment of the deteriorating patient has been implemented within adult areas in ABMU

Health Board. 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.

.

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.

Good Practice

The Abbey Pain score tool has also been piloted for patients who are not

able to clearly communicate their level of pain. Local audits have also recently been carried out across the Health Board to improve awareness

and compliance. Training sessions have also been undertaken across ABMU Health Board


User Experience Question 110

Throughout your stay, how often did you feel that you were made to feel comfortable?

Graph 10

Question 111

Throughout your stay/attendance, how often did you feel that you were, as far

as possible, kept free from pain?

Graph 11

Findings

97% of patients felt that they were always or usually made to feel comfortable and 97% of patients were always or usually kept free from

pain.

Patient Comments

“More pillows”.

“No pain”.

“There were a high number of patients that have responded as not

applicable to this question”.

79.52%

17.57% 2.64% 0.26%

0%

20%

40%

60%

80%

100%


78.49%

18.69%

2.18% 0.64% 0%

20%

40%

60%

80%

100%



4.1.7 Standard 8 - Personal hygiene, appearance & foot care


Table 8



patient's hygiene needs have been assessed and discussed with

the patient or advocate?

91%

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


90%

Q57 Does the clinical area have access to mirrors for patients to

use? 88%


patient's foot and nail condition has been assessed using a

recognised, evidence based tool and discussed with the patient

or advocate?

28%

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


last 24 hours?

36%

Q60 Does the clinical area have supplies of toiletries for patients who

have been admitted without them? 87%

Overall Score 73%

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 90% of patient records had documentary evidence of up to date care plans.

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. This should be clearly documented within

the Fundamentals of care nursing assessment. Only 28% of notes showed any written evidence of an assessment using a recognised tool has taken

Place and discussed with the patient. Only 36% of those with an identified risk had evidence of an up to date care plan which had been reviewed in

the previous 24 hours.


Good Practice

A Diabetes Foot Care Pathway Group has been set up in ABM Health Board. Discussions have been around the importance of foot examinations and

early identification of problems as vital for all patients with an ‘at risk’ foot. Patients with Diabetes and/or Peripheral Arterial Disease are amongst the

largest groupings.

User Experience

Question 112

Throughout your stay, how often did you feel that your personal hygiene needs were met?

Graph 12

Findings

96% of patients felt that their personal hygiene needs were always or

usually met.

Patient Comments

“Not enough bathrooms”.

“Nurses regularly soaked my feet in a bowl”.

83.71%

13.48% 1.83% 0.98%

0%

20%

40%

60%

80%

100%



4.1.8 Standard 9 - Eating and Drinking


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?

63%

Q62 Prior to meal times, are patients that require help assisted into

a suitable position? 93%

Q63 Prior to meal service, are bed tables and communal areas

cleared and tidied for the meal? 92%

Q64 Are patients meals placed within easy reach? 95%

Q65 Are all patients given the opportunity to wash or cleanse their

hands with hand wipes prior to eating meals? 81%

Q66 Are patients given the opportunity to go to the toilet before

meal time? 93%

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?

90%

Q68 Are water jugs changed 3 times daily? 40%

Q69 Is drinking water available for patients and where applicable,

are drinking water jugs and glasses within the patient's reach? 89%

Q70 During a 24 hour period, how many beverage rounds are

carried out within your clinical area? 72%

Q71 Does a Registered Nurse supervise every meal time? 87%

Q72 Is there evidence that all members of the nursing team are

engaged in the mealtime service? 93%

Q73 Does the clinical area have access to weighing scales and a

height measurement stick in good working order? 95%

Q74 Is a range of snacks available for patients who have missed a

meal or who are hungry between meals? 91%

Q75 For patients who require a food chart, is there evidence that

they are being kept up to date and evaluated? 90%

Q76 For patients who require a fluid chart, is there evidence that

they are kept up to date and evaluated? 89%

Q77 Is there a system in place to allow family/friends to assist with

meal times? 86%

Overall Score 85%


Overall performance with this standard demonstrated high compliance however 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 ABMU Health

Board is achieving seven or more beverage rounds in 72% of areas, but only 40% of areas currently comply with the requirement for replenishing

fresh water jugs. These findings will be shared with catering managers and

are being addressed as part of the Health Board action plan against the All Wales Nutrition and catering Standards for Food and Fluid for Hospital

inpatients.

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

poor, ABMU Health Board has provided assurances to Welsh Government of intention to prioritise engagement and work towards achieving the

target of 100% compliance. The All Wales Fluid Chart E-Learning

programme is now also available. Issues around access are currently being addressed. Group Sessions have been undertaken and further sessions are

in the process of being set up. Links have also taken place with the University to improve compliance for student nurses. Compliance is

monitored in clinical areas monthly via the care indicators.

Swallow Assessment

The audit results identifies that 63% 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 have

specifically engages specially trained nurses in assessing whether a patient has a safe swallow following a stroke as part of the stroke pathway.

Hand washing opportunities for Patients.

81% of patients were offered the opportunity to wash or cleanse their

hands prior to meal times. All patients should have this opportunity and re enforcement is needed at a local leave.


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 89% and 90% respectively. Spot checks are carried out by senior nursing staff as

part of the Quality and Nursing Assurance agenda set up by the Acting Director of Nursing. Nutrition is also one of the priorities audited as part of

the POINT review process. Snacks have been implemented across the Health Board as part of the actions within the All Wales Nutrition and

Catering Standards for Food and Fluid for Hospital Inpatients

In addition to the annual FOC audit there is a requirement on all in patient

areas to electronically report monthly monitoring data which includes, nutritional score completed within 24 hours of admission and number of

patients that are re assessed appropriately. This provides an on-going measure of performance and a benchmark against the national

Position. (graph 13)

User Experience

Question 105

Question 105

Throughout your stay, how often did you feel that you were provided with

nutritious food and snacks?

Graph 14

65.32%

22.98% 9.25% 2.46%

0%

20%

40%

60%

80%

100%



Findings

88% of patients felt that they were always or usually provided with nutritious food and snacks.

Patient comments “My snacks were lovely”.

“Biscuits not healthy” “Nutritious food”.

“Breakfast late and a long time before eating since last meal”. “ Food nutritios but not a great taste”.

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

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

Findings

Patient satisfaction with the availability and quality of food and drink

appears to be high.

88% of patients felt that they were always or usually provided with nutritious food and snacks throughout their hospital stay

83.24%

12.16% 2.70% 1.89%

0%

20%

40%

60%

80%

100%


81.17%

12.86% 4.38% 1.59%

0%

20%

40%

60%

80%

100%



93% of patients acknowledged that they were always or usually provided with fresh drinking water and plenty of drinks when they

needed them

95% agreed that they were always or usually helped with feeding

and drinking if they needed it

Patient Comments

“A water dispenser is needed”.

“Food not nice don’t like thickened drinks”

“Tea machine excellent idea”.

There were many not applicable answers in relation to question 107

help with eating and drinking.

4.1.9 Standard 10 - Oral Health & Hygiene


Table 10



patient been assessed using the All Wales Oral Health tool with

respect to their oral health needs?

59%

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?

64%

Overall Score 61%

The All Wales Oral Health Tool is currently in the process of being introduced across all health boards including ABMU Health Board. This

process is taking place in a partnership between nursing and dental health colleagues. Compliance at present is poor at 59% further work around

education and compliance is needed. The Health Board documentation

nursing group is currently looking at a shortened version of risk assessments to use as a trigger for full risk assessment for suitable

patients. Oral health questions will be part of this assessment.


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

Findings

90% 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.

Patient comments

“Some nurses always offered me the support and opportunity to clean my

teeth”.

4.1.10 Standard 11 - Toileting Needs


Table 11



patient's toileting needs has been assessed and discussed with


88%


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?

87%

Overall Score 88%

The data confirms that compliance with this standard is satisfactory in the assessment and planning of patient toileting requirements. The All Wales

Bowel and Bladder assessment is used across ABMU Health Board, and is looking at integrating the All Wales Continence Bundle into its current

Nursing Documentation. This will also be discussed as part of the All Wales Fundamentals of Care Steering group.

64.84%

25.20%

6.45% 3.52%

0%

20%

40%

60%

80%

100%



Good Practice

The Health Board has recently set up an intranet page in relation to continence as part of the work undertaken by the Health Board’s steering

Group. Although this audit confirms high levels of compliance and performance in assessment of patients, there is need to remain vigilant

and pro-active

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

Findings

92% of patients surveyed agreed that their toilet needs were always or usually responded to quickly and discreetly.

Patient Comments

“Nurses busy tried to come as soon as they could”.

“Good explanation where the toilets were”

“My daughter helped me”.

4.1.11 Standard 12 - Preventing Pressure Sores


Table 12



patient's skin condition has been assessed and discussed with


95%


as requiring assistance with looking after their skin, is there

evidence that there is an up to date plan of care, which is being


last 24 hours.

93%

Overall Score 94%

75.20%

17.63% 5.62% 1.56%

0%

20%

40%

60%

80%

100%



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. 95% of the patient notes reviewed provided documentary evidence that patients’ skin condition had been assessed and

discussed with the patient or advocate and 93% of patients who were identified to be at risk or needing assistance to maintain skin health had a

care plan which had been reviewed in the previous 24 hours.

Good Practice

Healthcare acquired pressure ulcers are reported monthly into the National

Nursing Dashboard and also at a local level. 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 and investigated. See Graph 19, ABMU Health Board is

below The All Wales Average.

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

74.73%

17.62% 4.80% 2.85%

0%

20%

40%

60%

80%

100%



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.

Patient Comments

“The nurses were always checking”.

There were no other comments.

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.


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?

49.91% 39.71% 9.78% 0.60%

Q86 Our organisation aims to, ensure that as an employee you are treated with

dignity and respect. Do we achieve this?

26.46% 40.98% 29.55% 3.01%

Q87 Our organisation aims to, make you feel safe at work. Do we achieve this? 30.01% 43.10% 23.16% 3.73%

Q88 Our organisation aims to, make you feel you have a positive contribution to

patient care. Do we achieve this?

34.00% 39.38% 24.72% 1.91%

Q89 Our organisation aims to, provide you with sufficient equipment to do your

job. Do we achieve this?

22.19% 47.93% 27.89% 1.99%

Q90 Our organisation aims to, provide you with opportunities to enhance your

skills and professional development. Do we achieve this?

25.43% 35.14% 32.30% 7.13%

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?

20.66% 24.98% 34.57% 19.79%

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?

25.69% 40.03% 28.95% 5.33%

Q93 Our organisation aims to, provide opportunities for you to raise any concerns

that you have. Do we achieve this?

32.13% 32.82% 29.63% 5.43%

Q94 Our organisation aims to, provide you with the opportunity to establish a

work life balance. Do we achieve this?

22.60% 40.35% 30.30% 6.75%

Q95 Our organisation aims to, make you feel a valued member of the

organisation and have a sense of belonging. Do we achieve this?

21.54% 31.40% 36.94% 10.12%

Q96 Our organisation aims to, make you feel proud to be a nurse. Do we achieve

this?

22.59% 30.45% 37.25% 9.71%

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?

32.23% 44.28% 21.05% 2.45%


Staff Survey

The FOC staff survey was carried out across Health Boards and Trusts in Wales on October 7th 2013. All registered nurses and clinical health care

support workers on duty in those clinical areas undertaking the annual FOC audit from 7am on that day to 7am on 8th 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 578 nurses from across

ABMU Health Board were uploaded into the FOC system.

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 ABMU Health Board the 2013 FOC audit considers responses from Registered 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 four 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

4. Provide you with opportunities to enhance your skills and professional development.

1. 45% 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. 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. 52% of nurses reported that they were always or usually made to feel a

valued member of the organisation and had a sense of belonging. 10%

who responded to this question said that this never happened. There is a need to provide regular feedback in all arears and at all levels.


3. 53% of the nurses reported that ABMU Health Board always or usually made them feel proud to be a nurse. 9.7% 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. Appraisals are monitored closely in

all clinical areas via the FOC Care Indicators. These are discussed as part of the Acting Director of Nursing’s performance Dashboard meetings.

4. 59% of staff reported that ABMU Health Board always or usually provided

opportunities to enhance your skills and professional opportunities. 7% of staff said this never happens.

5. The staff survey reported positively that ABMU Health Board performed well

in the provision of information for staff. 80% of nurses responded that

ABMU Health Board 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.

Commentary from staff frequently reflected concerns about current staffing levels and the time taken to complete the amount of paperwork which was

expected of them. The OD team has devised a set of health and well being indicators to be used as a ‘Pulse Check’ (questionnaires) for staff across

ABMU Health BOard. 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 nursing resource. Two actions to support these issues currently 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.

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.

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. At present 61 wards have implemented Transforming Care across ABMU

Health Board.

One initiative that has yielded positive outcomes for staff working in pressured environments has been the introduction of Schwartz Centre

Rounding which is currently being piloted in NPT Hospital. These rounds provide a forum for staff from a range of disciplines to meet and explore


together some of the challenging psychosocial and emotional issues that arise from caring for patients.

The 2013 FOC audit provides evidence that nursing staff across ABMU Health Board are predominantly caring, kind and compassionate.


5 Recommendations

5.1 Actions for Improvements (for all elements that scored less than 85% compliance rate)

Standard (Where

applicable)

Action to be taken By whom By When

1

Operational

issue

Care plans should reflect any difficulties the

patient experiences with communication and discussed with the patient/advocate

Senior nurses/ Ward

Managers

Sept

2014

1 Operational

issue

Reinforce the need to complete the memory

screening question within the FOC assessment and look at adding a prompt in relation to the

Butterfly Scheme.

Documentation group June

2014

1 Operational issue

Consideration of memory problems in the care planning process

Documentation group June

2014

1 Operational Issue

Ensure clear documentation on medication charts Ward nursing Staff/Pharmacists/Doctors

Sept

2014

1 Operational Issue

Staff that are able to speak welsh need to wear the All Wales Badge. Raise awareness of the staff

available.

Ward Manager/ Senior NUrse

On going

2&5 Operational issue

Continue to raise staff awareness of carers rights and ensure discussions are documented

Documentation group On-going


Work with pastoral leads and nurses to identify how best to capture the cultural and spiritual needs of the increasingly diverse patient

population

Pastoral leads

FOC nurse

June 2014

2&5 Operational Monitor compliance around the use of single sex Senior Nurses On


issue toilet , bathroom facilities going


Monitort compliance with obtaining consent to sharing information.

Senior nurse, Documentation group

On going

3 Operational

issue

Identify waste management audit requirement for

all clinical areas and inform ward managers

FOC nurse Feb

2014

4 Operational issue

Work with the Focus on Flow improvement to improve compliance with discharge planning,

documentation and estimated date of discharge, using practice such as board rounds .

Senior nurses On going

Work

4 Operational issue

Promote good practice in recording carer role and document any communication/involvement of family in discharge planning

Senior nurses July 2014

6 Operational & patient issue

Investigate the causes of sleep disturbances for patients and actions for improvement in specific

areas

FOC nurse/ Senior nurse/ Ward Manager

July 2014

7 Operational issue

Promote awareness of the consequences of anxiety and fear and the need for documented

measures and response to interventions

Senior Nurse/ Ward Manager

On going

8 Operational issue

Link wit the ABMU Helath Board Diabetic foot care pathway group and key professionals.

FOC Lead/Documentation group

June 2014

9 Operational issue

Discuss audit findings with speech and language therapy lead to determine next steps to manage timely swallow assessments

FOC nurse

Speech therapist

June 2014


Standard (Where applicable)

Action to be taken By whom By When

9 Operational issue

Continue to work through the Health Board action plan in relation to the provision of changing of water jugs and

drink provision

Via Key groups such as the food

service and nutrition group

Ongoing

9 Operational issue

Continue to promote engagement of all staff in protected mealtime and the need for a registered nurse to supervise and offer hand wipes to all patients where

required prior to meal times.

FOC nurse

Senior nurses

On-going

10 Operational

issue

Continue with work in integrating the continence bundle

into the nursing documentation and POINT reviews and FOC audit during 2014

Continence

nurses/ Documentation

group leads

July

2014

10 Operational issue

Closely monitor compliance with oral care bundle. Further education around this area.

Key leads for the roll out/ Senior

nurses.

Sept 2014

staff Where this is not already happening identify appropriate feedback mechanism for staff relating to incidents

reported

HON

Senior nurses

Ward managers

July 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


5.2 Monitoring and Assurance

The 2013 FOC ABMUHB 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 five key standards:-

Oral Health (Standard 10)

Sleep and rest (Standard 6) Ensuring comfort and alleviating pain (Standard 7)

Ensuring personal hygiene and foot care (Standard 8) Respecting people & relationships (standard 2&5)

Monitoring progress with implementation of the ABMU Health Board FOC action plan for improvement will require:

a. This report will be presented at Directorate/Locality key

meetings to share the findings, alongside the specific Directorate/Locality findings.

b. The report will be presented at the Nursing Midwifery Board

c. The report and action plan will be reported and monitored

through the Quality & safety Board.

d. 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.

e. Implementation of action plans will be monitored and

supported by senior nurses and reported via

Directorate/Locality key meetings 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.

f. Improving Quality Together (IQT) model for improvement

Bronze and Silver level will be applied to support improvement projects


5.3 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 ABMU

Health Board. 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 ABMU Health Board and we strive to continue to enhance their experiences. Further work will be continued at a local and All

Wales basis to continue to update and improve the tool.


6 References

1. 1000 Lives+ (2013) Improving Quality Together

2. ABMU Health Board Policy on the supply, ordering storage,

administration and disposal of medicines.

3. Francis, R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry

4. Keogh, B (2013) Review into the quality of care and treatment

provided by 14 hospital trusts in England

5. NHS Institute for Innovation and Improvement (2008) Model for Improvement

6. NWIS (2012) Nursing Dashboard

7. 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 - Safer 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

16. Welsh Government (2013) NHS Wales Staff Survey Report: ABMU 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


7 Appendix A: Fundamentals of Care Audit - Compliance Scoring Matrix

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 identified in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA



A

St. No.

Quest

No. Assessment Include issues identified in the audit R Recommended Action for Improvement NOTE: Each recommendation should have a PDSA



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



Fundamentals of Care 2013 Annual Audit

DO Describe what actually happened when you ran the test

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

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