Audit - Evaluating Quality Care. Mrs M Somerville Director of Hospital & Community Learning Disability Services. Mr S Peover Permanent Secretary Department of Environment. Mrs Mairead Mitchell Assistant Director Service Improvement and Governance. Setting The Scene
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Director of Hospital & Community Learning Disability Services
Department of Environment
Assistant Director Service Improvement and Governance
Muckamore Abbey Hospital
Community and Hospital
Population - 160,000
Staff - 3,500
Income - £145M
Service Locations - 50
A Centre of Excellence in the treatment and care of people with Learning Disabilities since the late 1950’s
Hospital Core Standards
Evaluating Quality Care
EQC is an all inclusive tool used to measure the Core Standards of the Hospital
It is a multidisciplinary / multidepartmental audit of the quality of care provided to patients
It encompasses the entire treatment and care provided to the patient
Themed questions allow audit tools to be created specifically relating to each department, e.g.
Other themes allow audits to be completed in relation to specific areas , e.g.
Advice to auditor: See policy files – (1) Operational policy file and (2) Policy manual specific to the dept. These must be assessible to all staff at all times (available in seniors office in day-care depts)
IS THERE A NAMED ROOM / BED PLAN ?
Advice to auditors: see plan – 2 storey buildings require a copy upstairs and downstairs – see both
IS INDUCTION TRAINING GIVEN FOR NEW TEAM MEMBERS ?
Advice to auditors: See induction booklet belonging to the 2 most recent staff to join the team. This must be completed and signed. Hotel Services – evidence of induction on staffs individual training cards
ARE ALL DRUGS STORED ACCORDING TO POLICY (inc controlled drugs) ?
Advice to auditors: Check drug cupboards are locked and controlled drugs are kept in a cupboard within the locked drug cupboard
Advice to auditor: Ask 2 random staff what to do in the case of a fire: sound alarm, call switchboard by dialling 6666, on hearing alarm evacuate all patients, leave the building by the nearest safest root, close all doors, report to assembly point, check all present by role call
IS THE TEMPERATURE CHECKED TWICE DAILY AND RECORDED IN THE REPORT BOOK ?
Advice to auditors: see day and night reports for the previous week
ARE ALL ELECTRICAL DEVICES SAFE AND RECOREDE ACCORDING TO THE ELECTRICITY AT WORK ACT ?
Advice to auditors: Check dates on tags have not expired, check 3 pieces of electrical equipment in the facility.(Check steriliser in Podiatry)
Advice to auditors: Check care plan of 5 randomly selected patients. Check quick reference information section on ‘buff’ personal details sheet, this should have information that a new staff starting the ward that day would immediately require to keep the patient safe, i.e. prone to choking, absconding, special diets, behaviour, mental health, allergies, alerts, epilepsy, level of observations, etc
Competence, training and behaviour of the auditor is crucial
Auditors selected for their
the all facilities
Copies of audits to
all depts – master and
Action Plan to Facility Manager & SNM(When applicable)
EQC Steering Group monitor actions & review & update toolEQC Process
Audit dates arranged
Audit of Action Plan
Ward 1 September 2006
Care Plan 70%
Facility Management 89%
Leisure & Education 100%
Medical Notes 100%
Multidisciplinary Care 100%
Patient Charter 96%
Patient Needs 100%
Overall Score 93%
Pass mark 100% Score 60%
DO STAFF RECEIVE MANDATORY TRAINING?
Comments: Training cancelled because of staff shortages
Notes: staff unable to attend
Action to be taken: Discuss with management
Completion date: Feb 07
Assigned to: Charge Nurse
It is also
To allow the patients have an input into the audit, many of the questions reflect what has been asked in the wards / depts.
Are you happy with the meals?
50 – 90% of people with Learning Disabilities have some communication difficulties
4 out of 5 people with severe Learning Disability have no effective speech
Contribution to the development of Patient Satisfaction Survey
Assistant Director of Hospital Services
Mrs E Steele
Assistant Director of Hospital Services
Provides a fair broad base for all issues – all areas have the same audit by trained auditors using the same criteria
Steering group is a Multidisciplinary group, meaning that all disciplines have ownership