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Fundamentals of Care Annual Audit Report 2013

1 Fundamentals of Care Annual Audit 2013 | Welsh Government

INDEX 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

4.1.1 Overall Summary 8

4.1.2 Std 1 – Communication and Information 10

4.1.3 Std 2 and 5 – Respecting People and Relationships 14

4.1.4 Std 3 – Ensuring Safety 17

4.1.5 Std 4 – Promoting Independence 19

4.1.6 Std 6 – Rest and Sleep 21

4.1.7 Std 7 – Ensuring Comfort, Alleviating Pain 23

4.1.8 Std 8 – Personal Hygiene, Appearance and Foot Care 25

4.1.9 Std 9 – Eating and Drinking 27

4.1.10 Std 10 – Oral Health and Hygiene 31

4.1.11 Std 11 – Toileting Needs 32

4.1.12 Std 12 – Preventing Pressure Sores 34

4.2 Fundamentals of Care Staff Survey 36

5. Conclusion 48

6. Recommendations

7. Appendix 1 – Summary of Recommendations 51


1. Executive Summary

“I dreaded coming in because I am blind but I cannot express my thanks enough for the wonderful treatment and care I have received”

Cardiff and Vale University Health Board Strategy Caring for People: keeping people well puts patients at the centre of everything we do to deliver safe and effective care, ensuring excellent patient (carer/user) experience and excellent staff experience.

The Francis review (February 2013) of care delivered at Mid Staffordshire NHS Foundation Trust identified 5 key themes, underpinned by the requirement for a fundamental quality improvement culture and the adoption of common values across organisations focusing on: • Fundamental standards • Openness, transparency and candour • Compassionate, caring and committed staff • Strong, patient centred healthcare leadership • Accurate, useful and relevant information The Fundamentals of Care (FOC) National Audit System has been redesigned during 2012 to ensure that it supports these values, providing quality assurance and identifying improvements where required within services, health boards and across NHS Wales. The 2013 NHS Wales FOC National Audit results provide assurance from the operational audit, patient survey and staff survey where compliance with the 12 standards and excellent experience is demonstrated. Within the Health Board, the FOC audit is one means of providing assurance to the Board of compliance with the key themes of the Health Board’s strategy: • Getting things right for patients and the public that we serve • Being a great place to work • Knowing how well are doing and improving • Making decisions and getting things done The overall FOC audit results demonstrate a high level of achievement against the standards across the Health Board with only one of the twelve standards falling below an achievement level of 73%. Whilst positive, particularly in respect of the feedback and comments received from patients and service users, the audit results do identify where we need to focus improvements where scores are reported below the 85% compliance rate (green RAG rating). The detailed results of each question within the audit are presented in this report, the summary findings include:

1) Feedback from patients confirms the high standards of care provided across the Health Board and the need to focus improvement with: Standard 6 (Rest and Sleep)


2) The operational audit supports the findings in the patient survey and confirms standards for improvement: Standard 6 (Rest and sleep); Standard 7 (Ensuring comfort and alleviating pain); Standard 10 (Oral Health and Hygiene).

Comments provided by the surveys from staff and patients indicate that

attention is required to the physical appearance of the environments of care, including clutter and storage of equipment. It is recognised that this issue will need further consideration by the Board in the broader context of facility management and refurbishment.

3) The survey provides evidence that nursing staff across the Health Board are

caring, kind and willing to go the extra mile for their patients however staff have expressed frustration that elements of their working arrangements impact upon their own satisfaction levels when delivering care on a day to day basis. The staff survey results have therefore been reviewed in partnership with Workforce colleagues and where appropriate, work is now being progressed which ensures that the results from the recently undertaken Health Board Pulse survey and the 2013 NHS Wales staff survey are also considered. Actions for improvement are being taken forward with a particular focus on activity which enables staff to feel valued, enables the provision of feedback and provides opportunity to learn and develop.

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. Ruth Walker Executive Director of Nursing and Midwifery


2. Situation

This report summarises the outcomes the annual All Wales Fundamentals of Care audit (FOC) undertaken at the Cardiff and Vale University Health Board. This report highlights areas of good practice identified across the 12 Fundamentals of Care Standards. It also identifies areas where improvement is required. It is recognised that a plan for improvement is required to drive up standards in the year ahead. Actions for improvement will be developed in collaboration with Clinical Board teams. Health Boards across Wales are required to repeat the audit exercise on an annual basis as a minimum and present an annual report of findings to the Board, prior to submission to be submitted to Welsh Government Office of the Chief Nurse (CNO). There is also an expectation that the Board make the report public. Although the CNO submission will exclude data collected from Mental Health, Paediatrics and Midwifery, these areas have participated in the audit within Cardiff and Vale University Health Board. 3. Background The Fundamentals of Care (FOC) is a Welsh Government initiative which provides guidance on the quality of care service users should expect from health and social care providers. The all Wales FOC audit tool involves benchmarking local practice against a set of 12 nationally agreed standards. The FOC audit tool was formally introduced to Welsh NHS organisations in 2009 and included user/patient feedback as well as questions focused on operational practice. Audit questions were available for bed holding and non bed holding areas and the audit was adopted in all areas across the Health Board, with the exception of the community settings. The FOC system is not intended for use to compare organisations across NHS Wales. However, the CNO issues an annual All Wales FOC report indentifying achievement levels against each standard within each NHS Wales organisation. The FOC audit results generated are for local measurement to inform quality improvements, learning and to share and celebrate good practice. This year, the questions to inform the operational and patient surveys were significantly revised to reduce duplication of data collection and to align the questions with the FOC care indicators. By drawing these important pieces of work together it is intended that frontline staff will have a greater understanding of the inter-relationship and inter-reliability of the Fundamentals of Care Standards on national priorities, as identified, for example, by Welsh Government within the Tier 1 priorities.


The revisions to the audit tool also resulted in the following: • Design of specific audit questions for key specialist areas resulting in a suite of

audit questions being made available for:

General wards Unscheduled care tool Theatres tool ( no patient survey for this area) Endoscopy Day Hospital/ Day surgery

• Introduction of a Nursing staff survey with consideration to extending this to all

staff groups in the future • Development of a compliance matrix, with 85% compliance measure required for

each standard (appendix 1)

• Guidance from the chief statistician in Welsh Government to provide assurance on validity of the FOC system and data collection methodology

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:

1. 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 2. To have a voice in the quality of the care they receive 3. It ensures an openness and transparency with the quality standards

It empowers staff:

1. To make a difference and ensures ownership of their practice 2. To have a voice in the care that they provide and ensure the focus is on essential

elements of care and caring. 3. To identify areas of good practice and highlight issues for concern 4. To develop action plans which enables them to monitor change It enables organisations:

1. To have a mechanism to monitor/measure the quality of care 2. To develop organisational policies and procedures 3. 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). Work will continue at an all Wales level to align the questions with Maternity, Paediatrics, and Mental Health Services and to develop the tool to enable audit of standards of practice within community settings. The FOC National Audit Autumn 2013 The 2013 National FOC audit was completed by 81 bed holding and 31 non bed holding areas across the Health Board between 1 October and the 30 November 2013 using the: • Patient Survey • Staff Survey • 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 reviewing delivery of care and the assessment of the operational application of the 12 FOC standards. This included: • Examination of patient records to measure compliance against the standards • 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. 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. 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 demonstrate that the organisation achieved a level of compliance for the operational questions of 85% and over for 4 out of the 12 standards identified within the All Wales fundamentals of care standards. Eight areas were identified as amber (scoring less than 85% compliance with the standard). No standard scored less than 50% which would have indicated a red in the overall RAG rating score (Table 1).

Table 1

Operational Question Overall Summary RAG % Std 1 Communication and Information 82%

Std 2 & 5 Respecting people and Relationships 83%

Std 3 Ensuring Safety 92%

Std 4 Promoting Independence 87%

Std 6 Rest and Sleep 73%

Std 7 Ensuring Comfort and Alleviating Pain 77%

Std 8 Personal hygiene, appearance and Foot Care 83%

Std 9 Eating and Drinking 86%

Std 10 Oral Health and Hygiene 52%

Std 11 Toileting Needs 83%

Std 12 Preventing Pressure Sores 90%

Overall Health Board Score 84% The action plan for improvement will focus particular attention on Standard 6 (Rest and sleep), Standard 7 (comfort and pain) and Standard 10 (Oral health and hygiene). It should be noted that although the overall score of 82% was achieved in respect of Standard 1 (Communication and Information), areas for improvement have been identified as necessary for the documentation aspect of this standard (communication). This element of the standard will therefore also be progressed as an area for further improvement activity.

User Experience The user experience surveys were undertaken on the 6th November 2013 across all audit areas within the Health Board and across all organisations in Wales, except within theatre departments. A total of 1077 patients/carers were surveyed across Cardiff and Vale UHB. Individuals were asked to complete the survey by selecting a “frequency” rating of their experience of care. The response to the survey is detailed in Appendix 1. Service users were also asked to give a score between 1 and 10, (where 1 is the lowest score and 10 is excellent) for their overall experience, as shown in graph 1.



Graph 1 - Overall User Experience Summary (All Questions) The combined results for all user experience survey questions demonstrates that the majority of patients surveyed were satisfied with the standards of care that they received from the Health Board. When specifically asked to rate their overall satisfaction with the care provided to them and their families, service users gave the organisation a rating of 89% enabling the Health Board to achieve a RAG rating of green in accordance with the All Wales fundamentals of care audit criteria. The response to the survey is detailed in Table 2

75.88%

18.26%

0%

50%

100%

Always Usually

4.78% 1.08%

Sometimes Never


Table 2 Questions Always Usually Sometimes Never No of

responses Q99.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?

68.67% 24.11% 6.19% 1.03% 1066

Q100. Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect?

86.26% 10.68% 2.32% 0.74% 1077

Q101. Throughout your stay/attendance, how often did you feel that you were given the privacy that you need?

80.43% 15.75% 2.89% 0.93% 1073

Q102. 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?

76.91% 17.91% 4.31% 0.88% 1022

Q103. Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy and not cluttered?

76.74% 19.35% 3.44% 0.47% 1075

Q104. Throughout your stay/attendance, how often did you feel that when you called us that we responded in a timely manner?

67.51% 24.98% 6.73% 0.78% 1025

Q105. Throughout your stay, how often did you feel that you were provided with nutritious food and snacks?

64.28% 21.51% 11.65% 2.56% 781

Q106. 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?

79.20% 12.61% 4.89% 3.30% 880

Q107. Throughout your stay, how often did you feel that you were given help with feeding and drinking if you needed this?

79.53% 15.29% 3.29% 1.88% 425

Q108. Throughout your stay/attendance, how often did you feel that you were made to feel safe?

85.11% 12.01% 2.02% 0.86% 1041

Q109. Throughout your stay, how often did you feel that you were able to get enough rest and sleep?

47.09% 32.98% 17.20% 2.73% 843

Q110. Throughout your stay, how often did you feel that you were made to feel comfortable?

75.00% 19.55% 4.38% 1.07% 844

Q111. Throughout your stay/attendance, how often did you feel that you were, as far as possible, kept free from pain?

74.97% 17.55% 6.13% 1.35% 815

Q112. Throughout your stay, how often did you feel that your personal hygiene needs were met?

82.21% 14.29% 2.88% 0.63% 798


Questions Always Usually Sometimes Never No of responses

Q113. Throughout your stay/attendance, how often did you feel that if you needed help to use the toilet that we responded quickly and discreetly?

74.57% 19.22% 4.19% 2.02% 692

Q114. 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?

71.43% 18.75% 5.89% 3.93% 560

Q115. 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?

74.53% 16.46% 4.81% 4.19% 644

Total 74.64% 18.42% 5.38% 1.56% 14661

4.1.2 Standard 1 – Communications and Information Operational Questions

Table 3

Standard 1 Operational Questions RAG % Q1 Are the patient's demographic details clearly recorded on

all the patient's documentation? 96%

Q2 Is there documented evidence that the patient's ability to achieve effective communication has been assessed and discussed with the patient or advocate?

91%

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?

79%

Q4 Is there documented evidence that each plan of care has been assessed and discussed with the patient or advocate?

74%

Q5 Are the contact details of the first point of contact recorded in the patient’s documentation?

88%

Q6 Is there information clearly displayed regarding how patients/relatives/advocates can raise a formal or informal concern?

76%

Q7 Do all patients wear an identification band which states their first and last name, date of birth and NHS number?

90%

Q8 Is the patient's identity checked visually and verbally prior to giving medication or undertaking a procedure?

97%

Q9 Are all clinical staff wearing staff identification badges? 86%

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

98%

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?

46%

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?

61%

Q13 Are all medication charts completed clearly and is patient information complete?

80%

Q14 Is a nurse present during the contact between doctors/consultants/GPs and patients?

76%

Q15 Are patients able to communicate in Welsh with nursing staff in the clinical area, if they wish to?

60%

Overall Score 82%

Care planning and Communication Completion of patient assessments and documentation, involving patient or advocates with the plan of care, and nurses being present with patients during medical ward rounds may improve the communications between teams and in turn the patient experience.


Practical solutions have already been indentified to drive improvement in this area of practice: • The Clinical Standards and Innovation Group (CSIG) has already commissioned

a review of nursing documentation and has highlighted the importance of patient assessment and subsequent planning and evaluation of care to improve the patient’s experience.

• The revision of the assessment document will incorporate the core data set out

by the new Welsh Government statutory guidance Integrated Assessment, Planning and Review Arrangements for Older People (2013). The time frame for completion and implementation for this is April 2014.

• Revision of the patient care plan documents used within wards and department

has commenced • ‘Board rounds’ have been introduced in a number of wards with rounds taking

place at a set time during the day. This work will underpin the improvements required in care planning and patient documentation Details of patient’s first point of contact Although 88% of areas reported that they were documenting the patient’s first point of contact (question 5) the audit has highlighted that this field is not routinely completed on registering patients in the outpatients setting. The Health Board FOC group, a multidisciplinary working group focused on improving fundamentals of care, will work with the Health Records manager to find a means of incorporating the patient’s first point of contact within the patient’s out -patient documentation. Cognition Screening There was failure to reach an acceptable level of performance in this particular element of the standard, in particular in ensuring that the agreed cognition screening question had been asked at the point of admission (question 11). This screening question does not currently form part of the nursing documentation, but action has already been taken to ensure that the required screening check is included within the revised patient assessment nursing documentation due to be implemented within the Health Board from April 2014. Despite a failure to reach an acceptable level of performance in this particular element of the standard, steps have been taken within the Health Board to ensure that patients with cognitive impairment are cared for appropriately: • The Butterfly scheme, a system used in hospital to identify patients with

cognitive impairment, has been rolled out across the medicine Clinical Board and a decision to use is made in partnership between nurses and carers or families. Other areas across the Health Board have also started to implement the scheme and positive informal feedback has been received on the benefits to the patient experience from families and staff.


Medicines management 97% of areas have reported that staff check patient identification verbally and visually prior to the administration of medicines. The audit also highlighted that 90% of patients were wearing appropriately completed identification bands. It should be noted that arm bands are not worn in the Day hospital setting or Adult Mental Health Wards. Whilst these levels of compliance with the standard are high, the audit highlighted that action is needed to improve the completion of medication charts. The “March on Medicines’’ campaign, initiated through CSIG, is aimed at bringing a focus to medicines management throughout the month of March 2014. This campaign will draw attention to all staff groups of the importance of accurate and full completion of medication charts. It is intended that this approach will supplement the continuing education and training already provided to staff through medicines management programmes. Compliance with all aspects of medicines management will be monitored in the coming months as part of an Internal Audit medicine managed review. Communicating in Welsh 60% of the clinical areas identified the ability to speak in Welsh with staff if Welsh is identified as the patient’s language of choice. The comments provided within the audit highlight that where Welsh speaking staff are not available, a member of staff can be identified from another area if required. Welsh speaking nurses are easily identifiable by the embroidered badge on their uniforms. In an effort to increase the number of Welsh speaking staff within the organisation the Health Board, in partnership with the Cardiff University, offers Welsh classes for beginners and at an intermediate level. The Health Board has also raised awareness to all staff of the need to offer the opportunity to all patients to receive their consultation through the medium of Welsh. User experience of Communication 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

69.99%

24.11%

5.54% 0.37%0%

20%

40%

60%

80%

100%

Always Usually Sometimes Never


Findings The majority of patients who responded were satisfied with the quality and frequency of information given and the manner in which it was provided. 94% of patients felt that they were always or usually given full information about their care in a way they could understand. Comments provided by patients/users and a review of the scores within the operational questions suggest that a small number of staff, but nevertheless an important issue, do not always communicate with patients, carers or each other in as effective a way as possible. It is therefore recognised that some work is needed to enhance communication skills but in particular to focus on: • improve communications between teams • communication regarding waiting times in the OPD Patient Comments • “Doctor very professional and patient and always explains things very well” • “Took a long time to get through on telephone to find out when my appointment

was due” • “Answer to most questions can vary depending on staff rotas” • “I often had to ask for test results and still not given” • “Better communication needed to family / carers” • “they will repeat things twice” • “There is a need to explain that there is more than one clinic going on” • “we understand everything as everything is explained“ Communication failure features in the top 10 concerns made to the Health Board. The feedback patients also aligns with the findings of the “2 minutes of your time” survey undertaken at the Health Board, this is short patient survey to obtain real time views on key determinants of dignity and respect which includes communication. The real time feedback enables the Sister/ Charge nurse to address areas of concern raised at that time with the patient/care so to improve their experience. In order to enable further improvement, the Clinical Boards will be engaged through the FOC group to develop a robust approach to communication and sharing information with patients. 4.1.3 Standard 2 and 5 – Respecting People and Relationships

Operational Questions Table 4

Standard 2 and 5 Operational Questions RAG % Q16 Does the patient's documentation capture their preferred

name and/or title? 80%

Q17 Is there documented evidence that an assessment of the carers needs has been considered?

76%

Q18 Is there documented evidence that the patient's cultural needs has been assessed and discussed with the patient or advocate?

68%


Q19 Is there documented evidence that the patient's spiritual needs has been assessed and discussed with the patient or advocate?

63%

Q20 Is there evidence to demonstrate that patient identifiable information is treated in a confidential and secure manner?

97%

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?

51%

Q22 Is there a facility for patients to talk in private to staff (e.g. a quiet room or office)?

98%

Q23 Is there a quiet room for patients to spend time with their visitors away from their bedside?

86%

Q24 Within the clinical area, are all the bays single sex bays? 90%

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

85%

Q26 Is there a facility to preserve patient dignity by communicating to others that care is in progress?

95%

Q27 Can staff demonstrate they know the procedure if a safeguarding concern is identified?

98%

Overall Score 83%

This standard cross references with the dignity and respect agenda, a Tier 1 priority and the subject of attention by the Commissioner for Older People in Wales within the report Dignified Care? Patient Privacy The audit information indicates that patient privacy and dignity is receiving the consideration expected by the Health Board. Good practice is demonstrated by the use of ‘Care in Progress/ Do not disturb’ signs to promote privacy and reduce interruptions to the patient whilst receiving care. 95% of areas have a quiet room that can be utilized for conversations between patients and staff to protect their privacy. Of the 81 inpatient areas that responded to the survey, only 86% had access to a quiet room for patients to spend time with their family away from the bedside. The comments within the audit suggest that in ward areas where there is no provision of a visitor’s room, plans are in place to reallocate ward space so that a visitor’s room can be accommodated.

Single sex accommodation Although only 78% of areas report to providing single sex accommodation for patients, further scrutiny of this data found the majority of inpatient ward areas provide single rooms or single sex bays for patients within mixed sex wards. The Welsh Government Single Sex accommodation Policy states:

“other than in circumstances where immediate care is the priority (such as Intensive care units, coronary care units, theatre recovery units and paediatric


units) hospitals are required to ensure patients are care for in single sex accommodation”

The single sex accommodation report submitted to by the Chief Operating Officer to the Quality, Safety and Experience committee in December 2013 indicates specific areas of non–compliance which require further consideration by Clinical Boards and the Corporate Estates team. These are the hyper acute areas, day case/surgery units, assessment units and the critical care areas. All new build schemes will consider the requirements within the Policy and Clinical Boards have been request to report any breaches so that the frequency and location of breaches can be monitored and auctioned through the Clinical Board performance review process. Consent to sharing information with others It is disappointing that only 58% of areas document that consent has been gained from patients to share their information with others. Commentary suggests however that although this is not documented, patients are asked for their consent during the patient admission process. Inclusion of this question in the new patient assessment document being developed by the CSIG group will remind staff of the importance to ask the question and to document that consent has been received. Compliance with completion of documentation will be monitored by Senior Nurse using the Senior Nurse Ward visiting guide. Compliance will also be monitored by the corporate nursing whilst undertaking unannounced observations of care. Carers’ Needs Carers’ needs were assessed in only 67% of the 81 inpatient and 33 non bed holding areas that participated in the audit. Comments include that cares needs are discussed during the complex discharge process, are included as part of the patient pathway or addressed through the Unified Assessment process. The introduction of the new patient assessment nursing documentation will prompt staff to ensure that the needs and thoughts of all cares, be them formal or informal, are documented and addressed as part of the admission process. Activities at the Health Board are being undertaken to raise awareness of the Carers Measure, launched by Welsh Government in 2012. Carers Strategy The UHB Carers Strategy “Partners in Care” was developed in partnership with Local Authority partners, Third Sector agencies and carers to drive forward implementation of the Carers Measure. Two aspects of the strategy are Awareness Raising and Education and Training achievements against these sections include: Education and training To date approximately 1171 staff across the Health Board have been educated and trained about the issues that carers face and their rights under the Carers Measure. Carers training is included within corporate induction as well as within the Skills2Lead programme and the RCN Clinical Leadership cohorts providing a twice-yearly opportunity to discuss with senior nursing and therapy staff the need to engage and support carers. These sessions are also incorporated into mandatory training session for existing staff. In addition to these formal training sessions the facilitator supporting training


and awareness is visiting each ward to meet staff and raise the profile of the carers agenda and carers rights. Raising awareness ‘Could you recognise a carer?’ leaflet was also attached to every staff members pay slip attached to their pay slip as anther means of raising awareness to the Carers Measure. Carer’s stories have been collected and used to raise awareness of carers and their issues. A powerful carer’s story was presented at the biannual UHB Nursing and Midwifery Conference held in October 2013. The Health Board intranet site has been developed and used to highlight carers’ issues and publicise information for carers as it has become available. Introduction of a dedicated email address for carers to contact the UHB Addition of a link to NHS Wales Direct Carers information on the UHB intranet homepage to enable clinical staff to access to carer support information directly from clinical workstations. Carers Survey The Health Board is in the process of carrying out a Carers survey in collaboration with Cardiff council and the Vale of Glamorgan council. The survey tool used is the same as that used as part of the Carers study undertaken in 2011 by the same collaboration. The aim of the survey is to gather feedback on the pressures involved with being a Carer and gauge the support received. The survey is being administered in the following ways:

Surveys have been sent to all Carers currently held on Cardiff council and the Vale council databases.

Surveys have also been issued to the Council leads for completion by selected

Third sector organizations.

The survey will be made available for completion on the Cardiff and Vale UHB intranet and internet pages. This will be for a 3 week period from 17/02/2014.

Surveys have been provided to the ward managers of various Mental Health

Service for Older People Wards ( MHSOP wards) at the Health Board It is hoped that the summary report for the study will be available mid/late March. User Experience of Dignified Care Question 100 Throughout your stay/attendance, how often did you feel that you were treated with dignity and respect?


Graph 3

89.36%

9.29% 1.22% 0.12%0%

50%

100%


Question 101 Throughout your stay/attendance, how often did you feel that you were given the privacy that you needed? Graph 4

82.92%

14.86%1.72% 0.49%

0%

50%

100%


Findings It is pleasing to note that the majority of patients report that they have been treated with dignity and that their privacy has been respected by kind, professional and friendly staff. Action is now required to make sure that the experience of all patients is positive and it is disappointing that patients make reference to some staff being rude, and patronising to older patients, but with a further comments from patient stating that the good outweighed the negative. There is also a patient comment of dignity being affected by other patients wandering, but that staff are there to address this.

Patient Comments • “ staff excellent, treating me with dignity and friendliness” • “Most staff are brilliant. Just one or two on how they speak to older

persons” • “there are certain staff on duty that seem to begrudge and their manners leave a

lot to be desired (the good out way the negative)” • “ we feel as a family that our father’s care has always been dealt with, with

dignity and respect“ • “ Nursing staff were caring, polite respectful and always helpful” • “Nursing care and professional care received throughout was friendly,

courteous and of a high standard” • “other patients wandering but nurses are there to help” The Health Board has engaged with all staff groups to develop value statements that drive behaviour of staff towards one another and to patients. These statements have been clearly highlighted in a “face of the UHB” poster which is available across Health Board sites, as well as through a mangers guide to ensure that the values are consistently applied at all levels. Communication skills course are also available, and utilised for staff that may require an update on communicating with dignity and respect.


4.1.4 Standard 3 – Ensuring Safety

Operational Questions

Table 5

Standard 3 Operational Questions RAG % Q28 Has the Infection Prevention & Control Audit (ICNA) been

undertaken within the last 12 months? 70%

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

88%

Q30 Has a Waste Management Audit been undertaken within the last 12 months?

85%

Q31 Has a Waste Management Audit been undertaken within the last 12 months. Please enter the compliance score as a percentage.

95%

Q32 Are staff able to give examples of the correct procedure for source isolating patients?

98%

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?

96%

Q35 Are any Manual Handling aids and slings regularly checked for wear and tear?

95%

Q36 Within the clinical area, are all fire restraint doors free from obstruction or closed if not automatic self closing?

91%

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 92%

The FOC audit data confirms the excellent compliance in practice in key areas of this standard. Areas are reporting that equipment is being maintained and is in good repair and that fire precautions are being respected in the majority of areas. It is also very reassuring to see that 97% of drug cupboards were found locked/secured at the time of the audit, and for those that were not, comments confirm that action was taken immediately to remedy this. Monitoring will continue through the Senior Nurse Visiting guide and through the outcomes of Internal audit department findings to ensure that there is consistency with good practice.


Waste Management and Infection Prevention and Control (IPC) audits Although the Health Board is achieving the 85% compliance for the standard for the waste audit element of this standard, only 70 % of areas report having an IPC audit in the last year. The frequently of the waste and IPC audits for each ward/department should be clarified for example, do inpatient and outpatient areas require the same frequency? This will be clarified with the waste management manager and IPC department to ensure compliance in all areas is achieved. User Experience of Ensuring Safety Question 103 Throughout your stay/attendance, how often did you feel that the clinical area was kept clean, tidy and not cluttered?

Graph 5

77.70%

19.73%2.57% 0.00%

0%

50%

100%


Although 98% of patients who responded felt that the clinical area was always or usually clean, tidy and uncluttered, the comments made are quite varied as identified below. Patient Comments • “always very clean and tidy” • “ward is not dirty, maybe untidy” • “ no, as a result of a very outdated ward with outdated facilities” • “ward often unclean, particularly the floors and communal areas” • “ward unclean most of time” • “the treatment room is spotless, as are the dining room and lounge. Our bedrooms

are as clean as a new brush” The comments align with the finding of the 2 minutes of your time survey which has found a slight downward trend in views of overall cleaning in the last 4 months. As a result, an external review been commissioned to identify the key issues affecting standards of cleaning, as reported in the Board meeting in January 2014. Question 108 Throughout your stay/attendance, how often did you feel that you were made to feel safe?


Graph 6 87.26%

11.35%1.26% 0.13%

0%

50%

100%


Findings Most patients have reported feeling safe, but where comments have been made, it seems that patients feel that their safety is compromised by other patients. • “wandering patients at night can be unsettling” • “recently made to feel uneasy by another patient wandering” • “we are always safe” • “feeling of safety present at all times” Patients have also made numerous comments that more staff are needed (afternoon and night and more qualified staff at the weekend), but it is not know if they feel that the lack of staff affects their safety, or if the comments have been made in general. • “need more staff” • “Nurses are always short of staff and busy” • “despite the very few nurses, especially in the afternoon..” • “too few staff to cope with volumes of patients” Two actions are being undertaken to ensure that appropriate and safe staffing levels are in place: • The Nursing Establishment review – CNO staffing levels • National Patient Acuity tool (from April 2014) Progress with the Nursing establishment review was reported to the Board in December 2013 and together with the acuity tool, these measures and will be used alongside nursing care indicators and professional judgment to ensure staffing levels are safe and appropriate. This work will aim to ensure a good patient and staffing experience. 4.1.5 Standard 4 – Promoting Independence


Table 6

Standard 4 Operational Questions RAG % Q41 For this episode of care, is there documented evidence the

patient's mobility has been assessed and discussed with the patient or advocate?

93%

Q42 For this episode of care, where the patient has been 89%


identified as requiring support and/or assistance with mobility, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

Q39 For this episode care, is there documented evidence that the patient’s level of independence has been assessed and discussed with the patient or advocate?

90%

Q40 For this episode of care, where the patient has been identified as requiring support and/or assistance to maximise independence, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

85%

Q43 For this episode of care, is there documented evidence the patient's risk of falls has been assessed and discussed?

91%

Q44 For this episode of care, where the patient has been identified as being at risk of falls, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

88%

Q45 Where appropriate, do all patients have written evidence of a discharge assessment and plan?

83%

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?

78%

Q48 Does the clinical area allow patients to bring in personal items to assist with patient orientation/familiarity?

100%

Overall Score 87% Overall, the audit data suggests good practice is being observed with the assessment of patient mobility and risk of falls. Care planning was undertaken by nursing staff and there was evidence of review of care planned in 85% of records reviewed as part of the audit. The work undertaken by the CSIG to highlight the importance of patient assessment and care planning will underpin the improvements required to further improve care planning and evaluation of care of all patients here. 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. Predicted date of discharge (PDD) is used across the Health Board as a guide to proactively plan the patient journey through the hospital system. This aims to reduce delays in ensuring all requirements for a safe discharge are anticipated and organised in advance of being medically fit to leave hospital. The audit results suggest that in nearly 20% of cases there is no evidence of discharge plans being developed.


Examples of good practice are provided in the comments section of the operational audit: notably, that family asked to complete carer’s perspective, that staff value the input of carers, and that families are involved in discharge meetings. There are also pockets of good examples in the Health Board with a discharge checklist and guideline introduced to ensure that patients and carers understand the discharge process. This is in addition to the information available from the integrated discharge teams The patient/user experience of discharge planning was not included in FOC User survey but patient and care involvement in the discharge process consistently scores low in the “2 minutes of your time survey”. In an effort to improve the engagement of patient and cares in plans to go home, a newly launched “discharge leaflet” will be disturbed across acute adult areas in the Health Board in the next month. Bathroom and toilet facilities It is evident from the narrative provided that the refurbishment of bathroom and toilet facilities in 5 wards on the UHW site has led to a positive impact on patient care. In areas where upgrading has not commenced, staff are reporting the following: • bathrooms are too small for lifting aides • there are no disabled facilities • there are delays in getting faults repaired • and step up showers are too high for patients Patients have also commented on the need to refresh paintwork, that there is clutter in bathrooms, facilities are outdated and that shower cubicles are hazardous to step into. There are also 2 patient comments made about broken toilet seats and the delay in getting them repaired. Discussion with Capital Planning has confirmed that there are currently no plans to extend the refurbishment work to other wards or other sites at the Health Board, and the allocation of funding for future work will be dependent on the Integrated Business plans of Clinical Boards. However in light of the findings from this audit the Board, led by the Executive Director of Planning, should give consideration to how the issues identified within the audit relating to environments of care will be addressed. User Experience of Promoting Independence 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

79.77%

16.49%3.09% 0.64%

0%20%40%60%80%100%



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

66.84%

26.35%

6.30% 0.51%0%

20%

40%

60%

80%

100%


Nearly all patients expressed satisfaction that they were always or usually assisted to be as independent as they would want to be. Similarly, more than 93% of respondents were always or usually responded to in a timely manner. Where comments have been made, it is evident that some patients have an understanding that nurses are sometimes delayed due to caring needs of other patients. • “some are more encouraging than others” • “on good days, given every opportunity” • “”I am used to doing things for myself, but the nurses are always there if I need

them” • “wait too long for the toilet” • “few people cannot be everywhere“ • “sometimes slow in answering buzzer, understand that ward is short staffed” • “rarely get therapies as promised” • “unit was very busy and full, staff did the best they could” As part of the Transforming Care programme, intentional rounding has been adopted by ward areas across the Health Board which ensures that patients are asked at regular intervals if they need a drink, if they are warm enough or if they need to use the toilet. Adoption and embedding of intentional rounding in all areas will help ensure that the needs of patients are addressed in a timely manner in order to protect their dignity and respect. Implementation of this initiative is being monitored through the FOC Group so that good practice can be shared across care areas. 4.1.6 Standard 6 – Rest and Sleep


Standard 6 Operational Questions RAG % Q49 For this episode of care, is there documented evidence that

the patient's normal sleep pattern and needs have been assessed and discussed with the patient or advocate?

82%


Q50 For this episode of care, where the patient has an identified sleep issue or sleep has been recorded as poor/disrupted is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

61%

Overall Score 73%

This standard rendered one of the lowest scores from the operational audit and patient comments on sleep and rest also reflect that some considerable work is required to improve the patient’s experience. It is evident that nurses recognise the importance of sleep and rest with 82% of areas reporting that the patient’s sleep pattern is assessed on admission. But the audit identifies that only 68% of those patients with an identified need actually has a care plan in place. The CSIG group, through the review of nursing documentation has highlighted the importance of patient assessment and subsequent planning and evaluation of care to improve the patient’s experience. This work will underpin the action for improvement required for this standard. User Experience of Sleep and Rest Question 109 Throughout your stay, how often did you feel that you were able to get enough rest and sleep? Graph 9

44.36% 34.17%19.28%

2.19%0%20%40%60%80%100%


Findings Of all twelve standards audited Sleep and Rest was the standard that service users reported most dissatisfaction. Less than 78% of patients agreed that they were always or usually able to get enough rest and sleep while in hospital. It is important to emphasise that patients indentify a variety of issues which impact on their ability to sleep/rest: • normal sleep pattern is generally poor • noise from other patients • noise whilst patients are receiving care • lights • too cold ( form a variety of ward areas and sites) • noisy nurses


These comments as well as the comment illustrated below have featured in FOC audits completed in previous years and are also reflected in the 2 minutes of your time surveys undertaken at the Health Board: • “needs to be quieter during the night time” • “feel uncomfortable when sleeping time and there is noise and light in the

corridor” • “better pillow fillings” • “change pillows and beds” • “my comment about sleep is that if they are busy with an ill patient it can be

disturbed but I understand that.” • “very busy ward sometimes disturbed sleep can’t be helped • “nurses have accepted my preference to sleep in the chair next to my bed- same

as I do at home” • Can get cold at times and had to bring my own duvet in.

The Health Board FOC group is focusing on practical measures to reduce the avoidable noise level at night. A schedule of announced night visits to 10 ward areas are already planned to explore what the challenges are for patients and nurses at night. Any particular nursing actions required to support improvement will be taken to the Clinical Standards and innovations group ion March 2014 so that an agreed plan of action can be developed in collaboration with Clinical Boards.

4.1.7 Standard 7 – Ensuring Comfort and Alleviating Pain


Table 8

Standard 7 Operational Questions RAG % Q51 For this episode of care, is there documented evidence that the

patient's pain has been discussed and assessed using an appropriate pain assessment tool?

77%

Q52 For this episode of care, where the patient has an identified problem with pain is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

78%

Q53 For this episode of care, is there documented evidence that the patient's concerns/anxieties or fears has been assessed and discussed with the patient or advocate?

83%

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?

69%

Overall Score 77%

Pain The audit outcome has highlighted that not all areas have adopted a pain assessment chart. However, surgical areas have revised the NEWS chart to incorporate a pain assessment. The issue of a standardised pain assessment tool has been considered at the FOC group and it is recognised that all areas require a


tool to support pain assessment tool for all patients to include those with cognitive impairment. The FOC group has already enlisted the support of the Health Board Pain team to introduce pain assessment tools suitable for all patients, especially those who are unable to self report (dementia, learning difficulties, confused). Feedback will be presented in the April 2014 FOC group meeting. As identified above, work is in place to drive improvements in the patient assessment and care planning. User Experience of Comfort and Pain Question 110 Throughout your stay, how often did you feel that you were made to feel comfortable? Graph 10

77.45%

19.17%2.91% 0.46%

0%

50%

100%


Question 111 Throughout your stay/attendance, how often did you feel that you were, as far as possible, kept free from pain? Graph 11

76.37%

17.68%5.32% 0.63%

0%

20%

40%

60%

80%

100%


Findings It is evident from the results that the majority of patients (92%) responded that they were always or usually kept free from pain, and patients have also reported a high level of satisfaction with comfort and p[in through the 2 minutes of your time surveys undertaken at the UHB. However the negative comments received from the patient in relation to this standard reflect issues associated with comfort of pillows, being cold and timeliness of pain relief. • “the nurses and doctors showed genuine care and made my stay comfortable” • “appropriate pain relief needs to be in place for my needs. “ • I do not like the bed or the pillows I find them very uncomfortable. • occasionally get pain but nurses act quickly to give me extra painkillers • “staff shortages sometimes mean a long wait for pain killers”


• “occasionally get pain but nurses act quickly to give me extra painkillers • “Can get cold at times and had to bring my own duvet in” • “Freezing cold by night and draughty rooms” The CSIG’s “March on Medicines “, bringing focus to medicines management throughout March 2014, will focus attention on reinforcing the importance of timeliness of provision of pain relief as one of the key messages of this campaign. Dialogue with the Patient Experience team with regards to the quality of the pillows procured for the Health Board will continue. The intentional rounding tool used at the Health Board provides a reminder to staff to ask patient if they are warm enough although further scrutiny of the data is required to see if the comments made in the audit tool relate to particular areas. Once this level of scrutiny has been undertaken action will be identified to address the issues raised. 4.1.8 Standard 8 – Personal Hygiene, Appearance and Foot Care


Table 9


the patient's hygiene needs have been assessed and discussed with the patient or advocate?

95%

Q56 For this episode of care, where the patient's hygiene needs have been identified is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours?

88%

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

94%

Q58 For this episode of care, is there documented evidence that the patient's foot and nail condition has been assessed using a recognised, evidence based tool and discussed with the patient or advocate?

54%

Q59 For this episode of care, where the patient has an identified risk or requires assistance with foot or nail care, is there evidence that there is an up to date plan of care which is being implemented and evaluated and has been reviewed within the last 24 hours?

54%

Q60 Does the clinical area have supplies of toiletries for patients who have been admitted without them?

98%

Overall Score 83%

Hygiene Data confirms evidence of good practice in the assessment and planning of patient hygiene needs. In 95% of documents reviewed there was written evidence that


hygiene needs had been assessed and discussed but with only 88% of patient records with documentary evidence of up to date care plans. The documentation review being undertaken will underpin the improvements required for this element of the standard. Foot care The operational score achieved for this standard is one of the lowest for the audit and is influenced by wards not using a foot and nail assessment tool which is currently being progressed at an all Wales level. Despite this, areas are reporting that nail and foot care is being incorporated in an overall assessment of hygiene needs and that nurses are utilising the foot and nail procedure that was approved early this year by the UHB Nursing and Midwifery Board. The procedure supports nurses to undertake simple nail and foot assessment and care as part of the overall agenda of improving foot health and reducing harm from falls. There is also evidence from the audit that staff are attending training days provided by the Health Board for the last 3 years to enable competent and confident delivery of foot and nail care to patients. The importance of foot and nail care will continue to be reinforced through the education and training programme already in place for nurses. Patient Supplies Not all patients bring into hospital the toiletries required to maintain their hygiene needs and whilst these are available to order centrally, it would appear that wards are relying on ward funds to purchase toiletries, or the goodwill of nursing staff to purchase or donate toiletries to the ward. Although products are available to order through Procurement, comments suggest that these are of poor quality. There FOC group will engage with Procurement to review the products listed and identify if any improvements to the quality of products can be made. The group will also provide a product list and order codes for Sister/ Charge nurse to help facilitate ordering of these products. User Experience of Personal Hygiene, appearance and foot care Question 112 Throughout your stay, how often did you feel that your personal hygiene needs were met?

Graph 12

83.36%

14.22%2.26% 0.16%

0%20%40%60%80%100%


Findings Patients have reported satisfaction with the level of privacy and sensitivity shown by staff when tending to their hygiene needs. There is one comment made that curtains


are not long enough to maintain dignity. The data for this particular element of the audit will be further scrutinised so that the ward/ department to which this relates can be supported to rectify this.

Other patient comments relating to this element of the standard include: • “I had my own shower in my room so this was not a problem for me” • “The staff always take me” • “I would not like to have help from a male nurse” • “I have help from the nurses every day” 4.1.9 Standard 9 – Eating and Drinking


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?

64%

Q62 Prior to meal times, are patients that require help assisted into a suitable position?

98%

Q63 Prior to meal service, are bed tables and communal areas cleared and tidied for the meal?

94%

Q64 Are patients meals placed within easy reach? 98%

Q65 Are all patients given the opportunity to wash or cleanse their hands with hand wipes prior to eating meals?

74%

Q66 Are patients given the opportunity to go to the toilet before meal time?

92%

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?

94%

Q68 Are water jugs changed 3 times daily? 48%

Q69 Is drinking water available for patients and where applicable, are drinking water jugs and glasses within the patient's reach?

98%

Q70 During a 24 hour period, how many beverage rounds are carried out within your clinical area?

67%

Q71 Does a Registered Nurse supervise every meal time? 88%

Q72 Is there evidence that all members of the nursing team are engaged in the mealtime service?

92%

Q73 Does the clinical area have access to weighing scales and a height measurement stick in good working order?

75%

Q74 Is a range of snacks available for patients who have missed a meal or who are hungry between meals?

96%

Q75 For patients who require a food chart, is there evidence that they are being kept up to date and evaluated?

97%


Q76 For patients who require a fluid chart, is there evidence that they are kept up to date and evaluated?

90%

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

94%

Overall Score 86% Overall performance with this standard demonstrated high compliance however two areas for improvement were identified.

Fluids The All Wales Nutrition and Catering Standards for Food and Fluid for Hospital Inpatients (Welsh Government 2012) provide technical guidance for caterers, dieticians and nursing staff responsible for meeting the nutritional needs of patients who are capable of eating and drinking. This was published in response to Welsh Audit Office 2012 Catering and Nutrition Review which identified that although good practice was demonstrated in some areas, there needed to be more consistent standards of quality and service delivery across Wales. Within these standards it is identified that 7 – 8 beverage rounds should take place per day offering hot and cold beverages and that water in jugs should be changed three times a day. Data suggests that the Health Board is achieving seven or more beverage rounds in 67% of areas, but only 48% of areas currently comply with the requirement for replenishing fresh water jugs three times a day. The Health Board Nutrition and Catering Steering Group is already monitoring the provision of hot beverage rounds and replenishing water jugs to ensure that action is taken to achieve compliance with the standard. It is recognised however that urgent action is required to ensure that the standards associated with beverage provision are achieved consistently. As such the Nurse Director has tasked the Executive Director of Therapies and Health Science, who is the lead executive for the Nutrition and Catering Steering Group to progress this work. The audit highlighted that there is a need to improve compliance with completion of fluid charts. The directorate of medicine have already drafted a Standard Operating Procedure (SOP) for the completion of fluid balance charts to address inconsistency and uncertainties around when and how they should be completed. It is proposed that the SOP is approved for adoption on a Health Board wide basis as this will help to underpin the improvements required to ensure that fluid balance charts are consistently completed fully and accurately. This approach will be progressed through CSIG and the Nursing and Midwifery Board as part of the work on improving nursing documentation. Preparation for meal times Most wards report to have adopted protected meal times and that patients are supported to prepare for meal time and to eat and drink where necessary. Patients requiring support are identified on a Patient Status at a glance Board (PSAG board) or during intentional rounding. The opportunity to offer fluids to patients is also taken during intentional rounding. Action is now required to make sure that good practice is adopted by all wards and that meal and beverage rounds are supervised by a registered nurse.


In support of this, a PROTECTED poster has been developed by the FOC group to remind all staff across disciplines of the core principles of protected meal times and this will be distributed to all ward areas by the end of February 2014. The poster has been shared with the All Wales Nutrition and Catering group who are keen to adopt the poster on an All Wales basis. Assessment of patient needs In addition to the annual FOC audit there is a requirement on all in patient areas to electronically report monthly monitoring data on a FOC national clinical indicator: numbers of patients having a nutritional score completed within 24 hours of admission. This provides an on-going measure of performance and a benchmark against the national position (Graph 13). Graph 13

Source: Nursing & Midwifery Dashboard for Wales, Welsh Government

User Experience of Eating and Drinking Question 105 Throughout your stay, how often did you feel that you were provided with nutritious food and snacks?

Graph 14

64.34%

21.89% 11.28% 2.49%0%20%40%60%80%100%



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 80.82%

12.59% 3.95% 2.64%

0%20%40%60%80%

100%


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 78.34%

16.88%3.50% 1.27%

0%

50%

100%


Findings Patients provide a variety of comments about the quality, choice and quantity of food provided in the Health Board and this aligns with the findings of the 2 minutes of your time surveys. • “water tends to be changed more regularly as it does not stay cold” • “same options all the time as on fork mashable diet” • “Food very good. Lots of choice” • “Very hard to eat when poorly” • “ not a wide choice of vegetarian food available” • “more fruit and veg please” • “I’m a fussy eater so they would find it hard to please me all the time” The Patient Experience team and Dietetic team are already progressing with the review of compliance with the All Wales Nutrition Standards but it is recognised that it is a challenge to provide a menu to suit all tastes and preferences. The teams are particularly aware of the need to improve the choice of fork mashable diet and the vegetarian diet options and work is being progressed on this issue. The majority of patients reported to having been offered plenty of drinks, and timely support with eating and drinking, if it was required. Where this is not the case, reinforcing the key principles of protected meal times through the “Protected” poster will underpin the improvements required.


4.1.10 Standard 10 – Communications and Information Operational Questions

Table 11


the patient been assessed using the All Wales Oral Health tool with respect to their oral health needs?

36%

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?

74%

Overall Score 52%

The score for this standard is in line with the findings of other Health Boards across Wales, but despite the overall score achieved, it is reassuring that patients are satisfied with the support provided to them with mouth care. The All Wales oral health assessment and care plan was launched by the CNO in September 2013 and was piloted in 5 ward areas at the UHB. The assessment document in itself is lengthy and cumbersome to use. As such as part of the CSIG work plan for documentation, the oral health assessment is being integrated into the overall patient assessment document which is to be implemented by in April 2014. Although this approach will mean that the specific all-Wales too, issued through Welsh Government, will not be utilised in its current format the key elements will be incorporated into revised nursing documentation. This will ensure that the oral health needs of all patients are considered on admission and that the use of the full risk assessment is targeted appropriately. A list of products available for effective oral care, along with order codes and location, has been made available to all senior nurses and sister/ Charge nurses to ensure that products are available to enable good practice. In the meantime, commentary supports that established tools are being used within the Health Board and that there is partnership working between nurses and community dental teams in areas where patients normally experience longer lengths of stay.

User Experience of Oral Health and Hygiene 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 74.07%

17.80% 5.49% 2.64%0%20%40%60%80%100%



Findings 95% of patients responded that they were always or usually given the help they needed to ensure their teeth and gums were kept healthy. However, the comments illustrated below indicate that improvement is required to make sure that patients are offered support when it is required.

• “nurses attended daily hygiene/teeth as unable to use hands” • “husband visits every day and cleans teeth. However nurses no not ask

and check every day” • “staff cleaned my teeth when I wasn’t able to” The roll out of the oral health assessment and the patient assessment and care planning review being undertaken by the CSIG will underpin the improvements required for this standard and help reinforce the importance of assisting patients to maintain a good standard of oral care

4.1.11 Standard 11 – Toileting Needs


Table 12


the patient's toileting needs has been assessed and discussed with the patient or advocate?

83%

Q81 For this episode of care, where the patient has been identified as requiring assistance with their toileting needs, is there evidence that an appropriate assessment has taken place with an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours?

83%

Overall Score 83%

The results confirm the need to improve compliance in the assessment and planning of patient toileting requirements and the documentation will support the improvement required for assessment and care planning for the patient’s toileting needs. The All Wales Continence Bundle was launched by the CNO in June 2013 and the Continence Lead at the Health Board has since been providing education and support to clinical areas and Cardiff University Students to maximise the opportunity to improve the patient experience. As with the Oral Health assessment, the UHB has adopted a targeted approach to its introduction and roll out to the UHB. There will be a focus on patients at risk of falls and those identified with continence needs during the patient assessment process to make sure that their continence needs are addressed in a dignified manner.


User Experience of Toileting needs 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

74.87%

19.47%3.89% 1.77%

0%

20%

40%

60%

80%

100%


Findings Patient comments relate to the occasional delay in nurses assisting the patient to the toilet and there is evidence that activities from improvement programmes of 1000 lives and Transforming care are used to improve the patient’s experience, with toileting being offered to patients during intentional rounding. Although 94% of patients surveyed agreed that their toilet needs were always or usually responded to quickly and discreetly. However, for 13 of the 692 patients who responded to this question, this was never the case. Comments made by patients include: • sometimes nurses are very busy and I may have to wait a couple of minutes for

assistance • Walk to toilet alone, takes too long waiting for nurse • improve the shower and toilet facilities, the toilet seats were always off despite the

staff constantly reporting it. Shower is small and awkward • sometimes had accidents – embarrassment. Nurses very sensitive with this and

helpful • To improve - Toilets for visitors room and rest room.

Engagement with Clinical Boards through the FOC group will reinforce the need to ensure that the toileting needs of all patients are addressed promptly to maintain dignity and respect and to review intentional rounding to make sure that the frequency of rounding is tailored for individual patient needs.

4.1.12 Standard 12 – Preventing Pressure Sores Operational Questions

Table 13


the patient's skin condition has been assessed and 88%


discussed with the patient or advocate? Q84 For this episode of care, where the patient has been

identified as requiring assistance with looking after their skin, is there evidence that there is an up to date plan of care, which is being implemented and evaluated and has been reviewed within the last 24 hours.

93%

Overall Score 90%

The Health Board has successfully introduced the 1000 lives+ SKIN Bundle to all in-patient wards across the UHB with the aim of improving the culture and practice associate with skin care and pressure damage prevention. Improvement methodology, introduced through Transforming Care and 1000 lives+, has been used to introduce and embed the bundle with clear measures of improvement displayed in ward areas. Healthcare acquired pressure ulcers are reported monthly into the National Nursing Dashboard (care indicators, see Graph 18). This provides a process for reporting, measurement and monitoring of incidents to inform targeted improvement. The Health Board reports all incidents of pressure damage to include moisture lesions and device associated damage and will support work undertaken at an All Wales level to provide clarity around the indicator descriptor. Additionally, any incidence of new skin damage/pressure ulcer development is reported through Datix. A report to include the number of category of pressure sores is and provided to Clinical Boards on a monthly basis. Graph 19

Source: Nursing & Midwifery Dashboard for Wales, Welsh Government


User Experience of prevention of pressure sores

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 75.58%

15.31%4.65% 4.46%

0%

20%

40%

60%

80%

100%


Findings 91% of service users responded that they were always or usually given help to look after their skin to prevent the formation of pressure ulcers. But 4.19% of patients who responded to the questions (n=644) responded that they were never assisted. Comments • “don’t seem to suffer from these” • “unsure of what help should be given so hard to answer this” • “ I was always asked if I had a problem” • “I do wish he could be moved more often as he sites in one position for a

long time” • “x3 repose cushions”

A review of patient bed side information is being undertaken at the Health Board is being undertaken by CSIG and this provides an opportunity to provide patients and cares with information on how to reduce the risk of pressure ulcers and what help the patient can expect from staff. The Health Board is monitoring the levels of Hospital acquired pressure ulcers on a monthly basis through the Clinical Board performance management review process. Work is planned with the Clinical Boards to further support best practice in the management of pressure ulcers. 4.2 Fundamentals of Care Staff Survey

“In general terms, the more positive the experiences of staff within an NHS trust, the better the outcomes for that Trust. (West et al 2011)

The staff survey component was introduced in 2013 for the first time as part of the annual FOC audit. 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. Staff were asked to complete the survey by selecting a “frequency” rating of always, usually, sometimes or 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 14 and from scrutinising the data; the “usually” frequency has rendered the highest rate of response for all questions. The average rating for their overall satisfaction with the care that they provide to patients and their families was 79%. Staff were invited to add comments and on scrutinising the date, there are very few comments to support why staff are satisfied. The majority of comments highlighted staff concerns, and reasons for not being able to achieve something.

The FOC staff survey was carried out across Health Boards and Trusts in Wales on 7 October 2013. All qualified nurses and midwives and clinical health care support workers (HCSW)/nursing assistants on duty in those clinical areas undertaking the annual FOC audit for a 24 hour period from 12 midnight on that day were given the staff survey questionnaire at the start of their shift and asked to return the survey before they went off duty. Just over a 1000 nurses, midwives and HCSW responded to the survey. The survey provides evidence that nursing staff across the Health Board are caring, kind and willing to go the extra mile for their patients: • Work additional hours to achieve the level of care needed for patients • Buy newspapers for patients on the way to work • Bring in toiletries for patient who are without • Overcome logistical difficulties, (space, lack of privacy , poor equipment) to

deliver a good standard of care Nursing staff expressed shared frustrations and difficulties in being able to deliver the quality of care they aspire to. Specific comments made by staff include: • too few staff • high patient acuity • not enough equipment • too much paper work Provisional analysis suggests that the areas for improvement important to our staff are: • professional development • learning from good practice • feedback from incidents/ accidents • feeling valued



Table 14 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?

53.06% 35.87% 10.61% 0.45%

Q86 Our organisation aims to, ensure that as an employee you are treated with dignity and respect. Do we achieve this?

36.27% 41.64% 20.75% 1.34%

Q87 Our organisation aims to, make you feel safe at work. Do we achieve this? 36.19% 45.20% 17.57% 1.05% Q88 Our organisation aims to, make you feel you have a positive contribution to

patient care. Do we achieve this? 39.58% 41.69% 17.07% 1.66%

Q89 Our organisation aims to, provide you with sufficient equipment to do your job. Do we achieve this?

20.72% 51.95% 25.83% 1.50%

Q90 Our organisation aims to, provide you with opportunities to enhance your skills and professional development. Do we achieve this?

25.49% 38.01% 33.18% 3.32%

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?

28.66% 30.20% 31.74% 9.40%

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?

30.11% 43.47% 23.96% 2.46%

Q93 Our organisation aims to, provide opportunities for you to raise any concerns that you have. Do we achieve this?

41.74% 36.49% 19.52% 2.25%

Q94 Our organisation aims to, provide you with the opportunity to establish a work life balance. Do we achieve this?

33.44% 41.68% 20.61% 4.27%

Q95 Our organisation aims to, make you feel a valued member of the organisation and have a sense of belonging. Do we achieve this?

26.20% 37.50% 30.87% 5.42%

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

28.55% 38.93% 27.79% 4.73%

Q97 Our organisation aims to, ensure that you have the knowledge and skills to deliver a consistent standard in the fundamental aspects of compassionate care. Do we achieve this?

29.06% 44.65% 15.23% 1.06%

The highest ranked questions are as follows: 1. Our organisation aims to make sure you are able to access up to date

information to enable you to do your job, do we achieve this? The staff survey reported positively that the Health Board performed well in the provision of information to staff. 89% of the nurses responded that there was always or usually access to up to date information. Commentary suggests that access to computers and the intranet search system requires improvement and nurses have also requested for journals and e-library. Cardiff University Library has already offered a sum of moneys for the Health Board to allocate for improving facilities/access for nursing staff. The outcome of how the moneys will be agreed at the next Nursing and Midwifery Board to be held in April 2014. In the meantime, there is an opportunity to work in partnership with the Library services to advertise what is available for nursing staff to use. 2. Our organisation aims to make sure that as an emplo9yee you are

treated with dignity and respect. Do we achieve this? It is pleasing that the majority of nurses responded that they were always (36.67%) or usually (43.14%) treated with dignity and respect. However, where comments have been made, they suggest that staff do not always treat each other with dignity and respect.

“At an organisational level, yes. However, I do think there’s work to be done to educate some professional groups and individuals to treat their colleagues with dignity and respect.”

In order to improve this, the Health Board has engaged with all staff groups to develop value statements that drive behaviour of staff towards one another and to patients. These statements have been clearly highlighted in the “face of the UHB” poster and a manager’s guide to ensure that the values are consistently applied at all levels. 3. Our organisation aims to make you feel safe at work The majority of staff have responded to the always (35.7%) and usually (47/04%) frequency and the comments made reflect the situations when staff state affect their safety at work. Lack of staff, lack of equipment, placement of patients with mental health needs and caring for confused aggressive patients are some of the themes that staff state affect their safety at work. Lack of staff was also raised as an issue by the patient/user survey. 4. ..to make you feel you have a positive contribution to patient care “Patients make me feel I have a positive contribution to their care” The majority of responses are in the always (39.03%) and usually (42.69%) frequencies and it is clear from the comment made that nurses value positive feedback from patients. The comments made are in relation to when nurses feel that


they do not contribute positively to care. Lack of resources and shortage of staff is the most frequently reason provided. Two actions are being undertaken to support these issues: • The Nursing Establishment review – CNO staffing levels • National Patient Acuity tool (from April 2014) Progress with the Nursing establishment review was reported to the Quality, Safety and Experience Committee in December 2013 and together with the introduction of the acuity tool, these measures will be used alongside nursing care indicators and professional judgment to ensure staffing levels are safe and appropriate. This will aim to ensure a good patient and staffing experience. 5. Opportunities to raise concerns

78% of nurses who responded to the question said that they usually or always had the opportunity to raise concern. Some staff felt that are not listened to, or that feedback is not given and this aligns with the findings of the NHS staff survey undertaken in November 2012. On a positive note, it is pleasing that further comments suggest that improvement has been made since the launch of the Health Board “Safety Valve”. 6. the opportunity to establish a work life balance “I think people who work for the NHS generally know and expect that it is a challenge to achieve work life balance and accept it” The majority of responses for this question fall into the always (32.93%) and usually (41.84%) frequencies and a variety of comments have been made: • often quick turnaround form days and nights • for chosen few • only if you have children • shifts could be fairer, especially for those without children, • more notice needed for off duty • shifts change without asking There are also positive comments about managers doing a good job with the off duty, and that Rosterpro is fair. Actions in place to ensure work life balance for all staff include: • Prioritise further roll out of Rosterpro to targeted areas • Reinforcing rostering principles and monitoring by the Senior Nurse • Review of the Health Board Rostering policy ( current) • Provision of an established Employee Well being service


7. Ensure that you have the knowledge and skills to deliver a consistent standard of the fundamental aspects of care.

84% of nurses agreed that the Health Board ensured that they have the knowledge and skill to deliver a consistent standard of the fundamental aspects of care. However 10 of the 1011 staff who responded to this question said that this never happened. Some comments indicate that staff are updating their skills and knowledge in their own time and a common theme for the commentary is the lack of staff and the consequent lack of opportunity for study leave. The following questions rendered split scores across the frequencies: 8. to provide you with opportunities to enhance your skills and

professional development This is a very similar to question 7, but has rendered a spilt in the responses across the frequency scores (sometimes 32.57%: usually 37.23%; always 26.73%).Some comments indicate that the Health Board offers good training opportunities that CPD/PDR have been useful, and that team away days are good. Some comments relate to study leave being cancelled due to lack of staff. Interestingly, there is one comment that there is too much study leave available and not been able to honour it for all staff. The Learning and education Department are currently reviewing with the Clinical Boards that way that study leave and course selection is allocated with the aim of balancing individual request with service development need. 9. to provide you with sufficient equipment to do your job The spread of responses for this question are across the sometimes (26.01%), usually (51.92%) and always (20.59%) and the findings are interesting. The operational survey reported that that equipment is well maintained and calibrated, and equipment was available but the comments made for this question contradicts this. Firstly, comments point to not having enough basic equipment (hoists, glide sheets, thermometers, monitors), and that the lack of equipment makes it difficult to care for patients. Further scrutiny of the data is required to establish if provision and maintenance of equipment warrant further review. 10. to provide you with feedback on the outcomes of incidents /accidents

that you report This question has rendered the highest level of never response (7.77%) across the staff survey, but oh the whole nearly 60% of staff have indicated that feedback was always or usually given. The majority of comments however state that feedback is not provided, which is aligned to the findings of the NHS survey and is a priority to learn from concerns and incidents to reduce the risk of reoccurrence.


11. to identify and learn from good practice to bring about improvement in

care

Nurses have identified that there is less opportunity of experienced role models due to restructuring of posts, and that workers do not all embrace change. Comments however support the value of team away days and that nurses share good practice within teams. 12. Feel a valued member of staff

The scores for this question are split across sometimes (31%) usually (36%) and always (27%) One comment that stands out is that the Health Board’s strategy “Caring for people, keeping people well” has brought people together. Other comments are not so positive and again a theme on individual behaviour is coming through, “it depends on who is on”, “sometimes not”. This was also a theme raised in comments made by patient’ users. Nurses comment however that they feel valued by patients and at ward level, and that they enjoy being a nurse. 13. Proud to be a nurse 69% of nurses indicated that the Health Board always or usually make them feel proud to be a nurse. 44 nurses who responded indicated that the organisation never made them feel proud. The NHS staff survey identified that those staff who have an individual appraisals are more likely to hold positive views that those who do not have one. Although not the only form of feedback, an appraisal provides an opportunity to self judge performance and to have a clear set of objectives.

14. Overall satisfaction question: using a scale of 1-10, where 1 is very bad

how would you rate your overall satisfaction with the care that you provide to your patients and their families

The score for this question has been translated into an overall 79% satisfaction rating for the Health Board. This section has been used to provide general comments and staff constraints, behaviour of some staff and lack of equipment remain a general theme.

“without time to learn, money for all kit needed and staff, enough for every shift, care will not reach a high standard”

The nursing staff survey has provided a rich source of information of how it feels to be nurse in the Health Board. Very few comments have been made to support what is done well and this is despite the always and usually frequency being selected mostly across all questions.


Work will now continue in partnership with Workforce and OD colleagues to review the staff survey data in greater detail and make use of mapping with the findings of the recently undertaken Health Board Pulse survey and the NHS staff survey undertaken in November 2012.

5. 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 Cardiff and Vale University 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 the Health Board and we strive to continue to enhance their experiences. As such the areas which have been identified for improvement are referenced within the Summary of Recommendations (Appendix 1) , although it is recognised that the Board will need to give particular, prompt consideration to some specific areas of improvement. 6. Recommendations The Board is asked to:

• Note the content of this report and the level of compliance achieved with the 12 Fundamentals of Care Standards

• Note the areas for improvement identified within the summary of recommendations provided in Appendix 1 and support implementation of the action required to deliver improvement

• Agree to support the decision not to implement the all-Wales Oral Health Assessment Tool in its current format and to support the integration of the key elements of the tool within revised nursing documentation

• Give specific consideration to the areas for action required by the responsible executive leads to address the 4 key issues identified through the audit:

o Ensuring that arrangements are in place to enable full compliance with the provision of fluids (water jugs and warm beverages) in all clinical areas within the Health Board

o The development of a schedule of improvement works which will enhance patient experience of their care environments with a particular focus on bathroom and toilet facilities.



o A continued focus on staffing levels which ensures that the workforce is fit for purpose and able to respond positively to patient need. This includes the need for attention on activities which enhance communication skills and behaviours amongst the workforce as a whole.

APPENDIX A


Summary of Recommendations (for elements that scored less than 85% compliance rate)

Standard Action to be taken By whom By When

1

Operational issue Revision of patient assessment nursing documentation and care plans to enable full assessment and individualized care planning throughout the patient’s journey

CSIG April 2014

1 Operational issue Add memory screening question to initial patient assessment nursing documentation and monitor use using Ward visiting guide

CSIG Senior nurse

April 2014

1 Operational issue Review of information fields for Outpatients department to enable inclusion of first point of contact field

FOC group May 2014

1 Operational issue Reinforce the need for full completion of medications charts as part of the Health Board March on Medicines

CSIG Nurse Advisor Pharmacy

March 2014

2&5 Operational issue Continue to raise staff awareness of carer’s rights and ensure discussions are documented. Monitor using ward visiting guide/ documentation audits

Patient Experience team Senior Nurse

On-going

2&5 Operational issue Reinforce the obtaining consent to share information following introduction of revised patient assessment nursing documentation

Senior Nurse On- going

2&5 Patient and staff survey

Reinforce key principles of the Values and behaviours highlighted on the “face of the UHB” poster to all staff groups

Clinical Boards

3 Operational issue Identify waste management and FOC audit requirement for all clinical areas and inform Clinical Boards

FOC Group April 2014

4 Operational issue Work with the Integrated discharge teams to improve compliance with discharge planning, documentation and predicted date of discharge. Revised Discharge documentation to be rolled out

Senior nurses CSIG

April 2014 onwards

4 Operational issue Provision of suitable toilet and bathroom facilities to all patients Clinical Boards For review

6 Operational & patient issue

Undertake observations of care across 10 ward areas to realize the challenges faced by patients and staff by night and engage with Clinical Boards to develop an action plan to reduce any avoidable noise indentified

FOC Group Clinical Boards

April 2014

APPENDIX A


Standard Action to be taken By whom By When

7 Operational issue To develop and make available e an evidence based pain assessment tool suitable for all patients, to include those with cognitive impairment

Pain team FOC Group

April 2014

8 Operational issue Work with procurement to review the list of toiletries available to order and indentify improvements where needed. Provide a list of available toiletries to Sister/ Charge nurse

FOC Group July 2014

9 Operational issue Reinforce to Ward Sister Charge nurse the required frequency of refilling of water jugs and monitor outcome

Nutrition and Catering Steering group

Jan 2014 Review date to be agreed

9 Operational issue Reinforce the key principles of protected mealtimes through provision of Protected poster to all in-patient areas

FOC Group February 2014

10 Operational issue Continue with plan for roll out of continence assessment and care planning bundles during 2014

Continence Director

10 Operational issue Continue with roll out of oral health assessment and care plans during 2014

August 2014

Q 91 staff Identify appropriate feedback mechanism for staff relating to incidents reported

Clinical Boards June 2014

staff Work in Partnership with OD with mapping of the FOC staff survey, the NHS Wales staff survey and the Health Board Pulse survey

Assistant Director of Nursing Head of OD

During 2014

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