quality network for eating disorders
TRANSCRIPT
Final Report – Cycle 1 Newmarket House
Date: 27 April 2016
Trust/Organisation Name: Newmarket House
Jane Waterston Ward Manager Cambridgeshire & PeterboroughNHS Foundation Trust
Name Job Title/Designation Organisation
Self-Review Period 9th June - 5th September 2014
Date of Peer-Review 5th November 2014
The Peer-Review Team
Mark Beavon(Observer)
QED DeputyProgramme Manager
RCPsych Centrefor Quality Improvement
Sonia Parsons Carer Representative -
Christine Vize Consultant Psychiatrist Oxford HealthNHS Foundation Trust
Joanne Wallace (Lead Reviewer) Modern Matron
South West Londonand St Georges NHSMental Health Trust
iv
viii
Standards Summary ix
xi
xi
Results:
Environment and Facilities Audit 1
15
16
31
32
55
16
69
71
72
81
82
98
99
Patient and Carer Questionnaires Summary
Environment and Facilities Audit Summary
Ward Manager Questionnaire
Training Grid
CONTENTS
Introduction to QED
Report Layout
Overall Summary
Feedback From Host Team
Checklist
Checklist Summary
Staff Questionnaires
Ward Manager / Training Grid Summary
Patient and Carer Questionnaires
Action Plan
Staff Questionnaires Summary
Health Record Audit
Health Record Audit Summary
iv
Objectives
· accrediting adult inpatient eating disorder wards;
· creating a national network to support staff through:- a database of standards for care;- the QED peer-review process;- an email discussion group;- events.
· maintaining a database of standards for inpatient eating disorder services.
The ‘Mission Statement’ and Standards
The ‘mission statement’ for QED is:
· Type 1: failure to meet these standards would result in a significant threatto patient safety, rights or dignity and/or would breach the law;
· Type 2: standards that an accredited ward would be expected to meet;
· Type 3: standards which are aspirational or standards that are not the direct responsibility of the ward.
The College Website
Wards who are members of QED will be listed on the Royal College of Psychiatrists’ website. Once a final accreditation rating has been awarded, this will be posted on the website next to the ward name.
The standards are drawn from a range of authoritative sources and also incorporate feedback from patient and carer representatives, pilot studies and experts from a range of relevant professions.
The set of standards is comprehensive and some standards are aspirational; it is unlikely that any ward could meet all of them. To support their use in the accreditation process, each standard has been categorised as follows:
The standards were used to generate a series of data collection tools for use in the self- and peer-review processes. Some standards were not included because they cannot be measured objectively and reliably.
There are several data collection tools because it is important that each standard is evaluated using the most appropriate method and source of information. The methods are described more fully in the sections that describe the ‘self-review’ and the ‘peer-review’.
Introduction to the Quality Network forEating Disorders (QED)
The purpose of QED is to improve the care provided by adult inpatient eating disorder services in the United Kingdom. It achieves this by:
Eating disorder services offer a timely and purposeful admission withina safe and therapeutic environment.
v
The Accreditation Process
Phase 1: Self-Review
Carer Questionnaire;Patient Questionnaire;Staff Questionnaire;Ward Manager Questionnaire;an audit of Health Records;an audit of other key documents ('Checklist') including policies, procedures and protocols;an audit of the environment by the multi-disciplinary team.
Phase 2: Peer-Review Visit by an External Team
Phase 3: Accreditation Decision
There are three categories of accreditation status:
- meet all type 1 standards; - meet >80% of type 2 standards;- meet many type 3 standards.
· Category 1: “accredited”.The ward would at the point of peer-review :
Data from the self- and peer-review are compiled by the QED team into a summary report of the ward’s strengths and areas for improvement. Once this has been verified by the lead reviewer who visited the ward, the QED Combined Committee for Accreditation considers the data and decides an accreditation status for the ward.
The time from registration as a member of QED to a decision being made about a ward’s accreditation status will be between six and nine months. There are three main phases: self-review; a peer-review visit, and; the decision about accreditation status and feedback.
This is an opportunity for the local multi-disciplinary team to review their local procedures and practices against the QED standards and, if necessary, to make the changes required to achieve accreditation.
At the beginning of the self-review period, the local QED lead is sent a copy of the QED ‘Standards for Acute Inpatient Wards' and the self-review data collection tools. The latter should be completed and returned within three months.
The self-review has a number of components:
A summary of the results from the self-review are used to inform discussions at the visit by the peer-review team.
The purpose of the one-day visit by a peer-review team is to validate the self-review findings and to provide a valuable opportunity for discussion, and for the review team members to share ideas, make suggestions, offer advice and give support.
The peer-review visit is scheduled for 4-8 weeks after the self-review data has been returned. Staff from wards participating in QED are invited to act as members of peer-review teams, and the team will typically consist of 5 members. The team will have undergone specific training at the Royal College of Psychiatrists.
vi
- not be meeting one or more type 1 standards but demonstrate the capacity to
- not be meeting a substantial number of type 2 standards but demonstrate the
- fail to meet one or more type 1 standard and not demonstrate the capacity to
- fail to meet a substantial number of type 2 standards and not demonstrate the
The Appeals Process
The grounds for an appeal against a decision about accreditation category are that:
· the decision has been made on the basis of a summary report that containsfactual inaccuracies about the ward at the time of the review, and/or;
· the decision is not consistent with stated criteria that determine categories of accreditation.
An appeal must be lodged within eight weeks of the accreditation decision having been communicated to the local QED lead. Appellants are asked to provide documentary evidence to support claims of factual inaccuracy and/or a clear statement of in what way(s) they consider the decision to be inconsistent with the stated criteria for the category of accreditation awarded. A detailed description of the stages of the appeals process is available on request.
· Category 2: “accreditation deferred”.The ward would at the point of peer-review :
meet these within a short time;
capacity to meet the majority within a short time.
The ward receives a report detailing the strengths and weaknesses that have been identified, with an emphasis on those standards that needed to be addressed for accreditation to be awarded. Evidence is then collected over a 3 - 12 month period (depending on the number and nature of the Not Met standards) to confirm that the ward now meets the criteria for accreditation.
· Category 3: “not accredited”.The ward would at the point of peer-review :
meet these within a short time;
capacity to meet these within a short time.The ward receives a report detailing the strengths and weaknesses that have been identified and a clear statement of which standards have to be met for the ward to be approved. Ongoing support will be given from the project team to help the service to work towards meeting these standards.
vii
· Environment and Facilities Audit· Ward Manager Questionnaire and Staff Training · Patient Questionnaire· Checklist· Staff Questionnaire· Health Record Audit· Carer Questionnaire
Here is an example of the layout of the booklet, followed by an explanation of the column headings:
NO. [TYPE]
SELF-REVIEW
MET/ NOT MET
U37.1 [1] Yes Met
This box contains the results of the self-review. This will be in the form of either:
PEER-REVIEW COMMENTS
This section is completed during the course of the peer-review visit, and includes any comments that the review team felt were pertinent.
SELF-REVIEW
· 'Yes' or 'No' for the Environment & Facilities Audit and the Checklist.
· '# of responses: # yes # no' for the Health Record Audit and the Questionnaires (e.g. '20 responses: 16 yes 4 no').
MET/NOT MET
This column indicates whether a standard has been MET or NOT MET, based on the self-review data and the findings of the peer-review team.
This box repeats the wording that appeared in the self-review data collection tool. For the questionnaires, the word 'STATEMENT' is replaced by the word 'QUESTION' (NOTE: Type 1 standards appear in BOLD).
Report Layout
This report is divided into seven sections. Each section corresponds with the seven main sessions of the peer-review visit, and contains the results of the ward’s self-review:
ENVIRONMENT AND FACILITIES AUDIT
STATEMENT PEER-REVIEW COMMENTS
SECTION 2: TIMELY AND PURPOSEFUL ADMISSIONEmergency medical equipment, as required by Trust/organisation guidelines, is available within three minutes.
This equipment is kept on the ward within thenursing office.
NO. [TYPE]
This box refers to the number of the standard(s) that the statement corresponds with (from the document ‘Standards for Adult Inpatient Eating Disorder Services’) and the level that the standards are set at in square brackets (NOTE: Type 1 standards appear in BOLD).
STATEMENT
viii
Standards Summary Environment and Facilities Audit
Type of Standards Number in Section Number Met 1 23 19 2 43 37 3 4 4
Type 1 Standards Not Met: Measures are taken to address blind spots and ensure sightlines are not
impeded, e.g. by the use of mirrors. An assessment of the necessity of any fitting that could be a potential ligature
point is undertaken. Where this is unavoidable, fixings are not able to bear a load larger than 20 kilos.
Emergency medical equipment, as required by Trust/Organisation guidelines, is available within three minutes.
Hypostop or equivalent is available on the ward/unit. Checklist
Type of Standards Number in Section Number Met 1 30 30 2 12 12 3 2 2
Health Record Audit
Type of Standards Number in Section Number Met 1 18 18 2 24 24 3 1 1
Ward Manager Questionnaire
Type of Standards Number in Section Number Met 1 22 22 2 28 25 3 3 2
Training Grid
Type of Standards Number in Section Number Met 1 8 6 2 16 16 3 1 1
Type 1 Standards Not Met: All staff attend identified statutory and mandatory training as determined by
the Trust/organisation and a record is kept of this. All staff have received diversity awareness training.
ix
Staff Questionnaires
Type of Standards Number in Section Number Met 1 16 15 2 16 16 3 3 3
Type 1 Standard Not Met: All staff are able to take regular allocated breaks away from patients during
their shift. Patient and Carer Questionnaires
Type of Standards Number in Section Number Met 1 10 10 2 28 25 3 2 0
Overall Percentages
Type of Standards % Met
1 94.49 (120/127) 2 92.81 (155/167) 3 81.25 (13/16)
Total 92.90 (287/310)
Accreditation was originally deferred in order to meet the Type 1 Standards listed above. The QED Project Team subsequently received
evidence demonstrating that these standards have been Met. The ward was then awarded accreditation by the QED Accreditation Committee.
x
FINAL SUMMARYAreas of achievement.
There is good support for progress and independent eating, demonstrated for example by the table in dining room and the approach to normalising food. The unit is recovery-focused, with good risk assessments, data and follow-up. There is patient artwork around the unit and a piano. There is collaborative working on the unit, with good management and working supportively alongside challenging patients. There are good forms in place for patients to sign, stating that they understand information sharing, treatment plans and expectations. The Ward Manager is warm and approachable, and willing to take on board issues which could be addressed. Patients felt that the atmosphere on the ward was good, aided their recovery, and that they were treated as individuals rather than "people with eating disorders". The therapeutic programme is individualised. Carer feedback was positive, with comments relating to the welcoming environment and helpful staff - it was felt that the continuity of staff was a big asset.
Action points.
To ensure that support does not drop off when 1:1 observations are happening. Leave medication and patient/carer access to pharmacy to be investigated further. To address the many ligature points observed throughout the ward. To ensure that the crash bag is equipped appropriately, with oxygen, adrenaline, and hypostop. To ensure that a capacity assessment following a standardised process is carried out for the patients on the ward. The review team noted that even in the case on 1:1 observation, patients admitted in a physically compromised state were quite isolated upstairs, and that in an emergency it would be a struggle to either get patients down, or for the emergency services to make it up. To ensure that twice weekly progress reviews are carried out. To consider moving to an electronic note-taking system as paper notes can be chaotic.To provide copies of care plans for patients and that they are aware of the availability of advocacy. To ensure that all staff have undertaken mandatory Trust training, and diversity awareness training. There is a suggestion to use a traffic light system for overdue training. (Ward Comment: "We already use a traffic light system for identifying overdue staff training.")To employ a formal system for auditing supervision, and cascade supervision better. To include patients/carer representatives in the interview process for members of the MDT. The review team noted that there was too much responsibility for the Ward Manager surrounding supervision. It is suggested that measures are taken to ease this pressure.
FEEDBACK FROM HOST TEAMFeedback received from the Host Team at the Final Meeting.
xi
xii
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
Info
rmat
ion
is a
vaila
ble
for
p
atie
nts
/car
ers
abou
t:
how
to
mak
e a
verb
al c
omp
lain
t;Y
es
how
to
mak
e a
wri
tten
com
pla
int;
Yes
how
to
sug
ges
t se
rvic
e im
pro
vem
ents
/en
han
cem
ents
;Y
es
how
to
mak
e a
wri
tten
com
plim
ent;
Yes
how
to
mak
e a
don
atio
n.
Yes
PQ
: W
ere
you
tol
d h
ow t
o m
ake
a co
mp
lain
t if
you
wan
ted
to?
9 r
esp
onse
s:
3 y
es 6
no
CQ
: W
ere
you
tol
d h
ow t
o m
ake
a co
mp
lain
t if
you
wan
ted
to?
7 r
esp
onse
s:
1 y
es 6
no
U1
2.3
[1
]W
her
e sm
okin
g is
per
mit
ted
, th
ere
is a
sa
fe a
lloca
ted
are
a fo
r th
is p
urp
ose.
Yes
Met
U1
0.2
[1
]
This
info
rmat
ion
is a
vaila
ble
in t
he w
elco
me
pack
and
di
spla
yed
on t
he w
alls
of th
e un
it.
Met
ENV
IRO
NM
ENT
AN
D F
AC
ILIT
IES
AU
DIT
Sm
okin
g
SEC
TIO
N 1
: G
ENER
AL
STA
ND
AR
DS
Com
plim
ents
an
d C
omp
lain
ts
1
13.5
[2]
The
team
has
inte
grat
ed p
atie
nt r
ecor
ds u
sed
by a
ll st
aff.
Yes
Met
U2
7.1
[1
]Th
ere
is a
n a
nn
ual
an
d c
omp
reh
ensi
ve
gen
eral
ris
k as
sess
men
t to
en
sure
th
e sa
fety
of
the
clin
ical
en
viro
nm
ent.
Yes
Met
U2
7.2
[1
]Th
ere
is a
man
agem
ent
pla
n t
o ad
dre
ss
any
shor
tfal
ls in
th
e sa
fety
of
the
clin
ical
en
viro
nm
ent.
Yes
Met
31.4
[2]
The
war
d/un
it h
as a
cces
s to
equ
ipm
ent
to
supp
ort
the
prev
ention
of pr
essu
re u
lcer
s in
lo
w w
eigh
t pa
tien
ts,
e.g.
pre
ssur
e-re
lievi
ng
mat
tres
s sy
stem
s.
Yes
Met
U34
.1 [
2]W
hils
t en
suri
ng a
ppro
pria
te le
vels
of se
curi
ty,
patien
ts a
re c
ared
for
in t
he le
ast
rest
rict
ive
envi
ronm
ent
poss
ible
Yes
Met
34
.2 [
1]
Mea
sure
s ar
e ta
ken
to
add
ress
blin
d s
pot
s an
d e
nsu
re s
igh
tlin
es a
re n
ot im
ped
ed,
e.g
. b
y th
e u
se o
f m
irro
rs.
No
Not
Met
U3
4.3
[1
]
Faci
litie
s en
sure
rou
tes
of s
afe
entr
y to
an
d e
xit
from
th
e w
ard
/u
nit
in t
he
even
t of
an
em
erg
ency
rel
ated
to
dis
turb
ed/
viol
ent
beh
avio
ur.
Yes
Met
War
d C
om
men
t: "
We
are
a sm
all,
info
rmal
uni
t w
ith
a hi
gh
staf
f ra
tio
and
patien
ts a
re v
ery
rare
ly o
ut o
f st
aff si
ght.
We
have
pro
cedu
res
in p
lace
to
ensu
re p
atie
nts
who
may
req
uire
in
crea
sed
supe
rvis
ion
are
acco
mpa
nied
aro
und
the
build
ing
as r
equi
red.
"
QED
Com
men
t: E
vid
ence
dem
onst
rati
ng
com
plia
nce
w
ith
th
is s
tan
dar
d r
evie
wed
an
d a
ccep
ted
by
Acc
red
itat
ion
Com
mit
tee
23
/3
/1
6.
Saf
ety
SEC
TIO
N 4
: EN
VIR
ON
MEN
T A
ND
FA
CIL
ITIE
S
Pre
ssu
re U
lcer
Car
e
SEC
TIO
N 2
: TI
MEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
SEC
TIO
N 3
: S
AFE
TY
2
U34
.4 [
2]Th
ere
is s
ecur
e, lo
ckab
le a
cces
s to
a p
atie
nt’s
ro
om,
with
exte
rnal
sta
ff o
verr
ide.
No
Not
Met
The
revi
ew t
eam
not
ed t
hat
room
s ar
e no
t lo
ckab
le,
how
ever
pa
tien
ts h
ave
thei
r ow
n sa
fe.
U3
4.5
[1
]Fu
rnit
ure
is a
rran
ged
so
that
ala
rms
can
b
e re
ach
ed a
nd
doo
rs a
re n
ot o
bst
ruct
ed.
Yes
Met
U3
4.6
[1
]
An
ass
essm
ent
of t
he
nec
essi
ty o
f an
y fi
ttin
g t
hat
cou
ld b
e a
pot
enti
al li
gat
ure
p
oin
t is
un
der
take
n.
Wh
ere
this
is
un
avoi
dab
le,
fixi
ng
s ar
e n
ot a
ble
to
bea
r a
load
larg
er t
han
20
kilo
s.
Yes
Not
Met
The
revi
ew t
eam
wer
e co
ncer
ned
abou
t th
e lig
atur
e ri
sks
pres
ent
on t
he w
ard,
and
did
not
fee
l com
fort
able
with
the
man
a gem
ent
plan
of no
t ad
mitting
pat
ient
s pr
esen
ting
with
a su
icid
e ri
sk.
War
d C
omm
ent:
"W
e ca
rry
out
ligat
ure
risk
ass
essm
ents
bu
t w
e w
ill e
ndea
vour
to
redu
ce t
he n
umbe
r of
liga
ture
poi
nts
as s
oon
as p
ossi
ble.
"
QED
Com
men
t: E
vid
ence
dem
onst
rati
ng
com
plia
nce
w
ith
th
is s
tan
dar
d r
evie
wed
an
d a
ccep
ted
by
Acc
red
itat
ion
Com
mit
tee
23
/3
/1
6.
34.1
6 [2
]
Doo
rs h
ave
view
ing
pane
ls o
r ob
serv
atio
n w
indo
ws
and
thei
r us
e is
man
aged
to
bala
nce
priv
acy
and
safe
ty.
Gui
danc
e: s
taff s
houl
d no
t be
abl
e to
be
alon
e in
a r
oom
with
a pa
tien
t w
itho
ut b
eing
obs
erve
d.
No
Not
Met
The
unit h
as s
olid
doo
rs.
U3
6.1
[1
]S
ecu
rity
mea
sure
s, e
.g.
alar
m s
yste
ms
or
call
bu
tton
s to
ale
rt s
taff
, ar
e av
aila
ble
.Y
esM
et
36.2
[2]
Ala
rm s
yste
ms/
call
butt
ons/
pers
onal
ala
rms
are
avai
labl
e to
sta
ff.
Yes
Met
U36
.6 [
2]Ala
rms
are
acce
ssib
le in
inte
rvie
w r
oom
s,
rece
ptio
n ar
eas
and
othe
r ar
eas
whe
re o
ne
patien
t an
d on
e st
aff m
embe
r w
ork
toge
ther
.Ye
sM
et
Ala
rm S
yste
ms
3
U36
.7 [
2]Ala
rm s
yste
ms/
call
butt
ons/
pers
onal
ala
rms
are
chec
ked
and
serv
iced
reg
ular
ly.
Yes
Met
U3
7.1
[1
]Em
erg
ency
med
ical
eq
uip
men
t, a
s re
qu
ired
by
Tru
st/o
r gan
isat
ion
gu
idel
ines
, is
ava
ilab
le w
ith
in t
hre
e m
inu
tes.
Yes
Not
Met
U3
7.2
[1
]Th
e cr
ash
bag
is m
ain
tain
ed a
nd
ch
ecke
d
wee
kly
and
aft
er u
se.
Yes
Met
U37
.3 [
2]Th
e w
ard/
unit h
as a
cces
s to
a s
peci
fic r
oom
for
ph
ysic
al e
xam
inat
ions
and
min
or m
edic
al
proc
edur
es.
Yes
Met
37
.4 [
1]
Hyp
osto
p o
r eq
uiv
alen
t is
ava
ilab
le o
n t
he
war
d/u
nit
.N
oN
ot M
et
This
has
now
bee
n or
dere
d.
War
d C
om
men
t: "
Follo
win
g th
e re
view
Hyp
osto
p is
now
av
aila
ble.
"
QED
Com
men
t: E
vid
ence
dem
onst
rati
ng
com
plia
nce
w
ith
th
is s
tan
dar
d r
evie
wed
an
d a
ccep
ted
by
Acc
red
itat
ion
Com
mit
tee
30
/9
/1
5.
U3
8.1
[1
]A
ll p
atie
nt
info
rmat
ion
is k
ept
in lo
cked
ca
bin
ets,
lock
ed o
ffic
es o
r is
sec
ure
ly
pas
swor
d-p
rote
cted
on
IT
syst
ems.
Yes
Met
Ther
e is
no
adre
nalin
e or
oxy
gen
avai
labl
e.
War
d C
omm
ent:
"Fo
llow
ing
the
revi
ew w
e no
w h
ave
oxyg
en
on s
ite
and
trai
ning
has
bee
n de
liver
ed t
o al
l nur
ses"
.
QED
Com
men
t: E
vid
ence
dem
onst
rati
ng
com
plia
nce
w
ith
th
is s
tan
dar
d r
evie
wed
an
d a
ccep
ted
by
Acc
red
itat
ion
Com
mit
tee
30
/9
/1
5.
Med
ical
Eq
uip
men
t
Con
fid
enti
alit
y
4
U38
.2 [
2]
In s
pace
s w
here
per
sona
l and
con
fiden
tial
di
scus
sion
s ar
e he
ld,
such
as
inte
rvie
w r
oom
s an
d co
nsul
ting
/exa
min
atio
n/tr
eatm
ent
spac
es,
conv
ersa
tion
s ca
nnot
be
hear
d ou
tsid
e of
the
ro
om.
Yes
Met
In s
ervi
ces
wh
ere
secl
usi
on is
pra
ctic
ed,
ther
e is
a d
esig
nat
ed r
oom
fit
for
th
e p
urp
ose.
N
/A
The
secl
usi
on r
oom
:
allo
ws
clea
r ob
serv
atio
n;
0
is w
ell i
nsu
late
d a
nd
ven
tila
ted
;0
has
acc
ess
to t
oile
t/w
ash
ing
fac
iliti
es;
0
is a
ble
to
wit
hst
and
att
ack/
dam
age;
0
has
a t
wo-
way
com
mu
nic
atio
n s
yste
m;
0
has
a c
lock
th
at p
atie
nts
can
see
.0
U4
0.1
[1
]A
ll fi
xtu
res,
fit
tin
gs
and
eq
uip
men
t ar
e in
a
goo
d s
tate
of
rep
air.
Yes
Met
The
war
d en
viro
nmen
t is
ver
y w
ell m
aint
aine
d.
U4
0.2
[1
]B
ath
room
s ar
e in
a g
ood
sta
te o
f re
pai
r an
d a
re c
lean
.Y
esM
et
Sec
lusi
on
Use
of
Roo
ms
and
Sp
ace
N/A
Sec
lusi
on is
not
pra
ctis
ed o
n th
e un
it.
U3
9.2
[1
]
5
U40
.3 [
2]Are
as w
hich
nee
d to
be
quie
t ar
e lo
cate
d as
far
aw
ay a
s po
ssib
le fro
m a
ny s
ourc
es o
f un
avoi
dabl
e no
ise.
Yes
Met
U40
.4 [
2]Th
ere
is a
t le
ast
one
room
for
inte
rvie
win
g an
d m
eeting
with
indi
vidu
al p
atie
nts
and
rela
tive
s,
whi
ch is
fur
nish
ed w
ith
com
fort
able
sea
ting
.Ye
sM
et
40.5
[2]
The
war
d/un
it is
man
aged
to
allo
w o
ptim
um
use
of a
vaila
ble
spac
e an
d ro
oms.
Yes
Met
40.6
[2]
Ther
e is
a d
esig
nate
d sp
ace
for
patien
ts t
o re
ceiv
e vi
sits
fro
m c
hild
ren.
Yes
Met
40.8
[2]
A s
epar
ate
area
is m
ade
avai
labl
e to
rec
eive
pa
tien
ts w
ith
polic
e es
cort
s (t
his
may
be
a de
sign
ated
136
sui
te o
ff t
he w
ard/
unit if
av
aila
ble)
.
No
N/A
The
revi
ew t
eam
cha
n ged
thi
s st
anda
rd fro
m N
ot M
et t
o N
/A.
U40
.9 [
2]
Ther
e is
a d
esig
nate
d ar
ea o
r ro
om (
de-
esca
lation
spa
ce)
that
sta
ff m
ay c
onsi
der
usin
g, w
ith
the
patien
t’s a
gree
men
t,
spec
ifica
lly for
the
pur
pose
of re
duci
ng a
rous
al
and/
or a
gita
tion
. N
ote:
thi
s ar
ea is
in a
dditio
n to
the
sec
lusi
on r
oom
, an
d m
ay b
e th
e pa
tien
t’s o
wn
room
if t
hey
are
the
sole
oc
cupi
er.
Yes
Met
40.1
0 [2
]Th
e w
ard/
unit e
nvir
onm
ent
is s
uffic
ient
ly
flexi
ble
to a
llow
for
spe
cific
indi
vidu
al n
eeds
in
rela
tion
to
gend
er (
N/A
for
sin
gle-
sex
war
ds).
Yes
Met
The
art
room
is u
sed
sepa
rate
ly a
s a
spac
e fo
r m
ales
on
the
unit.
6
U40
.11
[2]
The
war
d/un
it e
nvir
onm
ent
is s
uffic
ient
ly
flexi
ble
to a
llow
for
spe
cific
indi
vidu
al n
eeds
in
rela
tion
to
ethn
icity.
Yes
Met
U40
.12
[2]
The
war
d/un
it e
nvir
onm
ent
is s
uffic
ient
ly
flexi
ble
to a
llow
for
spe
cific
indi
vidu
al n
eeds
in
rela
tion
to
disa
bilit
y.Ye
sN
ot M
et
The
revi
ew t
eam
not
ed t
hat
all b
edro
oms
on t
he w
ard
are
upst
airs
on
the
first
flo
or,
with
no li
ft.
40
.13
[1
]
Mal
e an
d f
emal
e p
atie
nts
hav
e se
par
ate
slee
pin
g a
ccom
mod
atio
n in
sep
arat
e ar
eas
of t
he
war
d/u
nit
(N
/A f
or s
ing
le-s
ex
war
ds)
.
Yes
Met
Ther
e ar
e si
ngle
en
suite
room
s fo
r m
ale
patien
ts.
U40
.14
[2]
The
war
d/un
it o
ffer
s a
rang
e of
sem
i-pr
ivat
e an
d pu
blic
spa
ces
outs
ide
the
priv
ate
bedr
oom
, w
hich
allo
w p
eopl
e a
differ
ent
leve
l of
part
icip
atio
n w
ith
the
life
of t
he u
nit.
Yes
Met
40.1
5 [2
]Th
ere
are
loun
ge a
reas
tha
t m
ay b
ecom
e si
ngle
-sex
are
as a
s re
quir
ed (
N/A
for
sin
gle-
sex
war
ds).
No
Met
The
revi
ew t
eam
cha
nged
thi
s st
anda
rd t
o M
et.
Whe
re
nece
ssar
y, t
he a
rt r
oom
is d
esig
nate
d fo
r us
e as
a lo
unge
ar
ea b
y m
ale
patien
ts.
U40
.18
[2]
Soc
ial s
pace
s ar
e lo
cate
d to
pro
vide
vie
ws
into
ex
tern
al a
reas
.Ye
sM
et
40.1
9 [2
]Th
ere
is a
qui
et r
oom
with
com
fort
able
sea
ting
.Ye
sM
et
40.2
5 [2
]
The
war
d/un
it m
akes
rea
sona
ble
atte
mpt
s to
ac
com
mod
ate
mal
e pa
tien
ts a
nd a
dapt
s th
e en
viro
nmen
t ac
cord
ingl
y, i.
e. a
sep
arat
e be
droo
m,
bath
room
and
sitting
roo
m c
an b
e m
ade
avai
labl
e (N
/A for
sin
gle-
sex
war
ds).
Yes
Met
7
40.2
6 [3
]Pa
tien
ts a
re a
ble
to p
erso
nalis
e th
eir
own
spac
e.
Yes
Met
U41
.1 [
2]
The
dini
ng a
rea
is b
ig e
noug
h to
allo
w p
atie
nts
to e
at in
com
fort
and
to
enco
urag
e so
cial
in
tera
ctio
n, in
clud
ing
the
abili
ty for
sta
ff t
o en
gage
with
and
obse
rve
patien
ts d
urin
g m
ealtim
es.
Yes
Met
U4
1.2
[1
]Th
e d
inin
g a
rea
is r
eser
ved
for
din
ing
on
ly
du
rin
g a
lloca
ted
mea
ltim
es.
Yes
Met
This
was
con
firm
ed b
y th
e re
view
tea
m o
n th
e da
y.
41.1
8 [3
]Th
e fo
od is
fre
shly
coo
ked
on t
he h
ospi
tal
prem
ises
, ra
ther
tha
n be
ing
rehe
ated
. Ye
sM
et
41
.19
[1
]
Ther
e is
a c
hoi
ce o
f w
ell-
pre
par
ed f
ood
fr
om a
men
u t
hat
su
its
all n
utr
itio
nal
, in
div
idu
al,
cult
ura
l an
d c
linic
al d
ieta
ry
nee
ds.
Yes
Met
The
revi
ew t
eam
fel
t th
at t
his
was
ver
y go
od.
U42
.1 [
2]All
patien
ts h
ave
acce
ss t
o lo
ckab
le s
tora
ge,
whi
ch m
ay in
clud
e th
eir
own
indi
vidu
al r
oom
s or
acc
ess
to a
saf
e on
the
war
d/un
it.
Yes
Met
42.2
[2]
Ther
e is
acc
ess
to t
he d
ay r
oom
at
nigh
t fo
r pa
tien
ts w
ho c
anno
t sl
eep.
Yes
Met
Cat
erin
g
Dig
nit
y
8
Pat
ien
ts c
an w
ash
an
d u
se t
he
toile
t in
p
riva
te.
Yes
PQ
: W
ere
you
ab
le t
o w
ash
an
d u
se t
he
toile
t in
pri
vate
?9
res
pon
ses:
8
yes
1 n
o
PQ
: If
not
, d
id s
taff
exp
lain
wh
y?7
res
pon
ses:
4
yes
3 N
/A
U42
.7 [
2]Pa
tien
ts c
an m
ake
and
rece
ive
tele
phon
e ca
lls
in p
riva
te.
Yes
Met
Patien
ts a
re a
llow
ed t
o us
e th
eir
own
phon
es a
fter
fou
r w
eeks
.
U42
.9 [
2]La
undr
y fa
cilit
ies
are
avai
labl
e to
all
patien
ts.
Yes
Met
U4
2.1
0
[1]
Pat
ien
ts h
ave
acce
ss t
o it
ems
asso
ciat
ed
wit
h s
pec
ific
cu
ltu
ral,
rel
igio
us
or s
pir
itu
al
pra
ctic
es,
e.g
. co
vere
d c
opie
s of
fai
th
boo
ks.
Yes
Met
U42
.11
[2]
Rel
evan
t as
sist
ive
tech
nolo
gy e
quip
men
t, s
uch
as h
oist
s an
d ha
ndra
ils,
are
prov
ided
to
mee
t in
divi
dual
nee
ds a
nd t
o m
axim
ise
inde
pend
ence
.
Yes
Met
Met
42
.4 [
1]
9
Patien
ts h
ave
acce
ss t
o th
e fo
llow
ing
withi
n or
ne
ar t
o th
e w
ard/
unit/h
ospi
tal s
ite:
phys
ical
act
ivity
and
exer
cise
;Ye
s
mus
ical
act
ivitie
s an
d eq
uipm
ent;
Yes
mul
ti-f
aith
pra
yer/
wor
ship
roo
m;
Yes
bank
ing
faci
litie
s;Ye
s
libra
ry fac
ilities
;Ye
s
basi
c sh
op (
with
esco
rts
for
shop
vis
its
if re
quir
ed);
Yes
inte
rnet
acc
ess;
Yes
acce
ss t
o a
priv
ate
tele
phon
e.Ye
s
U43
.1 [
2]Th
e w
ard/
unit is
abl
e to
con
trol
ligh
t.Ye
sM
et
U43
.2 [
3]Th
e w
ard/
unit is
abl
e to
con
trol
tem
pera
ture
.Ye
sM
et
U43
.3 [
2]Th
e w
ard/
unit is
abl
e to
con
trol
ven
tila
tion
.Ye
sM
et
U43
.4 [
2]Th
e w
ard/
unit h
as a
rran
gem
ents
to
cont
rol
avoi
dabl
e no
ise.
Yes
Met
U42
.12
[2]
Met
Pat
ien
t C
om
fort
10
U43
.5 [
3]
Ther
e is
an
alte
rnat
ive
(suc
h as
nig
htlig
hts)
to
brig
ht flu
ores
cent
ligh
ting
in b
edro
oms,
pr
ovid
ing
differ
ent
leve
ls o
f lig
htin
g w
hich
bot
h pa
tien
ts a
nd s
taff c
an c
ontr
ol.
Yes
Met
U4
3.6
[1
]Th
e d
esig
n o
f w
ind
ows
con
sid
ers
safe
ty
and
pat
ien
t co
mfo
rt a
nd
is c
onsi
sten
t w
ith
H
ealt
h B
uild
ing
Not
es.
Yes
Met
U44
.1 [
2]In
form
atio
n on
wor
k re
late
d co
unse
lling
se
rvic
es is
cle
arly
dis
play
ed.
No
Not
Met
U44
.2 [
2]
Info
rmat
ion
leaf
lets
abo
ut r
elev
ant
men
tal
heal
th p
robl
ems
and
trea
tmen
ts a
re a
vaila
ble.
Th
ese
are
also
ava
ilabl
e in
diff
eren
t fo
rmat
s an
d la
ngua
ges
whe
n re
quir
ed.
No
Not
Met
Info
rmat
ion
is a
vaila
ble
for
staf
f an
d pa
tien
ts/c
arer
s ab
out
men
tal h
ealth
and
loca
l pu
blic
and
vol
unta
ry s
ecto
r se
rvic
es t
hat
are
avai
labl
e w
hich
incl
ude:
serv
ices
and
exp
ecte
d w
aiting
tim
es;
Yes
faci
litie
s;Ye
s
advo
cacy
ser
vice
s;Ye
s
loca
l sup
port
/adv
ice
orga
nisa
tion
sfo
r pa
tien
ts a
nd c
arer
s;Ye
s
heal
th p
rom
otio
n.Ye
s
Pro
visi
on o
f In
form
atio
n
U44
.3 [
2]M
et
11
44.4
[2]
Info
rmat
ion
is u
p-to
-dat
e an
d re
gula
rly
supp
lied
to a
ll re
leva
nt s
ervi
ce a
reas
in
suffic
ient
qua
ntity.
Yes
Met
All
patien
ts c
an a
cces
s a
rang
e of
cur
rent
cu
ltur
ally
-spe
cific
res
ourc
es for
ent
erta
inm
ent,
w
hich
ref
lect
the
war
d/un
it’s
pop
ulat
ion,
and
w
hich
incl
ude
the
follo
win
g:
good
qua
lity
mag
azin
es;
Yes
daily
new
spap
ers;
Yes
boar
d ga
mes
;Ye
s
card
s;Ye
s
a TV
and
VCR/D
VD
with
vide
os/D
VD
s;Ye
s
com
pute
rs a
nd in
tern
et a
cces
s.Ye
s
a ga
mes
con
sole
.Ye
s
U46
.1 [
2]Th
e w
ard/
unit h
as d
irec
t ac
cess
to
an o
utsi
de
spac
e fo
r ex
erci
se a
nd a
cces
s to
fre
sh a
ir,
whi
ch is
saf
e an
d ha
s se
atin
g.Ye
sM
et
U46
.2 [
2]If
sm
okin
g is
per
mitte
d in
the
gar
den
ther
e is
a
sepa
rate
allo
cate
d ar
ea for
thi
s.Ye
sM
et
Ou
tsid
e S
pac
e
Act
ivit
y Eq
uip
men
t
Met
U45
.1 [
2]
12
U47
.1 [
2]W
ard/
unit-b
ased
sta
ff h
ave
acce
ss t
o a
dedi
cate
d st
aff ro
om,
eith
er o
n or
off t
he
war
d/un
it.
Yes
Not
Met
The
revi
ew t
eam
cha
nged
thi
s st
anda
rd t
o N
ot M
et,
stat
ing
that
the
re is
no
staf
f ro
om a
vaila
ble.
U47
.2 [
2]All
staf
f ha
ve a
cces
s to
a lo
cker
or
lock
ed a
rea
to s
tore
per
sona
l bel
ongi
ngs.
No
Met
The
revi
ew t
eam
cha
nged
thi
s st
anda
rd t
o M
et,
stat
ing
that
th
ere
are
lock
ers
avai
labl
e to
sta
ff.
A m
inut
ed p
atie
nt c
omm
unity
mee
ting
tak
es
plac
e at
leas
t on
ce p
er w
eek.
Yes
PQ
: W
as t
here
a m
inut
ed p
atie
nt c
omm
unity
mee
ting
at
leas
t on
ce p
er w
eek?
8 re
spon
ses:
8
yes
PQ
: W
ere
you
able
to
atte
nd if
you
wan
ted
to?
8 re
spon
ses:
8
yes
Soc
ial/
recr
eati
onal
act
ivit
ies
are
pro
vid
ed
at w
eeke
nd
s.Y
es
PQ
: W
ere
ther
e so
cial
/rec
reat
ion
al
acti
viti
es a
t w
eeke
nd
s?9
res
pon
ses:
1
yes
8 n
o
Soc
ial/
recr
eati
onal
act
ivit
ies
are
pro
vid
ed
du
rin
g t
he
even
ing
s.Y
es
PQ
: W
ere
ther
e so
cial
/rec
reat
ion
al
acti
viti
es d
uri
ng
th
e ev
enin
gs?
9 r
esp
onse
s:
1 y
es 8
no
Sta
ff
Ther
apeu
tic
Mili
eu
53
.11
[1
]
52.1
[2]
Met
Met
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
This
tak
es p
lace
eve
ry M
onda
y an
d is
min
uted
by
staf
f an
d pa
tien
ts;
thes
e m
inut
es a
re d
ispl
ayed
thr
ough
out
the
wee
k.
The
revi
ew t
eam
not
ed t
hat
this
pro
cess
see
ms
to b
e w
orki
ng
wel
l.
Met
Ther
e ar
e al
way
s ga
mes
ava
ilabl
e, a
s w
ell a
s a
box
of
equi
pmen
t. P
atie
nts
are
enco
urag
ed t
o m
anag
e th
eir
own
unst
ruct
ured
tim
e an
d de
vise
act
ivitie
s fo
r th
emse
lves
. A
pam
peri
ng a
ctiv
ity
is a
vaila
ble
for
the
patien
ts o
n Sat
urda
ys.
The
prog
ram
me
occu
pies
mos
t of
the
day
. Th
e po
st-m
eal
supe
rvis
ion
peri
od is
use
d to
pla
y ga
mes
as
a re
crea
tion
al
activi
ty.
Dur
ing
the
even
ing
peri
od,
som
e pa
tien
ts a
re a
ble
to
go in
to t
he c
ity
on le
ave.
53
.12
[1
]
13
Str
uct
ure
0 Saf
ety
Que
stio
n 59
, de
pend
ing
on d
isab
ility
SEL
F-R
EVIE
W C
OM
MEN
TS
0 Faci
litie
s
14
To a
ddre
ss t
he m
any
pote
ntia
l lig
atur
e po
ints
thr
ough
out
the
war
d; m
any
of t
hese
wer
e ob
serv
ed in
bed
room
s be
hind
sol
id
door
s w
ith n
o ob
serv
atio
n w
indo
w.
The
revi
ew t
eam
not
ed t
hat
staf
f di
d no
t ap
pear
suf
ficie
ntly
aw
are
of t
he p
oten
tial f
or
fixtu
res
and
fittin
gs t
o be
use
d as
liga
ture
poi
nts,
and
the
refo
re t
he r
isk
man
agem
ent
plan
for
the
se c
ould
not
be
cons
ider
ed r
obus
t.To
ens
ure
that
the
em
erge
ncy
equi
pmen
t in
clud
es o
xyge
n, t
he r
evie
w t
eam
not
ed t
hat
this
sho
uld
be c
onsi
dere
d a
basi
c re
quirem
ent.
The
revi
ew t
eam
not
ed t
hat
even
in t
he c
ase
on 1
:1 o
bser
vatio
n, p
atie
nts
adm
itted
in a
phy
sica
lly c
ompr
omis
ed s
tate
wer
e qu
ite is
olat
ed u
psta
irs,
and
tha
t in
an
emer
genc
y it
wou
ld b
e a
stru
ggle
to
eith
er g
et p
atie
nts
dow
n, o
r fo
r th
e em
erge
ncy
serv
ices
to
mak
e it
up.
Furt
her
to t
his,
the
uni
t co
uld
not
be c
onsi
dere
d ac
cess
ible
for
dis
able
d pa
tient
s.
Are
as o
f ac
hie
vem
ent.
It is
a lo
vely
war
d en
viro
nmen
t, w
ith a
hom
ely
atm
osph
ere.
Th
e un
it is
rec
over
y fo
cuse
d, w
ith g
ood
risk
ass
essm
ents
, da
ta a
nd fol
low
up.
Th
e fo
od is
fre
shly
coo
ked
on s
ite a
nd p
atie
nts
and
staf
f pr
aise
d its
qua
lity,
as
wel
l as
the
kitc
hen
faci
litie
s.
Ther
e is
pat
ient
art
wor
k ar
ound
the
uni
t, a
s w
ell a
s a
pian
o.
Ther
e is
an
inde
pend
ent
dini
ng t
able
, an
d th
e un
it lo
oks
at n
orm
alis
ing
food
.
ENV
IRO
NM
ENT
AN
D F
AC
ILIT
IES
AU
DIT
- S
UM
MA
RY
Act
ion
po
ints
.
15
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
2.7
[1
]
Ther
e is
a p
olic
y on
th
e n
urs
ing
of
hig
hly
d
istu
rbed
or
very
sic
k p
atie
nts
an
d t
he
staf
fin
g le
vels
of
the
war
d/u
nit
en
able
st
aff
to im
ple
men
t th
is p
olic
y.
Yes
Met
Doe
s th
e w
ard
/un
it h
ave
its
own
d
edic
ated
lead
con
sult
ant
clin
icia
n?
Yes
Do
they
pro
vid
e ex
per
t in
pu
t in
to k
ey
mat
ters
of
serv
ice
del
iver
y, s
taff
su
pp
ort
and
su
per
visi
on,
and
ove
rall
serv
ice
co-
ord
inat
ion
?
Yes
Are
sp
ecif
ic s
essi
ons
set
asid
e in
th
e co
nsu
ltan
t’s
job
pla
n t
o en
sure
su
ffic
ien
t ti
me
is a
vaila
ble
for
th
eir
con
sist
ent
and
re
gu
lar
inp
ut
to t
he
team
an
d r
elat
ed
foru
ms?
Yes
Ther
e is
one
Con
sultan
t Ps
ychi
atri
st p
er
war
d/un
it.
-
Num
ber
of C
onsu
ltan
t Ps
ychi
atri
sts
spec
ified
in C
onte
xtua
l Dat
a:2
(0.2
WTE
)
Met
MD
T S
taff
U3.
2 [3
]M
et
Ther
e ar
e tw
o Con
sultan
t Ps
ychi
atri
sts,
bot
h of
who
m w
ork
in
the
loca
l NH
S T
rust
and
sha
re t
he o
n-ca
ll ho
urs
betw
een
them
.
Sta
ffin
g L
evel
s
U3
.1 [
1]
SEC
TIO
N 1
: G
ENER
AL
STA
ND
AR
DS
CH
ECK
LIS
T
16
3.3
[1
]Is
th
ere
a n
amed
Con
sult
ant
Psy
chia
tris
t fo
r ea
tin
g d
isor
der
s w
ho
has
reg
ula
r in
pu
t in
to p
atie
nt
care
?Y
esM
et
Ther
e is
acc
ess
to d
edic
ated
ses
sion
al o
r pa
rt-
sess
iona
l adm
inis
trat
ive
supp
ort
whi
ch m
eets
th
e ne
eds
of t
he w
ard/
unit.
-
Num
ber
of A
dmin
istr
ator
ssp
ecifi
ed in
Con
text
ual D
ata:
3 (1
.96
WTE
)
The
war
d/un
it h
as d
edic
ated
inpu
t fr
om a
di
etitia
n.-
Num
ber
of D
ietitian
ssp
ecifi
ed in
Con
text
ual D
ata:
1 (0
.1 W
TE)
Ther
e is
a c
lear
and
wri
tten
pol
icy
on t
he
recr
uitm
ent
and
use
of b
ank
and
agen
cy s
taff
in
clud
ing:
a sy
stem
to
ensu
re s
taff h
ave
basi
c sk
ills,
attitu
des
and
com
pete
ncie
s re
quir
ed;
prop
er a
rran
gem
ents
for
the
indu
ctio
n an
dm
anag
emen
t of
ban
k an
d ag
ency
sta
ff;
Yes
a sy
stem
to
rout
inel
y m
onitor
and
rep
ort
on t
he u
se o
f ba
nk a
nd a
genc
y st
aff.
Ye
s
Rec
ruit
men
t an
d R
eten
tion
of
Sta
ff
U3.
11 [
2]M
et
U5.
2 [2
]M
et
The
unit u
ses
thei
r ow
n ba
nk o
f st
aff an
d re
tent
ion
is g
ood.
3.12
[2]
Met
A s
peci
alis
t di
etitia
n, w
ho o
vers
ees
mea
l pla
ns,
is a
vaila
ble
ever
y W
edne
sday
as
wel
l as
on a
n ad
hoc
bas
is.
Yes
17
The
war
d/u
nit
has
cle
ar c
linic
al
sup
ervi
sion
gu
idel
ines
wh
ich
inco
rpor
ate
sup
ervi
sion
con
trac
ts b
etw
een
su
per
viso
r an
d s
up
ervi
see
to c
over
:
lear
nin
g/t
rain
ing
ob
ject
ives
;Y
es
reso
luti
on o
f co
nfl
ict
(arb
itra
tor
iden
tifi
ed);
Yes
role
s an
d r
esp
onsi
bili
ties
;Y
es
pra
ctic
alit
ies,
e.g
. lo
cati
on;
Yes
bou
nd
arie
s, e
.g.
Tim
ean
d a
gre
ed a
gen
da;
Yes
doc
um
enta
tion
to
be
use
d;
Yes
con
fid
enti
alit
y (a
dh
eren
ce t
op
rofe
ssio
nal
cod
e of
con
du
ctan
d T
rust
/org
anis
atio
n p
olic
y);
Yes
acti
on in
eve
nt
ofn
on-a
tten
dan
ce o
r ca
nce
llati
on;
Yes
freq
uen
cy a
nd
du
rati
on.
Yes
U1
0.1
[1
]Th
ere
are
clea
r p
olic
ies
and
pro
ced
ure
s fo
r m
anag
ing
com
pla
ints
.Y
esM
et
U1
1.1
[1
]In
ter-
agen
cy p
roto
cols
are
in p
lace
for
th
e sa
feg
uar
din
g o
f ad
ult
s.Y
esM
et
U6
.2 [
1]
Com
plim
ents
an
d C
omp
lain
ts
Ap
pra
isal
, S
up
ervi
sion
an
d S
taff
Su
pp
ort
Met
Rep
orti
ng
In
app
rop
riat
e/A
bu
sive
Car
e
18
U1
1.2
[1
]
Ther
e ar
e p
roto
cols
/pro
ced
ure
s/
stra
teg
ies
in p
lace
for
th
e co
nfi
den
tial
re
por
tin
g o
f or
‘wh
istl
eblo
win
g’ o
n a
bu
se
or in
app
rop
riat
e ca
re.
Yes
Met
U1
2.1
[1
]Th
ere
is a
sm
oke-
free
pol
icy
for
staf
f an
d
pat
ien
ts,
wh
ich
fol
low
s H
DA
gu
idan
ce a
nd
b
est
pra
ctic
e.N
oM
et
The
revi
ew t
eam
cha
nged
thi
s st
anda
rd t
o M
et,
noting
tha
t th
ere
is a
sm
okin
g sh
elte
r.
Ther
e is
an
info
rmat
ion
-sh
arin
g p
roto
col
con
firm
ed a
t Tr
ust
/org
anis
atio
n b
oard
le
vel o
f w
hic
h a
ll st
aff
are
awar
e, a
nd
th
is
is p
ub
licis
ed t
o vi
sito
rs a
nd
pat
ien
ts.
Yes
SQ
: A
re y
ou a
war
e of
th
e Tr
ust
/org
anis
atio
n's
info
rmat
ion
-sh
arin
g
pro
toco
l?
19
re
spon
ses:
1
7 y
es 2
no
13.1
1 [2
]
Info
rmat
ion
and
guid
ance
abo
ut t
he s
peci
alis
t se
rvic
e, in
clud
ing
tim
esca
les
from
ref
erra
l to
adm
issi
on a
nd w
ritt
en r
efer
ral c
rite
ria,
is
read
ily a
vaila
ble
to r
efer
rers
.
Yes
Met
13.1
2 [2
]
The
adm
issi
on p
olic
y de
scri
bes
how
dec
isio
ns
rega
rdin
g th
e ap
prop
riat
e pl
ace
of a
dmis
sion
fo
r ol
der
peop
le a
re p
rim
arily
bas
ed o
n m
enta
l an
d ph
ysic
al n
eed.
Yes
Met
SEC
TIO
N 2
: TI
MEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
U1
3.1
[1
]M
et
Sm
okin
g
19
Ther
e ar
e pr
otoc
ols
for
tran
sfer
or
shar
ed c
are
betw
een
lear
ning
dis
abili
ty a
nd g
ener
ic m
enta
l he
alth
ser
vice
s w
hich
cle
arly
spe
cify
:
cons
ulta
nt r
espo
nsib
ility
;Ye
s
the
role
s an
d re
spon
sibi
litie
s of
inpa
tien
tan
d co
mm
unity
team
s in
bot
h m
enta
lhe
alth
and
lear
ning
dis
abili
ty s
ervi
ces;
Yes
the
requ
irem
ent
for
join
t ca
repl
anni
ng a
t an
indi
vidu
al le
vel;
Yes
the
requ
irem
ent
for
a w
ritt
en c
are
plan
to
spec
ify w
hat
supp
ort
each
serv
ice
can
expe
ct fro
m t
he o
ther
;Ye
s
role
s an
d re
spon
sibi
litie
s in
rel
atio
n to
CPA
;Ye
s
info
rmat
ion-
shar
ing.
Yes
14
.1 [
1]
Bed
occ
up
ancy
is m
anag
ed a
t a
serv
ice
leve
l, a
nd
th
ere
is a
cle
ar p
roce
ss f
or
exce
edin
g a
gre
ed o
ccu
pan
cy le
vels
.Y
esM
et
Con
trol
of
Bed
Occ
up
ancy
13.1
3 [2
]M
et
20
On
th
e d
ay o
f th
eir
adm
issi
on o
r as
soo
n
as t
hey
are
wel
l en
oug
h,
the
pat
ien
t is
g
iven
a “
wel
com
e p
ack”
or
intr
odu
ctor
y b
ookl
et..
.
...t
hat
con
tain
s th
e fo
llow
ing
:
a cl
ear
des
crip
tion
of
the
aim
s of
th
e w
ard
/un
it;
Yes
the
curr
ent
pro
gra
mm
ean
d m
odes
of
trea
tmen
t;Y
es
a cl
ear
des
crip
tion
of
wh
at is
exp
ecte
dan
d r
igh
ts a
nd
res
pon
sib
iliti
es;
Yes
a si
mp
le d
escr
ipti
on o
f th
e w
ard
/un
it's
ph
iloso
ph
y, p
rin
cip
les
and
th
eir
rati
onal
e;Y
es
the
war
d/u
nit
tea
m m
emb
ersh
ip,
incl
ud
ing
th
e n
ame
of t
he
pat
ien
t's
Con
sult
ant
Psy
chia
tris
t an
d K
eyW
orke
r/P
rim
ary
Nu
rse;
Yes
visi
tin
g a
rran
gem
ents
;Y
es
per
son
al s
afet
y on
th
e w
ard
/un
it;
Yes
war
d/u
nit
fac
iliti
es a
nd
th
ela
you
t of
th
e w
ard
/un
it;
Yes
war
d/u
nit
pro
gra
mm
e of
act
ivit
ies;
Yes
wh
at p
ract
ical
item
s p
atie
nts
nee
d in
hos
pit
al a
nd
wh
at s
hou
ld b
e b
rou
gh
t in
;Y
es
reso
urc
es t
o m
eet
eth
nic
ity
and
gen
der
nee
ds;
Yes
PQ
: W
ere
you
giv
en a
"w
elco
me
pac
k" o
r in
tro
du
cto
ry b
oo
klet
?9
res
pon
ses:
8
yes
1 n
o
Ad
mis
sion
Pro
cess
U1
8.5
[1
]
This
was
obs
erve
d by
the
rev
iew
tea
m o
n th
e da
y.
Met
21
18
.6 [
1]
If t
he
pat
ien
t is
ad
mit
ted
info
rmal
ly,
on
the
day
of
thei
r ad
mis
sion
or
as s
oon
as
they
are
wel
l en
oug
h t
hey
are
giv
en
acce
ssib
le w
ritt
en in
form
atio
n o
n t
hei
r ri
gh
ts,
rig
hts
to
ad
voca
cy a
nd
sec
on
d
opin
ion
, ri
gh
t of
acc
ess
to in
terp
reti
ng
se
rvic
es,
pro
fess
ion
al r
oles
an
d
resp
onsi
bili
ties
an
d t
he
com
pla
ints
p
roce
du
re.
Yes
Met
U1
8.7
[1
]
If t
he
pat
ien
t is
det
ain
ed e
ith
er o
n
adm
issi
on o
r su
bse
qu
entl
y, t
hey
are
, in
ac
cord
ance
wit
h S
ecti
on 1
32
of
the
MH
A,
giv
en w
ritt
en in
form
atio
n o
n t
hei
r ri
gh
ts.
No
N/A
This
sta
ndar
d w
as c
hang
ed b
y th
e re
view
tea
m fro
m N
ot M
et
to N
/A a
s th
e un
it o
nly
adm
its
info
rmal
pat
ient
s.
(18
.6 [
1]
/U
18
.7
[1])
PQ
: H
ave
you
bee
n g
iven
wri
tten
in
form
atio
n o
n y
our
rig
hts
as
an in
form
al
or d
etai
ned
pat
ien
t?
9 r
esp
onse
s:
7 y
es 2
no
-
Du
rin
g in
tim
ate
or p
hys
ical
exa
min
atio
ns
a ch
aper
one
is a
lway
s co
nsi
der
ed,
dep
end
ing
on
th
e ri
sks
and
nee
ds
of t
he
pat
ien
t or
sta
ff,
and
th
e w
ard
/un
it h
as a
p
roto
col r
elat
ing
to
this
.
Yes
SQ
: D
uri
ng
inti
mat
e or
ph
ysic
al
exam
inat
ion
s, is
a c
hap
eron
e al
way
s co
nsi
der
ed,
dep
end
ing
on
th
e ri
sks
and
n
eed
s of
th
e p
atie
nt
or s
taff
?
6 r
esp
onse
s:
6 y
es
Init
ial A
sses
smen
t
U1
9.2
[1
] M
et
The
unit is
abl
e to
sou
rce
mal
e ch
aper
ones
whe
re n
eces
sary
.
22
U2
3.3
[1
]
Ther
e is
a s
tan
dar
dis
ed p
roce
ss f
or t
he
asse
ssm
ent
of m
enta
l cap
acit
y, u
sin
g a
fo
rmal
doc
um
ent/
stan
dar
dis
ed
asse
ssm
ent
tool
.
Yes
Met
Met
, ho
wev
er t
he r
evie
w t
eam
not
ed t
hat
the
war
d ha
d no
t co
nsid
ered
how
the
MCA c
ould
be
appl
icab
le t
o th
eir
patien
ts.
U24
.4 [
2]Th
e w
ard/
unit h
as a
gree
d st
anda
rds
for
revi
ews.
Yes
Met
U25
.2 [
2]M
anag
ers
and
prac
tition
ers
have
agr
eed
stan
dard
s fo
r tr
ansf
er/d
isch
arge
pla
nnin
g.Ye
sM
et
25
.11
[1
]Th
ere
is a
pro
ced
ure
in p
lace
for
info
rmal
p
atie
nts
wh
o d
isch
arg
e th
emse
lves
ag
ain
st m
edic
al a
dvi
ce.
Yes
Met
25
.33
[1
]
Ther
e ar
e tr
ansf
er p
roto
cols
in p
lace
to
tran
sfer
pat
ien
ts in
to a
cute
med
ical
se
rvic
es a
nd
th
ese
com
ply
wit
h M
AR
SIP
AN
re
com
men
dat
ion
s.
Yes
Met
Rev
iew
s
Dis
char
ge
Pla
nn
ing
Con
tin
uou
s A
sses
smen
t
23
Ther
e is
a p
olic
y on
pat
ien
t sa
fety
an
d t
he
use
of
ther
apeu
tic
inte
rven
tion
s an
d
obse
rvat
ion
th
at in
clu
des
:
how
act
ivit
ies,
th
erap
ies
and
sta
ffsk
ill m
ix a
re u
sed
sp
ecif
ical
ly t
oim
pro
ve p
atie
nt
safe
ty;
Yes
how
pat
ien
ts a
re in
form
ed a
bou
tm
ain
tain
ing
th
eir
per
son
al s
afet
yin
clu
din
g t
he
use
of
alar
ms;
Yes
wh
o ca
n in
stig
ate
obse
rvat
ion
ab
out
the
gen
eral
leve
l an
d w
ho
can
chan
ge
the
leve
l of
obse
rvat
ion
;Y
es
wh
o sh
ould
rev
iew
th
e le
vel o
fob
serv
atio
n a
nd
wh
en r
evie
ws
shou
ldta
ke p
lace
(at
leas
t ev
ery
shif
t);
Yes
how
th
e p
atie
nt'
s p
ersp
ecti
vew
ill b
e ta
ken
into
acc
oun
t;Y
es
the
pro
cess
th
rou
gh
wh
ich
a r
evie
wb
y a
full
clin
ical
rev
iew
will
tak
e p
lace
ifob
serv
atio
n a
bov
e th
e g
ener
al le
vel
con
tin
ues
for
mor
e th
an o
ne
wee
k.
Yes
Pat
ien
ts r
ecei
ve in
form
atio
n a
bou
t th
e le
vel o
f ob
serv
atio
n t
hat
th
ey a
re u
nd
er,
how
it is
inst
igat
ed,
the
revi
ew p
roce
ss
and
how
pat
ien
t p
ersp
ecti
ves
are
take
n
into
acc
oun
t.
Yes
PQ
: H
ave
you
bee
n g
iven
info
rmat
ion
ab
out
the
leve
l of
obse
rvat
ion
you
wer
e u
nd
er?
9 r
esp
onse
s:
8 y
es 1
no
28
.2 [
1]
Met
U2
8.1
[1
]M
et
Ther
e is
hou
rly
obse
rvat
ion
thro
ugho
ut t
he n
ight
whi
ch is
re
view
ed w
ith
a do
ctor
.
SEC
TIO
N 3
: S
AFE
TYO
bse
rvat
ion
24
U2
9.2
[1
]
Ther
e is
an
op
erat
ion
al p
olic
y on
se
arch
ing
, b
ased
on
leg
al a
dvi
ce,
wh
ich
co
mp
lies
wit
h N
ICE
gu
idan
ce a
nd
th
e H
um
an R
igh
ts A
ct.
Yes
Met
Ther
e is
a w
ritt
en m
utu
al c
ode
of c
ond
uct
or
sim
ilar
for
war
d/u
nit
beh
avio
ur
of
wh
ich
pat
ien
ts a
re a
dvi
sed
, an
d a
dh
eren
ce
to t
his
is m
onit
ored
.
Yes
PQ
: W
as it
exp
lain
ed t
o yo
u t
hat
th
ere
is a
'c
ode
of c
ond
uct
', o
r ru
les
on h
ow s
taff
an
d p
atie
nts
sh
ould
beh
ave,
wh
ich
you
w
ere
exp
ecte
d t
o fo
llow
wh
ile o
n t
he
war
d?
9 r
esp
onse
s:
9 y
es
U29
.4 [
2]
Ther
e ar
e ag
reed
pro
toco
ls in
pla
ce w
ith
loca
l po
lice
whi
ch e
nsur
e ef
fect
ive
and
sens
itiv
e lia
ison
reg
ardi
ng in
cide
nts
of c
rim
inal
ac
tivi
ty/h
aras
smen
t/vi
olen
ce.
Yes
Met
U29
.5 [
2]
Ther
e ar
e lo
cal p
roto
cols
to
ensu
re t
hat
the
polic
e an
d st
aff ar
e aw
are
of t
he p
roce
dure
s an
d as
crib
ed r
oles
in a
n em
erge
ncy,
in o
rder
to
prev
ent
mis
unde
rsta
ndin
g be
twee
n di
ffer
ent
agen
cies
. T
he p
olic
ies
set
out
wha
t co
nstitu
tes
an e
mer
genc
y re
quir
ing
polic
e in
terv
ention
.
Yes
Met
Man
agem
ent
of V
iole
nce
U2
9.3
[1
]M
et
This
is c
over
ed b
y th
e ag
reem
ent
sign
ed b
y pa
tien
ts u
pon
adm
issi
on;
patien
ts k
eep
a co
py o
f th
is.
Som
etim
es a
co
ntra
ct is
giv
en for
indi
vidu
al p
atie
nts.
Th
ere
is in
form
atio
n re
gard
ing
'exp
ecta
tion
s' in
the
wel
com
e pa
ck.
25
U2
9.6
[1
]
An
y in
cid
ent
req
uir
ing
rap
id
tran
qu
illis
atio
n,
ph
ysic
al in
terv
enti
on o
r se
clu
sion
is r
ecor
ded
con
tem
por
aneo
usl
y,
usi
ng
a lo
cal t
emp
late
, w
hic
h r
ecor
ds
the
use
of
thes
e in
terv
enti
ons
and
th
e p
roce
du
res
take
n d
uri
ng
th
ese
inte
rven
tion
s, a
nd
an
y ad
vers
e ou
tcom
es.
No
N/A
The
revi
ew c
hang
ed t
he s
tand
ard
from
Not
Met
to
N/A
as
rapi
d tr
anqu
illis
atio
n, p
hysi
cal i
nter
vent
ion
or s
eclu
sion
are
no
t pr
actise
d on
the
uni
t.
U2
9.7
[1
]Th
e w
ard
/un
it h
as m
ech
anis
ms
to
doc
um
ent
and
mon
itor
all
inci
den
ts o
f vi
olen
ce a
nd
ag
gre
ssio
n.
Yes
Met
29
.11
[1
]
Ther
e ar
e w
ritt
en p
olic
ies
on t
he
use
of
rest
rain
t of
wh
ich
all
staf
f ar
e aw
are.
Th
e p
olic
ies
incl
ud
e p
rovi
sion
for
rev
iew
of
each
inci
den
t of
res
trai
nt,
an
d it
s ap
plic
atio
n is
au
dit
ed.
No
N/A
This
sta
ndar
d w
as c
hang
ed fro
m N
ot M
et t
o N
/A a
s re
stra
int
is n
ot u
sed
on t
he u
nit.
31
.1 [
1]
Ther
e is
a p
olic
y on
th
e p
reve
nti
on a
nd
m
anag
emen
t of
pre
ssu
re s
ores
.Y
esM
et
Pre
ssu
re U
lcer
Car
e
26
The
war
d/u
nit
has
a s
trat
egy
for
the
com
pre
hen
sive
car
e of
pat
ien
ts w
ith
du
al
dia
gn
osis
th
at in
clu
des
:
liais
on b
etw
een
men
tal h
ealt
han
d s
ub
stan
ce m
isu
se s
ervi
ces;
Yes
reg
ula
r d
rug
/alc
ohol
scr
een
ing
to s
up
por
t d
ecis
ion
s ab
out
care
/tre
atm
ent
opti
ons;
Yes
liais
on b
etw
een
men
tal h
ealt
h a
nd
stat
uto
ry a
nd
vol
un
tary
ag
enci
es;
Yes
staf
f tr
ain
ing
(w
hic
h in
clu
des
inp
ut
from
th
e p
olic
e);
No
the
app
oin
tmen
t of
key
sta
ff w
ho
will
lead
clin
ical
dev
elop
men
ts;
Yes
clea
r p
roto
cols
, ag
reed
wit
h t
he
pol
ice;
Yes
con
sid
erat
ion
as
to t
he
imp
act
onot
her
pat
ien
ts o
f ad
vers
e b
ehav
iou
rd
ue
to a
lcoh
ol/d
rug
ab
use
.Y
es
U3
3.2
[1
]
Ther
e ar
e cl
ear
and
com
pre
hen
sive
p
olic
ies
and
pro
ced
ure
s re
gar
din
g p
osit
ive
risk
-tak
ing
an
d il
licit
dru
g u
se w
ith
in t
he
inp
atie
nt
war
d/u
nit
.
Yes
Met
U3
9.1
[1
]Th
ere
is a
cle
ar w
ritt
en p
olic
y on
th
e u
se
of s
eclu
sion
, w
hic
h c
omp
lies
wit
h t
he
MH
A
and
NIC
E C
G2
5.
No
N/A
This
sta
ndar
d w
as c
hang
ed fro
m N
ot M
et t
o N
/A a
s se
clus
ion
is n
ot p
ract
ised
at
the
unit.
Sec
lusi
on
Man
agem
ent
of A
lcoh
ol a
nd
Ille
gal
Dru
gs
U3
3.1
[1
]M
et
Whi
lst
this
sta
ndar
d is
met
, it is
unl
ikel
y th
at p
atie
nts
with
dual
dia
gnos
is w
ould
be
adm
itte
d.
SEC
TIO
N 4
: E
NV
IRO
NM
ENT
AN
D F
AC
ILIT
IES
27
41
.15
[1
]
The
war
d/u
nit
has
a w
ritt
en p
olic
y fo
r h
ow p
atie
nts
are
th
erap
euti
cally
su
pp
orte
d a
t m
ealt
imes
. T
his
pol
icy
incl
ud
es s
taff
eat
ing
th
e sa
me
food
wh
en
eati
ng
wit
h p
atie
nts
.
Yes
Met
U42
.8 [
2]
Ther
e is
a p
olic
y on
the
use
of de
vice
s w
ith
the
capa
city
to
com
mun
icat
e an
d/or
rec
ord,
whi
ch
is c
omm
unic
ated
to
staf
f, p
atie
nts
and
visi
tors
, e.
g. b
y m
eans
of a
post
er/l
eafle
t. Th
is
incl
udes
dev
ices
suc
h as
mob
ile p
hone
s.
No
Met
The
revi
ew t
eam
cha
nged
thi
s st
anda
rd t
o M
et.
Patien
ts s
ign
an a
gree
men
t su
rrou
ndin
g th
e us
e of
mob
ile p
hone
s, a
nd
phon
es a
re h
eld
by t
he s
taff for
the
fir
st fou
r w
eeks
.
49
.1 [
1]
Ther
e is
a p
olic
y th
at s
tate
s th
at o
ral
refe
edin
g is
th
e p
refe
rred
met
hod
, an
d
ther
e is
a p
olic
y fo
r w
hen
en
tera
l fee
din
g
is u
sed
.
Yes
Met
SEC
TIO
N 5
: T
HER
AP
IES
AN
D A
CTI
VIT
IES
Dig
nit
y
Cat
erin
g
Ref
eed
ing
28
Ther
e ar
e p
olic
ies
on t
he
follo
win
g
med
ical
an
d p
sych
iatr
ic e
mer
gen
cies
th
at
occu
r in
eat
ing
dis
ord
ers
and
sta
ff
dem
onst
rate
aw
aren
ess
of w
hat
to
do
in
thes
e si
tuat
ion
s:
refe
edin
g s
ynd
rom
e;Y
es
elec
trol
yte
dis
turb
ance
;Y
es
extr
eme
agit
atio
n;
Yes
hyp
ogly
caem
ia.
Yes
SQ
: A
re y
ou a
war
e of
wh
at t
o d
o if
em
erg
enci
es s
uch
as
the
follo
win
g o
ccu
r:
refe
edin
g s
ynd
rom
e;7
res
pon
ses:
6
yes
1 n
o
elec
trol
yte
dis
turb
ance
;7
res
pon
ses:
6
yes
1 n
o
extr
eme
agit
atio
n;
7 r
esp
onse
s:
7 y
es
hyp
ogly
caem
ia?
7 r
esp
onse
s:
7 y
es
49
.5 [
1]
Ther
e is
a w
ritt
en p
roto
col o
n h
ow t
o m
anag
e re
feed
ing
. Y
esM
et
49
.8 [
1]
Wh
en n
asog
astr
ic f
eed
ing
is u
sed
, th
e R
oyal
Col
leg
e of
Psy
chia
tris
ts' a
nd
NP
SA
g
uid
ance
is a
dh
ered
to.
Yes
N/A
This
was
cha
nged
to
N/A
as
the
unit d
oes
not
prac
tise
na
soga
stri
c fe
edin
g.
49
.4 [
1]
Met
29
49
.9 [
1]
Res
trai
nt
to f
eed
an
d/o
r n
asog
astr
ic
bri
dle
s ar
e on
ly u
sed
in li
fe-t
hre
aten
ing
si
tuat
ion
s or
as
par
t of
a c
aref
ully
co
nsi
der
ed m
ult
i-d
isci
plin
ary
care
pla
n,
wh
ich
is r
egu
larl
y re
view
ed.
No
N/A
This
was
cha
nged
to
N/A
by
the
revi
ew t
eam
.
U53
.8 [
2]At
leas
t on
e st
aff m
embe
r lin
ked
to t
he
war
d/un
it is
del
iver
ing
one
prob
lem
-spe
cific
, hi
gh in
tens
ity
psyc
holo
gica
l int
erve
ntio
n.
Yes
Met
U53
.9 [
3]
At
leas
t on
e st
aff m
embe
r lin
ked
to t
he
war
d/un
it is
del
iver
ing
two
or m
ore
prob
lem
-sp
ecifi
c, h
igh
inte
nsity
psyc
holo
gica
l in
terv
ention
s (t
o co
rres
pond
to
two
or m
ore
diag
nost
ic c
rite
ria
as p
er N
ICE
guid
ance
).
Yes
Met
Ther
e is
a s
tru
ctu
red
th
erap
euti
c p
rog
ram
me
from
Mon
day
to
Frid
ay a
nd
th
e ti
met
able
is m
ade
avai
lab
le t
o p
atie
nts
.
Yes
PQ
: W
as t
her
e a
stru
ctu
red
th
erap
euti
c p
rog
ram
me
from
Mon
day
to
Frid
ay?
9 r
esp
onse
s:
9 y
es
Met
53
.28
[1
]
Ther
e is
a c
opy
of t
his
in t
he w
elco
me
pack
.
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
30
CH
ECK
LIS
T -
SU
MM
AR
Y
It w
ould
be
usef
ul t
o sa
fegu
ard
phon
es.
The
revi
ew t
eam
fel
t th
at b
oth
ligat
ure
poin
ts a
nd s
ight
line
s sh
ould
be
addr
esse
d.It
was
not
ed b
y th
e re
view
tea
m t
hat
the
care
pla
n ap
pear
ed t
o be
ver
y m
edic
ally
led;
it is
sug
gest
ed t
hat
the
war
d co
nsid
er w
ays
to im
prov
e th
e in
clus
ion
of t
he v
iew
s an
d ob
serv
atio
ns o
f ot
her
team
mem
bers
in t
he r
evie
w p
roce
ss.
Act
ion
po
ints
.
The
unit
mak
es c
aref
ul r
efer
rals
. D
octo
rs a
nd n
urse
s ar
e av
aila
ble
on-c
all.
Ther
e is
col
labo
rativ
e w
orki
ng o
n th
e un
it an
d th
ere
is g
ood
rete
ntio
n of
pos
itive
sta
ff.
The
unit
wor
ks a
nd m
anag
es w
ell a
long
side
cha
lleng
ing
patie
nts.
It
is g
ood
that
hyp
osto
p ha
s be
en o
rder
ed.
Are
as o
f ac
hie
vem
ent.
31
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
An
initia
l ver
bal r
espo
nse
to r
efer
rers
withi
n tw
o w
orki
ng d
ays
of r
ecei
pt o
f a
wri
tten
re
ferr
al.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
A for
mal
wri
tten
rep
ort
withi
n 14
day
s of
as
sess
men
t w
ith
the
serv
ice.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e0
An
iden
tifi
ed a
nd
doc
um
ente
d c
onta
ct o
r lin
k p
erso
n f
or e
ach
ag
ency
invo
lved
wit
h
each
pat
ien
t.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
SEC
TIO
N 2
: T
IMEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
16.7
[2]
Com
men
ts
0
U1
7.1
[1
]
Com
men
ts
0
On
or
Bef
ore
Ad
mis
sion
HEA
LTH
REC
OR
D A
UD
IT
0
NB
: C
omm
ents
wer
e on
ly r
equ
ired
for
'No'
an
d 'N
/A' r
esp
onse
s
Ref
erra
ls
16.2
[2]
Com
men
ts
32
All
com
mun
ity
asse
ssm
ent
docu
men
tation
, av
aila
ble
to t
he a
dmitting
tea
m w
hen
the
patien
t ar
rive
d on
the
war
d/un
it,
incl
udin
g m
enta
l hea
lth
and
curr
ent
risk
ass
essm
ents
an
d st
ated
pur
pose
of ad
mis
sion
.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
Wh
ere
a p
atie
nt
was
ad
mit
ted
dir
ectl
y fr
om t
he
com
mu
nit
y, t
he
adm
itti
ng
nu
rse
chec
ked
th
at t
he
refe
rrin
g a
gen
cy g
ave
clea
r in
form
atio
n a
s to
th
e se
curi
ty o
f th
e p
atie
nt’
s h
ome,
wh
erea
bou
ts o
f ch
ildre
n/a
nim
als
etc.
11
re
spon
ses:
9
yes
2 N
/A
Met
Res
pons
e
N/A
N/A
A ful
l phy
sica
l exa
min
atio
n, c
arri
ed o
ut a
s pa
rt
of t
he a
dmis
sion
pro
cess
.11
res
pons
es:
11 y
es
Met
Res
pons
e
0
Com
men
ts
Patien
t ad
mitte
d fr
om p
aren
ts' h
ome,
no
hom
e se
curi
ty
info
rmat
ion
need
ed
Patien
t m
arri
ed,
husb
and
look
aft
er m
arital
hom
e, n
o de
pend
ents
U19
.1 [
2]
Com
men
ts
0
17.3
[2]
Com
men
ts
0
18
.10
[1
]
Ad
mis
sion
Pro
cess
Init
ial A
sses
smen
t
33
Furt
her
targ
eted
exa
min
atio
ns a
re u
nder
take
n if
the
phys
ical
his
tory
or
phys
ical
sym
ptom
s de
man
d (i
nclu
din g
blo
od t
ests
, ur
inal
ysis
, EC
G,
EEG
, x-
rays
, br
ain
imag
ing)
. T
his
is
unde
rtak
en p
rom
ptly
and
a n
amed
indi
vidu
al is
re
spon
sibl
e fo
r fo
llow
-up.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
U19
.3 [
2]
Com
men
ts
0
34
Wh
ere
the
pat
ien
t is
fou
nd
to
hav
e a
ph
ysic
al c
ond
itio
n w
hic
h m
ay in
crea
se t
he
risk
to
them
of
colla
pse
or
inju
ry d
uri
ng
re
stra
int,
th
is is
:
a. c
lear
ly d
ocu
men
ted
in t
hei
r re
cord
s;
b.
reg
ula
rly
revi
ewed
;1
1
resp
onse
s:
11
N/
A
c. c
om
mu
nic
ated
to
all
MD
T m
emb
ers;
11
re
spon
ses:
1
1 N
/A
d.
eval
uat
ed w
ith
th
em a
nd
, w
her
e ap
pro
pri
ate,
th
eir
care
r/ad
voca
te.
11
re
spon
ses:
1
1 N
/A
N/A
Patien
ts a
re n
ot r
estr
aine
d at
[un
it n
ame]
Com
men
ts
Res
trai
nt n
ot c
arri
ed o
ut a
t [u
nit
nam
e]
Res
trai
nt n
ot c
arri
ed o
ut a
t [u
nit
nam
e]
Res
trai
nt n
ot p
ract
ised
withi
n th
e un
it
U1
9.4
[1
]1
1
resp
onse
s:
11
N/
A
Patien
ts a
re n
ot r
estr
aine
d w
ithi
n th
e un
it
Res
trai
nt n
ot c
arri
ed o
ut a
t [u
nit
nam
e]
Res
trai
nt n
ot u
sed
in t
his
faci
lity
Res
trai
nt n
ot p
ract
ised
withi
n [u
nit
nam
e]
Res
trai
nt n
ot c
arri
ed o
ut a
t [u
nit
nam
e]
Res
trai
nt n
ot p
ract
ised
at
[uni
t na
me]
Res
trai
nt is
not
car
ried
out
at
[uni
t na
me]
35
The
pat
ien
t w
as in
form
ed o
f th
e le
vel o
f ri
sk t
o th
eir
ph
ysic
al h
ealt
h.
If t
he
pat
ien
t g
ave
con
sen
t, t
his
was
als
o sh
ared
wit
h
thei
r ca
rer/
fam
ily.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0 9
resp
onse
s: 7
yes
2
no
PQ
: W
ere
you
giv
e in
form
atio
n o
n t
he
risk
s to
you
r p
hys
ical
hea
lth
of
hav
ing
an
eat
ing
dis
ord
er?
19
.5 [
1]
Com
men
ts
0
36
The
imm
edia
te r
isk
asse
ssm
ent
of t
he
pat
ien
t in
clu
des
:
a. id
enti
fica
tion
of
wh
eth
er t
hey
may
be
pre
dat
ory
or li
kely
to
abu
se o
r of
fen
d;
b.
pot
enti
al p
hys
ical
, p
sych
olog
ical
an
dso
cial
ris
ks t
o th
emse
lves
an
d/o
r ot
her
s;
11
re
spon
ses:
1
1 y
es
c. r
isk
of s
elf-
har
m;
11
re
spon
ses:
1
1 y
es
d.
risk
of
suic
ide;
11
re
spon
ses:
1
1 y
es
e. le
vel o
f su
bst
ance
use
;1
1
resp
onse
s:
11
yes
f. a
bsc
ond
ing
ris
k, a
s w
ell a
s ri
sk o
fh
arm
if t
he
pat
ien
t ab
scon
ds;
11
re
spon
ses:
1
1 y
es
g.
Pot
enti
al p
hys
ical
ris
ks,
incl
ud
ing
fal
lsri
sk,
mal
nu
trit
ion
/deh
ydra
tion
ris
k,p
ress
ure
ulc
er d
evel
opm
ent
risk
etc
;
11
re
spon
ses:
1
1 y
es
Met
This
is it
emis
ed o
n th
e ri
sk a
sses
smen
t sh
eet.
U1
9.7
[1
]
11
re
spon
ses:
9
yes
2 N
/A
37
h.
con
sen
t or
ref
usa
l of
con
sen
t to
tre
atm
ent;
11
re
spon
ses:
1
1 y
es
i. s
exu
al v
uln
erab
ility
;1
1
resp
onse
s:
11
yes
j. f
inan
cial
vu
lner
abili
ty.
11
re
spon
ses:
1
1 y
es
k. s
elf-
neg
lect
;1
1
resp
onse
s:
11
yes
l. p
ub
lic p
rote
ctio
n a
nd
safe
gu
ard
ing
issu
es.
11
re
spon
ses:
1
1 y
es
"
"
Com
men
ts
a) P
atie
nt h
as n
o hi
stor
y of
offen
ding
or
abus
ive
beha
viou
r
No
hist
ory
of a
busi
ve o
r of
fend
ing
beha
viou
r
38
The
pat
ien
t m
et w
ith
th
eir
Pri
mar
y or
A
lloca
ted
Nu
rse
to c
omp
lete
th
e in
itia
l as
sess
men
t an
d in
itia
te t
hei
r ca
re p
lan
w
ith
in t
he
firs
t 7
2 h
ours
fol
low
ing
ad
mis
sion
. T
his
incl
ud
ed:
a. e
thn
icit
y;
b.
emp
loym
ent
stat
us;
11
re
spon
ses:
1
1 y
es
c. s
pir
itu
al n
eed
s;1
1
resp
onse
s:
11
yes
d.
cult
ura
l nee
ds;
11
re
spon
ses:
1
1 y
es
e. s
ocia
l nee
ds;
11
re
spon
ses:
1
1 y
es
f. p
hys
ical
nee
ds;
11
re
spon
ses:
1
1 y
es
g.
asse
ssm
ent
of m
enta
lca
pac
ity
(if
req
uir
ed);
11
re
spon
ses:
1
1 y
es
h.
con
tin
uin
g c
onse
nt
or r
efu
sal
of c
onse
nt
to t
reat
men
t.
11
re
spon
ses:
1
1 y
es
Met
19
.8 [
1]
This
is it
emis
ed o
n th
e pe
rson
al d
etai
ls s
heet
and
ris
k as
sess
men
t sh
eet.
11
re
spon
ses:
1
1 y
es
Com
men
ts
0
39
A f
orm
al a
sses
smen
t of
nu
trit
ion
al s
tatu
s is
car
ried
ou
t b
y a
qu
alif
ied
die
titi
an o
n
adm
issi
on,
wit
hin
tw
o w
orki
ng
day
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
All
care
pla
ns
wer
e n
egot
iate
d w
ith
th
e p
atie
nt
as f
ar a
s p
ossi
ble
, an
d w
ere
bas
ed
on a
com
pre
hen
sive
ph
ysic
al,
psy
chol
ogic
al,
soci
al a
nd
cu
ltu
ral/
spir
itu
al
asse
ssm
ent.
Th
ey in
clu
ded
a
com
pre
hen
sive
ris
k an
d s
tren
gth
s as
sess
men
t, t
akin
g in
to a
cco
un
t p
atie
nt
pre
fere
nce
s an
d g
oals
.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Withi
n 24
hou
rs o
f ad
mis
sion
the
re w
as a
nu
tritio
nal c
are
plan
in p
lace
.11
res
pons
es:
11 y
es
Met
Res
pons
e
0
All
asse
ssm
ents
wer
e d
ocu
men
ted
, si
gn
ed/v
alid
ated
(el
ectr
onic
rec
ord
s) a
nd
d
ated
by
the
asse
ssin
g p
ract
itio
ner
.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Com
men
ts
1
9.1
7 [
1]
0
Car
e P
lan
nin
g
20.6
[2]
Com
men
ts
0
20
.1 [
1]
0
Com
men
ts
U2
0.9
[1
]
Com
men
ts
0
40
A t
eam
man
agem
ent
plan
for
ri
sky/
viol
ent/
abus
ive
beha
viou
r th
at t
he
Prim
ary
Nur
se o
r de
lega
ted
depu
ty n
egot
iate
d w
ith
the
patien
t, o
utlin
ing
issu
es a
nd
appr
opri
ate
inte
rven
tion
s.
11 r
espo
nses
: 9
yes
2 N
/A
Met
Res
pons
e
N/A
N/A
Fin
din
gs
from
ris
k as
sess
men
ts w
ere
com
mu
nic
ated
acr
oss
rele
van
t ag
enci
es
and
car
e se
ttin
gs,
in a
ccor
dan
ce w
ith
th
e la
ws
rela
tin
g t
o p
atie
nt
con
fid
enti
alit
y.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
The
iden
tity
of
the
pat
ien
t’s
mai
n c
arer
s an
d t
hei
r co
nta
ct d
etai
ls.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Car
ers
U2
2.1
[1
]
No
hist
ory
of r
isk,
vio
lent
or
abus
ive
beha
viou
r or
evi
dent
in
curr
ent
pres
enta
tion
U21
.2 [
2]
Com
men
ts
0Plan
not
nec
essa
ry o
r pa
tiet
doe
s no
t pa
rtak
e in
ris
k, v
iole
t or
ab
usiv
e be
havi
ours
Com
men
ts
0
Man
agem
ent
of R
isk
U2
1.3
[1
]
Com
men
ts
41
If n
eeds
wer
e id
entifie
d th
at c
anno
t be
met
by
the
war
d/un
it t
eam
, a
refe
rral
was
mad
e to
a
serv
ice
that
cou
ld.
The
ref
erra
l was
mad
e w
ithi
n a
spec
ified
tim
e pe
riod
aft
er id
entify
ing
the
need
, an
d th
e da
te o
f th
e re
ferr
al r
ecor
ded
in t
he n
otes
.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
Wei
gh
ing
was
car
ried
ou
t re
gu
larl
y (n
o m
ore
than
tw
ice
a w
eek)
.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
A c
omp
reh
ensi
ve,
ong
oin
g a
sses
smen
t of
ri
sk t
o se
lf a
nd
oth
ers
wit
h f
ull
invo
lvem
ent
of t
he
pat
ien
t an
d t
hei
r ca
rer
(if
the
pat
ien
t g
ave
con
sen
t),
and
co
rres
pon
din
g c
are
pla
ns.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
U23
.1 [
2]
Com
men
ts
U
23
.8 [
1]
Com
men
ts
00
23
.6 [
1]
Com
men
ts
0
Con
tin
uou
s A
sses
smen
t
42
A C
MH
T/cr
isis
tea
m r
epre
sent
ativ
e is
invi
ted
to
atte
nd t
he fir
st r
evie
w.
11 r
espo
nses
: 10
yes
1 n
o M
et
Res
pons
e
No
Act
ions
fro
m r
evie
ws
wer
e fe
d ba
ck t
o th
e pa
tien
t (a
nd/o
r ca
rers
, w
ith
the
patien
t’s
perm
issi
on).
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
A C
PA
rev
iew
mee
tin
g w
ith
in t
he
firs
t fo
ur
wee
ks o
f ad
mis
sion
.
11
re
spon
ses:
5
yes
4 n
o 2
N
/A
Met
Res
pons
e
N/A No
N/A No
No
No
was
don
e sh
ortly
afte
rwar
dsCom
men
ts
Rev
iew
s
24.1
5 [2
]
Com
men
ts
0
24
.23
[1
]Th
is is
gen
eral
ly a
'yes
', ho
wev
er c
an o
ccas
iona
lly b
e sl
ight
ly
long
er.
Com
men
ts
Arr
ange
d w
ithi
n 5
wee
ks
24.1
1 [2
]
Arr
ange
d w
ithi
n 5
wee
ks
Patien
t ad
mitte
d on
14.
07.1
4, C
PA r
evie
w y
et t
o be
arr
ange
d
Arr
ange
d w
ithi
n 5
wee
ks
A C
PA o
ccur
red
shor
tly
outs
ide
the
4 w
eek
peri
od in
ord
er t
o ge
t al
l pro
fess
iona
ls t
oget
her
CPA
can
celle
d du
e to
unf
ores
een
circ
umst
ance
s
43
A d
ocum
ente
d ad
mis
sion
pla
nnin
g m
eeting
w
ith
the
patien
t w
ithi
n on
e w
eek
of t
he
patien
t's a
dmis
sion
.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
The
patien
t is
act
ivel
y in
volv
ed in
dev
elop
ing
thei
r tr
ansf
er/d
isch
arge
pla
n.11
res
pons
es:
11 y
es
Met
Res
pons
e
0 9 re
spon
ses
: 3
yes
1 no
5 N
/A
The
patien
t is
giv
en t
imel
y no
tific
atio
n of
tr
ansf
er o
r di
scha
rge.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0 9 re
spon
ses
: 4
yes
5 N
/A
24.2
5 [2
]
Com
men
ts
U25
.3 [
2]
25.5
[2]
0
Dis
char
ge
Pla
nn
ing
Com
men
ts
0 PQ
: W
ere
you
invo
lved
in d
evel
opin
g yo
ur t
rans
fer/
disc
harg
e pl
an?
Com
men
ts
0 PQ
: W
ere
you
give
n tim
ely
notific
atio
n of
tra
nsfe
r or
di
scha
rge?
44
Wri
tten
cop
ies
of d
isch
arge
pla
ns w
ere
sent
out
w
ithi
n se
ven
days
of di
scha
rge
to t
he p
atie
nt,
care
r(s)
whe
re r
elev
ant,
soc
ial w
orke
rs,
com
mun
ity
men
tal h
ealth
nurs
es,
GPs
, an
d ot
her
com
mun
ity,
res
iden
tial
and
day
-car
e st
aff.
11 r
espo
nses
: 2
yes
1 no
8
N/A
M
et
Res
pons
e
N/A
N/A No
N/A
N/A
N/A
N/A
N/A
N/A
Patien
t no
t ye
t di
scha
rged
patien
t no
t ye
t di
scha
rged
Patien
t ha
s no
t be
en d
isch
arge
d as
yet
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
25.1
0 [2
]
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Com
men
ts
45
Dis
char
ge p
lann
ing
is c
onsi
dere
d w
ithi
n th
e fir
st a
nd e
very
sub
sequ
ent
care
pla
n re
view
.
11 r
espo
nses
: 2
yes
1 no
8
N/A
M
et
Res
pons
e
No
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
25.3
1 [2
]AIM
S C
omm
ent
- W
ard
expe
rien
ced
trou
ble
ente
ring
'Yes
' re
spon
se.
Plea
se s
ee w
ard
com
men
ts.
All
11 r
espo
nses
sh
ould
the
refo
re b
e 'Y
es',
with
a pe
rcen
tage
of 10
0%.
Com
men
ts
Dis
char
ge p
lann
ing
is c
onsi
dere
d w
ithi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
unab
le t
o pu
t in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
side
red
withi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
t pu
t in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
sder
ed w
ithi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
side
red
withi
n th
e fir
st a
nd e
vry
subs
eque
nt c
are
plan
rev
iew
- u
nabl
e to
put
in y
es r
espo
nse
and
proc
eed
Dis
char
ge p
lann
ing
is c
onsi
dere
d w
ithi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
side
red
withi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
sder
ed w
ithi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
side
red
withi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
dD
isch
arge
pla
nnin
g is
con
side
red
withi
n th
e fir
st a
nd e
very
su
bseq
uent
car
e pl
an r
evie
w -
una
ble
to p
ut in
yes
res
pons
e an
d pr
ocee
d
46
Dis
char
ge p
lann
ing
incl
udes
rel
apse
pre
vent
ion
plan
ning
. 11
res
pons
es:
11 y
es
Met
Res
pons
e
0
Unl
ess
the
patien
t w
as t
rans
ferr
ed t
o an
othe
r sp
ecia
list
men
tal h
ealth
serv
ice,
arr
ange
men
ts
for
follo
w-u
p w
ithi
n se
ven
days
of di
scha
rge.
11 r
espo
nses
: 2
yes
1 no
8
N/A
M
et
Res
pons
e
N/A
N/A No
N/A
N/A
N/A
N/A
N/A
N/A
A p
ost-
dis
char
ge
and
rel
apse
pre
ven
tion
p
lan
incl
ud
ed w
ith
th
e C
PA
d
ocu
men
tati
on.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
25.3
6 [3
]
25
.38
[1
]
Com
men
ts
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t tr
ansf
erre
d
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Patien
t no
t ye
t di
scha
rged
Com
men
ts
25.3
2 [2
]
Com
men
ts
00
47
An
y in
cid
ent
req
uir
ing
rap
id
tran
qu
illis
atio
n,
ph
ysic
al in
terv
enti
on o
r se
clu
sion
was
rec
ord
ed
con
tem
por
aneo
usl
y, u
sin
g a
loca
l te
mp
late
, w
hic
h r
ecor
ds
the
use
of
thes
e in
terv
enti
ons
and
th
e p
roce
du
res
take
n
du
rin
g t
hes
e in
terv
enti
ons,
an
d a
ny
adve
rse
outc
omes
.
11
re
spon
ses:
1
no
10
N/A
N
/A
Res
pons
e
N/A
N/A
N/A
N/A
N/A
N/A No
N/A
N/A
N/A
N/A
Not
par
t of
[un
it n
ame]
pro
toco
l
Com
men
ts
Not
par
t of
pro
toco
l
Not
pra
ctis
ed a
t [u
nit
nam
e],
not
part
of pr
otoc
ol
Not
pra
ctis
ed a
t [u
nit
nam
e],
not
part
of pr
otoc
ol
Not
pra
ctis
ed a
t [u
nit
nam
e],
not
part
of pr
otoc
ol
Sec
lusi
on,
rapi
d tr
anqu
ilisa
tion
and
phy
sica
l int
erve
ntio
ns n
ot
nece
ssar
y or
pra
ctis
ed w
ithi
n th
e un
it
Rap
id t
ranq
uilis
atio
n, s
eclu
sion
and
phy
sica
l int
erve
ntio
n no
t pr
actise
d w
ithi
n th
e un
it
Not
pra
ctis
ed a
t [u
nit
nam
e],
not
part
of pr
otoc
ol
Man
agem
ent
of V
iole
nce
Not
par
t of
[un
it n
ame]
pro
toco
l
Rap
id t
ranq
uilis
atio
n, p
hysi
cal i
nter
vent
ion,
sec
lusi
on n
ot
prac
tise
d at
[un
it n
ame]
Beh
avio
ur is
not
pra
ctis
ed a
s pa
rt o
f th
e pr
otoc
ol
U2
9.6
[1
]
SEC
TIO
N 3
: S
AFE
TY
48
Whe
re m
enu
choi
ces
have
bee
n re
stri
cted
as
part
of tr
eatm
ent,
the
re is
a c
lear
pla
n fo
r re
intr
oduc
ing
choi
ce a
nd e
ncou
ragi
ng p
atie
nts
to im
prov
e th
eir
rela
tion
ship
with
food
in a
re
cove
ry-f
ocus
ed w
ay.
11 r
espo
nses
: 10
yes
1 N
/A
Met
Res
pons
e
N/A
SEC
TIO
N 4
: EN
VIR
ON
MEN
T A
ND
FA
CIL
ITIE
SC
ater
ing
41.2
2 [2
]
Com
men
ts
No
inci
dent
s of
vio
lenc
e/ag
gres
sion
dur
ing
the
patien
t's s
tay
at [
unit n
ame]
49
Patien
ts’ p
refe
renc
es w
ere
take
n in
to a
ccou
nt
duri
n g t
he c
hoic
e of
med
icat
ion
and
acte
d up
on
as far
as
poss
ible
, fo
llow
ing
a di
scus
sion
of:
a. t
he p
atie
nt’s
his
tory
;
b. t
he r
elat
ive
bene
fits
of t
he m
edic
atio
n;11
res
pons
es:
11 y
es
c. t
he s
ide
effe
cts;
11 r
espo
nses
: 11
yes
d. a
lter
native
s;11
res
pons
es:
11 y
es
e. t
he p
atie
nt’s
phy
sica
l,em
otio
nal a
nd s
ocia
l nee
ds;
11 r
espo
nses
: 11
yes
f. t
he r
oute
of ad
min
istr
atio
n (w
hich
may
incl
ude
cons
ider
atio
n of
the
nee
dfo
r co
vert
med
icin
es a
dmin
istr
atio
n if
med
icat
ion
refu
sal i
s an
issu
e).
11 r
espo
nses
: 11
yes
Met
SEC
TIO
N 5
: TH
ERA
PIE
S A
ND
AC
TIV
ITIE
SM
edic
atio
n
11 r
espo
nses
: 11
yes
0
Com
men
ts
U48
.2 [
2]
50
Upo
n co
mm
ence
men
t of
new
med
icat
ion,
or
whe
re m
edic
atio
n m
anag
emen
t is
an
active
or
curr
ent
issu
e, t
he p
atie
nt’s
Allo
cate
d N
urse
m
onitor
s th
e to
lera
bilit
y an
d si
de e
ffec
ts o
f m
edic
atio
n on
a d
aily
bas
is.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0
The
resp
onsi
ble
clin
icia
n an
d th
e Pr
imar
y N
urse
m
onitor
ed t
he t
hera
peut
ic r
espo
nse
to
med
icat
ion
on a
wee
kly
basi
s.
11 r
espo
nses
: 10
yes
1 N
/A
Met
Res
pons
e
N/A
The
war
d/un
it h
elpe
d th
e pa
tien
t to
und
erst
and
the
func
tion
s, li
mitat
ions
and
sid
e ef
fect
s of
th
eir
med
icat
ions
and
to
self-
man
age
as far
as
poss
ible
.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0 8 re
spon
ses
: 4
yes
4 no
Ther
e is
a for
m for
pat
ient
s to
sig
n w
hich
sta
tes
that
the
y un
ders
tand
the
ir t
reat
men
t.
48.7
[2]
U48
.3 [
2]
Com
men
ts
0
48.4
[2]
Com
men
ts
Patien
t no
t on
any
psy
chot
ropi
c m
edic
atio
n, o
nly
PRN
m
edic
atin
for
ong
oing
ski
n co
nditio
n
Com
men
ts
0 PQ
: D
id s
taff h
elp
you
to u
nder
stan
d th
e fu
nction
s, li
mitat
ions
an
d si
de e
ffec
ts o
f yo
ur m
edic
atio
n an
d to
sel
f-m
anag
e as
far
as
pos
sibl
e?
51
Wh
en p
resc
rib
ing
dru
gs
that
may
co
mp
rom
ise
card
iac
fun
ctio
n,
the
pre
scri
bin
g c
linic
ian
sh
owed
evi
den
ce t
hat
ri
sk h
as b
een
con
sid
ered
an
d c
onsu
ltat
ion
h
ad o
ccu
rred
wh
ere
nec
essa
ry,
and
th
is
was
doc
um
ente
d a
nd
ap
pro
pri
atel
y m
onit
ored
by
ECG
.
11
re
spon
ses:
6
yes
5 N
/A
Met
Res
pons
e
N/A
N/A
N/A
N/A
N/A
Ass
essm
ent
of t
he
risk
fac
tors
for
re
feed
ing
syn
dro
me,
wit
h a
pp
rop
riat
e ac
tion
tak
en if
ind
icat
ed.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Pat
ien
ts in
th
e ea
rly
stag
es o
f re
feed
ing
w
ere
mon
itor
ed c
lose
ly f
or s
ign
s of
b
ioch
emic
al,
card
iova
scu
lar
and
flu
id
bal
ance
dis
turb
ance
.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Com
men
ts
49
.7 [
1]
0
Com
men
ts
No
med
icat
ion
is p
resc
ribe
d th
at w
ould
com
prom
ise
card
iac
func
tion
Com
men
ts
48
.18
[1
]
Patien
t no
t pr
escr
ibed
med
icat
ion
that
may
com
prom
ise
card
iac
func
tion
No
med
icat
ion
for
card
iac
prob
lem
s
No
med
icat
ion
is p
resc
ribe
d th
at m
ay c
ause
com
prom
ise
to
card
iac
func
tion
0No
med
icat
ion
is p
resc
ribe
d th
at w
ould
com
prom
ise
card
iac
func
tion
Ref
eed
ing
49
.10
[1
]
52
Goa
ls a
rou
nd
wei
gh
t re
stor
atio
n t
arg
ets
(i.e
. ra
te a
nd
am
oun
t of
gai
n)
wer
e in
div
idu
ally
pla
nn
ed a
cco
rdin
g t
o p
atie
nt
nee
d.
11
re
spon
ses:
1
1 y
es
Met
Res
pons
e
0
Patien
ts h
ave
a m
inim
um o
f tw
o do
cum
ente
d se
ssio
ns w
ith
thei
r Pr
imar
y or
Allo
cate
d N
urse
pe
r w
eek
to r
evie
w t
heir
pro
gres
s.
11 r
espo
nses
: 6
yes
5 no
M
et
Res
pons
e
No
No
No
No
No
Each
pat
ient
has
the
opp
ortu
nity
to
have
su
ppor
tive
one
-to-
one
sess
ions
with
staf
f ev
ery
day.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0 8 re
spon
ses
: 5
yes
3 no
Com
men
ts
Eng
agem
ent
Com
men
ts
0 PQ
: W
ere
you
give
n th
e op
port
unity
to h
ave
supp
ortive
one
-to
-one
ses
sion
s w
ith
staf
f ev
ery
day?
U50
.5 [
2]
0
Com
men
ts
50.2
[2]
Tim
e lim
its
occa
sion
ally
mea
ns t
hat
we
are
unab
le t
o ha
ve
two
sess
ions
a w
eek
but
difn
itel
y ha
ve a
t le
ast
one
Som
etim
es u
nabl
e to
due
to
tim
e re
stri
ctio
ns
We
try
to b
ut s
omet
imes
tim
e lim
ited
Tim
e lim
its
occa
sion
aly,
mea
ns t
hat
we
are
unab
le t
o ha
ve
two
ses
sion
s a
wee
k bu
t de
finitel
y ha
s at
leas
t on
e
Som
etim
es u
nabl
e to
due
to
tim
e re
stri
ctio
ns
49
.11
[1
]
53
The
patien
t ha
d th
e op
port
unity
to b
e in
volv
ed
in n
egot
iating
an
activi
ty a
nd t
hera
py
prog
ram
me,
rel
evan
t to
the
ir id
entifie
d ne
eds,
th
at in
clud
es e
veni
ng a
nd w
eeke
nd a
ctiv
ity.
Th
is is
reg
ular
ly m
onitor
ed a
nd r
evie
wed
.
11 r
espo
nses
: 11
yes
M
et
Res
pons
e
0 9 re
spon
ses
: 8
yes
1 no
Com
men
ts
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
U53
.3 [
2]
0 PQ
: W
ere
you
give
n th
e op
port
unity
to b
e in
volv
ed in
ne
gotiat
ing
an a
ctiv
ity
and
ther
apy
prog
ram
me?
54
The
heal
th r
ecor
ds a
re t
horo
ugh,
with
sep
arat
e re
cord
s of
hos
pita
l app
oint
men
ts.
Ther
e ar
e go
od for
ms
in p
lace
for
pat
ient
s to
sig
n, s
tatin
g th
at t
hey
unde
rsta
nd in
form
atio
n sh
arin
g, t
reat
men
t pl
ans
and
expe
ctat
ions
. N
otes
are
kep
t ch
rono
logi
cally
, ra
ther
tha
n by
dis
cipl
ine,
whi
ch a
ids
revi
ew.
Sin
ce t
he w
ard
trea
ts u
nder
wei
ght
patie
nts
who
may
be
taki
ng p
oten
tially
car
diot
oxic
dru
gs,
it is
sug
gest
ed t
hat
the
war
d ob
tain
the
ir o
wn
ECG
mac
hine
to
repl
ace
the
need
to
atte
nd t
he G
P su
rger
y fo
r th
is.
To e
nsur
e th
at w
ard
staf
f ar
e fu
lly a
war
e of
the
ir r
espo
nsib
ilitie
s re
gard
ing
safe
guar
ding
. To
ens
ure
that
tw
ice
wee
kly
prog
ress
rev
iew
s ar
e ca
rrie
d ou
t.
Not
es o
n pa
per
can
be c
haot
ic,
and
coul
d pe
rhap
s be
mov
ed t
o an
ele
ctro
nic
syst
em.
To p
rovi
de c
opie
s of
car
e pl
ans
for
patie
nts.
D
etai
ls a
bout
mov
ing
and
hand
ling
coul
d be
mor
e sp
ecifi
c.
To r
evis
it th
e cu
rren
t sy
stem
in p
lace
reg
ardi
ng t
he p
resc
ribi
ng a
nd d
ispe
nsin
g of
med
icat
ion.
Sig
nific
ant
quan
titie
s of
m
edic
atio
n m
ay b
e gi
ven
to p
atie
nts
for
leav
e an
d th
is c
urre
nt s
yste
m s
eem
s un
likel
y to
be
able
to
cope
with
the
nee
d fo
r fr
eque
nt c
hang
es in
med
icat
ion
with
out
dela
ys a
nd/o
r w
aste
.
Act
ion
po
ints
.
Are
as o
f ac
hie
vem
ent.
HEA
LTH
REC
OR
D A
UD
IT -
SU
MM
AR
Y
55
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
U1.
3 [2
]Are
pol
icie
s an
d pr
otoc
ols
revi
ewed
by
your
Trus
t/or
gani
sation
at
leas
t ev
ery
thre
e ye
ars?
Yes
Met
U1.
4 [2
]D
o yo
u au
dit
the
impl
emen
tation
of po
licie
s an
d pr
oced
ures
rel
atin
g to
the
war
d/un
it,
and
prov
ide
feed
back
to
MD
T st
aff?
Yes
Met
Earl
yQ
ualif
ied:
Unq
ualif
ied:
1 3
Late
Qua
lifie
d:U
nqua
lifie
d:1 3
Nig
htQ
ualif
ied:
Unq
ualif
ied:
1 1
U2
.1 [
1]
Do
you
hav
e an
ag
reed
min
imu
m s
taff
ing
le
vel a
cros
s al
l sh
ifts
an
d is
th
is g
ener
ally
m
et?
Yes
Met
U2
.2 [
1]
The
agre
ed m
inim
um
sta
ffin
g le
vel
incl
ud
es o
ne
or m
ore
reg
iste
red
nu
rse(
s)
per
sh
ift.
-M
et
Min
imum
Sta
ffin
g Le
vels
spe
cifie
d in
Con
text
ual D
ata
-
Sta
ffin
g L
evel
s
Pol
icie
s an
d P
roto
cols
WARD
MA
NA
GER
QU
ESTI
ON
NA
IRE
SEC
TIO
N 1
: G
ENER
AL
STA
ND
AR
DS
56
Do
you
hav
e sy
stem
s in
pla
ce t
o en
sure
th
at t
he
follo
win
g f
acto
rs a
re t
aken
into
co
nsi
der
atio
n w
hen
rev
iew
ing
sta
ffin
g
nu
mb
ers
and
ski
ll m
ix: leve
ls o
f ob
serv
atio
n;
Yes
sick
nes
s an
d a
bse
nce
;Y
es
trai
nin
g;
Yes
sup
ervi
sion
;Y
es
esco
rts;
Yes
con
sult
atio
n,
outr
each
and
liai
son
fu
nct
ion
s;Y
es
the
nee
d t
o p
rom
ote
pat
ien
ts’ i
nd
epen
den
ce;
Yes
ther
apeu
tic
eng
agem
ent;
Yes
acu
ity
leve
ls;
Yes
con
form
ance
wit
h lo
cal
hu
man
res
ourc
es g
uid
ance
;Y
es
staf
f ca
pab
iliti
es;
Yes
clin
ical
mee
tin
gs?
Yes
Are
sta
ffin
g le
vels
rev
iew
ed o
n a
dai
ly
bas
is?
Yes
U2.
4 [3
]If
the
dai
ly s
taffin
g re
quir
emen
t is
not
met
, do
yo
u re
cord
thi
s an
d es
cala
te it
to
seni
or
man
agem
ent?
Yes
Met
U2
.3 [
1]
Met
The
unit h
as t
heir
ow
n ba
nk o
f st
aff.
Any
1:1
s w
ith
a pa
tien
t w
ill b
e w
ith
the
regu
lar
staf
f, w
ith
agen
cy s
taff o
n th
e flo
or
with
othe
r st
aff.
57
3.4
[1
]
Is t
her
e an
iden
tifi
ed d
uty
doc
tor
to
atte
nd
th
e w
ard
/un
it,
incl
ud
ing
ou
t-of
-h
ours
, w
ho
has
acc
ess
to e
xper
t ad
vice
to
dea
l wit
h m
edic
al a
nd
psy
chia
tric
em
erg
enci
es?
Yes
Met
Ther
e ar
e tw
o do
ctor
s on
-cal
l.
3.1
3 [
1]
Are
th
ere
pla
nn
ed c
over
arr
ang
emen
ts f
or
psy
chia
tric
, m
edic
al a
nd
die
teti
c n
eed
s fo
r w
hen
war
d/u
nit
sta
ff a
re o
n le
ave?
Yes
Met
U4.
1 [2
]
Is t
here
acc
ess
to r
elev
ant
faith-
spec
ific
supp
ort
for
patien
ts,
pref
erab
ly t
hrou
gh
som
eone
with
an u
nder
stan
ding
of m
enta
l he
alth
issu
es?
Yes
Met
U4.
8 [2
]D
o yo
u ha
ve c
ontr
ol o
ver
the
war
d/un
it
budg
et?
Yes
Met
Aft
er t
hree
epi
sode
s a
refe
rral
is m
ade
to H
R.
How
do
you
mon
itor
leve
ls o
f si
ckn
ess,
ab
sen
ce a
nd
in
juri
es?
U2
.5 [
1]
An
nu
al a
ud
it o
f si
ckn
ess
dis
pla
yed
to
staf
f b
y p
ie c
har
ts -
take
n t
o m
onth
ly m
anag
emen
t m
eeti
ng
s
U2.
6 [2
]
Wha
t po
sitive
act
ions
do
you
take
to
redu
ce s
ickn
ess
leve
ls?
Ret
urn
to w
ork
inte
rvie
ws,
ens
ure
annu
al le
ave
is t
aken
ap
prop
riat
ely
spre
ad o
ut t
hrou
ghou
t th
e ye
ar
Met
Met
MD
T S
taff
Acc
ess
to O
ther
Sta
ff/S
ervi
ces
58
U5.
1 [2
]
Whe
n nu
rsin
g/nu
rsin
g as
sist
ant
post
s ar
e va
cant
or
in t
he e
vent
of lo
ng-t
erm
sic
knes
s,
are
imm
edia
te a
rran
gem
ents
mad
e fo
r te
mpo
rary
sta
ff c
over
?
Yes
Met
U5.
3 [2
]Are
MD
T st
aff ex
it in
terv
iew
s fe
d ba
ck t
o yo
u?Ye
sM
et
U5.
4 [2
]
Are
the
re a
rran
gem
ents
in p
lace
so
that
ser
vice
us
er r
epre
sent
ativ
es c
an b
e in
volv
ed in
in
terv
iew
ing
pote
ntia
l mem
bers
of th
e M
DT
duri
ng t
he r
ecru
itm
ent
proc
ess?
No
Not
Met
It w
as c
onfir
med
tha
t th
is h
ad n
ot p
revi
ousl
y be
en
cons
ider
ed,
and
sugg
estion
s w
ere
mad
e by
the
rev
iew
tea
m
on h
ow t
o in
volv
e pa
tien
ts/c
arer
s.
U5.
5 [3
]
Are
the
re a
rran
gem
ents
are
in p
lace
so
that
ca
rers
/car
er r
epre
sent
ativ
es c
an b
e in
volv
ed in
in
terv
iew
ing
pote
ntia
l mem
bers
of th
e M
DT
duri
ng t
he r
ecru
itm
ent
proc
ess?
No
Not
Met
It w
as c
onfir
med
tha
t th
is h
ad n
ot p
revi
ousl
y be
en
cons
ider
ed,
and
sugg
estion
s w
ere
mad
e by
the
rev
iew
tea
m
on h
ow t
o in
volv
e pa
tien
ts/c
arer
s.
Do
you
rec
eive
an
an
nu
al a
pp
rais
al a
nd
p
erso
nal
dev
elop
men
t p
lan
nin
g o
r eq
uiv
alen
t?Y
es
SQ
: D
o yo
u r
ecei
ve a
n a
nn
ual
ap
pra
isal
an
d p
erso
nal
dev
elop
men
t p
lan
nin
g o
r eq
uiv
alen
t?
19
re
spon
ses:
1
5 y
es 4
no
Do
you
have
a c
lear
sys
tem
of m
onitor
ing
and
audi
ting
sup
ervi
sion
?N
o
Is t
his
revi
ewed
eve
ry 1
2 m
onth
s?N
o
U6
.1 [
1]
Met
Ther
e ar
e ye
arly
app
rais
als
with
action
pla
ns.
The
resp
onse
s gi
ven
as 'n
o' in
the
sel
f-re
view
will
hav
e be
en fro
m n
ew s
taff,
yet
to h
ave
had
an a
nnua
l app
rais
al.
U6.
5 [2
]N
ot M
et
This
is d
one
in a
dia
ry a
nd r
ecor
ded
in in
divi
dual
file
s.
A for
mal
sys
tem
is n
eede
d.
Ap
pra
isal
, S
up
ervi
sion
an
d S
taff
Su
pp
ort
Rec
ruit
men
t an
d R
eten
tion
of
Sta
ff
59
Are
all
new
clin
ical
sta
ff a
lloca
ted
a
men
tor/
pre
cep
tor
wh
o ov
erse
es t
hei
r in
du
ctio
n?
Yes
SQ
: A
re a
ll n
ew c
linic
al s
taff
allo
cate
d a
m
ento
r/p
rece
pto
r w
ho
over
sees
th
eir
ind
uct
ion
?
18
re
spon
ses:
1
7 y
es 1
no
U7.
4 [2
]Are
arr
ange
men
ts in
pla
ce t
o en
sure
tha
t ba
nk/a
genc
y st
aff ar
e in
duct
ed t
o th
e w
ard/
unit b
efor
e co
mm
enci
ng w
ork?
Yes
Met
The
unit u
ses
its
own
bank
of st
aff,
and
a n
ew s
taff m
embe
r is
not
left
alo
ne.
Do
all s
taff
, in
clu
din
g t
emp
orar
y/ag
ency
st
aff,
hav
e a
com
pre
hen
sive
ind
uct
ion
to
the
serv
ice,
wh
ich
cov
ers
key
asp
ects
of
care
. G
uid
ance
: th
ese
shou
ld in
clu
de:
the
ph
ysic
al c
are
of p
atie
nts
wit
h e
atin
g d
isor
der
s;Y
es
mea
ltim
e p
roto
cols
;Y
es
the
hig
hly
str
uct
ure
d n
atu
reof
eat
ing
dis
ord
er t
reat
men
t;Y
es
the
war
d/u
nit
pro
gra
mm
e;Y
es
acce
ss t
o fo
od,
dri
nk
and
exe
rcis
e;Y
es
suit
able
top
ics
of c
onve
rsat
ion
, w
ith
par
ticu
lar
refe
ren
ce t
o d
iscu
ssio
ns
abou
t w
eig
ht,
sh
ape
and
eat
ing
;Y
es
pat
ien
t co
erci
ve b
ehav
iou
r;Y
es
bou
nd
arie
s an
d t
her
apeu
tic
allia
nce
. Y
es
7.5
[1
]M
et
U7
.1 [
1]
Met
Sta
ff I
nd
uct
ion
60
U8.
1 [2
]
Do
budg
ets
enab
le a
ll st
aff to
mee
t re
quir
emen
ts for
the
ir c
ontinu
ing
prof
essi
onal
de
velo
pmen
t an
d th
e Kno
wle
dge
and
Ski
lls
Fram
ewor
k?
Yes
Met
U8
.2 [
1]
Is t
her
e a
stra
teg
y in
pla
ce t
o en
sure
th
at
trai
nin
g is
ava
ilab
le?
Yes
Met
U8.
10 [
2]
Is t
here
an
inve
stm
ent
in t
he d
evel
opm
ent
of
man
ager
ial a
nd le
ader
ship
com
pete
ncie
s of
yo
urse
lf, c
harg
e nu
rses
and
oth
er m
embe
rs o
f th
e M
DT
(ban
d 6
and
abov
e)?
Yes
Met
Do
you
hav
e a
wor
kin
g r
elat
ion
ship
wit
h a
ra
ng
e of
ad
voca
cy s
ervi
ces
that
incl
ud
es
the
IMC
A s
ervi
ce?
Yes
PQ
: W
ere
you
giv
en in
form
atio
n o
n w
hat
ad
voca
cy is
, an
d h
ow t
o ac
cess
it?
9 r
esp
onse
s:
3 y
es 6
no
U1
0.5
[1
]D
o yo
u h
ave
evid
ence
of
aud
it,
acti
on a
nd
fe
edb
ack
from
com
pla
ints
, su
gg
esti
ons
and
com
plim
ents
?Y
esM
et
13
.18
[1
]D
oes
the
war
d/u
nit
hav
e ac
cess
to
spec
ialis
t se
rvic
es t
o tr
eat
co-m
orb
id
con
dit
ion
s?Y
esM
et
Com
plim
ents
an
d C
omp
lain
ts
SEC
TIO
N 2
: TI
MEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
Sta
ff E
du
cati
on a
nd
Tra
inin
g
U9
.1 [
1]
Ad
voca
cy
Met
Whi
lst
this
is s
tate
d in
the
wel
com
e pa
ck a
nd d
ispl
ayed
on
the
wal
l, th
e un
it c
ould
re-
visi
t ho
w t
his
info
rmat
ion
is
rela
yed
to p
atie
nts
to e
nsur
e th
at t
hey
are
awar
e of
the
av
aila
bilit
y of
adv
ocac
y.
61
Are
th
ere
syst
ems
in p
lace
for
you
to
rais
e co
nce
rns
abo
ut
inp
atie
nt
mix
?Y
es
Are
you
r vi
ews
on in
pat
ien
t m
ix
con
sid
ered
by
the
sen
ior
team
?Y
es
SQ
: A
re t
her
e sy
stem
s in
pla
ce f
or y
ou t
o ra
ise
con
cern
s ab
out
inp
atie
nt
mix
?
18
re
spon
ses:
1
7 y
es 1
no
16
.1 [
1]
Doe
s a
des
ign
ated
mem
ber
of
the
team
, w
ith
ap
pro
pri
ate
eati
ng
dis
ord
er
exp
erie
nce
, re
view
all
refe
rral
s an
d a
ssig
n
pri
orit
y w
ith
in t
wo
wor
kin
g d
ays
of
rece
ipt?
Yes
Met
16
.6 [
1]
For
pat
ien
ts r
efer
red
for
ad
mis
sion
by
a n
on-s
pec
ialis
t se
rvic
e, a
re y
ou a
ble
to
pro
vid
e ex
per
t ad
vice
if a
bed
is n
ot
avai
lab
le t
o su
pp
ort
pat
ien
t sa
fety
?
Yes
Met
16
.9 [
1]
In c
ases
of
non
-att
end
ance
, d
o yo
u
con
tact
th
e re
ferr
er im
med
iate
ly t
o as
cert
ain
th
e p
atie
nt’
s le
vel o
f ri
sk?
No
Met
This
was
cha
nged
to
Met
by
the
revi
ew t
eam
, st
atin
g th
at t
he
unit o
f co
urse
tak
es im
med
iate
act
ion
in t
his
inst
ance
.
Ref
erra
ls
U1
4.2
[1
]M
et
Con
trol
of
Bed
Occ
up
ancy
62
Are
pat
ient
s an
d fa
mili
es in
vite
d to
vis
it t
he
war
d/un
it p
rior
to
adm
issi
on?
No
PQ
: W
ere
you
invi
ted
to v
isit t
he w
ard/
unit
prio
r to
adm
issi
on?
9 re
spon
ses:
4
yes
5 no
CQ
: W
ere
you
invi
ted
to v
isit t
he w
ard/
unit
prio
r to
adm
issi
on?
7 re
spon
ses:
1
yes
6 no
19.1
8 [2
]
Are
all
patien
ts w
ith
an e
atin
g di
sord
er o
ffer
ed
indi
vidu
alis
ed d
iete
tic
inte
rven
tion
s fr
om a
qu
alifi
ed d
ietitian
to
asse
ss n
utri
tion
al s
tatu
s,
pres
crib
e in
divi
dual
ised
eat
ing
plan
s an
d su
ppor
t be
havi
our
chan
ge a
roun
d fo
od?
Yes
Met
22.1
7 [2
]D
oes
the
war
d/un
it h
ave
a de
sign
ated
per
son
dedi
cate
d to
car
er s
uppo
rt (
care
r le
ad)?
Yes
Met
U23
.2 [
2]W
here
an
unm
et n
eed
is id
entifie
d, is
the
re a
cl
ear
mec
hani
sm for
rep
orting
it?
Yes
Met
24
.28
[1
]
Are
you
ab
le t
o p
rovi
de/
arra
ng
e ac
cess
to
an in
dep
end
ent
seco
nd
op
inio
n w
her
e th
ere
is d
oub
t, u
nce
rtai
nty
or
dis
agre
emen
t ab
out
trea
tmen
t?
Yes
Met
24.2
9 [2
]D
o yo
u pr
ovid
e w
ritt
en fee
dbac
k to
ref
erre
rs a
m
inim
um o
f on
ce e
very
eig
ht w
eeks
?Ye
sM
et
16.1
1 [2
]N
ot M
et
Whi
lst
this
sta
ndar
d is
Not
Met
, th
is is
bec
ause
the
co
mm
issi
oner
s do
not
enc
oura
ge o
r w
ant
this
. Pa
tien
ts d
o ha
ve o
ne a
sses
smen
t pr
ior
to a
dmis
sion
.
Car
ers
Con
tin
uou
s A
sses
smen
t
Init
ial A
sses
smen
t
Rev
iew
s
63
Is t
he p
atie
nt’s
allo
cate
d CM
HT
Car
e Co-
ordi
nato
r/CPN
invi
ted
to m
eet
with
the
patien
t pr
ior
to d
isch
arge
?Ye
s
SQ
: Is
the
pat
ient
’s a
lloca
ted
CM
HT
Car
e Co-
ordi
nato
r/CPN
invi
ted
to m
eet
with
the
patien
t pr
ior
to d
isch
arge
?
6 re
spon
ses:
6
yes
25.1
4 [2
]
Are
loca
l inf
orm
atio
n sy
stem
s ca
pabl
e of
pr
oduc
ing
accu
rate
and
rel
iabl
e da
ta a
bout
de
laye
d tr
ansf
ers/
disc
harg
es,
and
is a
ctio
n ta
ken
to a
ddre
ss a
ny id
entifie
d pr
oble
ms?
Yes
Met
25.3
4 [2
]
If a
pat
ient
req
uire
s tr
ansf
er t
o an
othe
r w
ard/
unit (
e.g.
med
ical
/psy
chia
tric
etc
.),
do
you
ensu
re t
hat
nutr
itio
nal s
uppo
rt a
nd
psyc
hoso
cial
inte
rven
tion
s ar
e m
aint
aine
d an
d ar
e M
ARSIP
AN
-com
plia
nt?
Yes
Met
25.3
5 [2
]Is
the
ser
vice
tha
t th
e pa
tien
t w
ill b
e di
scha
rged
to
invi
ted
to b
e in
volv
ed in
car
e re
view
mee
ting
s th
roug
hout
the
pat
ient
’s s
tay?
Yes
Met
U2
9.1
[1
]
At
all t
imes
, is
a d
octo
r av
aila
ble
to
qu
ickl
y at
ten
d a
n a
lert
by
staf
f m
emb
ers
wh
en in
terv
enti
ons
for
the
man
agem
ent
of d
istu
rbed
/vio
len
t b
ehav
iou
r ar
e re
qu
ired
, in
acc
ord
ance
wit
h N
ICE
CG
25
or
wit
hin
30
min
ute
s?
Yes
Met
Ther
e ar
e tw
o do
ctor
s on
-cal
l.
25.1
2 [2
]
SEC
TIO
N 3
: S
AFE
TYM
anag
emen
t of
Vio
len
ce
Dis
char
ge
Pla
nn
ing
Met
This
was
con
firm
ed b
y th
e re
view
tea
m.
64
Are
the
re s
yste
ms
in p
lace
to
ensu
re t
hat
post
-in
cide
nt s
uppo
rt a
nd r
evie
w a
re a
vaila
ble
and
take
pla
ce?
The
fol
low
ing
grou
ps s
houl
d be
co
nsid
ered
:
staf
f in
volv
ed in
the
inci
dent
;Ye
s
patien
ts;
Yes
care
rs a
nd fam
ily,
whe
re a
ppro
pria
te;
Yes
othe
r pa
tien
ts w
ho w
itne
ssed
the
inci
dent
;Ye
s
visi
tors
who
witne
ssed
the
inci
dent
.Ye
s
SQ
: Are
the
re s
yste
ms
in p
lace
to
ensu
re t
hat
post
-inc
iden
t su
ppor
t an
d re
view
are
ava
ilabl
e an
d ta
ke p
lace
? T
he fol
low
ing
grou
ps s
houl
d be
con
side
red:
staf
f in
volv
ed in
the
inci
dent
;
patien
ts;
19 r
espo
nses
: 18
yes
1 n
o
care
rs a
nd fam
ily,
whe
re a
ppro
pria
te;
19 r
espo
nses
: 17
yes
2 n
o
othe
r pa
tien
ts w
ho w
itne
ssed
the
inci
dent
;19
res
pons
es:
16 y
es 3
no
visi
tors
who
witne
ssed
the
inci
dent
.19
res
pons
es:
16 y
es 3
no
U29
.17
[2]
Met
Ther
e ar
e de
brie
fs,
and
grou
p su
perv
isio
n is
car
ried
out
eve
ry
two
wee
ks.
19 r
espo
nses
: 17
yes
2 n
o
65
Do
you
sign
post
car
ers
to n
earb
y fa
cilit
ies
for
them
to
stay
ove
rnig
ht w
hen
appr
opri
ate,
and
ca
n ad
vise
on
avai
labl
e fu
ndin
g?Ye
s
CQ
: H
ave
you
been
tol
d ab
out
near
by fac
ilities
fo
r yo
u to
sta
y ov
erni
ght
whe
n ap
prop
riat
e,
and
give
n ad
vice
on
any
fund
ing
that
mig
ht b
e av
aila
ble?
7 re
spon
ses:
5
no 2
N/A
41.1
6 [2
]D
oes
a di
etitia
n ov
erse
e th
e ca
teri
ng p
rovi
sion
to
ens
ure
the
indi
vidu
al n
utri
tion
al n
eeds
of
the
patien
ts a
re b
eing
met
?Ye
sM
et
49.2
[2]
Whe
n en
tera
l fee
ding
is u
sed,
is a
die
titian
co
nsul
ted
to e
nsur
e th
e fe
ed is
nut
rition
ally
co
mpl
ete?
No
N/A
This
was
cha
nged
fro
m N
ot M
et t
o N
/A b
y th
e re
view
tea
m
as e
nter
al fee
ding
is n
ot p
ract
ised
on
the
unit.
Cat
erin
g
SEC
TIO
N 5
: TH
ERA
PIE
S A
ND
AC
TIV
ITIE
SR
efee
din
g
Ther
e is
a lo
cal h
otel
, ho
wev
er t
here
are
a lo
t of
loca
l pa
tien
ts a
nd t
here
fore
thi
s is
not
nec
essa
ry.
SEC
TIO
N 4
: EN
VIR
ON
MEN
T A
ND
FA
CIL
ITIE
SU
se o
f R
oom
s an
d S
pac
e
40.2
7 [3
]M
et
66
Are
pat
ien
ts c
ared
for
on
a m
edic
al
war
d/u
nit
if t
hey
nee
d m
edic
al t
reat
men
t th
at is
un
avai
lab
le o
n t
he
spec
ialis
t ea
tin
g
dis
ord
er w
ard
/un
it,
e.g
.:
IV in
fusi
on;
Yes
arti
fici
al v
enti
lati
on;
Yes
card
iac
mon
itor
ing
;Y
es
CV
P li
nes
;Y
es
pro
visi
on o
f a
resu
scit
atio
n t
eam
;Y
es
trea
tmen
t of
ser
iou
sm
edic
al c
omp
licat
ion
s?Y
es
U53
.4 [
2]Are
the
re s
yste
ms
in p
lace
to
regu
larl
y re
view
w
ith
patien
ts a
nd s
taff t
he q
ualit
y an
d pr
ovis
ion
of t
hera
peut
ic a
nd s
ocia
l act
ivitie
s?Ye
sM
et
U53
.5 [
2]Is
the
fre
quen
cy,
regu
lari
ty a
nd d
iver
sity
of
activi
ties
mon
itor
ed?
Yes
Met
53.6
[2]
Are
all
patien
ts o
ffer
ed s
peci
fic p
sych
osoc
ial
inte
rven
tion
s ap
prop
riat
e to
the
ir p
rese
ntin
g ne
eds
and
in a
ccor
danc
e w
ith
nation
al
stan
dard
s (i
.e.
NIC
E)?
Yes
Met
49
.6 [
1]
Met
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
67
U5
3.7
[1
]Is
at
leas
t on
e st
aff
mem
ber
lin
ked
to
the
war
d/u
nit
del
iver
ing
on
e b
asic
, lo
w
inte
nsi
ty p
sych
olog
ical
inte
rven
tion
?Y
esM
et
Are
pat
ien
ts o
ffer
ed t
he
follo
win
g
inte
rven
tion
s:
med
icat
ion
;Y
es
ind
ivid
ual
psy
chol
ogic
al t
her
apie
s;Y
es
gro
up
th
erap
ies;
Yes
fam
ily in
terv
enti
ons
and
su
pp
ort;
Yes
bio
psy
chos
ocia
l in
terv
enti
ons?
Yes
53.3
2 [2
]D
o al
l the
rape
utic
inte
rven
tion
s co
mpl
y w
ith
the
Hum
an R
ight
s Act
, an
d no
t in
volv
e an
y fo
rm o
f de
priv
atio
n or
pun
ishm
ent?
Ye
sM
et
56.1
[2]
Do
you
rout
inel
y ev
alua
te o
utco
mes
usi
ng
valid
ated
mea
sure
s, in
clud
ing
eating
dis
orde
r-sp
ecifi
c m
easu
res,
gen
eric
mea
sure
s an
d pa
tien
t an
d ca
rer
pers
pect
ive
mea
sure
s?
Yes
Met
Ther
e ar
e a
vari
ety
of t
ools
use
d, a
nd a
new
per
son
in r
ole
to
cove
r th
is.
56.2
[2]
Are
out
com
e m
easu
res
used
as
an in
tegr
al p
art
of c
are
plan
ning
and
fee
dbac
k to
pat
ient
s, a
nd
to in
form
ser
vice
dev
elop
men
t?Ye
sM
et
The
unit is
fur
ther
bui
ldin
g on
thi
s.
Ou
tcom
e M
easu
res
Met
Ther
e is
DBT
as w
ell a
s ot
her
ther
apie
s an
d in
terv
ention
s.
53
.25
[1
]
68
War
d M
anag
erY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
Cha
rge
Nur
se
1Y
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
Cha
rge
Nur
se
2Y
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
Cha
rge
Nur
se
3Y
YY
NY
YN
YY
YN
YY
YY
YY
YY
YY
YY
YN
YY
Cha
rge
Nur
se
4Y
YY
YY
YY
YY
YN
YY
YY
YY
YY
YY
YY
YN
YY
Sta
ff N
urse
1Y
YY
YY
YY
YY
NY
YY
YY
YY
YY
YY
YY
YN
YY
Sta
ff N
urse
2Y
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YN
YY
Sta
ff N
urse
3Y
YY
NY
YY
YY
YN
YY
YY
YY
YY
YY
YY
YN
YY
Sta
ff N
urse
4Y
YY
YY
YY
YY
YN
YY
YY
YY
YY
YY
YY
YN
YY
Sta
ff N
urse
5Y
YY
YY
YY
YY
NN
YY
YY
YY
YY
YY
YY
YN
YY
Nur
sing
Ass
ista
nt 1
YY
YY
YN
/AY
YY
N/A
N/A
YY
YY
YY
YY
YY
YY
YN
/AN
/AY
Nur
sing
Ass
ista
nt 2
YY
YY
YN
/AN
YY
N/A
N/A
YY
YY
YY
YY
YY
YY
YN
/AN
/AY
Nur
sing
Ass
ista
nt 3
YY
YY
YN
/AN
YY
N/A
N/A
YY
YY
YY
YY
YY
YY
YN
/AN
/AY
Nur
sing
Ass
ista
nt 4
YY
YY
YN
/AN
NY
N/A
N/A
YY
YY
YY
YY
YY
YY
YN
/AN
/AY
Nur
sing
Ass
ista
nt 5
YY
YY
YN
/AN
YY
N/A
N/A
YY
YY
YY
YY
YY
YY
YN
/AN
/AY
Psyc
hiat
rist
1Y
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
Soc
ial W
orke
r Clin
ical
Lea
dY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
YY
Die
titia
nY
YY
YY
N/A
YY
NN
/AN
/AY
YN
/AY
N/A
YY
YY
YN
/AY
YY
N/A
YTr
aine
e H
ealth
Ps
ycho
logi
stN
YY
YY
YY
YY
N/A
YY
YY
YY
YY
YN
YY
YY
N/A
YY
TRA
ININ
G G
RID
(2
01
4)
Mandatory training in line with Trust organisational guidance (before
undertaking clinical duties)
Safeguarding children and vulnerable adults
Recognising the signs or symptoms associated with the following *
Diversity awareness
Risk management and risk assessment
Care planning and discharge planning, including CPA in England and Wales
How to assess capacity, and the Mental Capacity Act in England and
Wales
Self-harm and suicide awareness and prevention techniques
Physical health needs and referrals
Clinical leadership
Supervision
Responding to patients who express aconcern regarding their hospital
experience
Procedures for assessing carers' needs, including ensuring a carer's
assessment has been completed
Managing distorted perceptions of food and body image, managing clients
with co-morbidity and understanding the impact of trauma within eating
disorders
Delivering individual, family and group therapies for adults with eating
disorders
Training and support to provide basic psychological and psychosocial
interventions **
Training, support and supervision from experienced practitioners in providing one-to-one therapeutic
contact
Training, support and supervision from experienced senior practitioners
in providing therapeutic group work
Ongoing training and supervision to provide a repertoire of problem-
specific, low intensity psychological interventions
Ongoing training and supervision to provide a repertoire of problem-
specific, high intensity psychological interventions
Locally-agreed outcome measures
Basic eating disorder-specific training on psychoeducation, motivational
enhancement and working with families
How to involve patients and carers in all aspects of care
How to communicate effectively with people ***
Meal and post-meal support
The physical and psychological aspects of the use of enteral feeding
Assessment of competency to implement enteral feeding
69
Tota
l Y18
1919
1719
1314
1818
108
1919
1819
1819
1919
1819
1819
196
1319
Tota
l N1
00
20
05
11
25
00
00
00
00
10
00
07
00
Tota
l N/A
00
00
06
00
07
60
01
01
00
00
01
00
66
0
Tota
l Sta
ff19
1919
1919
1919
1919
1919
1919
1919
1919
1919
1919
1919
1919
1919
Tota
l App
licab
le19
1919
1919
1319
1919
1213
1919
1819
1819
1919
1919
1819
1913
1319
Sta
nd
ard
U8.
14
[1]
U8.
7 [1
]U
11.4
[1
]8.
16
[1]
U8.
25
[2]
U8.
23
[2]
U8.
24
[2]
U8.
26
[2]
U8.
30
[2]
8.9
[2]
U6.
6 [2
]U
8.36
[1
]U
8.37
[2
]U
8.38
[3
]53
.1 [2
]U
53.2
[2
]U
8.27
[2
]U
8.4
[1]
8.20
[2]
8.22
[2
]8.
21
[1]
8.29
[2]
8.34
[1]
U8.
28
[2]
10.3
[2
]
%95
%10
0%10
0%89
%10
0%10
0%74
%95
%95
%83
%62
%10
0%10
0%10
0%10
0%10
0%10
0%10
0%10
0%95
%10
0%10
0%10
0%10
0%46
%10
0%10
0%
Met
/N
ot
Met
Not
M
etM
etM
etN
ot
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
Met
QED Comment: Evidence demonstrating compliance with this standard reviewed and accepted by Accreditation Committee 30/9/15.
QED Comment: Evidence demonstrating compliance with this standard reviewed and accepted by Accreditation Committee 30/9/15.
Mandatory training in line with Trust organisational guidance (before undertaking
clinical duties)
Safeguarding children and vulnerable adults
Recognising the signs or symptoms associated with the following *
Diversity awareness
Risk management and risk assessment
Care planning and discharge planning, including CPA in England and Wales
How to assess capacity, and the Mental Capacity Act in England and Wales
Self-harm and suicide awareness and prevention techniques
Clinical leadership
Supervision
Training and support to provide basic psychological and psychosocial interventions
**
Ongoing training and supervision to provide a repertoire of problem-specific, low intensity
psychological interventions
Training, support and supervision from experienced senior practitioners in providing
therapeutic group work
Ongoing training and supervision to provide a repertoire of problem-specific, high intensity psychological interventions
How to involve patients and carers in all aspects of care
How to communicate effectively with people ***
Basic eating disorder-specific training on psychoeducation, motivational enhancement
and working with families
Meal and post-meal support
Responding to patients who express a concern regarding their hospital experience
Peer-Review Comments
Delivering individual, family and group therapies for adults with eating disorders
Procedures for assessing carers' needs, including ensuring a carer's assessment has
been completed
Managing distorted perceptions of food and body image, managing clients with co-
morbidity and understanding the impact of trauma within eating disorders
The physical and psychological aspects of the use of enteral feeding
Assessment of competency to implement enteral feeding
Locally-agreed outcome measures
Training, support and supervision from experienced practitioners in providing one-to-
one therapeutic contact
Physical health needs and referrals
49.3
[1]
N/A Enteral feeding is not practised on
the unit.
70
The
War
d M
anag
er is
war
m a
nd a
ppro
acha
ble,
list
ened
to
feed
back
and
is w
illin
g to
tak
e on
boa
rd is
sues
tha
t co
uld
be
addr
esse
d.
Act
ion
po
ints
.
To e
nsur
e th
at a
ll st
aff ha
ve u
nder
take
n m
anda
tory
Tru
st t
rain
ing,
and
div
ersi
ty a
war
enes
s tr
aini
ng.
Ther
e is
a s
ugge
stio
n to
use
a t
raffic
ligh
t sy
stem
for
ove
rdue
tra
inin
g. (
War
d Com
men
t: "
We
alre
ady
use
a tr
affic
ligh
t sy
stem
for
iden
tifyi
ng
over
due
staf
f tr
aini
ng."
)To
em
ploy
a for
mal
sys
tem
for
aud
iting
sup
ervi
sion
, an
d ca
scad
e su
perv
isio
n be
tter
. W
hils
t th
ere
is g
roup
sup
ervi
sion
eve
ry t
wo
wee
ks,
it is
des
irab
le t
o ha
ve t
his
afte
r an
y in
cide
nt o
r ex
perien
ce w
ith a
trick
y pa
tient
. To
incl
ude
patie
nts/
care
r re
pres
enta
tives
in t
he in
terv
iew
pro
cess
for
mem
bers
of th
e M
DT.
To
ens
ure
patie
nts
are
awar
e of
the
ava
ilabi
lity
of a
dvoc
acy.
WARD
MA
NA
GER
AN
D T
RA
ININ
G G
RID
- S
UM
MA
RY
Are
as o
f ac
hie
vem
ent.
71
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
Do
you
kn
ow h
ow t
o ac
cess
pol
icie
s,
pro
ced
ure
s an
d g
uid
elin
es?
19
re
spon
ses:
1
9 y
es
Are
you
ab
le t
o ac
cess
th
em w
hen
you
n
eed
to?
19
re
spon
ses:
1
8 y
es 1
no
U1.
2 [2
]Are
you
con
sulted
whe
n po
licie
s, p
roce
dure
s an
d/or
gui
delin
es t
hat
rela
te t
o yo
ur p
ract
ice
are
deve
lope
d or
upd
ated
?
18 r
espo
nses
: 12
yes
6 n
o M
et
A s
taff m
eeting
is h
eld
regu
larl
y in
whi
ch p
olic
ies
are
disc
usse
d. T
he m
inut
es for
thi
s m
eeting
s ar
e si
gned
to
indi
cate
hav
ing
bein
g re
ad b
y ea
ch in
divi
dual
.
Is t
her
e a
nom
inat
ed p
erso
n in
ch
arg
e of
ea
ch s
hif
t?9
res
pon
ses:
9
yes
Are
th
ey t
he
poi
nt
of c
onta
ct f
or
con
sult
atio
n,
neg
otia
tion
, an
d d
ecis
ion
-m
akin
g f
or a
ll w
ard
/un
it o
per
atio
nal
m
atte
rs?
9 r
esp
onse
s:
8 y
es 1
no
STA
FF Q
UES
TIO
NN
AIR
ES
SEC
TIO
N 1
: G
ENER
AL
STA
ND
AR
DS
2.8
[1
]
Sta
ff Q
uest
ionn
aire
s w
ere
rece
ived
fro
m t
he fol
low
ing:
Met
Adm
inis
trat
ors/
non-
clin
ical
sta
ff -
1;
Nur
sing
Ass
ista
nts
- 3;
Occ
upat
iona
l The
rapi
sts
- 1;
OT
Sup
port
Wor
kers
, Ass
ista
nt P
sych
olog
ists
or
Stu
dent
Nur
ses
- 7;
oth
er c
linic
al
staf
f -
1; Q
ualif
ied
Nur
ses
- 6
Met
Pol
icie
s an
d P
roto
cols
U1
.1 [
1]
Sta
ffin
g L
evel
s
72
2.9
[1
]
Is a
n e
xper
ien
ced
mem
ber
of
staf
f as
sig
ned
to
mai
nta
in g
ener
al o
bse
rvat
ion
in
pat
ien
t ar
eas,
mon
itor
pat
ien
t in
tera
ctio
n,
obse
rve
for
risk
beh
avio
ur
and
p
rovi
de
firs
t p
oin
t of
con
tact
to
dea
l wit
h
pat
ien
t n
eed
s w
hen
th
e P
rim
ary
or
Allo
cate
d N
urs
e is
ab
sen
t or
un
avai
lab
le?
9 r
esp
onse
s:
9 y
es
Met
3.6
[2]
Is t
here
vis
ible
and
acc
essi
ble
lead
ersh
ip a
t w
ard/
unit le
vel,
e.g.
Lea
d Con
sultan
t, M
oder
n M
atro
n, N
urse
Con
sultan
t?
18 r
espo
nses
: 17
yes
1 n
o M
et
U6.
4 [2
]D
o yo
u re
ceiv
e cl
inic
al s
uper
visi
on a
t a
min
imum
of ev
ery
eigh
t w
eeks
, or
mor
e fr
eque
ntly
as
per
prof
essi
onal
bod
y gu
idan
ce?
18 r
espo
nses
: 17
yes
1 n
o M
et
U6
.7 [
1]
Do
you
rec
eive
reg
ula
r m
anag
emen
t su
per
visi
on f
rom
a p
erso
n w
ith
ap
pro
pri
ate
exp
erie
nce
an
d q
ual
ific
atio
ns?
6 r
esp
onse
s:
4 y
es 2
no
Met
Ther
e is
a s
uper
visi
on s
truc
ture
in p
lace
. It
was
not
ed t
hat
the
man
ager
has
a v
ery
larg
e nu
mbe
r of
sta
ff t
o su
perv
ise
pers
onal
ly.
U6.
8 [2
]D
o yo
u re
ceiv
e re
gula
r lin
e m
anag
emen
t su
perv
isio
n?
11 r
espo
nses
: 9
yes
2 no
M
et
U6.
9 [2
]Are
you
abl
e to
con
tact
a s
enio
r co
lleag
ue a
s ne
cess
ary,
24
hour
s a
day?
19 r
espo
nses
: 18
yes
1 n
o M
et
6.1
0 [
1]
Are
you
aw
are
of y
our
leve
l of
auth
orit
y/ac
cou
nta
bili
ty a
nd
wh
at
dec
isio
ns
you
can
an
d c
ann
ot t
ake?
19
re
spon
ses:
1
8 y
es 1
no
Met
MD
T S
taff
Ap
pra
isal
, S
up
ervi
sion
an
d S
taff
Su
pp
ort
73
U6.
11 [
3]
Do
you
have
acc
ess
to a
war
d/un
it-b
ased
re
flect
ive
prac
tice
/sta
ff s
uppo
rt g
roup
to
disc
uss
clin
ical
wor
k at
leas
t m
onth
ly,
with
a su
itab
le fac
ilita
tor?
19 r
espo
nses
: 15
yes
4 n
o M
et
Ther
e is
a n
omin
ated
saf
egua
rdin
g le
ad.
Are
you
ab
le t
o ta
ke r
egu
lar
allo
cate
d
bre
aks
away
fro
m p
atie
nts
du
rin
g e
ach
sh
ift?
9 r
esp
onse
s:
5 y
es 4
no
U8
.3 [
1]
Hav
e yo
u h
ad t
rain
ing
can
celle
d d
ue
to
lack
of
staf
f co
ver
in t
he
last
12
mon
ths?
19
re
spon
ses:
5
yes
14
no
Met
U8
.5 [
1]
Hav
e yo
u b
een
ass
esse
d o
n y
our
com
pet
ency
to
adm
inis
ter
med
icat
ion
s in
th
e la
st 1
2 m
onth
s?
6 r
esp
onse
s:
3 y
es 3
no
Met
Sta
ff s
poke
n to
on
the
day
repo
rted
tha
t th
is h
ad b
een
done
.
U11
.3 [
2]
If a
dis
clos
ure
of a
buse
is m
ade,
do
you
info
rm
patien
ts/c
arer
s of
the
pro
cedu
res
that
wou
ld b
e fo
llow
ed a
nd r
eass
ure
them
tha
t th
ey w
ould
be
take
n se
riou
sly?
18 r
espo
nses
: 18
yes
M
et
som
etim
es t
oo b
usy
U6
.12
[1
]
If n
ot,
wh
y?
Sta
ff E
du
cati
on a
nd
Tra
inin
g
Not
Met
Ther
e ar
e re
gula
r in
stan
ces
of s
taff b
eing
una
ble
to t
ake
brea
ks.
War
d C
omm
ent:
"All
staf
f ar
e ab
le t
o ta
ke r
egul
ar b
reak
s aw
ay fro
m p
atie
nts
and
ther
e is
a d
esig
nate
d ar
ea for
thi
s.
The
nurs
e in
cha
rge
allo
cate
s tim
e sl
ots
on t
he s
hift
pla
nner
to
ens
ure
staf
f ge
t a
brea
k an
d en
cour
ages
the
m t
o m
ake
use
of t
his
prov
isio
n .
We
are
unsu
re w
hy t
he m
embe
rs o
f st
aff
resp
onde
d ne
gative
ly a
s th
is h
as b
een
in p
lace
for
som
e tim
e bu
t w
e ar
e aw
are
that
som
e st
aff do
not
tak
e th
eir
brea
ks
and
we
use
supe
rvis
ion
slot
s to
add
ress
thi
s."
QED
Com
men
t: E
vid
ence
dem
onst
rati
ng
com
plia
nce
w
ith
th
is s
tan
dar
d r
evie
wed
an
d a
ccep
ted
by
Acc
red
itat
ion
Com
mit
tee
30
/9
/1
5.
Rep
orti
ng
In
app
rop
riat
e/A
bu
sive
Car
e
Rar
ely
an o
ppor
tuni
ty a
s no
t en
ough
sta
ff,
if se
nior
sta
ff n
ot
will
ing
to t
ake
over
~ m
ore
oppo
rtun
ity
for
brea
ks o
n ni
ght
shift
s
Not
alw
ays
poss
ible
lath
ough
allo
cate
d br
eaks
are
giv
en s
omet
imes
the
re is
not
ad
equa
te c
over
on
war
d to
act
ually
tak
e th
em d
ue t
o m
onitor
ing
patien
ts.
Thi
s ca
n be
due
a p
atie
nt b
eing
esc
orte
d to
app
oint
men
t or
out
for
mea
l/sn
ack
as p
art
of t
heir
pr
escr
ibed
pro
gram
me.
How
wev
er,
staf
f ca
n us
ually
leav
e ea
rlie
r or
tak
e
74
Is t
her
e su
pp
ort
for
staf
f an
d p
atie
nts
to
assi
st w
ith
th
e sm
okin
g p
olic
y, in
clu
din
g:
con
sid
erat
ion
of
the
use
of
NR
T w
hile
on t
he
hos
pit
al p
rem
ises
to
hel
p w
ith
wit
hd
raw
al o
r as
a c
opin
g s
trat
egy;
a co
mp
reh
ensi
ve s
up
por
tp
rog
ram
me,
wit
h in
form
atio
nav
aila
ble
ab
out
the
sup
por
t on
off
er;
18
re
spon
ses:
1
2 y
es 6
no
stra
teg
ies
to m
ake
sure
sta
ff k
now
and
un
der
stan
d t
he
Tru
st/
org
anis
atio
n's
pol
icy,
an
dm
onit
or le
vels
of
com
pre
hen
sion
;
18
re
spon
ses:
1
4 y
es 4
no
advi
ce a
bou
t th
e p
oten
tial
eff
ects
of
smok
ing
ces
sati
on o
n s
eru
m C
loza
pin
ele
vels
an
d a
pp
rop
riat
e m
onit
orin
g?
6 r
esp
onse
s:
2 y
es 4
no
PQ
: W
ere
you
off
ered
an
y su
pp
ort
to
assi
st y
ou w
ith
th
e w
ard
/un
it's
sm
okin
g
pol
icy
(e.g
. n
icot
ine
rep
lace
men
t th
erap
y)?
5 r
esp
onse
s:
1 y
es 4
no
23
.11
[1
]
Is r
isk
man
aged
in a
way
th
at t
akes
into
ac
cou
nt
an u
nd
erst
and
ing
of
the
dev
elop
men
t an
d f
orm
ula
tion
of
the
pat
ien
t’s
pro
ble
ms
and
tre
atm
ent
his
tory
?
6 r
esp
onse
s:
5 y
es 1
no
Met
Con
tin
uou
s A
sses
smen
t
Sm
okin
g
18
re
spon
ses:
1
6 y
es 2
no
U1
2.2
[1
]M
et
SEC
TIO
N 2
: TI
MEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
75
24
.1 [
1]
Is t
her
e a
dai
ly h
and
over
bet
wee
n t
he
nu
rsin
g s
taff
, d
octo
rs a
nd
oth
er r
elev
ant
mem
ber
s of
th
e M
DT?
18
re
spon
ses:
1
8 y
es
Met
U2
4.2
[1
]
Doe
s ea
ch h
and
over
con
tain
a d
iscu
ssio
n
of r
isk
fact
ors
and
pat
ien
t n
eed
s, r
esu
ltin
g
in a
n M
DT
acti
on p
lan
for
th
e sh
ift
wit
h
ind
ivid
ual
an
d g
rou
p r
esp
onsi
bili
ties
?
18
re
spon
ses:
1
7 y
es 1
no
Met
24
.7 [
1]
Doe
s a
full
MD
T cl
inic
al r
evie
w m
eeti
ng
oc
cur
at le
ast
once
a w
eek?
18
re
spon
ses:
1
7 y
es 1
no
Met
24.1
7 [2
]Are
lead
clin
icia
ns a
vaila
ble
for
ad h
oc
mee
ting
s w
ith
patien
ts a
nd t
heir
car
ers
whe
n re
ques
ted?
6 re
spon
ses:
5
yes
1 no
M
et
Rev
iew
s
76
Are
pat
ien
ts g
iven
a c
opy
of a
wri
tten
af
terc
are
pla
n,
agre
ed o
n d
isch
arg
e, w
hen
th
ey le
ave
the
war
d/u
nit
, w
hic
h s
ets
out:
the
care
an
d r
ehab
ilita
tion
to b
e p
rovi
ded
;
the
nam
e of
th
eir
Car
e C
o-or
din
ator
(if
they
req
uir
e fu
rth
er c
are)
;6
res
pon
ses:
5
yes
1 n
o
the
acti
on t
o b
e ta
ken
sh
ould
sig
ns
ofre
lap
se o
ccu
r or
if t
her
e is
a c
risi
s, o
r if
the
pat
ien
t fa
ils t
o at
ten
d t
reat
men
t;
6 r
esp
onse
s:
4 y
es 2
no
spec
ific
act
ion
to
take
in t
he
firs
t w
eek?
6 r
esp
onse
s:
4 y
es 2
no
PQ
: W
ere
you
giv
en a
cop
y of
a w
ritt
en
afte
rcar
e p
lan
, ag
reed
on
dis
char
ge,
wh
en
you
left
th
e w
ard
/u
nit
?
8 r
esp
onse
s:
1 y
es 7
N/
A
U29
.18
[2]
Is t
here
a c
olle
ctiv
e re
spon
se t
o al
arm
cal
ls,
agre
ed b
efor
e in
cide
nts
occu
r, w
hich
is
cons
iste
ntly
reh
ears
ed a
nd a
pplie
d?
9 re
spon
ses:
8
yes
1 no
M
et
U29
.19
[2]
Whe
re r
isk
asse
ssm
ent
indi
cate
s, is
the
re a
n es
tabl
ishe
d, r
elia
ble
and
effe
ctiv
e m
eans
of
com
mun
icat
ion
duri
ng e
scor
ted
leav
e et
c. s
uch
as t
wo-
way
rad
ios
or m
obile
pho
nes?
9 re
spon
ses:
8
yes
1 no
M
et
Dis
char
ge
Pla
nn
ing
SEC
TIO
N 3
: S
AFE
TYM
anag
emen
t of
Vio
len
ce
Met
25
.6 [
1]
6 r
esp
onse
s:
4 y
es 2
no
77
42.5
[2]
Whe
re n
eces
sary
, do
you
pro
vide
sen
sitive
ad
vice
on
clot
hing
, hy
gien
e an
d pe
rson
al
pres
enta
tion
?
10 r
espo
nses
: 10
yes
M
et
U51
.1 [
2]
Dur
ing
the
deliv
ery
of t
he for
mal
the
rape
utic
pr
ogra
mm
e, is
the
re a
t le
ast
one
mem
ber
of
staf
f in
eac
h gr
oup
and
activi
ty,
and
othe
rs
avai
labl
e if
need
ed?
17 r
espo
nses
: 16
yes
1 n
o M
et
Do
patien
ts h
ave
acce
ss t
o lo
cal
com
plem
enta
ry t
hera
pies
, de
liver
ed b
y tr
aine
d pr
actition
ers?
18 r
espo
nses
: 18
yes
PQ
: W
ere
you
offe
red
any
com
plem
enta
ry
ther
apie
s?9
resp
onse
s:
8 ye
s 1
no
U51
.8 [
2]Are
you
giv
en p
lann
ed a
nd p
rote
cted
tim
e to
en
sure
act
ivitie
s an
d in
terv
ention
s ar
e pr
ovid
ed r
egul
arly
and
rou
tine
ly?
18 r
espo
nses
: 18
yes
M
et
U51
.10
[2]
Are
hea
lthc
are
assi
stan
ts,
occu
pation
al t
hera
py
supp
ort
wor
kers
, vo
lunt
eers
and
act
ivity
wor
kers
are
invo
lved
in fac
ilita
ting
a b
road
ra
nge
of t
hera
peut
ic a
nd le
isur
e ac
tivi
ties
bot
h on
and
off t
he w
ard/
unit?
18 r
espo
nses
: 18
yes
M
et
SEC
TIO
N 4
: EN
VIR
ON
MEN
T A
ND
FA
CIL
ITIE
S
U51
.7 [
3]M
et
SEC
TIO
N 5
: TH
ERA
PIE
S A
ND
AC
TIV
ITIE
SS
taff
ing
Dig
nit
y
78
Are
pat
ient
s of
fere
d, a
nd a
ctiv
ely
enco
urag
ed
to a
tten
d, a
var
iety
of in
divi
dual
, gr
oup
and
fam
ily t
hera
pies
?
18 r
espo
nses
: 18
yes
PQ
: W
ere
you
offe
red,
and
act
ivel
y en
cour
aged
to
att
end,
a v
arie
ty o
f in
divi
dual
, gr
oup
and
fam
ily t
hera
pies
?
9 re
spon
ses:
9
yes
53
.27
[1
]
Doe
s p
sych
olog
ical
tre
atm
ent
focu
s on
ea
tin
g b
ehav
iou
r an
d a
ttit
ud
es t
o w
eig
ht
and
sh
ape,
an
d w
ider
psy
chos
ocia
l iss
ues
? Th
is in
clu
des
sel
f-ca
re s
kills
, w
ork
or
stu
dy
skill
s, le
isu
re s
kills
an
d li
fe s
kills
, an
d p
rom
otes
ind
epen
den
t liv
ing
, co
mm
un
icat
ion
, as
sert
ion
an
d e
mot
ion
al
cop
ing
?
15
re
spon
ses:
1
5 y
es
Met
53.2
9 [2
]
Doe
s th
e co
nten
t of
the
str
uctu
red
ther
apeu
tic
prog
ram
me
incl
ude
tim
e fo
r m
eals
and
pos
t-m
eal s
uppo
rt,
grou
p an
d in
divi
dual
ses
sion
s an
d tim
e m
ade
for
leis
ure
tim
e?
18 r
espo
nses
: 18
yes
M
et
53.3
0 [2
]
Doe
s th
e co
nten
t of
the
gro
up p
rogr
amm
e in
clud
e a
rang
e of
the
rape
utic
mod
els,
in
clud
ing
psyc
hoed
ucat
ion,
psy
chol
ogic
al
grou
ps,
occu
pation
al t
hera
py g
roup
s an
d st
ruct
ured
res
t tim
e?
18 r
espo
nses
: 18
yes
M
et
53.2
6 [2
]M
et
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
79
U5
4.1
[1
]A
re g
rou
p a
ctiv
itie
s p
rote
cted
an
d n
ot
inte
rru
pte
d?
17
re
spon
ses:
1
3 y
es 4
no
Met
Gro
ups
are
only
inte
rrup
ted
for
bloo
ds a
nd E
CG
s.
54.6
[3]
Is m
utua
l sup
port
enc
oura
ged
by t
he
recr
uitm
ent
of for
mer
pat
ient
s as
vol
unte
ers,
an
d by
cur
rent
and
/or
form
er p
atie
nts
bein
g in
volv
ed in
fac
ilita
ting
rec
over
y an
d ot
her
grou
ps?
11 r
espo
nses
: 10
yes
1 n
o M
et
Gro
up
Act
ivit
ies
and
Th
erap
ies
80
The
revi
ew t
eam
not
ed t
hat
beca
use
of t
he fla
t nu
rsin
g st
ruct
ure
the
War
d M
anag
er s
uper
vise
s a
very
larg
e nu
mbe
r of
st
aff pe
rson
ally
. Th
is r
epre
sent
s a
pote
ntia
l sin
gle
poin
t fa
ilure
; fo
r ex
ampl
e, in
the
cas
e th
at t
he W
ard
Man
ager
is u
nabl
e to
att
end
wor
k du
e to
sic
knes
s. I
t is
sug
gest
ed t
hat
mea
sure
s ar
e ta
ken
to e
ase
this
pre
ssur
e.
To p
rovi
de a
sta
ff r
oom
or
a de
sign
ated
are
a fo
r st
aff to
be
able
to
relia
bly
take
bre
aks,
and
to
ensu
re t
hat
brea
ks a
re b
oth
allo
cate
d an
d ta
ken.
Sta
ff w
ere
plea
sed
to b
e w
orki
ng o
n th
e w
ard
and
wer
e ve
ry p
ositi
ve a
bout
the
war
d en
viro
nmen
t.
Act
ion
po
ints
.
Are
as o
f ac
hie
vem
ent.
STA
FF Q
UES
TIO
NN
AIR
ES -
SU
MM
AR
Y
81
NO
. [T
YP
E]S
TATE
MEN
T/Q
UES
TIO
NS
ELF-
REV
IEW
MET
/N
OT
MET
PEE
R-R
EVIE
W C
OM
MEN
TS
PQ
: W
ere
you
invo
lved
in d
ecis
ions
abo
ut
whe
n, w
here
and
with
who
m in
form
atio
n ab
out
you
was
goi
ng t
o be
sha
red
and
used
?
9 re
spon
ses:
9
yes
SQ
: Are
pat
ient
s in
volv
ed,
whe
reve
r po
ssib
le,
in d
ecis
ions
abo
ut w
hen,
whe
re a
nd w
ith
who
m
info
rmat
ion
abou
t th
em is
goi
ng t
o be
sha
red
and
used
?
6 re
spon
ses:
6
yes
PQ
: W
ere
you
info
rmed
of th
e pr
oces
s of
how
an
d w
hen
you
coul
d ac
cess
you
r cu
rren
t re
cord
s if
you
wis
hed
to d
o so
?
9 re
spon
ses:
2
yes
7 no
SQ
: Are
pat
ient
s in
form
ed o
f th
e pr
oces
s of
ho
w a
nd w
hen
they
may
acc
ess
thei
r cu
rren
t re
cord
s if
they
wis
h to
do
so?
6 re
spon
ses:
4
yes
2 no
SEC
TIO
N 2
: TI
MEL
Y A
ND
PU
RP
OS
EFU
L A
DM
ISS
ION
Pat
ien
t Q
ues
tio
nn
aire
Co
mm
ents
: "I
nfo
rmat
ion
"
0
13.2
[2]
Met
Patien
ts fel
t th
at t
heir
leve
l of re
spon
sibi
lity
had
incr
ease
d ap
prop
riat
ely
duri
ng t
heir
tre
atm
ent.
13.3
[2]
Met
PA
TIEN
T A
ND
CA
RER
QU
ESTI
ON
NA
IRES
82
PQ
: If
you
wer
e se
nt
on le
ave,
wer
e yo
u
told
ho
w t
o c
on
tact
an
d r
etu
rn t
o t
he
war
d/u
nit
if p
rob
lem
s ar
ose?
9 r
esp
onse
s:
5 y
es 4
N/
A
SQ
: W
hen
a p
atie
nt
goe
s on
leav
e, a
re
they
info
rmed
how
to
con
tact
an
d r
etu
rn
to t
he
war
d/u
nit
if p
rob
lem
s ar
ise?
9 r
esp
onse
s:
9 y
es
PQ
: W
hen
you
arr
ived
on
th
e w
ard
, d
id a
m
emb
er o
f st
aff
wel
com
e yo
u,
show
you
to
an
ap
pro
pri
ate
area
, an
d o
ffer
you
re
fres
hm
ents
?
9 r
esp
onse
s:
9 y
es
SQ
: Is
eac
h p
atie
nt
wel
com
ed o
n a
rriv
al,
show
n t
o an
ap
pro
pri
ate
area
, an
d o
ffer
ed
refr
esh
men
ts?
9 r
esp
onse
s:
9 y
es
PQ
: W
ere
you
intr
odu
ced
to
a m
emb
er o
f st
aff
wh
o w
ould
be
you
r p
oin
t of
con
tact
fo
r th
e fi
rst
few
hou
rs o
f ad
mis
sion
?
9 r
esp
onse
s:
9 y
es
SQ
: Is
th
e p
atie
nt
intr
odu
ced
to
a m
emb
er
of s
taff
wh
o w
ill b
e th
eir
poi
nt
of c
onta
ct
for
the
firs
t fe
w h
ours
of
adm
issi
on?
9 r
esp
onse
s:
9 y
es
PQ
: W
ere
you
ori
enta
ted
to
the
war
d/
un
it
envi
ron
men
t, in
clu
din
g t
oile
ts?
9 r
esp
onse
s:
7 y
es 2
no
SQ
: Is
th
e p
atie
nt
orie
nta
ted
to
the
war
d/u
nit
en
viro
nm
ent,
incl
ud
ing
toi
lets
, as
soo
n a
fter
ad
mis
sion
as
it is
saf
e to
do
so?
9 r
esp
onse
s:
9 y
es
Leav
e
15
.3 [
1]
Met
Met
18
.3 [
1]
Met
U1
8.1
[1
]M
et
Mos
t of
the
pat
ient
s on
the
war
d ar
e on
fre
e flu
ids
and
are
able
to
open
ly a
cces
s dr
inks
.
U1
8.2
[1
]
Ad
mis
sion
Pro
cess
83
PQ
: W
hen
staf
f ta
lk t
o yo
u, d
o th
ey t
ry t
o av
oid
usin
g cl
inic
al la
ngua
ge a
nd jar
gon?
9 re
spon
ses:
7
yes
2 no
SQ
: W
hen
talk
ing
to p
atie
nts
and
care
rs,
do
you
try
to a
void
usi
ng c
linic
al la
ngua
ge a
nd
jarg
on?
18 r
espo
nses
: 17
yes
1 n
o
PQ
: W
ere
you
told
the
nam
e(s)
of yo
ur
Prim
ary
Nur
se/c
are
team
and
how
to
arra
nge
to m
eet
with
them
?
9 re
spon
ses:
7
yes
2 no
SQ
: O
n th
e da
y of
the
ir a
dmis
sion
or
as s
oon
as t
hey
are
wel
l eno
ugh,
are
pat
ient
s (a
nd
care
r, w
here
per
mitte
d) t
old
the
nam
e(s)
of
thei
r Pr
imar
y N
urse
/car
e te
am a
nd h
ow t
o ar
rang
e to
mee
t w
ith
them
?
6 re
spon
ses:
6
yes
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
:"B
efor
e yo
u a
rriv
ed a
nd
th
e d
ay y
ou a
rriv
ed o
n t
he
war
d"
Hav
e be
en a
pat
ient
on
the
war
d be
fore
so
didn
't ne
ed t
o lo
ok a
roun
d.
I w
as t
old
I w
ould
hav
e a
sing
le r
oom
with
TV,
didn
't ge
t to
ld a
bout
any
gen
eral
day
-to
-day
stu
ff o
r ab
out
how
the
wei
ghin
g w
orke
d or
sta
ges!
U18
.4 [
2]
Patien
ts s
tate
d th
at t
hey
are
"tre
ated
as
equa
ls"
by t
he s
taff
team
.
Met
U18
.8 [
2]M
et
84
PQ
: W
hen
you
wer
e ha
ving
ass
essm
ents
, w
ere
are
you
able
to
invo
lve
the
peop
le y
ou r
ely
on
for
supp
ort
(car
ers/
rela
tive
s/ne
ighb
ours
/fri
ends
) in
the
m?
9 re
spon
ses:
8
yes
1 no
SQ
: Are
pat
ient
s ab
le t
o in
volv
e th
e pe
ople
th
ey r
ely
on for
sup
port
(c
arer
s/re
lative
s/ne
ighb
ours
/fri
ends
) in
the
ir
asse
ssm
ents
?
6 re
spon
ses:
6
yes
PQ
: W
ere
you
offe
red
a co
py o
f yo
ur c
are
plan
an
d th
e op
port
unity
to s
ign
this
, an
d/or
wer
e ab
le t
o ac
cess
you
r ca
re p
lan
whe
n re
ques
ted?
9 re
spon
ses:
9
yes
SQ
: Are
pat
ient
s of
fere
d a
copy
of th
eir
care
pl
an a
nd t
he o
ppor
tuni
ty t
o si
gn t
his,
and
/or
are
they
abl
e to
acc
ess
thei
r ca
re p
lan
whe
n re
ques
ted?
6 re
spon
ses:
6
yes
CQ
: W
ere
you
give
n a
copy
of th
e pa
tien
t's
care
pla
n?7
resp
onse
s:
7 no
SQ
: If
the
pat
ient
agr
ees,
are
car
ers
give
n a
copy
of th
e ca
re p
lan?
6 re
spon
ses:
4
yes
2 no
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "Y
our
firs
t fe
w d
ays
on t
he
war
d"
Not
Met
U20
.8 [
2]
Init
ial A
sses
smen
t
Met
Patien
ts a
re a
ble
to d
o th
is t
o th
e de
gree
tha
t th
ey a
re
com
fort
able
with.
Fam
ily g
roup
s ar
e fle
xibl
y of
fere
d to
all
patien
ts.
U19
.6 [
2]
Car
e P
lan
nin
g
U20
.7 [
2]M
et
Patien
ts s
ign
the
copy
of th
eir
care
pla
n w
hich
is k
ept
in t
heir
no
tes.
The
y ar
e ab
le t
o ac
cess
thi
s ho
wev
er d
o no
t ke
ep t
heir
ow
n co
py.
0
A c
arer
spo
ken
to o
n th
e da
y st
ated
tha
t th
ere
was
no
need
as
the
y w
ere
kept
upd
ated
by
the
patien
t.
85
CQ
: W
ere
you
cont
acte
d du
ring
the
pat
ient
's
adm
issi
on a
nd o
ffer
ed a
mee
ting
with
a na
med
pr
ofes
sion
al,
duri
ng w
hich
:
your
vie
ws
abou
t on
goin
g an
dfu
ture
invo
lvem
ent
wer
e re
cord
ed;
you
wer
e gi
ven
an e
xpla
nation
and
info
rmat
ion
shee
t ab
out
war
d/un
it p
roce
dure
s et
c.;
7 re
spon
ses:
3
yes
4 no
you
wer
e of
fere
d in
form
atio
non
car
er a
dvoc
acy;
7 re
spon
ses:
2
yes
5 no
staf
f ex
plai
ned
how
you
cou
ld c
onta
ctth
e w
ard/
unit for
ext
ra in
form
atio
n,ad
vice
or
supp
ort
as n
eede
d, in
clud
ing
outs
ide
of p
lann
ed m
eeting
s?
7 re
spon
ses:
5
yes
2 no
SQ
: Is
the
pri
ncip
al c
arer
con
tact
ed w
ithi
n 72
ho
urs
of t
he p
atie
nt's
adm
issi
on a
nd o
ffer
ed a
m
eeting
with
a na
med
pro
fess
iona
l?
6 re
spon
ses:
2
yes
4 no
CQ
: W
ere
you
advi
sed
how
to
obta
in a
n as
sess
men
t of
you
r ow
n ne
eds?
7 re
spon
ses:
7
no
SQ
: Is
the
pat
ient
's p
rinc
ipal
car
er a
dvis
ed h
ow
to o
btai
n an
ass
essm
ent
of t
heir
ow
n ne
eds?
6 re
spon
ses:
3
yes
3 no
Met
7 re
spon
ses:
3
yes
4 no
U22
.2 [
2]M
et
22.3
[2]
Car
ers
86
CQ
: If
the
pat
ient
gav
e co
nsen
t, w
ere
you
proa
ctiv
ely
invo
lved
at
ever
y st
age
of t
he
inpa
tien
t pr
oces
s in
clud
ing
asse
ssm
ent
and
plan
ning
pri
or t
o in
patien
t ad
mis
sion
, ad
mis
sion
, in
itia
l ass
essm
ent
and
care
pl
anni
ng,
cont
inua
l ass
essm
ent,
dis
char
ge
plan
ning
and
dis
char
ge?
6 re
spon
ses:
1
yes
3 no
2
N/A
CQ
: If
con
sent
was
withh
eld,
wer
e yo
u of
fere
d su
ffic
ient
non
-spe
cific
info
rmat
ion
to a
llow
you
to
offer
sup
port
to
the
patien
t?
6 re
spon
ses:
5
no 1
N/A
SQ
: W
ith
the
patien
t's c
onse
nt,
are
care
rs
proa
ctiv
ely
invo
lved
at
ever
y st
age
of t
he
inpa
tien
t pr
oces
s in
clud
ing
asse
ssm
ent
and
plan
ning
pri
or t
o in
patien
t ad
mis
sion
, ad
mis
sion
, in
itia
l ass
essm
ent
and
care
pl
anni
ng,
cont
inua
l ass
essm
ent,
dis
char
ge
plan
ning
and
dis
char
ge?
6 re
spon
ses:
5
yes
1 no
SQ
: If
con
sent
is w
ithh
eld,
are
car
ers
offe
red
suffic
ient
non
-spe
cific
info
rmat
ion
to a
llow
th
em t
o of
fer
supp
ort
to t
he p
atie
nt?
6 re
spon
ses:
4
yes
2 no
CQ
: W
ere
you
give
n in
form
atio
n on
sup
port
gr
oups
for
car
ers
of p
eopl
e w
ith
eating
di
sord
ers?
6 re
spon
ses:
2
yes
4 no
SQ
: Are
car
ers
give
n in
form
atio
n on
sup
port
gr
oups
for
car
ers
of p
eopl
e w
ith
eating
di
sord
ers?
9 re
spon
ses:
9
yes
22.1
5 [3
]M
et
Met
22.1
6 [2
]
Whi
lst
ther
e is
a B
EAT
serv
ice
in [
city
], a
cces
s to
sup
port
is
arra
nged
via
the
cou
nty'
s co
mm
unity
eating
dis
orde
r se
rvic
e fo
r lo
cal p
atie
nts.
87
PQ
: W
ere
you
mad
e aw
are
of t
he s
tand
ards
for
w
ard
roun
ds/r
evie
ws?
9 re
spon
ses:
8
yes
1 no
SQ
: D
o yo
u m
ake
patien
ts a
war
e of
the
st
anda
rds
for
revi
ews?
6 re
spon
ses:
6
yes
PQ
: At
the
first
and
sub
sequ
ent
revi
ews,
wer
e st
aff in
trod
uced
to
you?
8 re
spon
ses:
8
yes
SQ
: At
the
first
and
sub
sequ
ent
revi
ews,
is t
he
MD
T in
trod
uced
to
the
patien
t?18
res
pons
es:
18 y
es
CQ
: W
ere
revi
ews
faci
litat
ed t
o al
low
you
to
cont
ribu
te a
nd e
xpre
ss y
our
view
s?7
resp
onse
s:
5 ye
s 2
no
SQ
: Are
rev
iew
s fa
cilit
ated
to
allo
w c
arer
s to
co
ntri
bute
and
exp
ress
the
ir v
iew
s?6
resp
onse
s:
4 ye
s 2
no
Met
Som
e da
ys a
re t
oo b
usy
to h
ave
one-
to-o
ne s
essi
ons.
24.6
[2] Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "D
ay-t
o-d
ay li
fe o
n t
he
war
d"
[Do
staf
f gi
ve y
ou p
ost-
mea
l/sn
ack
supp
ort?
- "
On
occa
sion
."]
[Are
you
abl
e to
ac
cess
res
ourc
es t
hat
enab
le y
ou t
o m
eet
your
indi
vidu
al s
elf-
care
nee
ds?
- "M
ost
of
the
tim
e."]
Th
e st
aff se
em v
ery
torn
and
it s
eem
s to
be
who
ever
sho
uts
the
loud
est
gets
the
sup
port
and
the
y ar
e no
rmal
ly t
he o
nes
that
are
n't
stic
king
to
the
care
pla
n!
Whe
reas
the
pat
ient
s w
ho jus
t ge
t on
with
mea
ls a
nd p
roba
bly
need
sup
port
aft
er
rare
ly g
et a
cha
nce
as s
taff
are
cha
sing
up
othe
r pa
tien
ts t
hat
have
n't
com
plet
ed o
r ta
ke t
wo
hour
s to
eat
a m
eal.
24.1
0 [2
]
Met
[Are
you
giv
en t
he o
ppor
tuni
ty t
o ha
ve s
uppo
rtiv
e on
e-to
-one
ses
sion
s w
ith
staf
f ev
ery
day?
- a
nsw
ered
bot
h Ye
s an
d N
o]
Sta
ff a
re n
ot a
lway
s av
aila
ble
for
one-
to-o
nes
or c
atch
up a
fter
mea
l / s
nack
s.
Rev
iew
s
Met
24.9
[2]
88
PQ
: D
id y
ou h
ave
supp
orte
d pe
riod
s of
hom
e le
ave
to d
evel
op in
depe
nden
t ea
ting
, w
ell i
n ad
vanc
e of
dis
char
ge?
9 re
spon
ses:
3
yes
1 no
5
N/A
SQ
: D
o pa
tien
ts h
ave
supp
orte
d pe
riod
s of
ho
me
leav
e to
dev
elop
inde
pend
ent
eating
, w
ell i
n ad
vanc
e of
dis
char
ge?
18 r
espo
nses
: 18
yes
PQ
: W
ere
you
aske
d yo
ur v
iew
s on
the
ca
teri
ng a
rran
gem
ents
on
the
war
d, e
.g.
by
mea
ns o
f a
surv
ey/q
uest
ionn
aire
?
9 re
spon
ses:
2
yes
7 no
WU
MQ
: Are
pat
ient
s’ v
iew
s on
cat
erin
g au
dite
d?N
o
PQ
: D
id s
taff
ask
for
fee
db
ack
from
you
ab
out
the
food
pro
vid
ed o
n t
he
war
d/u
nit
?
9 r
esp
onse
s:
4 y
es 5
no
WU
MQ
: Is
pat
ien
t fe
edb
ack
sou
gh
t ab
ou
t th
e fo
od p
rovi
ded
on
th
e w
ard
/u
nit
?Y
es
Dis
char
ge
Pla
nn
ing
25.3
7 [2
]
This
is o
ffer
ed t
o pa
tien
ts w
here
pos
sibl
e, a
nd t
here
are
a
num
ber
of o
ppor
tuni
ties
to
prac
tice
foo
d pu
rcha
se,
food
pr
epar
atio
n, a
nd e
atin
g ou
t.
Met
0
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
:"P
rep
arat
ion
for
aft
erca
re a
nd
dis
char
ge"
SEC
TIO
N 4
: EN
VIR
ON
MEN
T A
ND
FA
CIL
ITIE
SC
ater
ing
Patien
ts g
ave
high
pra
ise
for
the
food
on
the
war
d, s
tating
th
at it
is n
utri
tiou
s, h
ome
cook
ed,
and
that
the
ir d
islik
es a
re
cons
ider
ed.
Met
41.5
[2]
This
item
is in
clud
ed in
the
sat
isfa
ctio
n qu
estion
nair
e w
hich
is
give
n to
pat
ient
s on
dis
char
ge.
Patien
ts r
epor
ted
that
in t
he p
ast
the
men
u ha
d be
en
mon
oton
ous,
and
fol
low
ing
this
fee
dbac
k ch
ange
s w
ere
succ
essf
ully
mad
e.
Met
41
.17
[1
]
89
PQ
: D
id s
taff
giv
e yo
u p
ost-
mea
l/sn
ack
sup
por
t?7
res
pon
ses:
7
yes
SQ
: D
o yo
u p
rovi
de
pos
t-m
eal/
snac
k su
pp
ort
to
pat
ien
ts?
18
re
spon
ses:
1
8 y
es
PQ
: W
ere
you
r fo
od c
hoi
ces
resp
ecte
d?
9 r
esp
onse
s:
7 y
es 2
no
SQ
: W
ith
in a
cle
arly
des
crib
ed m
enu
pla
n,
are
food
ch
oice
s of
pat
ien
ts r
esp
ecte
d,
as
per
th
e in
div
idu
al's
car
e p
lan
?
7 r
esp
onse
s:
7 y
es
CQ
: W
ere
you
invo
lved
in t
he p
atie
nt's
in
depe
nden
t ea
ting
pro
gram
me?
7 re
spon
ses:
1
yes
6 no
SQ
: W
here
pos
sibl
e, d
o yo
u in
volv
e fa
mily
/car
ers
in t
he in
depe
nden
t ea
ting
pr
ogra
mm
e?
6 re
spon
ses:
5
yes
1 no
PQ
: W
ere
you
r re
ligio
us
or e
thic
al d
ieta
ry
rest
rict
ion
s re
spec
ted
?9
res
pon
ses:
4
yes
5 N
/A
PQ
: If
not
, d
id s
taff
exp
lain
wh
y?5
res
pon
ses:
5
N/A
SQ
: A
re r
elig
iou
s an
d e
thic
al d
ieta
ry
rest
rict
ion
s re
spec
ted
, u
nle
ss t
hey
pre
sen
t a
thre
at t
o re
cove
ry?
18
re
spon
ses:
1
8 y
es
41
.24
[1
]
Met
41
.20
[1
]
Met
41
.21
[1
]
This
was
not
app
licab
le t
o th
e ca
rer
spok
en t
o on
the
day
.
Not
Met
41.2
3 [2
]
Met
The
revi
ew t
eam
wer
e pr
ovid
ed w
ith
seve
ral e
xam
ples
of
whe
n th
is h
ad h
appe
ned.
Even
pat
ient
s no
t ob
liged
to
have
pos
t-m
eal s
uper
visi
on
elec
ted
to d
o so
, st
atin
g th
at t
hey
valu
e th
is s
uppo
rt.
90
PQ
: A
re y
ou a
ble
to
acce
ss r
esou
rces
th
at
enab
le y
ou t
o m
eet
you
r in
div
idu
al s
elf-
care
nee
ds?
7 r
esp
onse
s:
7 y
es
SQ
: C
an p
atie
nts
acc
ess
reso
urc
es t
hat
en
able
th
em t
o m
eet
thei
r in
div
idu
al s
elf-
care
nee
ds,
incl
ud
ing
eth
nic
- an
d g
end
er-
spec
ific
req
uir
emen
ts?
6 r
esp
onse
s:
6 y
es
PQ
: D
o st
aff re
spec
t yo
ur p
erso
nal s
pace
, e.
g.
by k
nock
ing
and
wai
ting
bef
ore
ente
ring
you
r be
droo
m?
8 re
spon
ses:
8
yes
SQ
: D
o yo
u re
spec
t th
e pa
tien
t’s p
erso
nal
spac
e, e
.g.
by k
nock
ing
and
wai
ting
bef
ore
ente
ring
the
ir b
edro
om?
18 r
espo
nses
: 18
yes
Nee
d an
d as
ked
for
so m
any
mor
e op
tion
s on
men
us.
Alw
ays
have
the
sam
e m
eals
re
peat
ed a
nd [
nam
e] h
as h
undr
eds
of m
eals
in h
er fol
der!
Met
42.6
[2]
Dig
nit
y
U4
2.3
[1
]
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "Y
our
per
son
al s
pac
e an
d s
elf
care
"
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "C
ater
ing
"
Sta
ff a
re w
illin
g to
list
en t
o fe
edba
ck in
com
mun
ity
mee
ting
.
Patien
ts w
ere
happ
y w
ith
the
prov
isio
n of
res
ourc
es for
sel
f-ca
re.
Met
[Do
staf
f re
spec
t yo
ur p
erso
nal s
pace
, e.
g. b
y kn
ocki
ng a
nd w
aiting
bef
ore
ente
ring
yo
ur b
edro
om?
- "N
ine
out
of t
en t
imes
."]
91
PQ
: W
ere
you
offe
red
educ
atio
n an
d in
form
atio
n on
the
nat
ure,
cou
rse
and
trea
tmen
t of
eat
ing
diso
rder
s?
9 re
spon
ses:
5
yes
4 no
CQ
: W
ere
you
offe
red
educ
atio
n an
d in
form
atio
n on
the
nat
ure,
cou
rse
and
trea
tmen
t of
eat
ing
diso
rder
s?
6 re
spon
ses:
2
yes
4 no
SQ
: Are
pat
ient
s an
d, w
here
app
ropr
iate
, ca
rers
/fam
ily,
offe
red
educ
atio
n an
d in
form
atio
n on
the
nat
ure,
cou
rse
and
trea
tmen
t of
eat
ing
diso
rder
s?
6 re
spon
ses:
6
yes
PQ
: W
ere
you
offe
red
info
rmat
ion
and
harm
m
inim
isat
ion
advi
ce a
bout
the
sho
rt-
and
long
-te
rm r
isks
to
heal
th a
ssoc
iate
d w
ith
eating
di
sord
ers?
9 re
spon
ses:
5
yes
4 no
CQ
: W
ere
you
offe
red
info
rmat
ion
and
harm
m
inim
isat
ion
advi
ce a
bout
the
sho
rt-
and
long
-te
rm r
isks
to
heal
th a
ssoc
iate
d w
ith
eating
di
sord
ers?
6 re
spon
ses:
1
yes
5 no
SQ
: Are
pat
ient
s an
d th
eir
care
rs o
ffer
ed
info
rmat
ion
and
harm
min
imis
atio
n ad
vice
ab
out
shor
t an
d lo
ng-t
erm
ris
ks (
e.g.
dam
age
to t
eeth
, re
prod
uctive
sys
tem
, os
teop
oros
is)?
6 re
spon
ses:
6
yes
44.8
[2]
Patien
ts fel
t th
at t
his
is c
over
ed in
a n
umbe
r of
the
gro
ups,
an
d th
at s
taff
are
wel
l-in
form
ed.
Patien
ts a
re a
ble
to h
ave
thei
r bl
ood
resu
lts
expl
aine
d to
th
em a
t a
wee
kly
revi
ew.
Met
Met
44.9
[2]
Pro
visi
on o
f In
form
atio
n
92
PQ
: D
o st
aff op
enly
dis
cuss
the
ris
ks o
f so
cial
ne
twor
king
and
pro
-ano
rexi
a w
ebsi
tes?
9 re
spon
ses:
2
yes
7 no
SQ
: D
o yo
u op
enly
dis
cuss
the
ris
ks o
f so
cial
ne
twor
king
and
pro
-ano
rexi
a ne
rvos
a w
ebsi
tes
with
patien
ts?
10 r
espo
nses
: 8
yes
2 no
PQ
: W
hen
you
wer
e re
ceiv
ing
med
icat
ion,
wer
e yo
ur p
riva
cy,
dign
ity
and
conf
iden
tial
ity
ensu
red?
7 re
spon
ses:
7
yes
SQ
: D
urin
g th
e ad
min
istr
atio
n or
sup
ply
of
med
icin
es t
o pa
tien
ts,
is t
heir
pri
vacy
, di
gnity
and
conf
iden
tial
ity
ensu
red?
6 re
spon
ses:
6
yes
PQ
: W
ere
you
told
tha
t yo
u co
uld
spea
k to
a
phar
mac
ist
or p
harm
acy
tech
nici
an t
o di
scus
s m
edic
atio
ns?
8 re
spon
ses:
8
no
WU
MQ
: D
o pa
tien
ts h
ave
acce
ss t
o a
spec
ialis
ed p
harm
acis
t an
d/or
pha
rmac
y te
chni
cian
to
disc
uss
med
icat
ions
?N
o
44.1
0 [2
]
Met
U48
.1 [
2]
Ther
e is
no
acce
ss t
o a
phar
mac
ist;
pre
scri
ptio
ns g
o fr
om t
he
GP
surg
ery
to t
he c
omm
unity
phar
mac
y w
hich
del
iver
s to
the
w
ard,
but
has
no
wid
er r
emit.
Not
Met
U48
.5 [
2]
SEC
TIO
N 5
: TH
ERA
PIE
S A
ND
AC
TIV
ITIE
SM
edic
atio
n
Met
0
Pat
ien
t Q
ues
tio
nn
aire
Co
mm
ents
: "E
du
cati
on
"
This
is a
ddre
ssed
in t
he d
iscu
ssio
n ar
ound
'exp
ecta
tion
s'.
Patien
ts fel
t th
at t
his
was
add
ress
ed,
with
the
expe
ctat
ion
not
to lo
ok a
t th
is w
ebsi
tes
abid
ed b
y.
93
CQ
: W
ere
you
told
tha
t yo
u co
uld
spea
k to
a
phar
mac
ist
or p
harm
acy
tech
nici
an t
o di
scus
s m
edic
atio
ns?
6 re
spon
ses:
4
no 2
N/A
WU
MQ
: D
o ca
rers
hav
e ac
cess
to
a sp
ecia
lised
ph
arm
acis
t an
d/or
pha
rmac
y te
chni
cian
to
disc
uss
med
icat
ions
?N
o
PQ
: D
id s
taff t
ake
care
to
ensu
re t
hat
your
m
edic
atio
ns a
nd n
utri
tion
al s
uppl
emen
ts w
ere
cons
iste
nt w
ith
your
rel
igio
us o
r cu
ltur
al
prac
tice
s?
6 re
spon
ses:
6
yes
SQ
: D
o yo
u ta
ke c
are
to e
nsur
e th
at
med
icat
ions
and
nut
rition
al s
uppl
emen
ts a
re
cons
iste
nt w
ith
the
patien
t’s r
elig
ious
or
cultur
al p
ract
ices
?
6 re
spon
ses:
6
yes
PQ
: W
ere
you
info
rmed
of th
e in
form
ed o
f an
y ri
sks
to y
our
phys
ical
hea
lth
of t
he m
edic
atio
n yo
u w
ere
pres
crib
ed?
8 re
spon
ses:
3
yes
5 no
SQ
: Are
pat
ient
s in
form
ed o
f th
e ri
sks
of t
he
med
icat
ion
they
are
pre
scri
bed,
e.g
. SSRIs
and
pe
ptic
ulc
er d
isea
se?
6 re
spon
ses:
6
yes
48.1
7 [2
]
48.1
6 [2
]
Met
[Whe
n yo
u ar
e re
ceiv
ing
med
icat
ion,
is y
our
priv
acy,
dig
nity
and
con
fiden
tial
ity
ensu
red?
- "
Mos
tly.
"] [
Do
staf
f ta
ke c
are
to e
nsur
e th
at y
our
med
icat
ions
and
nu
tritio
nal s
uppl
emen
ts a
re c
onsi
sten
t w
ith
your
rel
igio
us o
r cu
ltur
al p
ract
ices
? -
"Mos
tly.
"]
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "M
edic
atio
n"
Met
Not
Met
48
.6 [
3]
The
revi
ew t
eam
not
ed t
hat
the
'no'
res
pons
es a
t se
lf-re
view
co
uld
be a
ttri
bute
d to
the
fac
t th
at n
ot a
ll pa
tien
ts a
re o
n m
edic
atio
n.
94
PQ
: D
o yo
u fe
el t
hat
staf
f tr
eat
you
with
resp
ect?
8 re
spon
ses:
8
yes
SQ
: D
o st
aff an
d pa
tien
ts t
reat
one
ano
ther
w
ith
mut
ual r
espe
ct?
19 r
espo
nses
: 18
yes
1 n
o
PQ
: W
as y
our
ther
apeu
tic
prog
ram
me
tailo
red
to y
our
indi
vidu
al n
eeds
?9
resp
onse
s:
5 ye
s 4
no
SQ
: Is
the
pat
ient
's t
hera
peut
ic p
rogr
amm
e ta
ilore
d to
the
ir in
divi
dual
nee
ds a
nd s
uppo
rted
by
a t
imet
able
?
18 r
espo
nses
: 18
yes
PQ
: D
id y
ou h
ave
acce
ss t
o in
terv
ention
s th
at
prom
ote
self-
man
agem
ent,
soc
ial i
nclu
sion
and
st
ayin
g w
ell p
lans
, ei
ther
on
an in
divi
dual
or
grou
p ba
sis?
7 re
spon
ses:
5
yes
2 no
SQ
: D
o pa
tien
ts h
ave
acce
ss t
o in
terv
ention
s th
at p
rom
ote
self-
man
agem
ent,
soc
ial
incl
usio
n an
d st
ayin
g w
ell p
lans
, ei
ther
on
an
indi
vidu
al o
r gr
oup
basi
s?
18 r
espo
nses
: 18
yes
Met
50.1
[2]
53.3
1 [2
]
Met
54.3
[2]
The
patien
ts m
et w
ith
on t
he d
ay w
ere
very
pos
itiv
e ab
out
how
the
y w
ere
trea
ted
as in
divi
dual
s w
ith
a ta
ilore
d ap
proa
ch.
Met
Eng
agem
ent
Pro
visi
on o
f A
ctiv
itie
s an
d T
her
apie
s
Gro
up
Act
ivit
ies
and
Th
erap
ies
95
CQ
: W
ere
you
able
to
acce
ss r
egul
ar g
roup
m
eeting
s th
at foc
used
on
unde
rsta
ndin
g m
enta
l illn
ess
and
its
trea
tmen
t, e
ithe
r on
or
off th
e w
ard/
unit?
6 re
spon
ses:
3
yes
3 no
SQ
: Are
car
ers
able
to
acce
ss r
egul
ar g
roup
m
eeting
s th
at h
ave
a ps
ycho
educ
atio
nal f
ocus
?6
resp
onse
s:
5 ye
s 1
no
PQ
: W
ere
you
able
to
leav
e th
e w
ard/
unit t
o at
tend
act
ivitie
s el
sew
here
in t
he b
uild
ing
?
8 re
spon
ses:
3
yes
1 no
4
N/A
PQ
: W
ere
you
able
to
acce
ss u
sabl
e ou
tdoo
r sp
ace
ever
y da
y?9
resp
onse
s:
9 ye
s
SQ
: Are
pat
ient
s ab
le t
o le
ave
the
war
d/un
it t
o at
tend
act
ivitie
s el
sew
here
in t
he b
uild
ing
and,
w
ith
appr
opri
ate
supp
orts
and
esc
orts
, to
ac
cess
usa
ble
outd
oor
spac
e ev
ery
day?
17 r
espo
nses
: 17
yes
PQ
: W
ere
you
supp
orte
d an
d en
cour
aged
to
acce
ss lo
cal o
rgan
isat
ions
, ad
voca
cy p
roje
cts
and
relig
ious
and
cul
tura
l gro
ups
from
you
r ow
n co
mm
unity?
9 re
spon
ses:
4
yes
5 no
SQ
: Are
pat
ient
s su
ppor
ted
and
enco
urag
ed t
o ac
cess
loca
l org
anis
atio
ns,
advo
cacy
pro
ject
s an
d re
ligio
us a
nd c
ultu
ral g
roup
s fr
om t
heir
ow
n co
mm
unity?
14 r
espo
nses
: 14
yes
Pat
ien
t Q
ues
tion
nai
re C
omm
ents
: "T
her
apy
and
act
ivit
ies"
[Do
you
have
acc
ess
to in
terv
ention
s th
at p
rom
ote
self-
man
agem
ent,
soc
ial i
nclu
sion
an
d st
ayin
g w
ell,
eith
er o
n an
indi
vidu
al o
r gr
oup
basi
s? -
"Kin
d of
."]
Exte
rnal
Act
ivit
ies
and
Th
erap
ies
Met
U55
.1 [
2]
An
exam
ple
was
pro
vide
d of
a p
atie
nt b
eing
abl
e to
acc
ess
thei
r lo
cal c
hurc
h.
Met
55.2
[2]
Not
Met
54.5
[3]
96
Car
er Q
ues
tion
nai
re C
omm
ents
This
was
[m
y re
lative
's]
seco
nd a
dmis
sion
to
[uni
t] s
o so
me
answ
ers
wer
not
rea
lly r
elev
ant.
[Wer
e yo
u ab
le t
o ac
cess
reg
ular
gro
up m
eeting
s th
at foc
used
on
unde
rsta
ndin
g m
enta
l illn
ess
and
its
trea
tmen
t, e
ithe
r on
or
off th
e w
ard/
unit?
- "O
ffer
ed,
but
un-a
ble
to a
tten
d."]
[W
ere
you
offe
red
info
rmat
ion
and
harm
min
imis
atio
n ad
vice
abo
ut t
he s
hort
- an
d lo
ng-t
erm
ris
ks t
o he
alth
as
soci
ated
with
eating
dis
orde
rs?
- "A
ll re
ady
awar
e."]
I ha
ve a
nsw
ered
the
que
stio
ns q
uite
neg
ativ
ely
but
I w
as n
ot o
ffer
ed a
ny o
f th
ese.
But
on
refle
ctio
n m
y da
ught
er n
eede
d an
adm
issi
on s
o I
was
ve
ry h
appy
with
the
help
she
got
. M
e on
the
oth
er h
and
was
left
in t
he d
ark
and
very
uns
uppo
rted
.
We
coul
d no
t fa
ult
the
care
giv
en t
o ou
r da
ught
er a
t [u
nit]
They
nee
d to
be
mor
e fle
xibl
e w
ith
the
stag
es a
s so
me
peop
le c
ould
com
e in
with
a lo
w B
MI
and
take
a w
hile
to
gain
wei
ght
(goe
s on
mor
e sl
owly
),
but
are
mor
e th
an c
apab
le t
o do
the
men
tal s
ide
of t
he p
rogr
am li
ke m
eal p
reps
, bu
t be
caus
e th
eir
BM
I is
n;t
at t
he r
ight
sta
ge t
hey
can'
t do
it a
nd
this
cou
ld e
asily
lead
to
losi
ng m
otiv
atio
n an
d po
sitivi
ty.
Pat
ien
t Q
ues
tio
nn
aire
- A
dd
itio
nal
Co
mm
ents
97
To r
evis
it th
e pr
oces
s fo
r pr
escr
ibin
g an
d di
spen
sing
med
icat
ion;
with
the
cur
rent
sys
tem
, pa
tient
s do
not
hav
e ac
cess
to
advi
se a
bout
the
ir m
edic
atio
n fr
om a
pha
rmac
ist.
To
con
side
r pr
ovid
ing
a gr
oup
for
care
rs in
whi
ch m
enta
l illn
ess
and
its t
reat
men
t ca
n be
dis
cuss
ed.
PA
TIEN
T A
ND
CA
RER
QU
ESTI
ON
NA
IRES
- S
UM
MA
RY
Are
as o
f ac
hie
vem
ent.
Act
ion
po
ints
.
Patie
nts
felt
that
the
atm
osph
ere
on t
he w
ard
was
goo
d, a
ided
the
ir r
ecov
ery,
and
tha
t th
ey w
ere
trea
ted
as in
divi
dual
s ra
ther
tha
n "p
eopl
e w
ith e
atin
g di
sord
ers"
. It
was
fel
t th
at t
he p
rogr
amm
e w
as w
ell-
tailo
red
to t
heir in
divi
dual
nee
ds.
Patie
nts
wer
e pl
ease
d w
ith t
he c
ater
ing
on t
he w
ard
and
that
sta
ff w
ould
acc
omm
odat
e th
eir
pref
eren
ces.
Car
er fee
dbac
k w
as p
ositi
ve,
with
com
men
ts r
elat
ing
to t
he w
elco
min
g en
viro
nmen
t an
d he
lpfu
l sta
ff -
it w
as fel
t th
at t
he
cont
inui
ty o
f st
aff w
as a
big
ass
et.
98
Act
ion
Pla
n
Rep
ort
se
ctio
n
Are
a f
or
imp
rovem
en
t
Wh
o n
eed
s to
be
invo
lved
/in
form
ed
an
d h
ow
?
So
urc
es
of
sup
po
rt/
info
rmati
on
to
develo
p p
lan
Hu
man
, fi
nan
cial
an
d t
ime r
eso
urc
es
yo
u m
ay n
eed
Lead
an
d
dead
lin
e(s
)
1.
2.
Envi
ronm
ent
& F
acili
ties
Aud
it
3.
99
Rep
ort
S
ect
ion
A
rea f
or
Imp
rovem
en
t
Wh
o n
eed
s to
be
invo
lved
/in
form
ed
an
d h
ow
?
So
urc
es
of
sup
po
rt/
info
rmati
on
to
develo
p p
lan
Hu
man
, fi
nan
cial
an
d t
ime r
eso
urc
es
yo
u m
ay n
eed
Lead
an
d
dead
lin
e(s
)
1.
2.
Che
cklis
t
3.
100
Rep
ort
S
ect
ion
A
rea f
or
Imp
rovem
en
t
Wh
o n
eed
s to
be
invo
lved
/in
form
ed
an
d h
ow
?
So
urc
es
of
sup
po
rt/
info
rmati
on
to
develo
p p
lan
Hu
man
, fi
nan
cial
an
d t
ime r
eso
urc
es
yo
u m
ay n
eed
Lead
an
d
dead
lin
e(s
)
1.
2.
Hea
lth
Rec
ord
Aud
it
3.
101
Rep
ort
S
ect
ion
A
rea f
or
Imp
rovem
en
t
Wh
o n
eed
s to
be
invo
lved
/in
form
ed
an
d h
ow
?
So
urc
es
of
sup
po
rt/
info
rmati
on
to
develo
p p
lan
Hu
man
, fi
nan
cial
an
d t
ime r
eso
urc
es
yo
u m
ay n
eed
Lead
an
d
dead
lin
e(s
)
1.
2.
Sta
ff a
nd W
ard
Man
ager
Q
uest
ionn
aire
s
3.
102
Rep
ort
S
ect
ion
A
rea f
or
Imp
rovem
en
t
Wh
o n
eed
s to
be
invo
lved
/in
form
ed
an
d h
ow
?
So
urc
es
of
sup
po
rt/
info
rmati
on
to
develo
p p
lan
Hu
man
, fi
nan
cial
an
d t
ime r
eso
urc
es
yo
u m
ay n
eed
Lead
an
d
dead
lin
e(s
)
1.
2.
Patie
nt
and
Car
er
Que
stio
nnai
res
3.
103
104
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