Audit Sheet 3 – Trust Lead

Ward/Area………………………….Date………………..

Ward Type (Surgical, Cardiovascular, etc.)…………………………………………..Matron/Senior Sister Name……………………………………………………………….

Ask 3 staff members ( including doctors/nurses/physio/OT) or observe:

Are services caring/responsive?

Questions Comments/observations Guidance for inspectors
1. Are staff aware of how to access Yes Yes Yes PALS, intranet
an interpreter? No No No
n/a n/a n/a
2. Do staff know how to report an Yes Yes Yes Datix-web system for on-line
incident? No No No reporting
n/a n/a n/a
3. Can staff describe how a patient’s Limited Limited Limited Capacity is always assumed unless
capacity to make decisions is good reason to suggest otherwise.
assessed? Adequate Adequate Adequate Capacity is assessed by a senior
doctor and any assessment must
Good Good Good always be documented.
4. Can staff give examples of the Yes Yes Yes Leaflets, signposting to other
types of information they would No No No resources , explanation of
give to a patient to help them n/a n/a n/a risks/benefits
understand their care &
treatment?
5. Can staff tell you who the Yes Yes Yes Adult ward s - David Flood,
safeguarding lead is for the Trust No No No Safeguarding Lead Nurse
(Adult wards) and how they n/a n/a n/a
would escalate a concern?
6. Can staff describe how they Limited Limited Limited Lock computer screens
protect patient’s confidentiality? Don’t leave notes or test results
Adequate Adequate Adequate lying around
Dispose of pt info securely – i.e.
Good Good Good hand over sheets
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7. Can staff to describe how they Limited Limited Limited Ask open questions to understand
would deal with a patient’s problem
concerns if raised? Adequate Adequate Adequate Take quick action where they can
If they can’t solve escalate to
Good Good Good someone who can
Refer to PALS in some cases
OBSERVE Yes Introducing themselves
8. Do staff interact with patients in No Not ‘shouting ‘ across bays
a caring and respectful way? n/a Actively listening to patients and
not speaking over them
Using patient’s preferred names as
opposed to a ‘pet name’ such as
‘love’
OBSERVE Yes
9. Are notice boards free from No
clutter? n/a
OSERVE Yes
10. Is the A3 interpreting services No
poster clearly visible on the notice n/a
board?

Are services effective?

Questions Comments/observations Guidance for inspectors

OBSERVE Yes
11. Are drinks/glass and jug of water No
in easy reach for patient? n/a
OBSERVE Yes
12. If on the ward at mealtimes – are No
patients with red-trays receiving n/a
assistance?

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OBSERVE Yes
13. If on the ward at mealtimes – is No
food siting out of reach of n/a
patients?

Are services safe?

Questions Comments/observations Guidance for inspectors
OBSERVE Yes
14. Are staff bare below the elbows No
OBSERVE Yes
15. Do staff appear neat, clean and No
professional in appearance n/a
OBSERVE Yes
16. Are staff washing hands /using No
alcohol gel between patients n/a
OBSERVE Commode 1 Commode 2 Commode 3 WEAR GLOVES AND APRON:
17. Sluice room – check 3 commodes 1. Check commode is visibly clean
are clean and labelled correctly 2. Turn upside down and check
with a green label underneath side of seat
3. Check the wheels are free from
dirt and hair.
OBSERVE Yes
18. Check 2 other pieces of ward No
equipment are clean and labelled n/a
correctly with a green label

Speak to staff:
Are services well led/responsive?
Questions Comments/observations Guidance for inspectors
19. Have staff had an appraisal in the last Yes Yes Yes
year? No No No
n/a n/a n/a

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20. Are staff up to date with MAST Yes Yes Yes

training? No No No
n/a n/a n/a
21. If new to the ward/area – have they Yes Yes Yes
had a local induction? No No No
n/a n/a n/a
22. Do they know where to find Trust Yes Yes Yes
policies such as Infection Control? No No No
n/a n/a n/a
23. Do staff know how to raise a Yes Yes Yes
concerns/ whistleblowing? No No No
n/a n/a n/a

Speak with the Nurse in charge of the ward:

Are services responsive/well led?

Questions Comments/observations Guidance for inspectors
24. Have you completed your Yes
Nurse in Charge No
competencies? n/a
25. Can you show me where Yes
the medicines trolley is at No
this point? (check this is n/a
locked or in line of sight if
in use )
26.
27. Can you show me the Yes The drugs trolley keys should always
medicines trolley keys and No be with a registered nurse
the Controlled Drugs keys ? n/a
*some areas have ‘pods’ or Check the CD key is separate from the
other form of medicines trolley drugs trolley keys

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28. Check the CD have been Yes

checked within the last 24 No
hours n/a

29. Show me the resus trolley Yes Top shelf of trolley should be checked
and the trolley checks No daily but all drugs on bottom shelf will
n/a be checked monthly.
30. Have the safety checks Yes There should be a daily check of
been completed today? No oxygen, suction equipment.
n/a
OBSERVE Yes
31. Is equipment stored safely No
and without causing an n/a
obstruction?
OBSERVE Yes
32. Are any medicines sitting No
out on patient bedside n/a
cabinets?
OBSERVE Yes
33. Are health records securely No
stored or not left sitting in n/a
an open access area?
Enter general overall observations comments here & continue on reverse if required

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