People First Quality Checkers. Observation Checklist

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2 Observation Checklist Is the Hospital is good decorative order? Does the hospital smell and look clean? Are staff speaking for people or are people speaking for themselves? Are people asking staff permission? Are the staff listening to what people are saying? Are choices being offered? Is information in accessible formats? How is the support plan, care plan or PCP written, does it use pictures, flip chart paper etc. Do people look like they are getting on? Has anyone told you they don t like someone else in the house (support worker or another patient)? Are people speaking nicely to one another? Are staff treating people s belongings with respect? Are staff showing respect for privacy where possible? Are people talking about personal things to do with people when they are there? Are staff talking about people in nice ways? Do any written notes about people use good, positive words? Are staff answering questions that the person themselves can answer? Is there any evidence that people are helped to communicate better with aides, easy read documents, Makaton signing? Are there visitors? Is there evidence that people get out and about? Are people making choices about what they do, what they eat, what they wear etc.? Are there personal things in people s rooms? All rights reserved All other reproduction is strictly prohibited without permission from the publisher People First Quality Checkers

3 KEY 1 Self Determination What if anything do the people who use the service decide about the running of the service? Do people who use the service have the opportunity to feedback about the service? If so, how do they do this? Is there an internal evaluation of the service? how often does this take place? Are people who use the service regularly asked about the service? are these comments actioned? Are families and carers involved in the self-evaluation? 3

4 Are people who use the service leading the evaluation? If so how? Do people who use the service have the opportunity to feedback about the service? If so, how do they do this? Are advocacy services available? Are people who use the service aware of Self advocacy and or advocacy services? Are advocacy and self-advocacy services advertised on the premises? What is the hospital s relationship with local self-advocacy groups? Are they consulted about the running of the hospital? 4

5 How do self-advocacy or advocacy organisations feedback to the service for service improvement? KEY 3 Money Is there a clear breakdown of how much the support is costed for each individual? Is this made available to family/carers and or the individual who uses the service? 5

6 KEY 5 Support What training do the staff receive? What was the last training you received from an external organisation? Do you have a training needs analysis? Can we see it? What are these issues? 6

7 Do line managers ever work alongside staff? Do staff feel supported by their line managers? Do line managers feel supported by their senior management? What are the figures for turn-over, vacancies, gender mix, sick leave holiday etc? 7

8 KEY 6 Safeguarding Does the hospital have a equality scheme that is compliant with the equality act? Do you have a safeguarding policy? Is this in easy read or accessible format? What would happen if somebody who uses your service wanted to make a safeguarding alert? When was the last safeguarding alert? 8

9 Is the hospital registered with the CQC? Are there any concerns in the CQC report? What is the overall CQC status? Does the hospital get inspected by any other organisation? Please specify Is there a mental health act inspection report? 9

10 Is there an action plan related to this report? Are people who use the service aware of the complaints procedure? How are they made aware of this? Do you have a format for compliments and complaints? Like comment cards provided? Are actions taken on the feedback that is received? How are these actions documented or recorded? All rights reserved All other reproduction is strictly prohibited without permission from the publisher People First Quality Checkers 10

11 Please make available the following items: Compliance CQC report provided including necessary evidence to support effective implementation of any actions CQC Mental Health Act Report to be provided An action plan associated with most recent report. Any other Inspection reports Evidence of voluntary external and internal scrutiny. Equality act compliance reports and assessments. Facilities PEAT Report or equivalent. Evidence of consideration of patient or client environment at regular staff meetings. Evidence of service user involvement in environmental decisions. Staff Numbers Evidence about staffing to include: Numbers of staff, breakdown of professions and bands (+experience profile) Turnover figures. Vacancies Gender mix Policy for holiday and sick leave Sickness levels (%) Staff Rota Policies. Whistleblowing policy Bullying and Harassment policy Sickness Absence policy Grievance policy Holiday and other absence policy. 11

12 Training and recruitment Job descriptions/person specs CRB checking arrangements References take up Competence/qualification checking Relevant professional registration Appraisal / Supervision notes. Staff Training Programme Training needs analysis and competency framework. Report detailing numbers/ % who have had training including detail of training provider and accreditation of training for each of the areas to be provided % of training specific to learning disability that is delivered by a person with a learning disability. Anonymised copies of clinical risk assessments. Safeguarding Local organisational policy Local Authority policy and evidence of use if applicable Evidence of staff training and knowledge. Incident management process Incident policy Evidence of learning from incidents and dissemination or lessons. Risk Management processes Anonymised notifications of events notified to CQC to be provided Non-clinical risk assessments available. Complaints and feedback processes & reports Evidence of accessible complaints and feedback procedures and records to show that patients and families have been made aware of these. Numbers of safeguarding issues raised over previous 2 years. Number of complaints for last year Number of feedback comments. Nature of complaints From whom received (e.g. patient, carer, staff etc.) Evidence of accessible comment cards. Details of specialist (e.g. non mandatory) training available and attended. Action plans generated from complaints are available. 12

13 List of complaints for the previous 2 years, both upheld and refuted. Evidence of how complaints are followed up in terms of staff learning, training and dissemination and how people involved following a complaint and kept informed Meetings Record of reviews, (notes, reports and minutes) Management meeting minutes Visiting policy included in all care plans where necessary Inspections Copies of audit reports Action plans resulting from audits and inspections. Clinical Clinical governance meeting minutes. Evidence of external professional involvement, including local GPs. Evidence of lead professional role being assigned. List of admission criteria. Comparative inspection for treatment programmes, client profile and admission criteria. Plans Provide a draft care plan for whom the placement is being considered Health Action Plan Evidence to demonstrate: Development of goals Planning for transition/transfer is inclusive and agreed Carer/family involvement Evidence of: Information about advocacy groups, accessibly provided, at the establishment. Evidence of advocacy involvement in the unit. Copies of advocacy reports where available. Interview with service users about availability and use of advocates. Operational policy of unit / visitors policy. Evidence of feedback from family carers. Policy for contact with family carers by the establishment. Family carer feedback (verbal or written). Visiting book. Record of visits by senior management. 13

14 All rights reserved All other reproduction is strictly prohibited without permission from the publisher People First Quality Checkers Thanks to The CHAMP s Team Nory Menneer - Nurse Consultant Margaret Upham Richard Bow NHS Devon and Torbay 14