Aneurin Bevan Health Board Wednesday 24 th November 1 Agenda Item: 2.4 Aneurin Bevan Health Board All Wales Fundamentals of Care Audit: Summary of the Health Board s compliance with the Standards 1 Introduction One of the key recommendations of the Free to Lead, Free to Care, Empowering Ward Sisters/Charge Nurses Ministerial Task and Finish Group was that: All ward sister/charge nurses should have access to an All Wales Audit Tool which should be developed to measure standards against the Fundamentals of Care Standards published in 3. Reports arising from use of this Audit Tool should be distributed to the NHS Board and the Chief Nursing Officer, Wales. A summary of the report is provided as Attachment One. The Board is requested to endorse the Fundamental of Care Audit. Financial Assessment and link to Financial Recovery Plan Risk Assessment Annual Operating Framework Standards for Health Services Wales Equality Impact Assessment The improvement actions in response to Fundamentals of Care Audit will need to be taken forward as part of existing operational budgets. The Fundamentals of Care Audit will be actively used to inform clinical and operational risk assessments. The Fundamentals of Care Audit will contribute across the Annual Operating Framework targets. The Fundamentals of Care Audit will contribute across the range of Standards for Health Services in Wales. No local impact assessment has been undertaken. 1
2. Background The Fundamentals of Care (3) is a Welsh Assembly Government initiative which aims to improve the quality of aspects of health and social care for adults. It contains 12 standards all relating to essential elements of care. The standards are monitored annually by the Welsh Assembly Government. In May 9 the all-wales Fundamentals of Care electronic Audit Tool was introduced, as one of the key recommendations of Free to Lead: Free to Care - Empowering Ward Sisters/Charge Nurses Ministerial Task and Finish Group (WAG 8). The Fundamentals of Care electronic audit tool is easy to use and accessible to all wards. It is versatile and provides the organisation with the evidence it needs to measure the quality of care it provides. The data collated can be benchmarked across Wales and best practice can be disseminated to benefit patients and staff. The All-Wales Fundamentals of Care Task & Finish Group continue to meet to further develop the electronic tool, under the leadership of the Aneurin Bevan Health Board Nurse Director. The tool has recently been updated to enable data capture in: Theatres, Day Units, Out Patient Departments and Accident & Emergency Departments. The audit tool was first used in the summer 9. 96 adult inpatient wards across Gwent Health NHS Trust were reviewed. The first report from this review was submitted to the Aneurin Bevan Health Board meeting in October 9. The electronic system analyses the data entered and automatically populates an Action Plan for every ward. Action Plans have been updated by the Ward Sister and reviewed regularly by the Senior Nurse. Each Division submits a quarterly report on progress and actions to the Nurse Director. To recap, the 9 Audit identified particular issues with nutritional screening, pressure ulcer care and documentation standards. There have been a number of active interventions aimed at improving compliance, namely: The introduction of the Nutritional Pathway and associated Food & Fluid Charts, guiding nursing staff in the assessment and management of patient s nutritional needs. 2
Financial investment in pressure relieving equipment and the implementation of the SKIN Bundle, with the aim of eradicating Hospital Acquired Pressure Ulcers. A new Patient Care Record designed by nursing staff has been implemented across the organisation. The new documentation Aims to improve the quality of patient information and communication between clinicians and other agencies. Transforming Care is being rolled out across the organisation; with the aim of improving the amount of time Nurses spend in Direct Care activities. In July and August 1, 112 adult in-patient wards audited their compliance with the All Wales Fundamentals of Care Standards. The increase in the number of Wards participating is associated with Health Board s responsibility for services for South Powys and involvement of Learning Disabilities. Information has been collated from 6 Acute Hospital Wards, 22 Community Hospital wards and 3 Mental Health units. An impressive 5,634 patient responses to the user questionnaire have been obtained and recorded, with the help of Age Concern, to ensure impartiality. Last year assistance was received from the Community Health Council for this exercise. Work will continue with Voluntary bodies to assist with the patient experience reviews, particularly focusing on vulnerable client groups to ensure their voice is heard. A selection of user comments have been included in the main body of the report. 3. Conclusion An organisational action plan to address key areas for improvement has been developed and all Ward Sisters/Charge Nurses will have completed plans available by the end of October, which will further inform the organisational plan. Completion of the audit tool has provided Ward Sisters/Charge Nurses with the information they require to successfully manage and develop their areas of responsibility, to improve patient experience. The information will also help the Ward Sister/Charge Nurse identify and support staff training and development needs. Data collated from completion of this audit tool will be used by Senior Nurses, Divisional Nurses and the Executive Director of 3
Nursing to measure compliance with the standards of the Fundamentals of Care, throughout the organisation. The information will be widely shared with other clinical agencies and relevant personnel from Health & Safety, Works & Estates, and Hotel Services to improve and maintain the quality and standard of services. The annual audit results will be presented to the Board by the Executive Director of Nursing in October of each year and an Action Plan addressing the areas for improvement forwarded to the Chief Nursing Officer for Wales by November of each year. Continuous improvement will be tracked and used as evidence for the Standards for Health Services, Hospital Patient Environment audits and Health Inspectorate Wales reviews. 4. Recommendations The Board is requested to note the overall improvements in the annual Fundamentals of Care Audit results for 1 across the organisation, agree the actions for 1/11, concentrating on improvements for Standards 2 and 5, 8 and1 and user experience in all areas and endorse the submission of the Fundamentals of Care Audit to the Welsh Assembly Government. Report prepared and sponsored by: Denise Llewellyn, Nurse Director 4
Attachment One Results The following table outlines the overall percentage compliance with the standards, comparing scores from 9 with the 1 results: Standard Operational Score compliance score 9 1 9 1 1 Communication & Information 71 83 93 96 2&5 Respecting People & Relationship 69 78 88 92 3 Ensuring Safety 87 91 93 97 4 Promoting independence 81 85 91 94 6 Sleep, rest and activity 75 82 87 9 7 Ensuring comfort, alleviating pain 77 82 94 97 8 Personal Hygiene and appearance 68 7 9 95 9 Eating & Drinking 81 87 9 89 1 Oral Health and hygiene 61 58 74 11 Toilet needs 86 89 93 96 12 Preventing pressure ulcers 89 82 87 Overall Average Organisational Score 76 83 88 92 For the overall operational score, all but one standard (1) has seen an increase in the percentage compliance between 9 & 1. Communication & Information (1) has seen a significant increase of 12. For the overall user experience element, all but one standard (9) has seen an increase in the percentage score between 9 & 1. Whilst Standard 9 has seen a decrease, it should be noted that this is only by 1. The 1 results highlight the need for specific action to be deployed against Standards: 2&5, 8 and 1 from an operational perspective, as these have scored below. Whilst this is the case it should be noted that the score for Standard 2 & 5 has seen an 9 increase between 9 and 1. The only standard scoring below in overall user experience is 1 oral health and hygiene. Interestingly, whilst 2&5 and 8 scored low in operational terms they scored highly in user experience, both of which seeing a fair increase on last years scores. The following graphs depict the audit results by Acute, Community Hospitals & Mental Health, enabling more specific analysis of the results and comparisons to last year. Average in 3 Acute Hospitals = 6 wards 5
It can be seen that across all but one standard for operational compliance (7 ensuring comfort) there has been an improvement on last years compliance. The same applies for user experience with only Standard 9 (eating & drinking) below last years score. Within Acute Hospitals the scores for Standard 8 & 1 are below 6 and therefore require specific attention. It should be noted that the user experience is 1 6 1 2&5 3 4 6 7 8 9 1 11 12 1 1 6 1 2&5 3 4 6 7 8 9 1 11 12 Operational 9 Operational 1 User experience 9 User experience 1 Average in 9 Community Hospitals = 22 Wards It is pleasing to note that across all Standards in Community Hospitals, operational & user, there has been an improvement compared to last year. Again Standard 1 (operational) is below 6 with user experience at 1 6 1 2&5 3 4 6 7 8 9 1 11 12 Operational 9 Operational 1 1 1 6 1 2 &5 3 4 6 7 8 9 1 11 User experience 9 User experience 1 Average compliance across Mental Health = 3 Wards (includes South Powys) 12 1 6 Operational Standard 8 & 1 (personal & oral hygiene respectively) have scored lower in 1 than recorded in 9, but interestingly are above 6. That said Standard 1, in user experience, has seen a significant improvement. 1 2&5 3 4 6 7 8 9 1 11 12 Operational 9 Operational 1 AREAS FOR ACTION ACROSS THE ORGANISATION 1 95 9 85 75 7 1 2&5 3 4 6 7 8 9 1 11 12 User experience 9 User experience 1 6
The following analysis of the Fundamentals of Care Standards highlight areas for action, whilst emphasising good practice that needs to be shared across the organisation. Alignment to the Standards for Health Services has also been undertaken. STANDARD 1 COMMUNICATION & INFORMATION STANDARDS FOR HEALTH SERVICES: 18 COMMUNICATING EFFECTIVELY Principle: You will receive full information about your care in a language and manner sensitive to your needs Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 71 93 9 Acute Services 68 81 93 97 Community Services 71 86 92 78 Mental Health Services 75 73 93 95 Operational 1 6 9 1 1 1 6 9 1 Summary of Issues / Key Themes The introduction of a new Patient Care Record, designed by nursing staff has assisted in improving the quality of patient information recorded and helped to enhance communication between clinicians and other agencies. Overall, there has been an improvement in the quality of patient information recorded, however the sharing of information with patients and their relatives needs to be encouraged. 7
Issue for improvement Patient communication needs and preferred language is not always assessed or recorded on the nursing documentation. Evidence that the patient s plan of care has been discussed and agreed with the individual, or an advocate, is not routinely documented. Good Practice with the following standards :- The clear recording of the patients demographic details in the patients records has improved. There has been a 3 improvement in identifying and recording the patients plan of care. Patient views and opinions: Overall patients were very complimentary. Information was not always available or given in a format that was easily understood by patients. STANDARD 2 & STANDARD 5 STANDARDS FOR HEALTH SERVICES: 2 EQUALITY, DIVERSITY & HUMAN RIGHTS, 1 DIGNITY & RESPECT RESPECTING PEOPLE Principle: Your human rights to dignity, privacy and informed choice will be protected at all times, and the care provided will take account of your individual needs, abilities and wishes RELATIONSHIPS Principle: You will be encouraged to maintain your involvement with family, friends and to develop relationships with others, according to your wishes Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 68 76 87 92 Acute Services 64 76 93 92 Community Services 69 81 82 91 Mental Health Services 75 71 92 93 8
Operational User eperience 1 1 6 6 9 1 9 1 Summary of Issues / Key Themes Acute Services Community Services Mental Health Efforts have been made to raise staff awareness of the need to respect patient s dignity and several wards have introduced measures to improve patient s privacy e.g. privacy pegs used to hold bed curtains together during intimate procedures. On admission there has been an improvement in the documentation re: patients dignity and respect needs. Issues for improvement The relatives/carer s needs are not always assessed and documented in Patient Care Record. Documented evidence is not always obtained to indicate that the sharing of information with relatives, carers and other professional has been discussed and agreed with the patient. Not all wards have access to quiet areas and overnight facilities for relatives/carers. Staff attendance at Diversity, Equality & Human Right Training and Protection of Vulnerable Adults is an area for attention. Good Practice with the following standards : The introduction of new nursing documentation has contributed to an improvement in the recording of the patient s spiritual and cultural needs. There has been an improvement in the effort made to ensure patients privacy is respected. Visiting times are agreed with ward sisters/charge nurses depending, on the patient needs as a key area within Free to Lead: Free to Care. Registered Nurses are available to speak to relatives during visiting times. Every effort is made to ensure single sex accommodation. Patient views and opinions:- Patients stated they were not asked about sharing personal information. Poor facilities for wheelchair users at Ty-Bryn. Staff were sometimes very busy and unable to talk to patients/relatives. 9
STANDARD 3 ENSURING SAFETY STANDARDS FOR HEALTH SERVICES: 7 SAFE & CLINICALLY EFFECTIVE CARE, 13 - INFECTION PREVENTION & CONTROL, 22 MANAGING RISK & HEALTH & SAFETY Principle: Your health, safety and welfare will be actively promoted and protected. Risks will be identified, monitored and were possible, reduced or prevented Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 86.8 91 92.9 97 Acute Services 88.3 92 91.5 96 Community Services 82.4 92 95.7 98 Mental Health Services 87 9 93.6 97 Operational 1 6 9 1 1 1 6 9 1 Summary of Issues / Key Themes Overall there has been an increase in the compliance to Standard 3, from an operational and user experience perspective. Issues to address Staff compliance to mandatory training continues to be problematic. Although overall night time Security in wards and departments has improved there are some areas where security by night remains inadequate Good Practice with the following standards :- There has been an improvement in the number of patients assessed with regard to their Manual Handling needs and documented evidence available to indicate assessments are being regularly reviewed and up dated. All aspects of Infection Control Policy {exception staff attendance at training} All aspects of Fire Safety Patient views and opinions:- Overall patients felt very satisfied. Very noisy throughout the 24 hr cycle. Not all staff washed their hands before attending to you. Sometimes disturbed at night by wandering patients. 1
STANDARD 4 PROMOTING INDEPENDENCE STANDARDS FOR HEALTH SERVICES: 8 CARE PLANNING & PROVISION, 9 PATIENT INFORMATION & CONSENT. Principle: The care you receive will respect your choices in making the most of your ability and desire to care for yourself Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 81.2 87 9.8 91 Acute Services.4 84 87.8 93 Community Services 78.5 86 96.2 98 Mental Health Services 85.5 9 92.2 83 Operational 1 6 9 1 1 1 6 9 1 Summary of Issues / Key Themes There has been an overall improvement in the compliance with this standard with the exception of user experience in Mental Health, where the score has dropped by 9.2. further analysis regarding this is being undertaken by the Division 11
Access to Physiotherapy and Speech and Language Therapy remains difficult in some Community Hospitals. Issues for Improvement Community Hospitals experience difficulty and delays in accessing a Speech & Language Therapy and Social Workers. Good Practice with the following standards :- The delay in patient discharge due to the lack of available equipment has been significantly reduced. Patient views and opinions:- Overall patients were satisfied. Had full assistance and always encouraged to be independent. Staff generally encouraged me to be up and about the ward. Only encouraged to participate with the Physiotherapist. STANDARD 6 SLEEP REST AND ACTIVITY STANDARDS FOR HEALTH SERVICES: 3 HEALTH PROMOTION, PROTECTION AND IMPROVEMENT. Principle: Consideration will be given to your environment and comfort so you may rest and sleep Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 75.6 85 87 86 Acute Services 7.4 81 87 89 Community Services 72.8 83 84.8 9 Mental Health Services 88.6 9 88.4 78 Operational 1 1 6 6 9 1 9 1 12
Summary of Issues / Key Themes Many ward areas have introduced protected periods during the day to enable patients to rest. Issues for improvement ABHB Roll out of protected rest period during the day. A policy for the restricted movement of patients during the night. Not all windows are free from draughts. Not all radios offer personal headphones. Good Practice with the following standards :- As part of the Transforming Care programme many wards have introduced protected rest periods (quiet times) for patients during the day. Patients views and opinions:- 3 of patients experience difficulty in sleeping during the night. Sometimes hard to rest when the Ward is so noisy. Patient was happy to answer yes, however identified that some days the ward environment was extremely busy leaving little room for rest. STANDARD 7 ENSURING COMFORT ALLEVIATING PAIN STANDARD FOR HEALTH SERVICES: 7 SAFE & CLINICALLY EFFECTIVE CARE. Principle: You will be helped to be as comfortable and pain free as your condition and Circumstances allow Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 77.4 83 94.2 92 Acute Services 78.3 83 92.7 97 Community Services 71.5 88 96.5 98 Mental Health Services 81 78 95.5 82 Operational 1 6 9 1 1 1 6 9 1 13
Summary of Issues / Key Themes The overall management of patient s pain has improved and access to a pain management team has increased across the organisation. Within Mental Health percentage compliance dropped within operational and user experience standards. Issues for Improvement Staff completing training or attending courses in pain management remains low. Good Practice with the following standards :- There has been an increase in the number of wards/departments who are able to access the Pain Management Team and specialist support service. The number of nursing staff attending the End of Life Care Pathway training has increased. Patient views and opinions Overall patients were very satisfied. Staff always listened when I was in pain. He was given the impression that he should call if experiencing any problems. Call bell was at hand, and there were frequent visits to the side room. STANDARD 8 PERSONAL HYGIENE, APPEARANCE & FOOT CARE STANDARDS FOR HEALTH SERVICES: 8 CARE PLANNING & PROVISION, 1 DIGNITY & RESPECT. Principle: You will be supported to be as independent as possible in taking care of your personal hygiene, appearance and foot care. Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 68.2 68 9.8 95 Acute Services 61.5 65 89.2 95 Community Services 76.2 87 9.6 96 Mental Health Services 74.8 51 94.3 93 Operational 1 6 9 1 1 1 6 9 1 14
Summary of Issues / Key Themes The documenting of the patients personal needs and hygiene requirements has increased by 5 across the organisation. Where possible additional designated male and female washing/shower facilities and toilets have been introduced within ward /department areas. However, nursing staff still experience difficulty in accessing hand and toe nail cutting equipment. Issues for improvement Every effort is made to ensure single sex washing facilities are available. However, there remain limited designated male and female facilities in some wards. Not all washing areas provided sockets for electrical appliance e.g. electric shavers. The patients foot care needs are not being assessed on admission and recorded in the nursing documentation. Access to Podiatry is limited across the organisation. Only a small number of nursing staff have received training on hand and foot care needs. Access to hand and foot nail cutting equipment is limited. Good Practice with the following standards :- Individual wash bowls are available in all ward areas. Patient views and opinions: Overall patients are very satisfied with the level of care provided. Very happy with the obvious care and sensitivity of the nursing staff. En-suite would have been nice. Nurses helped me every morning. STANDARD 9 EATING & DRINKING STANDARD FOR HEALTH SERVICES: 14 NUTRITION Principle: You will be offered a choice of food and drink that meets your nutritional and personal requirements and provided with any assistance that you need to eat and drink Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 81.7 85 9.6 82 Acute Services 78.1 85 88.2 84 Community Services 85.2 9 92.1 9 Mental Health Services 85.6 82 94.4 73 15
Operational 1 1 6 6 9 1 9 1 Summary of Issues / Key Themes The introduction of an All Wales Nutritional Pathway and associated Food & Fluid Chart has contributed to an overall improvement in the management of the patient s nutritional needs, although user experience scores have decreased compared to last year across Acute, Community & Mental Health. Issue for Improvement There is a delay in completing a Swallowing Screening Assessment for some patients. Hand washing opportunities prior to serving of meals needs to be improved. Not all wards have protected or uninterrupted meal times. Good Practice with the following standards :- There has been an increase in the number of patients assessed on admission for Nutritional Risk. There is a decrease in the number of patients waiting longer than 24hrs for a swallowing assessment. There is an improvement in the recording and documenting of patients weight on admission and regular review for patients identified at nutritional risk. 76 of wards have introduced Protected Mealtimes. There is good access to a specialist dietician and special diets. Traffic light systems are operational in most wards to identify patient nutritional requirements. Patient views and opinions 15 of patients continue to be disturbed during meals. I found the size of the helpings much more than I needed. Food not hot enough (Ward 3/1, NHH). Always had good choice of meals and could change my mind on menu choice. Snacks don't always arrive. 16
STANDARD 1 ORAL HEALTH & HYGIENE STANDARDS FOR HEALTH SERVICES: 7 SAFE & CLINICALLY EFFECTIVE CARE. Principle: You will be supported to maintain a healthy, comfortable mouth and pain free teeth and gums, enabling you to eat well and prevent related problems. Operational Percentage Percentage 9 1 9 1 Overall Organisational Score 61.9 58 74.7 77 Acute Services 57.7 62 69 Community Services 63.2 57 81.2 86 Mental Health Services 69 56 79.8 67 Operational 1 6 6 9 1 9 1 Summary of Issues / Key Themes There has been a decrease in overall operational compliance, with the exception of Acute Services, with the scores below 6. Issue for Improvement There is no evidence-based oral assessment tool available for use in all ward areas. Standardised evidence-based guidelines are not available for patients who need oral care. More assistance must be given to patients who need help with oral hygiene. Wards/departments continue to experience difficulty in accessing a dentist for patients experiencing oral problems. Good Practice with the following standards : Documented evidence demonstrates an improvement in assessing the patients oral hygiene and hygiene needs at the time of admission. Patient views and opinions 43 of patients stated that oral hygiene was not discussed with them. 37 stated if they experienced problems with their mouth care they were not referred to a dentist. Oral hygiene only discussed when assisting patient with cleaning of dentures. Mouth hygiene not discussed but carried out. 17
STANDARD 11 TOILET NEEDS STANDARDS FOR HEALTH SERVICES: 2 EQUALITY, DIVERSITY & HUMAN RIGHTS, 1 DIGNITY & RESPECT. Principle: Appropriate, discreet and prompt assistance will be provided as necessary taking into account your specific needs and privacy Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 85.7 87 93.7 97 Acute Services 85.6 92 91.8 95 Community Services 82.9 93 96.3 98 Mental Health Services 87.8 77 95.6 97 Operational 1 6 9 1 1 1 6 9 1 Summary of Issues / Key Themes There has been an overall improvement in all requirements to meet compliance within this standard, with Mental health the only area seeing a slight decrease in the operational compliance. Sluicing facilities have been improved and are in good working order in the majority of ward areas. Patient toilet facilities have been up-graded and refurbished in several ward/department areas. 18
Issue for Improvement Not all toilet areas accommodate mechanical aids and hoists. Good Practice with the following standards :- Hand washing facilities and paper towels are available in all toilet areas. There is excellent access to the continence advisory service and designated specialist continence nurse support across the organisation. Toilet areas are clean and in good repair. Toilet areas are well sign posted. Patient views and opinions:- 96 of patients stated when using the toilet they were given enough privacy. 97 stated the toilet facilities were clean and well equipped. 98 stated they had access to (or offered) hand washing facilities. STANDARD 12 PREVENTING PRESSURE SORES / PRESSURE ULCERS STANDARDS FOR HEALTH SERVICES: 3 HEALTH PROMOTION, PROTECTION & IMPROVEMENT, 7 SAFE & CLINICALLY EFFECTIVE CARE. Principle: You will be helped to look after your skin and every effort will be made to prevent you from developing pressures sores Operation Percentage Percentage 9 1 9 1 Overall Organisational Score 79.7 84 82.2 84 Acute Services.1 89 79.7 86 Community Services 78 89 85 85 Mental Health Services 78.8 76 87 83 Operational 1 1 6 6 9 1 9 1 19
Summary of Issues / Key Themes A comprehensive review of the Tissue Viability Service has been completed in 9. The SKIN Bundle is being rolled out across the organisation, with full compliance by December 1, in addition monthly prevalence surveys are conducted. This has raised staff awareness and improved overall compliance with the required standard of care Issue for Improvement 35 of nursing staff have not attended training on assessment of risk and prevention of pressure ulcers. Good Practice with the following standards :- There is good access to specialist support teams across the organisation e.g. Tissue Viability Nurses, Continence Advisory Service and Dieticians. There is good documented evidence that patients at risk of developing pressure damage are being assessed and relevant risk assessments undertaken. Patient views and opinions:- 25 patients were not aware of any measures being taken to prevent pressure damage. This was often due to lack of information. 15 of patients stated they had sore areas on their bottoms, heels or elbows. Some patients stated they would welcome more information or advise on how they can look after their skin. I Was encouraged to sit out for short periods when feeling better