Monthly Quality Audit Tool - Test

Reviewer name*
Audit date*
DD slash MM slash YYYY
Hospital site*
Activity Type*
Ward/department
Specialty*
Nurse in Charge during Review*
Staff receiving feedback following review
Ward/Department Environment - First Impressions
Leadership and Staffing

CURRENT STAFFING LEVELS | Review off duty info on ward (roster and paper copy) and cross ref to bank agency
LS01 Was the shift fully staffed?*
Please expand on staffing issues
LS02 Have staff had a local or 18 WS induction?

Staffing Observations

LS12 Staff are compliant with the uniform policy	LS13 Staff are wearing name badges (non-Covid environment)	LS14 Staff treat patients and ward visitors courteously	LS15 Staff are NOT talking over patients, are not speaking in another language over patients or stood chatting informally	LS16 Are the safeguarding Trust contacts available to the 18WS support staff?	Actions

There are no Staff members.

Please observe 5 staff throughout your visit across all roles/positions

W04 What makes staff or you, feel less confident or unsupported?*
Things that feel worrying, patients looking unkempt, bed spaces untidy, is the ward area tidy? Is the environment noisy
W05 Did you have a patient safety huddle?*
Please explain why there was no patient safety huddle
LS03 Did all relevant staff (HCAs, nurses, AHPs and doctors) attend the Patient Safety Huddle?*
- Yes
- No
- N/A
LS04 Is the Patient Safety Huddle Checklist completed appropriately?*
- Yes
- No
LS05 Did all relevant staff attend the WHO check list (where appropriate) and was it completed appropriately?*
- Yes
- No
- N/A
LS06 Is the NIC visible to staff, patients and or visitors?*
- Yes
- No
LS07 Was a team debrief conducted in the procedure room?*
Health Records Review

Patient Observation (N) and Escalation

N01 Were the patient’s observations recorded?	N02 Has the frequency of observations been documented on the chart?	N03 Are observations documented throughout the patient pathway?	N04 Staff know how to escalate a deteriorating patient. The escalation is recorded (need to understand that the trust link nurse needs to be informed)	Actions

There are no records.

Review 5 records

N Suggestions

Documentation – Admission to Discharge (AD)

AD01 There is a documented full initial assessment of the patient completed in conjunction with their clinical diagnosis/condition?	AD02 Does the documentation demonstrate evidence of implementation of care & evaluation of care based on the assessment?	AD03 Has the Discharge Planning Information section been completed including relatives being informed of planned discharge and location?	AD04 Where applicable, are the HCA signatures counter signed by the registered nurse?	Actions

There are no records.

Review 5 records

AD Suggestions

Medication Assessment

MA01 Is there an addressograph on the prescription chart and is it accurate throughout the patient pathway?	MA02 On the drug chart has the allergy and intolerances section been completed throughout the patient pathway? (Including no known allergies)	MA03 Is the patient’s weight recorded on the Drug chart throughout the patient pathway?	MA04 Are all details for each medication clearly legible throughout the patient pathway?	MA05 All prescriptions on the chart are signed and with a legible name printed throughout the patient pathway	MA06 Staff undertake positive patient identification at the point of care throughout the patient pathway (when appropriate e.g. for administration of medication)	MA07 If medications have been omitted have omission codes been recorded on the chart EVERY TIME?	Actions

There are no records.

Review 5 records

MA Suggestions
Environment
E01 Is there enough seating, available handgels and signposting of toileting facilities?*
- Yes
- No

Environment observations

E05 Do patients have call bells to hand?	E06 Do patients have tables close by with their essentials?	E07 Is hand gel available at each bed space?	E08 Are call bells and telephones answered in a timely manner?	Actions

There are no observations.

Please make 5 observations

E Suggestions
Safety and Quality

Please observe throughout your visit

Patient safety and quality observations

SQ01 Do you see positive Interactions between staff/patient/visitors?	SQ02 Permission is gained before entering any private areas/side rooms i.e. curtains, bathroom	SQ03 Dignity and modesty is maintained for those patients moving between care settings	Actions

There are no observations.

Please make 5 observations

SQ04 Emergency equipment checked daily?*
- Yes
- No
i.e. every day for the last month
SQ06 Are the Controlled Drugs checked daily?*
- Yes
- No
i.e. every day for the last month
SQ07 Controlled drug keys held by Registered Nurse?*
- Yes
- No
SQ08 Drug trollies/cupboards locked and secure?*
- Yes
- No
SQ09 Drug Fridge is locked and secure?*
- Yes
- No
SQ10 Drug Fridge temperatures monitored daily?*
- Yes
- No
i.e. every day for the last month
SQ11 Health records are stored correctly*
- Yes
- No
SQ12 Do Staff have IT logins and access to the system*
- Yes
- No

Staff safety and quality observations

SQ13 Staff know how to report an incident	SQ14 Staff know what to do if equipment is faulty or broken and how to report it for repair	SQ15 Staff use sharps bins at the point of use	SQ16 Sharps safety is observed in all clinical areas	SQ17 Staff are aware of correct procedure after sustaining a sharps injury	SQ18 Are Staff aware of their responsibilities under the Mental Capacity Act and what it means to their practice	SQ20 Staff are aware of where to access a manual sphygmomanometer to check deteriorating patient’s blood pressures	Actions

There are no staff members.

Ask 5 staff

SQ Suggestions
Hand Hygiene

Hand hygiene observations

HH01 The 5 moments for hand hygiene were observed after contact with a patient	HH02 The 5 moments for hand hygiene were observed after contact with the environment	HH03 Was the member of staff ‘bare below the elbow’?	Actions

There are no staff members.

Please make 5 observations

HH Suggestions
Safeguarding
Safer Surgery “Silent Observational” checklist audit
Sign in - Before starting anaesthesia
Date
MM slash DD slash YYYY
Confirm patient identity and operation
Confirm Surgical site marked
Confirm machine and medicines checked
Confirm allergy status
Confirm difficult airway / aspiration risk
Confirm risk of blood loss
Time out - Theatres before surgery starts
All team introduced themselves
Team confirm patient id and operation
Surgeon critical events
Anaesthetist critical events
Scrub nurse instrumentation
Antibiotics
Patient warming
Hair removal / shave
Glycaemic control
VTE prophylaxis
Imaging required available / displayed
Sign on - Theatres before surgeon leaves
Name of procedure recorded
Swabs & Instrument count confirmed
Specimens labelled
Any equipment issues identified
Surgeon concerns for recovery
Anaesthetist concerns for recovery
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Monthly Quality Audit Tool - Test

Ward/Department Environment - First Impressions

Leadership and Staffing

Health Records Review

Environment

Safety and Quality

Hand Hygiene

Safeguarding

Safer Surgery “Silent Observational” checklist audit

Sign in - Before starting anaesthesia

Time out - Theatres before surgery starts

Sign on - Theatres before surgeon leaves

18 Week Support

London

Birmingham

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