P5 MANAGEMENT AUDIT 2B

OA Reablement service OA Day Care OA Residential Care DMH Day Services DMH Supported Living DMH Residential Services EIA’d x  x     P5 POLICIES AND PROCEDURES MANAGEMENT AUDIT 2b

Establishment: Date of Audit: Name of person Filling in Audit: AUDITS Comments / Actions REGULATION 17 (18) Has an audit taken place within the last year? √ or X Internal Audit Report on display and actions completed / reviewed Health and Safety Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Issue date 27/02/08 P & P Amendment 8 9 10 11 12 13 Report/poster on display and actions completed / reviewed Infection Prevention & Control Report on display and actions completed / reviewed Financial Report available and actions completed / reviewed Personal monies M9 DIAG management checklist completed annually (M9 appendix 12) STAFFING Comments / Actions REGULATION 18 Are there any outstanding staff vacancies? If there are, what action has been taken?

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Issue date 27/02/08 P & P Amendment 8 9 10 11 12 13

of 14 P5 MANAGEMENT AUDIT 2b

Do the staffing levels meet the needs of the service users? If no – document action taken

STAFF FILE – Check one file from Comments / Actions each supervisor Staff initials

Supervision

S1 Agenda Agreement Appraisal (by end June) ½ yearly review (6 months) Positive Attendance

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

of 14 Risk Assessment M9 Manual Handling D1 DBS F5 PEEP Safeguarding (3 year refresher) Medication (5 year refresher) Medication competency checks (Annual) Fire Awareness/Fire Warden (3 year refresher) IT Security (Annually) Emergency first aid

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

SERVICE USER INFORMATION

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of 14 Service User Initials P14 DMH PSP

Photo Review and update record Contact sheets (or where kept) Personal and health information One page profile (including photo) Summary of person centred support Ensure protocols are in place for all identified support needs including prompting needs Individual Protocols (Dependant on individual) Relevant and current assessments Index Getting to know you (Pre-admission document)

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Risk assessments PEEPS DIAG records DOLS Best Interest MCA IPHP (Individual positive handling plan and review) Review / consultation records

P14 OA DAY PCCP Service User Initials

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

of 14 Photo Communication front sheet Hospital passport

Daily records

Monthly changes sheet

Pre-admission assessment

Referral information

Statement of purpose and service user guide Person centred care plan

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Stories and gifts

General risk assessment / Manual handling risk assessment Medication risk assessment

MEDICATION Comments / Actions REGULATION 12 & 13 M4 Medication Policy

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

of 14 Accompany staff during the medication round. Check MAR sheets, stock sheets and medications files. Use the checklist attached Appendix 1.

OBSERVATION / DISCUSSIONS Comments / Actions Talk to some service users. Do service users have their own choices? Are they happy with the service, do staff treat them with dignity and respect? Talk to relatives / families / professionals etc to get a mix of feedback.

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Are staff aware of who CQC are and what they do?

Do staff know who to go to when raising a concern?

Do staff know what safeguarding means?

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

of 14 Do staff know what The Health Protection Department do?

Misc Comments / Actions Service user engagement in recruitment and selection

ACTIVITIES Comments / Actions Activities taking place and are planned in according to service users’ needs and likes. GENERAL Comments / Actions What is the morale in the establishment like? How is the venue looking / smelling? What is the general feel of the place?

ENVIRONMENT Comments / Actions

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

Observation of the building and premises. Is the venue clean, have any maintenance issues been reported and action plan dealt with.

Are Fire checks and documentation in place? Have fire drills been completed? Are records complete?

Supervisor Signature: Date:

Locality / Registered Manager Signature: Date:

Operations Manager Signature (Operations Managers will only sample the audit): Date:

Date 16/04/15 26/05/15 08/08/15 20/01/16 23/03/17 01/08/17

of 14 Copies to be brought to each supervision meeting

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