Standard 3: Premises, Signage, Accessibility and Equipment (Version 11)

Why it matters. A patient who uses a wheelchair cannot register if the reception counter is too high to reach or speak across. A facility that cannot be used by every patient fails the basic test of access.

Sample. Check every reception and registration point on the facility's main routes.

1. At least one point is at a usable height.

Method. Measure the counter height at the accessible point.

Evidence to show. ENV-FRM-001 Accessibility Check Record (reception).

Pass when. At least one counter is at a height a wheelchair user can use.

2. A wheelchair user can communicate at eye level.

Method. Check that the accessible point has a space where a seated person can be served face to face.

Evidence to show. ENV-FRM-001 Accessibility Check Record (reception).

Pass when. Communication at eye level is possible at the accessible point.

3. The lower section stays clear.

Method. Check the lower section on the day of the visit and on a second unannounced check.

Evidence to show. ENV-SOP-001 Accessible Reception and Registration Points.

Pass when. The lower section is clear on both checks.

Immediate fail (any one means the criterion is not met)

• No reception or registration point can be used by a wheelchair user.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. International Organization for Standardization (2021). ISO 21542:2021. Building construction: Accessibility and usability of the built environment. Used for: accessible reception counters and approach for wheelchair users (3.1). https://news.gmj.ge/guideline/iso-21542-accessibility-usability-built-environment/

Why it matters. Long, unexplained waits drive patients away and hide problems. A defined queue, honest wait information and a check on waiting patients keep the flow safe and fair.

Sample. Review the queue log and wait-time reviews for the last month.

1. A defined queue system is in use.

Method. Check the queue log for registration, triage and ambulatory waiting.

Evidence to show. ACC-FRM-001 Queue Log; ACC-SOP-001 Queue and Wait-Time Management.

Pass when. A queue system is used in each of the three areas.

2. Wait-time information is shared with patients.

Method. Check that wait-time information is displayed or given to waiting patients.

Evidence to show. ACC-REG-001 Monthly Wait-Time Review.

Pass when. Information is visible or communicated during the wait.

3. Changes in condition are noticed while patients wait.

Method. Check the record of re-assessment for patients who waited longer than the set time.

Evidence to show. ACC-FRM-001 Queue Log, with re-assessment entries.

Pass when. Each long-waiting patient has a recorded re-assessment.

Immediate fail (any one means the criterion is not met)

• Patients wait with no queue system, and a waiting patient who deteriorates is not noticed.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. National Institute for Health and Care Excellence (UK) (2007). Acutely ill adults in hospital: recognising and responding to deterioration. Used for: Recognising and responding to deterioration while waiting (3.2). https://news.gmj.ge/guideline/acutely-ill-adults-in-hospital-recognising-and-responding-to-deterioration/
2. World Health Organization (2021). Emergency Triage Assessment and Treatment (ETAT): Manual for Participants. Used for: Triage of patients waiting for care (3.2). https://news.gmj.ge/guideline/emergency-triage-assessment-and-treatment-etat-manual-for-participants/

Why it matters. Water supply in a field setting is often the first thing to fail and the most important for health. Testing it on a schedule, with a plan for when supply stops, prevents disease outbreaks.

Sample. Review the water test records for the last 12 months.

1. Water quality is tested on a defined schedule.

Method. Compare the test dates with the schedule in the procedure.

Evidence to show. WAT-FRM-001 Water Test Record; WAT-SOP-001 Water Quality Testing and Safety.

Pass when. Tests are recorded on the scheduled dates.

2. A contingency plan exists for supply interruption.

Method. Read the plan and check that it names the alternative supply and the responsible person.

Evidence to show. WAT-PLN-001 Water Interruption Contingency Plan.

Pass when. The plan is approved and names both.

3. Results are reviewed and acted on.

Method. Check each out-of-range result for a recorded action.

Evidence to show. WAT-FRM-001 Water Test Record, with actions.

Pass when. Each out-of-range result has a recorded action.

Immediate fail (any one means the criterion is not met)

• Water is used for patients with no testing on record, or a supply failure has no contingency plan.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2022). WASH FIT: A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities, Second edition. Used for: Water supply and quality in care (3.3). https://news.gmj.ge/guideline/wash-fit-a-practical-guide-for-improving-quality-of-care-through-water-sanitation-and-hygiene-in-health-care-facilities-second-edition/
2. Pan American Health Organization (2020). Water, Sanitation, and Hygiene Standards in Health Care Facilities. Used for: Water safety standards in facilities (3.3). https://news.gmj.ge/guideline/water-sanitation-and-hygiene-standards-in-health-care-facilities/

Why it matters. Clinical equipment that is faulty and still in use causes injury. A maintenance schedule and removal of faulty items prevent it.

Sample. Select the clinical equipment in two clinical areas and check its service records.

1. A maintenance schedule covers all clinical equipment.

Method. Check the inventory against the maintenance schedule.

Evidence to show. EQP-REG-001 Equipment Inventory and Service Log.

Pass when. Every item on the inventory has a scheduled service.

2. Faulty equipment is taken out of use.

Method. Find any item marked faulty and check that it carries an out-of-use tag and is not in service.

Evidence to show. EQP-FRM-001 Out-of-Use Tag Record.

Pass when. Every faulty item is tagged out of use.

3. A named person runs the programme.

Method. Check the procedure for the named role responsible for maintenance.

Evidence to show. EQP-SOP-001 Medical Equipment Maintenance and Removal from Use.

Pass when. A named role is responsible, and the post-holder is known to staff.

Immediate fail (any one means the criterion is not met)

• Faulty clinical equipment is kept in use with no out-of-use tag.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2026). Regional manual with operating guides on respiratory care equipment and devices. Used for: Operating and maintaining respiratory care equipment (3.4). https://news.gmj.ge/guideline/regional-manual-with-operating-guides-on-respiratory-care-equipment-and-devices/

Why it matters. Shared clinical and waiting areas are where infection spreads from one patient to the next. Cleaning on a documented schedule, checked by more than a look, is what keeps those areas safe.

Sample. Review the cleaning records and the audit results for the last 3 months.

1. A cleaning schedule exists and is recorded.

Method. Compare the records with the schedule for each shared space.

Evidence to show. ENV-SOP-002 Cleaning of Shared Clinical and Waiting Areas.

Pass when. Each scheduled clean is recorded.

2. Cleaning is verified beyond a visual check.

Method. Check the audit records for a defined inspection process.

Evidence to show. ENV-FRM-002 Cleanliness Audit Record.

Pass when. Audits follow the defined process and are recorded.

3. High-touch surfaces are included.

Method. Check that high-touch surfaces are named in the schedule and in the audit.

Evidence to show. ENV-SOP-002 and ENV-FRM-002 .

Pass when. High-touch surfaces are named and audited.

Immediate fail (any one means the criterion is not met)

• Shared spaces have no cleaning schedule, or no records for the last 3 months.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Centers for Disease Control and Prevention (USA) (2008). Guideline for Disinfection and Sterilization in Healthcare Facilities. Used for: Cleaning and disinfection in facilities (3.5). https://news.gmj.ge/guideline/guideline-for-disinfection-and-sterilization-in-healthcare-facilities/

Why it matters. Facility risks tracked on separate lists, one for water, one for fire, one for equipment, are seen by different people and can be missed. One integrated register shows the whole picture to the people who must act.

Sample. Review the risk register and its review records for the last 12 months.

1. Water, fire and equipment data feed one register.

Method. Check that the register contains entries from each of the three sources.

Evidence to show. FAC-REG-001 Integrated Facility Risk Register.

Pass when. Entries from all three sources are in one register.

2. Leadership reviews the register on a schedule.

Method. Check the dates and attendees of the leadership reviews.

Evidence to show. FAC-SOP-001 Facility Risk Management Procedure.

Pass when. The register is reviewed on the scheduled dates by leadership.

3. Risks are prioritised.

Method. Check that each risk has a priority rating.

Evidence to show. FAC-REG-001 Integrated Facility Risk Register.

Pass when. Every risk has a priority.

Immediate fail (any one means the criterion is not met)

• No integrated risk register exists, and water, fire and equipment risks are held in untracked lists.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Hazard and risk assessment (3.6). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/
2. Pan American Health Organization (2020). A Checklist for COVID-19 Pandemic Risk and Impact Management. Used for: Integrated risk management (3.6). https://news.gmj.ge/guideline/a-checklist-for-covid-19-pandemic-risk-and-impact-management/

Why it matters. In an emergency, people must find the exit within seconds, and patients who cannot read a sign easily must still be guided. Clear, complete, consistent signage throughout the building is part of the emergency plan.

Sample. Walk every floor and check the signage on the evacuation routes and on department doors.

1. Evacuation routes are signed throughout.

Method. Walk each floor and check every evacuation route and exit.

Evidence to show. ENV-FRM-005 Signage Survey and Quarterly Check.

Pass when. Routes and exits are signed on every floor.

2. Restrooms and department doors are labelled consistently.

Method. Check the labels against the signage standard.

Evidence to show. ENV-SOP-003 Facility Signage Standard.

Pass when. Labels match the standard.

3. Signage is checked for damage and obstruction.

Method. Check the quarterly survey record for the last quarter.

Evidence to show. ENV-FRM-005 Signage Survey and Quarterly Check.

Pass when. The quarterly check is recorded, and defects have actions.

Immediate fail (any one means the criterion is not met)

• Evacuation routes or emergency exits are unsigned on any floor.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. International Organization for Standardization (2021). ISO 21542:2021. Building construction: Accessibility and usability of the built environment. Used for: signage, orientation and marked routes to exits in buildings (3.7). https://news.gmj.ge/guideline/iso-21542-accessibility-usability-built-environment/
2. Pan American Health Organization (2025). EVAC-H: Evacuation of hospitals and their critical areas. Used for: evacuation routes and exits that can be found and used in an emergency (3.7). https://news.gmj.ge/guideline/evac-h-evacuation-of-hospitals-and-their-critical-areas/

Why it matters. Power, water, medical gases and ventilation fail when they are only repaired after breaking. A tested schedule and analysis of failures prevent most of them.

Sample. Select every critical service and every failure recorded in the last 12 months.

1. Each critical service has an owner and a back-up.

Method. Check the plan for each service: power, water, medical gases, ventilation and clinical information systems.

Evidence to show. FAC-PLN-001 Critical Services Testing and Back-up Plan.

Pass when. Each service has a named owner and a documented back-up.

2. Critical services are tested on a schedule.

Method. Compare the test records with the schedule.

Evidence to show. FAC-FRM-003 Continuity Test Record, if held; FAC-PLN-001 .

Pass when. Tests are recorded on the scheduled dates.

3. Failures are analysed and followed by a change.

Method. Read each failure entry for an analysis and a preventive change.

Evidence to show. FAC-REG-002 Failure Log; FAC-SOP-002 Failure Logging and Analysis.

Pass when. Each failure has an analysis and a preventive action.

Immediate fail (any one means the criterion is not met)

• A critical service has no named owner or back-up, and a failure is not analysed.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Pan American Health Organization (2020). Recommendations for Heating, Ventilation, and Air Conditioning in Health Care Facilities. Used for: Critical building services and continuity (3.8). https://news.gmj.ge/guideline/recommendations-for-heating-ventilation-and-air-conditioning-in-health-care-facilities/
2. World Health Organization (2020). Hospital Emergency Response Checklist. Used for: Continuity of critical services (3.8). https://news.gmj.ge/guideline/hospital-emergency-response-checklist/

Why it matters. Endoscopes can carry infection from one patient to the next if they are not reprocessed correctly. Each use must follow a documented standard, with the equipment tested and recorded.

Sample. Select the endoscopes in use and trace their reprocessing for the last month.

1. Every endoscope is tested and maintained on schedule.

Method. Check each device's test record against the schedule.

Evidence to show. EQP-REG-002 Reprocessing and Test Log (endoscopy).

Pass when. Each device has its test recorded on schedule.

2. Reprocessing follows a documented, validated procedure.

Method. Check the procedure and the validation record.

Evidence to show. EQP-SOP-002 Endoscope Reprocessing Standard.

Pass when. The procedure is approved and validated.

3. Each procedure can be traced to its device and cycle.

Method. Select three procedures and trace each one to its device and reprocessing cycle.

Evidence to show. EQP-REG-002 Reprocessing and Test Log (endoscopy).

Pass when. Each of the three procedures can be traced.

Immediate fail (any one means the criterion is not met)

• An endoscope is used with no recorded test or reprocessing cycle.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2020). Decontamination and Reprocessing of Medical Devices for Health-care Facilities. Used for: Reprocessing and traceability of devices (3.9). https://news.gmj.ge/guideline/decontamination-and-reprocessing-of-medical-devices-for-health-care-facilities/

Why it matters. A patient who is unsteady and walks along a corridor can fall where there is nothing to hold. Continuous handrails on both sides let them hold on for the whole route.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Handrails are fitted continuously on both sides of each corridor, stair and ramp.

Method. Walk each route and check both sides.

Evidence to show. Environmental falls-risk survey ( ACS-FRM-001 ).

Pass when. Every route has continuous handrails on both sides.

2. The handrails are fixed and sturdy.

Method. Pull each handrail at three points on the walk.

Evidence to show. Survey record.

Pass when. No handrail moves under load.

3. Each quarterly survey is recorded.

Method. Check the survey dates for the last 12 months.

Evidence to show. Survey records.

Pass when. All four quarters are recorded, with findings closed.

Immediate fail (any one means the criterion is not met)

• A route used by patients has no handrail on one side, with no marking or action.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Falls prevention in the environment (3.10). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/
2. National Institute for Health and Care Excellence (UK) (2025). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Falls assessment and hazard control (3.10). https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/

Why it matters. Toilet transfers are one of the most common moments of falls in care. Grab bars in the right place and fixed firmly give the patient something to hold.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. Grab bars are placed for toilet transfer.

Method. Check each toilet for horizontal and vertical bars.

Evidence to show. Toilet and washroom check ( ACS-FRM-002 ).

Pass when. Every toilet checked has grab bars placed for transfer.

2. Grab bars are fixed and do not turn in their fittings.

Method. Apply force to each bar on the walk.

Evidence to show. Toilet and washroom check.

Pass when. No bar turns under load.

3. Defects are reported and fixed.

Method. Check the defect record for the last 12 months.

Evidence to show. Defect record.

Pass when. Every defect is fixed within the set time.

Immediate fail (any one means the criterion is not met)

• A grab bar turns in its fitting and is still used by patients.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. National Institute for Health and Care Excellence (UK) (2025). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Falls risk in toilets and washrooms (3.11). https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/
2. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Environmental falls prevention (3.11). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/

Why it matters. A patient who uses a wheelchair cannot use a toilet that is too small to turn in or has no bars to transfer with. At least one accessible toilet is needed for those patients to use the facility at all.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. At least one toilet is accessible for a wheelchair user.

Method. Measure the floor space and check the transfer bars.

Evidence to show. Accessibility check ( ENV-FRM-001 and ACS-FRM-002 ).

Pass when. At least one accessible toilet is present, with the space and bars the guidance sets.

2. The accessible toilet is signed and reachable.

Method. Walk from the main route to the toilet.

Evidence to show. Walk record.

Pass when. The route is clear and signed.

3. The design meets recognised guidance.

Method. Compare the measurements with the guidance.

Evidence to show. Design check record.

Pass when. Measurements meet the guidance used.

Immediate fail (any one means the criterion is not met)

• No toilet in the facility can be used by a wheelchair user.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Environmental falls prevention (3.12). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/
2. International Organization for Standardization (2021). ISO 21542:2021. Building construction: Accessibility and usability of the built environment. Used for: recognised international design guidance for accessible toilets (3.12). https://news.gmj.ge/guideline/iso-21542-accessibility-usability-built-environment/

Why it matters. A patient who falls behind a toilet door that opens inward may not be found in time. A door that opens outward, or that can be released from outside, lets staff reach the patient in an emergency.

Sample. Check 5 toilets and washrooms, including at least one accessible cubicle, on the day of assessment.

1. Toilet and washroom doors open outward, or release from outside.

Method. Open and release each door from outside on the walk.

Evidence to show. Toilet and washroom check ( ACS-FRM-002 ).

Pass when. Every door opens outward or releases from outside.

2. The release works in an emergency.

Method. Test the release from outside with a staff member.

Evidence to show. Test record.

Pass when. Each release works when tested.

3. Staff know how to release a door.

Method. Ask 3 staff to show the release.

Evidence to show. Staff check record.

Pass when. At least 2 of 3 staff show it correctly.

Immediate fail (any one means the criterion is not met)

• A patient who has fallen behind a toilet door cannot be reached from outside.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Pan American Health Organization (2025). EVAC-H: Evacuation of hospitals and their critical areas. Used for: evacuation of the critical areas of a hospital, including routes that allow patients to be moved (3.13). https://news.gmj.ge/guideline/evac-h-evacuation-of-hospitals-and-their-critical-areas/

Why it matters. Patients get up at night and move in poor light. A dark corridor or toilet is where a fall is most likely. Adequate light, and night lighting, make the route safe at all hours.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Corridors, stairs, toilets, washrooms and rooms are lit at a safe level.

Method. Measure the light level at each point on the walk.

Evidence to show. Lighting check on the survey.

Pass when. Every area on the route meets the set level.

2. Night lighting or motion lighting is on the routes patients walk at night.

Method. Check the night route after dark.

Evidence to show. Night check record.

Pass when. Night lighting is working on every night route.

3. Lights that fail are reported and fixed.

Method. Check the fault record.

Evidence to show. Fault record.

Pass when. Every fault is fixed within the set time.

Immediate fail (any one means the criterion is not met)

• A patient route at night has no working light.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Environmental falls prevention, including lighting (3.14). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/

Why it matters. A high bed is a common cause of falls when a patient climbs out. A low bed, with brakes on and the call bell in reach, keeps the patient safer in bed and on the way out.

Sample. Check 10 beds across the wards on the day of assessment, with the bed check records for the last 30 days.

1. Beds are set low when occupied, with brakes locked.

Method. Check each bed on the walk.

Evidence to show. Bed check ( ACS-FRM-003 ).

Pass when. At least 90% of occupied beds are low with brakes locked.

2. The call system and personal items are within reach.

Method. Test the call system and check the reach from the bed.

Evidence to show. Bed check.

Pass when. Every bed checked has the call system in reach.

3. Beds are checked each shift.

Method. Check the records for the last 30 days.

Evidence to show. Bed check records.

Pass when. At least 90% of shifts have a recorded check.

Immediate fail (any one means the criterion is not met)

• A patient is in a high bed with the brakes off.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. National Institute for Health and Care Excellence (UK) (2025). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Beds and chairs in falls prevention (3.15). https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/

Why it matters. A patient who needs a walking frame or a wheelchair but finds none, or finds one that is broken, is put at risk. Having the right aids, in the right sizes, and checking them on a schedule keeps them ready.

Sample. Check 10 walking aids and wheelchairs from the register, and the mobility equipment check records for the last 3 months.

1. Mobility equipment is available in the sizes needed.

Method. Compare the stock sizes with the needs of current patients.

Evidence to show. Mobility equipment register ( ACS-REG-001 ).

Pass when. Every size needed is in stock.

2. Equipment is in working order.

Method. Check each item on the walk.

Evidence to show. Mobility equipment register.

Pass when. Every item in use works.

3. Equipment is checked on the defined schedule.

Method. Check the check dates against the schedule.

Evidence to show. Mobility equipment register.

Pass when. At least 90% of items are checked on time, and faulty items are out of use.

Immediate fail (any one means the criterion is not met)

• A faulty walking aid or wheelchair is in use with a patient.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. National Institute for Health and Care Excellence (UK) (2025). Falls: assessment and prevention in older people and in people 50 and over at higher risk. Used for: Mobility aids in falls prevention (3.16). https://news.gmj.ge/guideline/falls-assessment-and-prevention-in-older-people-and-in-people-50-and-over-at-higher-risk/
2. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Mobility equipment (3.16). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/

Why it matters. A cable, a box or a mat on the floor is among the commonest causes of falls in a ward. Clear routes, with any hazard that cannot be removed marked, keep patients moving safely.

Sample. Walk 3 patient routes (ward corridor, stair or ramp, and route to the toilet) with the survey form on the day of assessment.

1. Patient routes are kept clear of trip hazards.

Method. Walk each route and record any hazard.

Evidence to show. Environmental falls-risk survey ( ACS-FRM-001 ).

Pass when. No hazard is found on a route, or every hazard is marked.

2. Each hazard that cannot be removed is marked and managed.

Method. Check each marked hazard for the mark and the plan.

Evidence to show. Hazard record.

Pass when. Every marked hazard has a plan and an owner.

3. Staff are trained in falls prevention.

Method. Check the training record for the ward staff.

Evidence to show. Falls prevention training record ( WRK-REG-005 ).

Pass when. At least 90% of ward staff are trained in the last 12 months.

Immediate fail (any one means the criterion is not met)

• A trip hazard is left on a patient route with no mark and no action.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Step Safely: Strategies for Preventing and Managing Falls Across the Life-Course. Used for: Clear routes and trip hazards (3.17). https://news.gmj.ge/guideline/step-safely-strategies-for-preventing-and-managing-falls-across-the-life-course/