The Basis

Sample. Emergency department: follow 2 patients from arrival to discharge or transfer, one medicine and one specimen each. Ward: follow 2 inpatients through one medicine round and one specimen collection. Records: the last 20 specimen labels and 10 medication charts per area. Staff: interview 3 people (one doctor, one nurse, one phlebotomist or lab staff).

1. Two identifiers are checked before every medicine.

Method. Observe one full medicine round. For each dose, see the nurse ask the patient for name and date of birth, or read the wristband, then compare with the medication chart.

Evidence to show. Medication chart for the observed doses; close-up photo of the wristband with identifiers masked and no face in frame.

Pass when. Every observed dose has two identifiers checked with the patient. One exception is a finding.

2. Two identifiers are checked before every specimen collection, with the patient present.

Method. Observe 2 specimen collections (one in ED, one on a ward). Check the label is written at the bedside, in front of the patient.

Evidence to show. Photo of the labelled tube with patient identifiers masked; the matching request form.

Pass when. Both collections are labelled at the bedside with two identifiers, date, time and initials.

3. Identification is checked again before blood products and procedures.

Method. Observe 1 blood transfusion or procedure check (ED or theatre). Check the check is repeated at the bedside, not copied from an earlier entry.

Evidence to show. Signed transfusion or procedure checklist for that patient (identifiers masked).

Pass when. A bedside check with two identifiers is written on the checklist at the time of the procedure.

4. Specimen labels are completed at the point of collection, not later.

Method. Review the last 20 specimen labels against the collection log. Check that the time, date and initials match the collection time.

Evidence to show. Log extract of 20 labels with the check recorded on each (identifiers masked).

Pass when. 20 of 20 labels are complete and match the collection time. Any label written away from the patient is a finding.

5. Every inpatient and ED patient wears a wristband that is present and legible.

Method. Walk the ED and one ward. Check the wristband on the 2 patients followed in the sample, plus 8 others at random.

Evidence to show. Photo of the wristband for each sampled patient, identifiers masked.

Pass when. All 10 patients have a legible wristband with name and date of birth. A missing or illegible wristband is a finding.

6. Staff describe the process correctly.

Method. Ask the 3 staff members: 'How do you confirm who a patient is before giving a medicine or taking a sample?'

Evidence to show. Interview notes (role, answer).

Pass when. Each answer names two identifiers checked with the patient. An answer based on bed, room or the chart alone is a finding.

7. Patients can state their identifiers when asked.

Method. Ask the 2 ED patients and 2 ward patients for their full name and date of birth. If the patient cannot answer, ask a family member and check the wristband.

Evidence to show. Notes of the answer and the wristband check.

Pass when. The patient or the wristband gives the correct full name and date of birth.

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

• A room or bed number is used as the only identifier.
• A medicine is given or a specimen is taken without two identifiers checked with the patient.
• A specimen label is written away from the patient.

Sample. ED and two wards. Walk the whole area; observe 20 hand hygiene opportunities per area using the WHO 5 Moments.

1. Hand hygiene stations are at every point of care, not only at ward entrances.

Method. Walk every bed space and treatment room. Count stations within arm's reach of each bed.

Evidence to show. Walk-round checklist with station count and photo of the bed-side station (no patients in frame).

Pass when. A working station, with soap or alcohol rub and paper towels, is within arm's reach of every bed space.

2. Staff use hand hygiene at the 5 Moments.

Method. Observe unannounced, at 20 opportunities per area. Record the moment and whether hands were cleaned.

Evidence to show. Observation tally sheet (no names).

Pass when. At least 80% of observed opportunities are followed by hand hygiene.

3. Supply is continuous.

Method. Check stock levels and dispenser refill records at each area.

Evidence to show. Refill log for the last 30 days.

Pass when. No area has been without product for more than one shift in the last 30 days.

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

• No hand hygiene product at the point of care in any sampled area.
• Compliance is recorded only by self-report.

Sample. Ask 3 patients who had a significant procedure in the last month. Review 10 consent records.

1. Consent covers risks, benefits and alternatives.

Method. Review 10 consent records for significant procedures. Check that each names the risks, benefits and at least one alternative.

Evidence to show. Consent forms with the discussion section filled in (identifiers masked).

Pass when. All 10 record risks, benefits and an alternative, not only the procedure name.

2. The patient can describe the procedure in their own words.

Method. Ask the 3 patients what the procedure involves, what the main risk is, and what else could be done.

Evidence to show. Interview notes.

Pass when. Each patient gives an accurate description of at least two of the three points.

3. Consent is obtained by a trained person, not a form alone.

Method. Ask 2 staff who take consent how they confirm understanding.

Evidence to show. Interview notes.

Pass when. Each describes a conversation with teach-back, not a signature alone.

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

• A significant procedure is performed with no recorded consent.
• Consent is taken from a patient who lacks capacity without the legal pathway being followed.

Sample. Review 10 admission records and 5 records after a change in condition. Walk 2 wards and 1 ED area.

1. Falls risk is assessed on admission and after any change in condition.

Method. Review 10 admission records and 5 records after a change in condition.

Evidence to show. Falls assessment entries (identifiers masked).

Pass when. Each record has an assessment on admission, and after each recorded change.

2. Measures are in place for patients at risk.

Method. For each at-risk patient in the sample, check the measures are in place: call-bell in reach, lighting, footwear, supervision or equipment.

Evidence to show. Photo of the bed area showing the measures (no patient in frame).

Pass when. Every at-risk patient in the sample has at least one visible measure in place.

3. Staff know the falls process.

Method. Ask 3 staff what they do when a patient is assessed as at risk.

Evidence to show. Interview notes.

Pass when. Each describes the assessment and at least one measure.

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

• A patient at risk has no assessment recorded on admission.
• A patient who has fallen has no reassessment recorded.

Sample. Interview 3 patients from different groups. Review the admission and referral policy and 10 referral records.

1. The admission and referral policy states non-discrimination.

Method. Read the policy. Check it names each protected ground in the statement.

Evidence to show. Policy with the relevant section highlighted.

Pass when. The policy names race, religion, sex, gender identity, sexual orientation, disability, nationality, migration status and ability.

2. Patients are not refused or moved on grounds listed in the policy.

Method. Review 10 refusal or referral records and the reason given.

Evidence to show. Referral log extract (identifiers masked).

Pass when. No refusal or transfer is recorded on a ground listed in the policy.

3. Patients can request an interpreter or accessible format.

Method. Ask 3 patients whether they were offered an interpreter or accessible format when they needed one.

Evidence to show. Interview notes.

Pass when. Each patient who needed support was offered it, or was not in need.

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

• A patient is refused care on a ground listed in the policy.
• No policy on non-discrimination exists.

Sample. Walk the emergency entrance, the ED and one ward. Review the last fire drill record.

1. The emergency entrance is marked, lit and kept clear.

Method. Walk the route from the entrance to the ED. Check signage, lighting and obstruction.

Evidence to show. Photo of the entrance (no people in frame).

Pass when. Marked, lit and clear at the time of the walk.

2. Fire safety equipment is tested on schedule.

Method. Review the test records for extinguishers, alarms and emergency lighting.

Evidence to show. Test log for the last 12 months.

Pass when. Every item was tested within its scheduled interval.

3. Staff have run an evacuation drill.

Method. Review the drill record and ask 3 staff what they do on the alarm.

Evidence to show. Drill report and interview notes.

Pass when. A drill has been run in the last 12 months, and staff describe the process.

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

• The emergency entrance is blocked.
• No fire test record exists for the last 12 months.

Sample. Ask 3 patients. Check the charter at 3 entry points.

1. The patient rights charter is displayed where patients pass.

Method. Walk the entry, waiting area and ward corridor. Check the charter is visible at each.

Evidence to show. Photo of the charter display (no people in frame).

Pass when. Displayed at all three points, in the languages the service uses.

2. The charter names privacy, dignity, confidentiality, information and choice.

Method. Read the charter.

Evidence to show. Copy of the charter.

Pass when. All five are named.

3. Patients can describe their rights in their own words.

Method. Ask 3 patients to name two rights.

Evidence to show. Interview notes.

Pass when. Each names at least two rights correctly.

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

• No charter is displayed.
• The charter does not name patient privacy.

Sample. Review 10 staff files across clinical roles, and 3 new starters from the last 6 months.

1. Qualifications are verified with the issuing body.

Method. Review 10 staff files. Check each qualification has a verification record from the issuer.

Evidence to show. Verification record for each file (names masked).

Pass when. All 10 have a verification record dated from the issuer.

2. Registration is current.

Method. Check the registration expiry date for each file.

Evidence to show. Register extract.

Pass when. No registration has expired without renewal.

3. New starters receive structured induction.

Method. Review the induction record for the 3 newest staff.

Evidence to show. Induction checklist signed by the supervisor.

Pass when. Each new starter has a signed checklist covering the core safety criteria.

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

• A clinical staff member works with an expired or unverified qualification.
• No structured induction is recorded for a new clinical starter.

Sample. Observe one medicine round. Review 10 prescriptions and the storage of the medicine fridge and cabinet.

1. Prescriptions are complete and legible.

Method. Review 10 prescriptions for name, date of birth, dose, route, frequency and prescriber signature.

Evidence to show. Prescription copies (identifiers masked).

Pass when. All 10 are complete and legible.

2. High-risk medicines have a second check by a trained, designated person.

Method. Observe the preparation of one high-risk medicine, and check the designated list.

Evidence to show. Second-check record.

Pass when. The second check is recorded and performed by a named, trained person.

3. Medicines are stored at the correct temperature.

Method. Read the temperature log for the fridge and the cabinet for the last 30 days.

Evidence to show. Temperature log extract.

Pass when. Every reading is within range, and any excursion has a recorded action.

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

• A medicine is given without a legible prescription.
• A high-risk medicine is given without the second check.

Sample. Walk every treatment room and clinical area. Check the disposal route for one day.

1. Sharps containers are at the point of use.

Method. Walk every treatment room and clinical area. Count containers at each point of use.

Evidence to show. Walk-round checklist with photos (no people in frame).

Pass when. A container is at each point where sharps are used.

2. Containers are not overfilled.

Method. Check the fill line on each container.

Evidence to show. Photo of each container sampled.

Pass when. No container is above the fill line.

3. Waste is segregated at disposal.

Method. Follow one day's waste from a ward to the store.

Evidence to show. Segregation record and photo of the store.

Pass when. Infectious, sharps, general and pharmaceutical waste are separated and labelled.

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

• A sharps container is overfilled and in use.
• Infectious and general waste are mixed at disposal.

Sample. Review the last 20 patient records and the last 20 incidents or complaints. Interview 2 patients.

1. Records contain all mandatory elements.

Method. Review 20 records against the mandatory list.

Evidence to show. Audit tool with the 20 records (identifiers masked).

Pass when. At least 18 of 20 are complete.

2. Patient information is kept private in practice.

Method. Observe a clinical conversation and a screen. Check whether others can see or hear the patient information.

Evidence to show. Photo of the screen placement (no people in frame).

Pass when. Information cannot be seen or overheard from the waiting area.

3. Incidents and complaints are reviewed and answered.

Method. Review the last 20 incidents or complaints for review, reply, and any change in practice.

Evidence to show. Incident log extract.

Pass when. Each has a review and a reply, and any needed change is recorded.

4. Records are kept securely for the required period.

Method. Check the retention schedule against the required period, and check that access to records is restricted to authorised staff.

Evidence to show. Retention schedule; access control list (no patient data).

Pass when. The schedule matches the required period, and access is restricted to authorised staff.

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

• Patient information is visible to other patients or the public as a routine.
• Incidents are logged but never reviewed.

Sample. Interview 3 patients. Review the patient feedback and decision records for 10 patients.

1. Patients are offered real choices.

Method. Review 10 records where options were discussed.

Evidence to show. Decision records (identifiers masked).

Pass when. Options and the chosen one are recorded in each sampled record.

2. Patients are taught what they need to manage their own care.

Method. Ask 3 patients what they were taught about their condition or treatment.

Evidence to show. Interview notes.

Pass when. Each describes at least one thing they were taught.

3. Patients and carers take part in shaping the service.

Method. Ask the service for the last patient or carer input and the change it led to.

Evidence to show. Meeting minutes or feedback log.

Pass when. At least one recorded change came from patient or carer input in the last 12 months.

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

• A patient's stated preference is not recorded or considered in a decision.

Sample. Review the accreditation scope statement and the service list. Compare with 3 service sites.

1. The setting is declared in writing.

Method. Read the scope statement.

Evidence to show. Scope statement.

Pass when. The setting under which the service is accredited is named.

2. Every service is listed.

Method. Compare the list with the services observed on the site walk.

Evidence to show. Service list and site walk checklist.

Pass when. Every observed service appears on the list, and no listed service is missing from the site.

3. Transport modes and routes are declared where relevant.

Method. Review the transport section of the scope.

Evidence to show. Scope statement extract.

Pass when. Each mode and route used is declared.

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

• A service is provided that is not declared.
• No written scope exists.

Sample. Review the safeguarding concern register for the last 12 months, and interview 3 staff chosen at random.

1. A written safeguarding policy covers children and adults.

Method. Read the policy. Check it names the referral route and a safeguarding lead.

Evidence to show. Approved policy with version and date.

Pass when. Policy approved, covers children and adults, names a referral route and a lead.

2. Staff can recognise and report abuse and neglect.

Method. Ask 3 staff what they would do if they suspected abuse. Check the training record for the last 12 months.

Evidence to show. Interview notes; training record.

Pass when. Each describes the report route, and at least 90% of patient-facing staff have training recorded.

3. Every concern is recorded, referred and followed up.

Method. Check each concern in the register for a referral record and a recorded outcome.

Evidence to show. Safeguarding concern register (identifiers masked).

Pass when. Every concern has a referral record and a recorded outcome.

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

• A suspected case of abuse or neglect is not reported.
• A concern has no record of referral or outcome.

Sample. Review the programme and the surveillance report for the last 12 months. Walk 2 wards and 1 procedure area.

1. A written IPC programme exists with a named lead.

Method. Read the programme. Check it names a lead and shows a review in the last 12 months.

Evidence to show. Approved IPC programme with review date.

Pass when. Approved, names a lead, reviewed in the last 12 months.

2. Hand hygiene and isolation work at the point of care.

Method. Observe 20 hand hygiene opportunities per area. Check isolation signs and supplies in each area.

Evidence to show. Observation tally (no names); photo of isolation signage (no patient in frame).

Pass when. At least 80% of observed opportunities are met, and isolation supplies are present in every area.

3. Healthcare-associated infections are counted and acted on.

Method. Check the surveillance report for the last 12 months and the action taken on each cluster.

Evidence to show. Surveillance report and action log.

Pass when. The report is produced at least quarterly, and each cluster has a recorded action.

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

• There is no written IPC programme or named lead.
• A cluster of infections has no recorded investigation or action.

Sample. Observe 5 handovers on 2 wards across a shift change. Review the handover records for 20 patient moves in the last 3 months.

1. Each handover uses a structured method.

Method. Observe handovers and check each against SBAR or I-PASS.

Evidence to show. Observation checklist (no names).

Pass when. Every observed handover follows a structured method, matching Standard 63.1.

2. The receiver confirms the key information.

Method. Check the handover record for read-back and both signatures.

Evidence to show. Handover record (HOS-FRM-004).

Pass when. Every sampled record has read-back and both signatures.

3. Patient moves carry a written handover.

Method. Check each sampled move for a written handover sent with the patient.

Evidence to show. Transfer record with handover.

Pass when. Every sampled move has a written handover.

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

• A patient is moved or transferred with no handover given.
• A deteriorating patient is handed over with no escalation plan.

Sample. Review the service structure and the job description of the named person, and interview 3 staff.

1. One named person is accountable for the service.

Method. Check the organisation chart and the job description for the named person.

Evidence to show. Organisation chart and job description (names as appropriate).

Pass when. The named person is in both documents and has signed the annual declaration.

2. The named person has the authority to act.

Method. Review the delegated authority record for the last 12 months.

Evidence to show. Delegation record.

Pass when. Authority for decisions on safety and staffing is recorded.

3. Staff know who is accountable.

Method. Ask 3 staff who is accountable for the service.

Evidence to show. Interview notes.

Pass when. Each names the same person.

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

• No named person is recorded for the service.

Sample. Review the operating plan and the policy list. Check the approval records for each policy.

1. A written operating plan exists and is approved.

Method. Read the operating plan and check the approval date.

Evidence to show. Approved operating plan.

Pass when. Approved within the last 12 months and signed by the named person.

2. Policies are written, approved and listed.

Method. Compare the policy register with the policies on file.

Evidence to show. Policy register extract.

Pass when. Every policy on the register is on file and approved.

3. Policies are reviewed on a set schedule.

Method. Check each policy review date.

Evidence to show. Policy review dates.

Pass when. No policy is overdue for review.

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

• The service has no written operating plan.

Sample. Choose 5 policies from the register. Audit each in practice.

1. Policies are followed in practice.

Method. For each of the 5 policies, observe the practice or review records of it.

Evidence to show. Policy application audit form for each policy.

Pass when. At least 70% compliance in each audited policy.

2. Gaps lead to action.

Method. Review the actions taken after any audit gap.

Evidence to show. Audit action record.

Pass when. Each gap has a named action and a close date.

3. Staff know the key policies.

Method. Ask 3 staff to name the policy for one key task.

Evidence to show. Interview notes.

Pass when. Each names the correct policy.

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

• A policy is in place but no one follows it, and no audit has been done.

Sample. Review the last 5 serious incidents from the incident log.

1. Serious incidents are investigated.

Method. Review the investigation for each of the 5 incidents.

Evidence to show. Root cause analysis record for each.

Pass when. Each has a recorded investigation.

2. Investigations are completed on time.

Method. Check the dates from incident to investigation close.

Evidence to show. Incident action tracker.

Pass when. Each investigation is closed within the target set in the policy.

3. Learning is shared.

Method. Ask 2 staff what changed after one investigation.

Evidence to show. Interview notes.

Pass when. Each can describe one change that followed.

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

• A serious incident has no investigation recorded.

Sample. Review the annual feedback questionnaire and results for the last 12 months.

1. Patients are asked for feedback at least once a year.

Method. Review the feedback questionnaire and its dates.

Evidence to show. Questionnaire and the date it was issued.

Pass when. Issued at least once in the last 12 months.

2. Results are summarised and shared.

Method. Read the summary and check where it was shared.

Evidence to show. Feedback summary.

Pass when. Summary exists and has gone to governance.

3. Feedback leads to action.

Method. Review the actions taken from the feedback.

Evidence to show. Action record.

Pass when. At least one action was taken from the last cycle.

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

• The service has never asked patients for feedback.

Sample. Review the governing body minutes for the last 12 months.

1. The board is accountable for safety and quality.

Method. Review the terms of reference.

Evidence to show. Terms of reference.

Pass when. Safety and quality are named in the board responsibilities.

2. The board makes decisions on safety and quality.

Method. Read the minutes for the last 12 months.

Evidence to show. Minutes and decision log.

Pass when. At least one decision on safety or quality is recorded in each quarter.

3. Membership is current.

Method. Check the register of members.

Evidence to show. Register of board members.

Pass when. The register is current and signed.

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

• The board has no recorded decision on safety or quality in the last 12 months.

Sample. Review the current strategic plan and its review record.

1. A written strategic plan exists and is approved.

Method. Read the plan and check its approval.

Evidence to show. Approved strategic plan.

Pass when. Approved and signed by the board.

2. The plan includes safety and quality goals.

Method. Read the plan for safety and quality goals.

Evidence to show. Plan extract.

Pass when. Measurable safety and quality goals are named.

3. The plan is reviewed each year.

Method. Check the review record.

Evidence to show. Review minutes.

Pass when. Reviewed within the last 12 months.

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

• No written strategic plan exists.

Sample. Review the last survey, its results and the action plan. Interview 3 staff.

1. A safety culture survey is run at least once a year.

Method. Review the survey procedure and the date of the last survey.

Evidence to show. Survey procedure and the survey report.

Pass when. Survey run within the last 12 months with a validated tool.

2. Results are reported to governance.

Method. Read the minutes where the results were discussed.

Evidence to show. Governance minutes.

Pass when. Results were presented to the board or governing committee.

3. Results lead to a recorded action plan.

Method. Review the safety culture action plan register.

Evidence to show. Action plan register extract.

Pass when. At least one action from the results has an owner and a date.

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

• No safety culture survey has been run in the last 12 months.
• Results have been collected but no action plan exists.

Sample. Review the last 3 months of in-stay feedback and the quarterly summary.

1. Patient experience is measured during the stay.

Method. Review the in-stay feedback form and the completed forms for the last 3 months.

Evidence to show. In-stay feedback form and completed forms.

Pass when. Forms are collected during the stay, not only after discharge.

2. Results are summarised each quarter.

Method. Read the quarterly summary.

Evidence to show. Quarterly summary.

Pass when. A summary exists for each quarter.

3. Results are acted on.

Method. Review one action taken from a result.

Evidence to show. Action record.

Pass when. At least one action was taken from the results.

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

• Patient experience is measured only after discharge, with no in-stay measure.

Sample. Review the ethics consultation log for the last 12 months.

1. An ethics consultation process exists.

Method. Read the policy and terms of reference.

Evidence to show. Policy and terms of reference.

Pass when. Policy is approved and names the process.

2. Consultations are logged.

Method. Review the consultation log.

Evidence to show. Ethics consultation log.

Pass when. Each consultation has a date, a question and an outcome.

3. Staff know how to request one.

Method. Ask 2 clinicians how to request a consultation.

Evidence to show. Interview notes.

Pass when. Each describes the route.

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

• No ethics consultation process exists.

Sample. Review the attendance register and one decision influenced by a patient representative.

1. Patients and families have a voice in governance.

Method. Review the governance terms of reference.

Evidence to show. Terms of reference naming the patient representative.

Pass when. A patient or family representative role is named.

2. Representatives attend.

Method. Review the attendance register for the last 12 months.

Evidence to show. Attendance register.

Pass when. At least half of meetings were attended.

3. Their input changes a decision.

Method. Find one decision recorded after representative input.

Evidence to show. Minutes.

Pass when. At least one recorded decision followed representative input.

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

• No patient or family representative takes part in governance.

Sample. Review every incident classed as harm in the last 12 months, and the disclosure record for each. Interview 3 managers.

1. Every harm incident is disclosed to the patient.

Method. Compare the list of harm incidents with the disclosure record for each.

Evidence to show. Incident register and disclosure record (identifiers masked).

Pass when. Every incident classed as harm has a disclosure record with the date and the person told.

2. Disclosure is timely and open.

Method. Check the time from the incident to the disclosure, and that each record shows what happened, what will happen next, and an apology.

Evidence to show. Disclosure record.

Pass when. At least 90% of disclosures are made within the timescale set in policy, and each record shows all three elements.

3. Staff are supported and the policy is known.

Method. Interview 3 managers: how they would disclose, and what support they receive.

Evidence to show. Interview notes; written policy.

Pass when. A written policy exists, and each manager describes the steps and the support available.

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

• A patient harmed by care is not told.
• A disclosure is made with no apology and no account of what happens next.

Sample. Review the assessment record for each digital care system in use or planned in the last 12 months.

1. Every digital care system is assessed before use.

Method. List the digital systems in use and check each has an assessment record.

Evidence to show. Digital tool assessment template and completed assessments.

Pass when. Every system in use has a completed assessment dated before its introduction.

2. The assessment covers safety, data and access.

Method. Read 3 assessments for those three areas.

Evidence to show. Digital tool assessment template.

Pass when. All three areas are covered in each sampled assessment.

3. Testing and support are arranged.

Method. Check the test and support record for the sampled systems.

Evidence to show. Digital system test and support record.

Pass when. Each system has a recorded test and a named support route.

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

• A digital care system is in use with no assessment.

Sample. Review the digital alternatives record and the access process. Ask 3 patients who do not use digital tools how they book and receive care.

1. An alternative route exists for every digital service.

Method. List each digital service and check a non-digital route is recorded.

Evidence to show. Digital care access and alternatives procedure.

Pass when. Every digital service has a non-digital alternative in the procedure.

2. Alternatives are used and recorded.

Method. Check the alternative records for the last 12 months.

Evidence to show. Digital alternative record.

Pass when. Alternatives used are recorded for every case where a digital route was not possible.

3. Patients are not disadvantaged.

Method. Ask the 3 patients whether they can book and receive care without a device.

Evidence to show. Interview notes.

Pass when. Each patient can get care through an alternative route.

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

• A patient without a device or internet cannot book or receive care.

Sample. Review the patient information on AI-supported care and 10 patient records where AI support was used.

1. Patients are told when AI supports their care.

Method. Check the 10 sampled records for a recorded notice.

Evidence to show. Patient information on AI-supported care (template) and the record of the notice.

Pass when. At least 70% of the sampled records have a recorded notice.

2. The information is available to patients.

Method. Check the patient information is on display or in the patient leaflet.

Evidence to show. Patient information on AI-supported care.

Pass when. The information is displayed in the facility and available on request.

3. Patients can ask questions.

Method. Ask 3 patients whether they were told about AI support in their care.

Evidence to show. Interview notes.

Pass when. Each patient who was told can say what the AI support was.

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

• A patient's care involved AI support and the patient was not told.

Sample. Review the AI policy, the assessment and monitoring register, and the staff consultation record for each AI system in use.

1. Staff are consulted before an AI system is introduced.

Method. Check the consultation record for each AI system in use.

Evidence to show. Staff consultation record.

Pass when. Every AI system in use has a consultation record dated before introduction.

2. AI systems are monitored.

Method. Review the monitoring register for the last 12 months.

Evidence to show. AI monitoring register.

Pass when. Each system has monitoring entries at least quarterly, with unintended effects recorded.

3. Each AI system has a named owner.

Method. Check the assessment for a named accountable owner.

Evidence to show. AI system assessment.

Pass when. Every AI system in use has a named owner in the assessment.

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

• An AI system is in use with no named owner.
• An AI system was introduced with no staff consultation.

Sample. Walk the reception area with a wheelchair user or a measuring tape. Observe 2 registrations.

1. At least one reception point is at wheelchair height.

Method. Measure the height of the lowest usable section of the counter.

Evidence to show. Accessibility check record with the measurement.

Pass when. Measured height is within the range set in the accessibility standard, with a clear approach in front.

2. A wheelchair user can speak to the receptionist at eye level.

Method. Observe a registration at the accessible point, or run a test with a staff member seated.

Evidence to show. Observation note or photo of the point in use.

Pass when. The receptionist and the patient can speak at a similar eye level.

3. The accessible section is kept clear.

Method. Check the accessible section on the day of the walk.

Evidence to show. Walk-round checklist.

Pass when. No files, equipment or signage block the section in at least 70% of checks over the last 30 days.

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

• The only reception counter is above the height a wheelchair user can reach.

Sample. Review the queue log for the last 30 days (about 100 patients or all if fewer). Observe the waiting area for one session.

1. A defined queue system is in use.

Method. Observe the registration and triage points during one session.

Evidence to show. Queue system description and a photo of the number system.

Pass when. A numbered or tracked system is used for every registration and triage.

2. Wait-time information is shared with patients.

Method. Check the wait-time board or the staff script used at the desk.

Evidence to show. Photo of the board or script.

Pass when. Expected wait is shown or stated for at least 70% of patients in the observation.

3. Patients waiting too long are checked on.

Method. Review the queue log for patients waiting beyond the set time.

Evidence to show. Queue log extract with arrival and seen times.

Pass when. At least 70% of patients who waited beyond the set time were checked on, with the check recorded.

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

• No queue system exists and patients are seen in an unknown order with no information.

Sample. Review the water test records for the last 12 months and the contingency plan. Check the water outlets on the day of assessment.

1. Water is tested on a defined schedule.

Method. Review the test schedule and the test records for the last 12 months.

Evidence to show. Water test record and the schedule.

Pass when. At least 70% of scheduled tests were done on time, and the results were recorded.

2. Results are acted on.

Method. Review the actions taken after any out-of-range result.

Evidence to show. Corrective action record.

Pass when. Every out-of-range result has a recorded action and a re-test.

3. A contingency plan exists for water interruption.

Method. Read the plan and check its last review date.

Evidence to show. Water interruption contingency plan.

Pass when. Plan is approved, covers storage and alternative supply, and was reviewed in the last 12 months.

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

• No water test has been done in the last 12 months.
• An out-of-range result has no recorded action.

Sample. Review the equipment register and the service records for 20 clinical devices chosen at random. Check the out-of-use tags on the day of assessment.

1. All clinical equipment is on the register.

Method. Compare the register with a walk-round of clinical areas.

Evidence to show. Equipment inventory and service log.

Pass when. At least 70% of clinical equipment seen on the walk is on the register.

2. Servicing is done on schedule.

Method. Check the service dates for the 20 sampled devices.

Evidence to show. Service log extract.

Pass when. At least 70% of the sampled devices were serviced within their scheduled interval.

3. Faulty equipment is removed from use.

Method. Check the out-of-use tags on the walk, and the tag records.

Evidence to show. Out-of-use tag record.

Pass when. Every faulty device seen is tagged out of use, with a date and a name.

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

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

Sample. Walk the shared clinical and waiting areas on the day of assessment. Review 3 months of cleanliness audit records.

1. Cleaning follows a documented schedule.

Method. Read the cleaning schedule and check the sign-off for the last 30 days.

Evidence to show. Cleaning schedule and sign-off sheets.

Pass when. At least 70% of scheduled cleans are signed off.

2. Cleanliness is checked beyond a visual check.

Method. Review the audit method, and check it includes a test such as ATP or a swab, or a checklist with set criteria.

Evidence to show. Cleanliness audit record.

Pass when. Audits use a set method, not only a visual check, and are done at least monthly.

3. Audit results lead to action.

Method. Review the actions from audits that failed.

Evidence to show. Audit action record.

Pass when. Each failed audit has a corrective action and a re-check.

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

• Shared areas are not cleaned on any documented schedule.

Sample. Review the risk register and the last 4 quarterly reviews. Check 5 facility risks against their named owners.

1. Facility risks are in one register.

Method. Check that water, fire, equipment and other facility risks appear in the same register.

Evidence to show. Integrated facility risk register.

Pass when. All five facility risk types appear in the single register.

2. The register is reviewed on a set schedule.

Method. Check the review dates in the last 12 months.

Evidence to show. Risk review minutes.

Pass when. Reviewed at least quarterly, with the minutes recorded.

3. Each risk has an owner and an action.

Method. Check the 5 sampled risks for an owner, a control and a target date.

Evidence to show. Register extract.

Pass when. At least 70% of the sampled risks have all three.

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

• Water, fire and equipment risks are held in separate records with no integrated register.

Sample. Walk the facility from the main entrance to every restroom, emergency exit and evacuation route. Check 20 signs chosen at random.

1. Evacuation routes and exits are signed.

Method. Walk each route from the furthest point in the building.

Evidence to show. Walk-round signage checklist.

Pass when. Every route and exit has a sign at each decision point.

2. Restrooms and procedure doors are signed.

Method. Check each restroom and procedure door on the walk.

Evidence to show. Walk-round signage checklist.

Pass when. At least 70% of the restrooms and procedure doors are signed.

3. Signs are kept in place and readable.

Method. Check the 20 sampled signs for damage, fading and obstruction.

Evidence to show. Signage survey and quarterly check.

Pass when. At least 70% of the sampled signs are intact, readable and not obstructed.

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

• The emergency exit or evacuation route is not signed.

Sample. Review the critical services list, the back-up plan and the failure log for the last 12 months.

1. Critical services are identified.

Method. Read the list and check it covers power, water, medical gases, ventilation and clinical information systems.

Evidence to show. Critical services list.

Pass when. All five critical services are on the list with an owner.

2. Back-up and testing are planned.

Method. Read the plan and check the test dates for the last 12 months.

Evidence to show. Critical services testing and back-up plan.

Pass when. Each critical service has a back-up arrangement and a test at least once a year.

3. Failures are logged and analysed.

Method. Review the failure log for the last 12 months.

Evidence to show. Failure log.

Pass when. Every failure has a log entry and an analysis or a recorded action.

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

• A critical service has no back-up arrangement.

Sample. Review the reprocessing and test log for the last 3 months and the records for 10 uses chosen at random.

1. Reprocessing follows a documented standard.

Method. Read the reprocessing standard and check it follows the manufacturer and national guidance.

Evidence to show. Endoscope reprocessing standard.

Pass when. Standard is approved and names each step from cleaning to storage.

2. Each use can be traced.

Method. For 10 uses, find the reprocessing record and the patient link.

Evidence to show. Reprocessing and test log.

Pass when. At least 70% of the 10 uses have a full record.

3. Equipment is tested before use.

Method. Check the leak and function tests in the log.

Evidence to show. Reprocessing and test log.

Pass when. Every endoscope in the sample has a passing test recorded before use.

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

• An endoscope was used with no reprocessing record.

Sample. Review the competency records for 10 staff chosen at random across three roles, and the evaluation policy.

1. Each sampled staff member has a competency assessment in the last 12 months.

Method. Check the assessment date for each of the 10 staff.

Evidence to show. Competency assessment form by role.

Pass when. At least 70% of the sampled staff were assessed within the last 12 months.

2. Assessments use the job description for the role.

Method. Compare the assessment form with the job description for each role sampled.

Evidence to show. Competency assessment form and job description.

Pass when. Each form lists the competencies of the role it is used for.

3. Gaps lead to a plan.

Method. Check the sampled records for any gap and its plan.

Evidence to show. Competency gap plan.

Pass when. Each recorded gap has a learning action with an owner and a date.

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

• Staff competency has never been assessed against the job description.

Sample. Review the training matrix and the training attendance for the last 12 months, and interview 3 staff.

1. A training matrix lists the required training by role.

Method. Read the matrix and check each role has its required courses.

Evidence to show. Training matrix register.

Pass when. Every role on the staff list has its required training listed.

2. Staff attend ongoing education.

Method. Check attendance for the last 12 months for the 10 sampled staff.

Evidence to show. Training attendance extract.

Pass when. At least 70% of the sampled staff attended at least one course in the last 12 months.

3. Staff can access education.

Method. Ask 3 staff how they request training and whether they have been released to attend.

Evidence to show. Interview notes.

Pass when. Each describes a route to request training and has been released when requested.

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

• No training matrix exists and no staff member has attended any training in the last 12 months.

Sample. Review the occupational health records, vaccination records and exposure reports for the last 12 months. Check 10 staff files.

1. Required vaccinations are in place.

Method. Check the vaccination status of the 10 sampled staff against the required list.

Evidence to show. Staff immunisation record.

Pass when. At least 70% of the sampled staff have every required vaccination, or a documented exemption.

2. Exposures are reported and managed.

Method. Review the exposure reports for the last 12 months and the response to each.

Evidence to show. Occupational exposure and needlestick response record.

Pass when. Each reported exposure has a response, follow-up and a recorded review.

3. Protective equipment is available.

Method. Check PPE stock on the walk and the PPE issue records.

Evidence to show. PPE issue record.

Pass when. PPE is available in all sampled clinical areas on the day of assessment.

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

• A reported exposure has no follow-up.

Sample. Review the staff concern log for the last 12 months (all cases, or 10 if more).

1. Concerns are logged.

Method. Review the concern log against the complaints and HR records.

Evidence to show. Staff concern and investigation record.

Pass when. Every concern raised in the period is logged.

2. Concerns are investigated within the time set in the procedure.

Method. Check the dates from raising to investigation close.

Evidence to show. Staff grievance and investigation procedure, with the log.

Pass when. At least 70% of the cases are closed within the set time.

3. The staff member is told the outcome.

Method. Check the outcome letter or record for each case.

Evidence to show. Outcome record.

Pass when. At least 70% of the cases have a recorded outcome shared with the staff member.

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

• A concern has been raised and no investigation is recorded.

Sample. Review the violence and aggression incident log for the last 12 months and the prevention plan. Interview 3 staff.

1. A prevention and response procedure exists.

Method. Read the procedure and check its approval and review date.

Evidence to show. Violence and aggression prevention and response procedure.

Pass when. Approved and reviewed within the last 12 months.

2. Incidents are recorded and followed up.

Method. Check each incident in the log for a response and a follow-up.

Evidence to show. Violence and aggression incident record.

Pass when. At least 70% of incidents have a recorded response and follow-up.

3. Staff know what to do.

Method. Ask 3 staff what they do when a patient or visitor becomes aggressive.

Evidence to show. Interview notes.

Pass when. Each describes the response in the procedure.

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

• Staff have no route to report violence or aggression.

Sample. Review the last staff feedback survey, its results and the action plan.

1. A survey of staff is run at least once a year.

Method. Check the date of the last survey.

Evidence to show. Staff feedback survey template and the completed survey.

Pass when. Survey run in the last 12 months.

2. Results are shared with staff.

Method. Check where and how the results were shared.

Evidence to show. Results communication record.

Pass when. Results were shared with staff within 3 months of the survey.

3. Results lead to action.

Method. Review the action plan from the survey.

Evidence to show. Action plan.

Pass when. At least one action has an owner and a date, and is reported as done or in progress.

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

• No staff feedback has been gathered in the last 12 months.

Sample. Review the sickness absence and turnover register for the last 12 months and the analysis done.

1. Sickness and turnover are recorded.

Method. Check the register for each month of the last 12 months.

Evidence to show. Sickness absence and turnover register.

Pass when. At least 10 of the last 12 months are recorded.

2. The data is analysed.

Method. Read the analysis for the last 12 months.

Evidence to show. Sickness and attrition analysis.

Pass when. Analysis is done at least twice a year, with the main reasons named.

3. The analysis leads to action.

Method. Check the actions from the analysis.

Evidence to show. Action record.

Pass when. At least one action was taken from the last analysis.

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

• Sickness and turnover are not recorded.

Sample. Review the workforce equity register for the last 12 months across recruitment, allocation, scheduling and promotion.

1. Equity data is collected.

Method. Check the register covers all four areas for the last 12 months.

Evidence to show. Workforce equity register.

Pass when. All four areas are covered for each quarter.

2. Patterns are reviewed.

Method. Read the review record.

Evidence to show. Workforce equity monitoring procedure and review.

Pass when. Reviewed at least once a year with a recorded finding.

3. Any pattern of inequity leads to action.

Method. Check any recorded pattern for an action.

Evidence to show. Action record.

Pass when. Each recorded pattern has an action with an owner.

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

• No equity data is collected for recruitment or promotion.

Sample. Review the written working hours and rest policy, the rota log for 8 weeks, and 10 staff records for hours worked.

1. Hours and rest are set in writing.

Method. Read the policy and check it sets maximum hours and minimum rest.

Evidence to show. Working hours and rest policy.

Pass when. Policy sets a maximum weekly hours figure and a minimum rest period.

2. Rotas follow the policy.

Method. Check the 8 weeks of rotas against the policy.

Evidence to show. Rota and working hours log.

Pass when. At least 70% of the sampled rota weeks are within the policy limits.

3. Excessive hours are reported.

Method. Check the records for any exceedance and its report.

Evidence to show. Rota and working hours log.

Pass when. Every exceedance recorded has a report and a response.

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

• Working hours are not set in writing.

Sample. Review the speak-up policy, the concern records for the last 12 months and the protection records. Interview 3 staff.

1. A speak-up route bypasses the line manager.

Method. Read the policy and check a named route exists outside the line.

Evidence to show. Speak-up policy.

Pass when. Policy approved, names at least one route outside the line management chain, and is reviewed in the last 12 months.

2. Concerns are handled and protection is recorded.

Method. Check the concern records for handling and any protection measures.

Evidence to show. Concern handling and protection record.

Pass when. Every concern in the period has a handling record, and any retaliation complaint is recorded and investigated.

3. Staff know the route and trust it.

Method. Ask 3 staff how they would raise a safety concern and whether they would.

Evidence to show. Interview notes.

Pass when. At least 2 of 3 name the route and say they would use it.

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

• Staff have no route to raise a safety concern that bypasses their line manager.
• A retaliation complaint has no recorded investigation.