Care Quality Commission Outcome 10 Audit

• Document No.

• Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• Personnel

CQC Outcome 10M - Sanitary Provisions

• 10M People who use services have access to toilets, baths and showers that enable people to maintain privacy and dignity that are in close proximity to their living areas.

• 10M
  2010.01.26 DSSA MENTAL HEALTH FAQS FINAL states in relation to Mental Health & Learning Disability Services:
  
  Same-sex accommodation is:
  Same-sex wards – a ward with dedicated toilet and washing facilities, occupied solely by either men or women, boys or girls
  Mixed-sex wards – with single bedrooms and same-sex toilet and washing facilities (preferably en-suite) or Mixed-sex wards – with bed bays (multi-bed rooms) occupied by either men or women with access to same- sex toilet and washing facilities
  In mixed-sex wards, it is good practice to create separate parts of the ward for men and women with designated areas, or zones, for the bedrooms and toilet/washing facilities for each sex. There maybe times, albeit not ideal, when a corridor or the bedroom area of a ward may be mixed. If this occurs, bedrooms, toilet and bathing facilities should be designated to achieve as much gender separation as possible and care supported by appropriate staffing.
  Men and women should not have to pass through the bedrooms or bed bays of the opposite sex to access their own bedrooms or toilet/washing facilities. Ideally, service users should not pass through mixed, communal areas adjacent to their bedrooms or bed bays to access their washing facilities. The exception is toilet facilities used while in day areas where service users are fully dressed.
  Some WCs and bathrooms contain specialist facilities (eg hoists) to make them accessible for disabled users. Such facilities may be designated unisex as long as they are for use by one person at a time, are lockable from the inside (with external override), a risk assessment has been conducted and, where necessary, the service user is escorted by a member of staff. The ideal remains to have segregated accessible facilities where this is possible.
  
  DSSA Frequently asked questions - acute setting states:
  Same-sex accommodation can be provided in:
  • Same-sex wards (i.e. the whole ward is occupied by men or women but not both) or
  • Single rooms with adjacent same-sex toilet and washing facilities (preferably en-suite) or
  • Same-sex bays or rooms, with designated same-sex toilet and washing facilities, preferably
  within or adjacent to the bay or room.
  Patients should not need to pass through accommodation or toilet/washing facilities used by the opposite sex to get to their own.
  Same-sex accommodation can be provided in:
  • Same-sex wards (i.e. the whole ward is occupied by men or women but not both) or
  • Single rooms with adjacent same-sex toilet and washing facilities (preferably en-suite) or
  • Same-sex bays or rooms, with designated same-sex toilet and washing facilities, preferably
  within or adjacent to the bay or room.
  Patients should not need to pass through accommodation or toilet/washing facilities used by the opposite sex to get to their own.
  

• Are all WCs, shower rooms and bathrooms provided in line with Delivering Same Sex Accommodation requirements to enable patient Privacy and Dignity.

  Yes

  No

• Describe location

Location

• Location and details

CQC Outcome 10F - Sanitary Provisions

• 10F People who use services and others who work in or visit the premises can be confident that in relation to design and layout, the premises have sufficient toilets, and where necessary bathroom and bathing facilities, that take into account people’s diverse needs and promote their privacy, dignity and independence.

• En-suite Facilities
  
  HBN 04-01 – Adult in-patient facilities states:
  En-suite sanitary facilities
  En-suite shower room to single-bed room
  5.6 Each single-bed room should have an en-suite shower room (with WC, shower and wash-hand basin).
  
  HBN 03-01 – Adult acute mental health units states:
  Single bedroom
  8.4 The bedroom should be a minimum of 15 m2 including an en-suite facility. If en-suite facilities are not achievable with projected numbers of beds, planners may wish to consider reducing the number of beds.

• Does each bedroom have an en-suite shower, WC and wash basin facility?

  Yes

  No

• HBN 04-01 – Adult in-patient facilities states:
  Multi-bed room sanitary facilities
  5.9 A multi-bed room [max 4No beds] should have [assisted] en-suite sanitary facilities, which can be accessed by patients without the need for them to travel or cross circulation routes.
  [Taken from example ADB Activity Database Pg24]
  
  5.10 in addition to 5.9, it is convenient to provide an assisted shower room (with WC, shower and wash-hand basin) and a separate semi-ambulant WC (with hand-rinse basin), both en-suite to the bed area. Thus one person showering does not prevent others from using the WC.

• Number of bedrooms without en-suite shower, WC and wash basin facility.

• Number of beds without en-suite shower, WC and wash basin facility.

• Does each room without an en-suite have a wash basin provision?

  Yes

  No

• How many rooms?

• HBN 04-01 – Adult in-patient facilities states:
  Assisted bathrooms and shower rooms
  5.13 In addition to en-suite facilities, an assisted bathroom or shower room is required, although this may be shared with other wards.

• Is an assisted bathroom or shower room available within the building?

  Yes

  No

• Number of assisted bathrooms

• Number of assisted shower rooms

• HBN 04-01 – Adult in-patient facilities states:
  General sanitary provisions
  
  4.25 For infection control purposes, in-patients, clinical staff and visitors should be provided with separate sanitary facilities, which should be clearly labelled.
  
  4.26 Facilities for visitors and non-clinical staff should be located close to the ward reception and waiting area.

• Which of the following are present

• Designated patient WCs

• Minimum provision of sanitary appliances for bedrooms in hotels, hostels and similar accommodation
  BS 6465-1:2006+A1:2009 Table 9

  

• Number of designated individual male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated individual female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of urinals

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated unisex WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated individual male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated individual female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of urinals

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated unisex WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Designated visitor WCs

• Are the provisions located near to the building reception/waiting area?

  Yes

  No

• Location of the provisions

• Number of designated individual male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated individual female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of urinals

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated unisex WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Designated staff WCs

• Workplace sanitary appliance provision
  BS 6465-1:2006+A1:2009 Table 3

  

• Workplace sanitary appliance provision
  BS 6465-1:2006+A1:2009 Table 4

  

• Estimated maximum number of staff accommodated within the building at any one time.

• Information provided by:

• Number of designated individual male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated individual female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal male WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of urinals

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated communal female WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of WC cubicles

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Number of designated unisex WCs

  Select 1 2 3 4 5 6 7 8 9 10

  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

CQC Outcome 10F - Compassionate Spaces

• 10F People who use services and others who work in or visit the premises can be confident that in relation to design and layout, the premises have somewhere private available for breaking bad news, where this is done.

• Position of the clinician(s) consulted

• Is there a need for the service(s) to break bad news to patients or carers in the building?

  Yes

  No

• Is there a private space(s) available where this can be done?

  Yes

  No

• Describe where this activity undertaken

• Describe location where this is undertaken

Location

• Location and details

CQC Outcome 10I - Compassionate Spaces

• People who use services and others who work in, or visit the premises can be confident that in relation to design and layout, the premises have space for a relative, carer or friend to be able to stay with the person using the service at the end of their life.

• Position of the clinician(s) consulted

• Is end of life care provided within the building?

  Yes

  No

• Is there space for a relative, carer or friend to be able to stay with the person using the service?

  Yes

  No

• Describe how carers and relatives, carers or friends accommodated when a service user is at the end of their life

• Describe location where this is undertaken

CQC Outcome 10F - Patient Call

• People who use services and others who work in or visit the premises can be confident that in relation to design and layout, the premises have call alarm systems that enable people who use services to get help when their mobility is limited for whatever reason.

• Position of the clinician(s) consulted

• Is there an operational nurse call system within the building?

  Yes

  No

• Provide details of how patients call for assistance.

• What formats of nurse call system are in place?
  Check one or both options.

• Fixed call points

• What level of coverage is provided?

• All patient areas

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Accessible spaces only

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

• Other

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

• Mobile handheld transmitters

• Are all patients issued with a handheld transmitter?

  Yes

  No

• Provide details as to how this is managed

• What level of coverage is provided?

• All patient areas

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Accessible spaces only

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

• Other

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

• Automated sensors

• What level of coverage is provided?

• All patient areas

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Accessible spaces only

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

• Other

• How does the system alert staff for assistance?

• Sounders and display panels throughout the unit

• Sounder and illuminated indicator at the location of the call

• Central board within the nurse base only

• Pagers

• Locations of coverage

Location

• Location and details

CQC Outcome 10M - External Therapeutic Spaces

• People who use services have access to outdoor space; this could be outdoor areas, gardens or grounds that allow individuals to benefit from being outside.

• Position of the clinician(s) consulted

• Number of distinct wards accommodated within the building

• Are outdoor spaces available directly from each distinct ward?

  Yes

  No

• Are outdoor spaces available from any of the distinct wards?

  Yes

  No

• Provide a brief description of each ward that has no direct access to an external space

Ward

• Ward details, including number of beds

• Describe how is access to an external space facilitated

• Provide a brief description of the spaces that have direct access from a ward

External space

• Location and details

• Do patients have open access to the external space at all times?

  Yes

  No

• Provide details of restrictions

• Provide a brief description of each ward that has no direct access to an external space

Ward

• Ward details, including number of beds

• Describe how is access to an external space facilitated

• Provide a brief description of the space

External space

• Location and details

• Do patients have open access to the external space at all times?

  Yes

  No

• Provide details of restrictions

CQC Outcome 10M - Internal Therapeutic Spaces

• People who use services have access to communal rooms that are of sufficient size, and that provide opportunities to comfortably participate in social, therapeutic, cultural, daily living or educational activities, either individually or with others.

• Health Building Note 04-01: Adult in-patient facilities states
  
  Informal social space
  5.24 Open, yet intimate, areas recognisably intended for casual meeting and talking (i.e. breakout spaces) may be all that is required to enable patients to socialise without the provision of dedicated day rooms.

• Environmental Design Guide - Adult Medium Secure Services states:
  
  Principles for room design
  Planners should take into account the need to provide rooms and other spaces with therapeutic benefit for patients that will contribute to the daily life of the service and the welfare of visitors. These should include:
  • education rooms
  • library
  • multi-faith rooms
  • visiting rooms
  • multi-gym and sports facilities
  • primary health care facilities
  • self catering/cooking
  • shop /café

• Mental Health Policy Implementation Guide National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments states:
  
  4.1 Rationale
  The physical environment of a PICU or Low Secure environment is one of its defining aspects. The design of any unit should maximise the primary functions of safety, therapy and security.
  
  4.12 Recreation/activity facilities
  4.12.1 Access should be available to a games room.
  4.12.2 An activities room in which board games, art equipment and stereo equipment is placed.
  4.12.3 Day room and sitting room equipped with television and video.

• Adult acute mental health units – Planning and design manual Version:0.4:England states:
  
  Sitting area/room
  10018 This is one of the main areas where service users may relax and socialise. A beverage point may be available close by.
  In order to increase flexibility and to create a central, light, communal space to the unit, this room could be open-plan with other spaces, for example the dining room or activity room.
  The sitting room may be located to give good views of the general activity in the area, with level access to the garden area. Good sightlines through the room to the garden may be conducive to service user relaxation; the garden could be considered as a “room without a roof”.
  Views to outside are important for service users. Fittings and furniture may include:
  • storage for games, books and magazines;
  • coffee tables and semi-easy and easy chairs;
  • entertainment facilities.
  
  Dining area
  10019 The size of the dining area will depend on the number of service users catered for and the amount of storage required in the area.
  If opting for central dining – that is, one dining area for a number of wards – careful consideration is required regarding the extent and location of dining provision on the unit for those service users who are unable to leave the ward areas, as it may involve duplicating furniture and equipment as well as space.
  The dining area could be multifunctional, potentially used for games, social activities and meetings, particularly if designed as part of an open-plan communal space as described above.
  The quality of the decor and furnishings is important in creating a comfortable, relaxed environment. Round tables and seating to accommodate four to five people are recommended.
  
  Quiet room
  10020 Quiet rooms provide an alternative to a larger communal sitting room, especially when the communal space is open-plan. It may be important to have at least one same-sex quiet room; inclusion of a quiet room within same-sex bedroom areas will assist in the functionality of these areas.
  Quiet rooms may offer a number of uses depending on where they are located within the unit. For example, they could be used for de-escalation, meetings or one- to-one therapy sessions. This would depend on local policy.
  
  Activity area
  10021 An activity area may be provided for games such as snooker or pool, table tennis and/or interactive computer games. The space requirements for equipment and storage will need to be assessed locally.
  Physical activities such as ball games or gym workouts may take place elsewhere in the unit, but it is important to provide an activity area for those service users who are not permitted to leave the unit.
  
  Arts and craft room
  10034 This room may be equipped for a range of activities, such as painting and pottery. Sink facilities and easy-to-clean flooring are required. If a kiln is provided, this could be located in a separate secure area with controlled access. Extract ventilation is essential, so external wall access is necessary.
  Lockable storage is required, including storage for flammable liquids. Drying space may also be required for artwork.
  The full range of activities will be decided locally and the operational policies will need to reflect the need for supervision and storage of some tools and materials.
  
  Group therapy rooms
  10035 Group therapy rooms have similar requirements to therapy rooms, but need to accommodate larger group activities, which may range from relaxation (where people may be prone or supine), to dance, drama, therapy and other physical activities.
  Storage space may be required for larger equipment such as musical instruments or media equipment.
  
  Therapy kitchen
  10036 The kitchen should be “domestic” in appearance and size, capable of accommodating a small group, and containing equipment similar to that found in the home.
  * Both gas and electric cookers may be made be available, but the cookers should not be located in corners.
  * Equipment required may include a microwave oven, a dishwasher and other portable electrical equipment such as mixers and blenders.
  * Lockable storage will be required.
  * There should be space for two or three service users to work with staff
  and to sit down and eat.
  
  Sports room/gym
  10037 An indoor exercise facility should be made available for use in inclement weather. This could be provided either within the building or as a covered/three-sided area located externally.
  The size of the sports room will depend on local requirements and whether or not it incorporates a gym. Provision of a dedicated gym will be a local decision. The layout and equipping of this room will depend on local decisions and operational policies, especially those relating to supervision within the area.
  If the space is a dedicated sports hall, a wooden or soft vinyl sports floor is appropriate.
  Space will be required for storage of sports or gym equipment. Access to drinking water should be provided. Cooling may be required.
  

CQC Outcome 10K - On Call Facilities

• People who use services can be confident that the staff caring for them are able to work effectively, because where they remain on the premises, staff on call have adequate facilities that ensure comfort, privacy and the ability to rest properly, and have access to a telephone connected to the premises’ network.

• Position of the clinician(s) consulted

• Is an on call provision operated from the building?

  Yes

  No

• Provide details of the on call service provided

• Location of on call accommodation

• Level of accommodation provided:

• Is the space private, with the ability to rest properly?

  Yes

  No

• Provide details

• Provide details

• Is the accommodation comfortable?

  Yes

  No

• Provide details

• Provide details

• Does the on call service have access to a telephone that is connected to the premises' network?

  Yes

  No

• Provide details

• Provide details

Clinic Locking Strategy

• Does the building have any clinic rooms?

  Yes

  No

• Clinic details

Clinic

• Location

• The Misuse of Drugs (Safe Custody) Regulations 1973 - Each door shall be fitted with an effective lock, being a single sided dead lock having resistance to manipulation and forcing.

• Is the door fitted with a sash lock or dead lock?

  Yes

  No

• Describe the locking mechanism.

• Adult Acute Mental Health Units - Planning and Design Manual V0.4 England
  Each ward's treatment room/dispensary should be fitted with a lock that is on an individual suite.

• Is the clinic door lock cylinder on an individual suite, under the grand master key?

  Yes

  No

• Describe how the suiting arrangement for the clinic door and the building as a whole.