Action Plan for Bereavement Service

Contents1

MORTUARYFACILITIES STANDARDS

MORTUARYFACILITIES STANDARDS

Introduction2
Guidelines for using the audit sheets3
Audit sheets5
Facilities5
Comprehensive facilities5
Limited facilities7
Design and décor8
Maintenance10
Diversity and inclusion11
Accessibility12
Governance13
Feedback sheets14
Bibliography15

1. Introduction2

MORTUARYFACILITIES STANDARDS

INTRODUCTION

We have used the term ‘mortuary facilities’ to refer to the areas used for body storage and/or viewing the bodies of deceased patients by bereaved relatives, and post mortem room/s where applicable.

The audit tool is designed for auditing all mortuary facilities, whether they are part of a comprehensive mortuary and post-mortem suite, or on sites where full facilities are not provided, for example where only a body store and viewing area are required.

Each audit sheet deals with a different standard and they can be used individually or together. The standards and criteria for the audit sheets were developed using a consistent methodology. A literature review was undertaken to identify relevant guidance, evidence, standards and policies (where applicable).

2. Guidelines3

MORTUARY FACILITIES STANDARDS

GUIDELINES FOR USING THE AUDIT TOOL

Format

All the audit sheets follow the same format. Each sheet covers particular aspect, and includes a standard statement, which explains the level of performance to be achieved. The standard statement is expanded upon by criteria that must be met in order for the standard to be achieved.

Criteria are marked either E for ‘essential or D for ’desirable’. Most of the criteria are ‘essential’, and it is expected that these will be met in all facilities. Other criteria are ‘desirable’ and demonstrate the highest level of quality we should be aiming to achieve. The audit sheets and criteria are numbered for ease of reference. The numbering is not a reflection on priority. The distinction between ‘essential’ and ‘desirable’ is the only way in which the criteria have been prioritised.

Scoring

All criteria should be marked either Yes, No or Non-applicable. A Non-applicable response may only be entered if a standard is not achievable. For example, in a facility that does not have windows; the following standard would be Non-applicable.

(h) / Window coverings / E/D / Yes / No / N/A / Comments
26 / Window coverings are designed to maximise light whilst maintaining privacy. / D /  / No windows.

It is not acceptable to enter a Non-applicable response where an improvement in a standard may be achieved.

(a) / Viewing facilities / E/D / Yes / No / N/A / Comments
7 / Toilet and wash basins are provided adjacent to or at least easily accessible to the viewing room. / E /  / Nearest toilet and wash basin are on a different floor, approximately 200m away.

In the example shown above it is not appropriate to mark Non-applicable where a toilet and wash basin are not easily available, as the Health Service Advisory Committee’s guidance is that these must be provided. Therefore, if this is not the case then a No score must be allocated. A No score indicates a problem which will need to be investigated further and, if possible, resolved. An action plan will be developed to reflect any remedial action required.

Comments should be written on the form for each of the criteria at the time of the audit clearly identifying any issues of concern or areas of good practice. These comments can then be incorporated into the final report. Whilst it is not essential to calculate scores for all audits, it may be useful to do so for comparative purposes.

2. Guidelines4

Level of compliance

We’ve aimed to set standards that are challenging but achievable. Compliance will be dependent upon meeting all ‘essential criteria’, and also achieving a satisfactory percentage overall. Please use the level of compliance using the categories below.

Compliant:All essential criteria are met with an overall score of 80% or above

Partial compliance:All essential criteria are met with an overall score of 70 to 79%

Minimal compliance:Not all essential criteria have been met and/or the overall score is 69% or below

Allocation of a compliance level for more than one audit score

A compliance level can be allocated to an individual facility based on the overall scores of several audit sheets. (Table 1)
A compliance level can also be allocated to one standard across several facilities. (Table 2)

The overall level of compliance in these instances can only be compliant if all essential criteria are met and all overall scores are 80% or above.

Table 1. Allocating a level of compliance when using more than one audit sheet in an individual facility.

Table 2. Allocating a level of compliance for audits of comprehensive facilities across the Division.

3.1.1 Comprehensive mortuary facilities5

MORTUARY FACILITIES AUDIT TOOL

COMPREHENSIVE FACILITIES

Standard: The facilities are adequate and the layout is fit for purpose.

Date:…………….. Facility:…………………… Auditor/s:……………………….

(a) / Body viewing facilities / E/D / Yes / No / N/A / Comments
1 / Facilities comprise a separate entrance, a waiting room, access to sanitary facilities, a viewing room and a bier room / area (where the trolley is placed for viewings). / E
(b) / Entrance / E/D / Yes / No / N/A / Comments
2 / Visitors can access the viewing facilities directly from outside, without having to enter any other parts of the mortuary. / E
3 / The corridor or route to the facilities is clean, well lit and well maintained. / E
(c) / Waiting room / E/D / Yes / No / N/A / Comments
4 / There is a dedicated waiting room or area away from the bustle of the hospital. / E
5 / Comfortable chairs (i.e. padded and upholstered) and a small table are provided. / E
6 / Drinking water is available. / E
7 / The waiting room is adjacent to the viewing room with a door between them. / D
(d) / Viewing room / E/D / Yes / No / N/A / Comments
8 / There is a private room where bereaved relatives can spend time with the deceased person. / E
9 / The viewing room connects with both the waiting room and the bier room. / E
10 / Comfortable chairs (i.e. padded and upholstered) are provided. / E

3.1.1 Comprehensive mortuary facilities6

11 / The entrance to the bier room can be covered by easily drawn curtains. / D
12 / The layout allows for visitors to have either partial, or complete, direct access to the body. / E
13 / The room has subdued lighting controlled by dimmer switches. / E
14 / There is an internal telephone in the viewing room or nearby to call for assistance if required or should an emergency arise. / E
(e) / Bier room / E/D / Yes / No / N/A / Comments
15 / The bier room adjoins the body store and the viewing room. / D
16 / The room has subdued lighting controlled by dimmer switches. / E
17 / The flooring is washable and continuous with that of the body store or the connecting link between the two. / D
18 / A pall cloth is provided which matches the general décor. / D
19 / The bier trolley is capable of height adjustment. / D
(f) / Sanitary facilities / E/D / Yes / No / N/A / Comments
20 / A toilet and wash basin are provided adjacent to or easily accessible to the waiting / viewing room. / E

3.1.2 Limited mortuary facilities7

MORTUARY FACILITIES AUDIT TOOL

SUMMARY FOR LIMITED FACILITIES

Standard: Where a comprehensive mortuary facility is not required, viewing facilities and/or body store/s are provided to the appropriate standard.

Date:……………….. Facility:………………….. Auditor/s:……………………….

(a) / Viewing facilities / E/D / Yes / No / N/A / Comments
1 / There is a private room where bereaved relatives can spend time with the body of the person who has died. / E
2 / The corridor or route to the room is clean, well lit and well maintained. / E
3 / The layout allows for visitors to have either partial, or complete, direct access to the body. / E
4 / Comfortable chairs (i.e. padded and upholstered) are provided. / E
5 / The viewing room has subdued lighting controlled by dimmer switches. / E
6 / A pall cloth is provided which matches the general décor. / D
7 / The bier trolley is capable of height adjustment. / D
8 / A toilet and wash basin are provided adjacent to or easily accessible to the viewing room. / E
9 / There is an internal telephone in the viewing room or nearby to call for assistance if required or should an emergency arise. / E
10 / Drinking water is available. / E

3.2 Design and décor 8

MORTUARY FACILITIES AUDIT TOOL

DESIGN AND DÉCOR

Standard: The interior design and décor of the facilities are pleasant, comfortable and fit for purpose.

Date:………………. Facility:……………………. Auditor/s:……………………..

(a) / Signage / E/D / Yes / No / N/A / Comments
1 / The external entrance is clearly and appropriately signposted. / E
2 / All signage uses appropriate language which does not imply a religious connection (e.g. the term ‘chapel of rest’ should not be used). / E
3 / The reception point and procedure are clearly identified. / E
4 / Where there is a need for visitors to call the attention of staff on their arrival, a simple bell with an appropriate notice is provided at the entrance. / E
5 / Internally, rooms are clearly labelled using appropriate words. / E
6 / There is a system to indicate to staff outside when the room is in use. / E
(b) / Privacy / E/D / Yes / No / N/A / Comments
7 / There is visual separation between the bereavement facilities and the mortuary / other areas. / E
8 / There is acoustic separation between the bereavement facilities and the mortuary / other areas. / D
(c) / General décor / E/D / Yes / No / N/A / Comments
9 / The interior design creates a pleasant, comfortable environment. / E
10 / The rooms have a relaxing, domestic and non-institutional feel. / D
11 / The rooms are decorated in a light, naturalistic colour scheme. / D
12 / Colour and contrast are used to
distinguish floors, walls and furniture. / D
(d) / Furniture / E/D / Yes / No / N/A / Comments
13 / Furniture is stable, robust and easily cleaned. / E

3.2 Design and décor 9

14 / Chairs are comfortable (i.e. padded and upholstered) and suitable for use by frail and / or elderly people (e.g. with arms positioned directly over legs for maximum stability). / E
(e) / Lighting / E/D / Yes / No / N/A / Comments
15 / Lighting provides for a warm non-institutional ambience. / E
16 / Artificial lighting is capable of providing the required levels of illumination at all times, and can be varied according to need (i.e. it is possible to dim the lights in the bier and viewing rooms). / E
17 / Natural and artificial lighting minimise glare and silhouettes. / D
(f) / Fittings and equipment / E/D / Yes / No / N/A / Comments
18 / Fittings and equipment are made of durable materials which will not deteriorate under regular hard use. / E
19 / Fittings and equipment are easy to clean. / E
20 / Fittings and equipment are free from sharp corners or projections. / E
(g) / Flooring / E/D / Yes / No / N/A / Comments
21 / Floor coverings contribute towards the creation of an attractive environment, but do not present a tripping or slipping hazard to people or the movement of wheeled equipment. / E
22 / Floor coverings can be effectively cleaned, maintained and, where necessary, repaired. / E
23 / Floor surfaces allow easy passage to wheelchair users. / E
24 / Floor surfaces minimise light reflection. / D
25 / Floor surfaces reduce reverberation. / D
(h) / Window coverings / E/D / Yes / No / N/A / Comments
26 / Window coverings are designed to maximise light whilst maintaining privacy. / D
(i) / Ventilation / E/D / Yes / No / N/A / Comments
27 / Ventilation is such that comfortable conditions are maintained in the waiting and viewing rooms. / E
28 / Ventilation prevents odours from entering the waiting and viewing rooms from other areas of the mortuary. / E

3.3 Maintenance 10