Audit Tool for Transfer Processes in Mental Health Services in (Location/ Service)

Objective of Audit tool:

This audit tool is to be used to retrospectively audit the processes used for Transfer Processes in line with the Mental Health Commission Code of Practice (2009), The Quality Framework for Mental Health Services in Ireland (2007), Article 15 of the Mental Health Act (2001) - Regulations (2006) and the MHC Guidance Document on Individual Care Planning MHS (2012).

Methodology:

Inclusion Criteria: All residents admitted to an Approved Centre

Frequency of Audit: Random Selection of Patient charts –(number and frequency to be decided by the MDT team)

Method:This is a retrospective care plan audit

Feedback: Completed Audit Tool to be kept by the CNM/ Unit Manager (to be agreed).

A copy of theOutcomessection of this Audit Tool (Section F) to be forwarded to Clinical Director/ Director of Nursing (to be agreed) for onward reporting of audit outcomes.

Audit Details:

Audit Type / Quarter 1 audit Quarter 2 audit Quarter 3 audit Quarter 4 audit
6 monthly audit Post incident
Random audit Other, Please state: / Date of Audit
Auditor(s) Name(s) / 1.
2.
3. / Auditor(s) Title (s) / 1.
2.
3.
Details of Prescription audited
Date reference number / 1. / 2. / 3.
4. / 5. / 6.

Methodology: RecordY for Yes, if the criteria is met. Record N for No, if criteria is not met or N/Afor Not applicable

Audit ofTransfer Processes in Mental Health Services

Unit Name: ______

Section A: Transfer Process

If during the course of resident’s admission there is reason to transfer the resident to another facility, there is evidence: / 1 / 2 / 3 / 4 / 5 / 6
A1 / The resident was transferred for one of the following reasons
  • It was believed to be in the best interest of the resident to be transferred to another facility

A2 /
  • The resident was in need of obtaining special treatment or care that can only be provided in another facility

A3 /
  • The resident requests to be transferred to another approved centre which may be closer to his/ her home

A4 /
  • The resident requests transfer to an independent facility for which he/ she has health insurance cover

A5 / The decision to transfer was made by the registered medical practitioner or Clinical Director as appropriate and this decision and reasons for the transfer are documented
A6 / The decision to transfer was made in consultation with the resident, the MDT and the family/ chosen advocate where appropriate
A7 / All options available were discussed with the resident and the family/ chosen advocate where appropriate
A8 / The decision to transfer was agreed with the receiving facility
A9 / A Risk Assessment was carried out prior to transfer
A10 / Appropriate control measures were agreed and implemented by the MDT
A11 / Resident’s consent was obtained prior to transfer and this was documented in the resident’s clinical file
A12 / Where consent was not obtained this should be documented and the reasons why
A13 / All relevant information, including the Risk Assessment and suicidal intent was conveyed to the receiving facility
A14 / All relevant information, including the Risk Assessment and suicidal intent was documented in the resident’s clinical file
A15 / The key worker was responsible for co-ordinating all stages of the resident’s transfer to the receiving facility
A16 / The key worker liased with the MDT in both facilities in preparation for the transfer
A17 / There was direct verbal commuication and liason at all times with the receiving facility and these communications are documented
A18 / Full and complete written information regarding the transferring resident was sent in advance or accompanied the resident upon transfer.
A19 / This information was sent to a named person in the receiving facility and a record of this was maintained
A20 / The information sent included: - The individual care and treatment plan
A21 / - A referral letter addressing the reasons for transfer
A22 / A copy of the referral letter was kept in the resident’s clinical file
A23 / There was a clear and documented plan for the transfer of the resident
A24 / Transfer took place before 17.00 hours and if it was after this time the reasons are clearly documented in the resident’s file
A25 / Personal property and possessions were returned to the resident
Total Scores for Yes
Total Scores for No
Total Scores for N/A
% Total = Total Scores for Yes X 100
Total = 25(Total – N/A)

Comment:______

______

______

Section B: Transfer Processes - Audit Outcomes

Unit Name: ______Date: ______

Audit Results / 1 / 2 / 3 / 4 / 5 / 6
% Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance / % Total Compliance
Section A
Audit Outcomes / 1 / 2 / 3 / 4 / 5 / 6
Yes / No / Yes / No / Yes / No / Yes / No / Yes / No / Yes / No
Care Plan processes were appropriately applied at all times
There were deviations from the correct Care Plan processes
Recommendations for improvement are required
Recommendations arising from the audit: / Date for completion / Responsibility
Resident 1
Resident 2
Resident 3
Resident 4
Resident 5
Resident 6

Auditor Signature: ______Date:______

CNM Signature:______Date:______

Director of Nursing Signature: ______Date: ______

Audit Tool for Transfer Process, QPS DML, Sept2014 Page 1 of 5