Step One      Understanding the Scale of Risks

To begin with we suggest it is helpful to look at the "Scale of Risks" to help understand what is actually being audited with this tool.
For the purposes of this audit, "risks" are given a score ranging from 1 (a rare and insignificant risk) to 25 (a catastrophic risk that is almost certainly likely) which is arrived at by rating both severity and likelihood and multiplying the two.
 

"likelihood" x "severity" = "score"

Figure 1 Likelihood and Severity Table

Severity
Severity is described in this audit tool by the following  terms:

• "Catastrophic" Multiply life threatening. Long term catastrophic harm to the environment. More than 50 people may be involved. Extended service closure. International publicity. Litigation costs exceeding £1 million.
• "Major" Life threatening or major permanent personal harm. Long terms severe harm to the environment. 16 to 50 people may be involved. Temporary service closure. National publicity. Average length of stay increased by over 15 days. Litigation costs between £500k and £1 million
• "Moderate" Semi Permanent Harm, critical impact on care. Moderate temporary personal harm. May involve 3 to 15 people. Loss of service affecting more than one department. Regional publicity. Average length of stay increased by 8 to 15 days. Litigation costs between £50k and £500k.
• "Minor" Manageable, non-permanent harm. No harm or trivial harm to the environment. Involves 1 to 2 people. Minor impact on service. Local publicity. Average length of stay increased by 1 to 7 days. Litigation costs between £50 and £50k.
• "Insignificant" No obvious harm. No impact on service. Litigation costs less than £50.

Likelihood
The severity of hazardous events in terms of their consequences is common to all areas, meaning that the effects of any event are not really variable between one area and another. However, the likelihood of a hazardous event happening will vary from one area to another; therefore this audit will be primarily based on estimating local likelihood using the following scores.             

• "Almost certain" Will most certainly happen again, possibly frequently                               
• "Likely" Will probably happen again but not persistently.                               
• "Possible" May happen occasionally                               
• "Unlikely" Is not expected to happen but is possible                               
• "Rare" Is not believed to happen again 

Actions Following the Audit                                      
The Scale of Risks in Figure 1 shows that a catastrophic event which is not believed to happen again is scored at 5, (requiring action within one month of the audit), whist an event of minor severity that is almost certain to happen is scored at 10 (requiring immediate action and an entry on the local risk register). For the purposes of providing a viable audit tool a threshold has been set that any risk that scores 10 or above requires immediate action (red) as there is at least a possibility of a" threat to life or major personal harm", whilst any risk that scores less than 10 requires action within one month of the audit, thus ensuring that even a rare possibility of a "catastrophic" risk is being given a high (amber) priority. This enables assessed risks to be prioritised across four thresholds each requiring a different level of urgency of action:

Figure 2 Table of Recommended Response Times

When you are using the Audit Tool you can go to all the sheets by clicking on the titles in the left hand column.

Step Two      Review the Audit Standards

                                    
If this is the first time you are using this audit then we recommend that you briefly review the Audit Standards that describe the kinds of hazards you may find in an In-patient setting. You may also wish to add further standards that are agreed as outcomes or learning points from any inquiries, national or local.
To help you enter or change information throughout the Tool, those cells that are shaded a pale yellow are where you can enter or change the information.

For example, if you want to add a new Audit Standard then click onto a shaded cell on the "Audit Standards" sheet and enter a new audit standard. (There are two cells for new standards under each of the headings on the sheet). This new standard is automatically copied into every audit sheet for the rooms that you will audit.

Once you have read the audit standards, and added to them if you need to, you can go to the next step. you don't have to read the standards every time you use the tool, in future you can go directly to the Local Audit Details.

Figure 3  Screen shot of the Audit Standards Sheet   

Step Three        Setting up the Audit Tool to fit your In-patient Ward

                                      
Once you have read the Audit Standards, and made any changes you need to, you should then go to the sheet for "Local Audit Details".

On this page you can confirm your local thresholds for responding to levels of risk. As the default the thresholds set in this audit tool are:

a) Scores from 1 to 3  are 'low risk' and if any actions are required they should be taken within 6 months of completing this audit.

b) Scores from 4 to 10  are 'moderate' and if any actions are required they should be taken within 1 month of completing this audit.

c) Scores from 11  to 25 are 'high risk' and if any actions are required they should be taken within 1day of completing this audit.

Adjusting these thresholds will change whether the identified risk are estimated as low, moderate or high, but will not change the recommended response time for taking actions to address any of the risks audited. To adjust these thresholds please use the drop down menu.

Further down the same page you will see the drop down menus used to select which rooms are applicable or not applicable to the ward being audited. This is an important step to make sure that the results of your audit accurately reflect the ward being audited and that "false results" are not included in your wards audit report.

Figure 4 Screen shot of the "Local Audit Details" sheet


It is a good idea to give a brief description of the location of each room by clicking on the appropriate cell under the heading "Brief Description of the location of each room" and entering details of exactly where each room is. This will help other people know exactly which rooms are which when they read the report, this is particularly important if any new staff need to be informed of your audit findings, of if the local Estates Department are asked to make any alterations to any of the rooms. The notes that are entered in each cell are automatically copied into the appropriate Audit Sheet.
                                              

Step Four       Carry out the Audit

Now that you have entered the details in Step 3 and saved the file, the audit sheets have been set up for all of the rooms you selected as applicable to your ward. To carry out an audit on any of these rooms just click on the number to the left of the room name and that will take you to the Audit Sheet for that room, (there is a separate Audit Sheet for each room, which includes the audit standards, questions and a summary table).

When you start to use an Audit Sheet you will see the title of the room, the name of the trust and ward and the room itself including the details of the location that you entered earlier.

The standards are presented in a column with a drop down menu for each standard that allows you to enter whether or not standard has been met in this room. The default answer on the menus when you first use them is "No answer", which means that that standard cannot be said to have been met in that room therefore a "red" score is given.

For each standard that you answer has been fully met, the audit tool automatically score a green.
For each standard that has not been answered the audit tool automatically scores a red.
For each standard where you answer that the standard has not been met, then you are prompted to estimate the likelihood of a suicide or self harm attempt happening in this room in relation to its standard. If you estimate it as "rare" (that is "not believed to happen again") then that tool gives a score of amber. If you estimate the likelihood as being  "unlikely, possible, likely" or "almost certain" then the tool gives a score of red given the potential severity of even an unlikely attempt as described in the Scale of Risks above.

Figure 5 Screen shot of the top of the Audit Sheet showing the titles, details of locations and drop down Menu's



As you continue through the audit sheet providing answers for all the standards, the tool automatically summarises the total of scores in the table at the bottom. In the table there is also a cell to enter the name of the person auditing the room and a cell to enter a date. When you enter the date that the audit was completed the table will tell you when the actions should be carried out for addressing the red amber and green standards for that room.

Figure 6 Screen shot of the bottom of the Audit Sheet showing the Summary Table of Score and dates for Action


As each room on the ward is audited the score for each room is then summarised back onto the "Local Audit Details" sheet, thus giving you a ward Environmental Audit Report.

Every page of the tool can be printed to provide a paper copy of the tool and its summary reports.