Cyclical clinical effectiveness audits · improvement loop
2
Active cycles
2
Reported to board
1
Closing the loop
2
Across all audits
Patient Refusal & Mental Capacity
Scheduled 2025-11-15 · Lead Dr Priya Sharma · Sample n=11
73%
Findings
Capacity assessment documented in 8/11 refusal cases. Two-step capacity test fully recorded in 6/11. Risk advice given documented in 11/11.
Action Plan
Capacity assessment proforma added to PRF · Dr Priya Sharma · due 2026-01-31
Mandatory mental capacity training day Q1 2026 · Thomas Clarke · due 2026-02-28
Adult Cardiac Arrest — Resuscitation Documentation
Scheduled 2026-03-01 · Lead Dr Priya Sharma · Sample n=14
92%
Findings
Documentation of adrenaline administration timing complete in 14/14. Two PRFs missing 12-lead ECG attachment post-ROSC (87%). Pre-alert call documented in 13/14.
Action Plan
Add 12-lead-attachment prompt to PRF post-ROSC · Dr Priya Sharma · due 2026-04-15
All clinical staff briefed at March CPD · Thomas Clarke · due 2026-04-01
Pain Management — Adult, Numerical Rating Scale
Scheduled 2026-03-15 · Lead Daniel Okafor · Sample n=22
86%
Findings
NRS recorded in 19/22 PRFs. Reassessment within 30 minutes of analgesia documented in 18/22. Three patients had pain managed without quantitative score.
Action Plan
Update PRF e-form to mandate NRS field for analgesia administration · Dr Priya Sharma · due 2026-05-31
Pain management lunchtime teaching session · Daniel Okafor · due 2026-05-12
Controlled Drugs — Stock & Documentation Compliance
Scheduled 2026-04-30 · Lead Thomas Clarke · Sample n=4
100%
Findings
All four CDs reconcile against register. All entries dual-signed. Storage compliant with Schedule 8 of Misuse of Drugs (Safe Custody) Regulations.
Action Plan
Quarterly external CD audit by Maitland Pharmacy · Thomas Clarke · due 2026-06-30
Pre-hospital Stroke Recognition (FAST)
Scheduled 2026-05-15 · Lead Daniel Okafor · Sample n=8
Hand Hygiene & Infection Prevention
Scheduled 2026-06-01 · Lead Sarah Mitchell · Sample n=0