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{"sheet":"Part1 PreAssessment Review","index":0,"n_rows":52,"n_cols":3,"rows_kept":52,"cut":false,"hidden":false,"merged":[[21,0,21,2],[5,0,5,2],[48,0,48,2],[49,0,49,2],[50,0,50,2],[2,0,3,0],[2,1,2,2],[3,1,3,2],[23,0,23,2],[30,0,37,0],[38,0,38,2],[39,0,39,2],[47,0,47,2],[46,0,46,2],[6,1,6,2],[7,1,7,2],[8,1,8,2],[20,0,20,2],[10,0,19,0],[22,0,22,2]]}
["Safer Care Victoria - Ligature Point Audit Tool",null,"UNCONTROLLED WHEN DOWNLOADED"]
["Part 1: Pre-assessment desktop review"]
["Refer to the following Safer Care Victoria documents for guidance and support in completing Part 1:","1. Improving Safety for consumers at risk of harm of ligature - Clinical Guidance document"]
[null,"2. Ligature Assessment Tool - Supporting Guidance Document"]
[]
["1) Pre-ligature point risk assesment data and information analysis"]
["1a) Ward / Unit / Area Name:"]
["1b) Location / Campus:"]
["1c) Date data analysis was reviewed / completed:"]
["1d) Those involved in review / analysis of information:","Name","Role / Job Title"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["2) Understanding local risk for individual ward/service area prior to undertaking a ligature point risk assessment"]
["2a) Provide a brief overview of the service area and it's model of care"]
[]
["2b) Sources of information \n(incident data; previous Ligature Risk Assessment etc)","2c) What are the themes and/or trends in experience/reporting data for this ward/service area?","2d) Reviewing previous audit's action plan: \nHave these been addressed before (N/A if not previously identified) If yes, when (date) how? Has this minimised risk? If no, why not and how are these being managed?\nPlease attach previous audit action plan"]
["VHIMS"]
["Audit Action Plan"]
["(Other)"]
["(Other)"]
["2e) Previous ligature audit risk assessment","List of the risks","Committee and date of endorsement"]
["List all risks that have been endorsed by executives, executive quality and safety and/or the health safety committee as acceptance of remaining risks, and provide the date it was endorsed"]
[]
[]
[]
[]
[]
[]
[]
[]
["3) Use of ligature cutters / tools"]
["3a) Are staff required to undertake ligature awareness / management training? \n(e.g. different roles / level of training)","3b) What is the percentage of workforce trained (including clinical and non-clinical staff)?","3c) Actions if non-compliant"]
[]
["3d) What ligature cutters are used in the area?\n(insert pictures as appropriate / helpful)","3e) What system is in place to ensure that they are maintained and kept where they should be?","3f) How are staff trained to use them? Does this include practical training?"]
[]
["3g) Is this information on ligature cutters included in local level induction?","3h) Is there a protocol of how staff should respond to a ligature event? (insert protocol here)","3i) Is information on how to respond to a ligature event included in local and temporary staffing induction?"]
[]
[]
["4) Any other information included in pre-ligature point assessment review and information analysis (ie: any outstanding or future capital works)"]
[]
[]
["5) Signed by those involved"]
["Name","Signature","Date"]

{"sheet":"Part2 Ligature Point Walkaround","index":1,"n_rows":30,"n_cols":14,"rows_kept":30,"cut":false,"hidden":false,"merged":[[22,0,22,13],[3,6,3,13],[6,0,6,2],[7,0,7,2],[5,7,5,13],[6,12,6,13],[6,7,6,11],[11,3,11,5],[12,3,12,5],[5,0,5,5],[8,0,8,2],[9,0,9,2],[10,0,10,2],[11,0,11,2],[10,12,10,13],[11,12,11,13],[6,3,6,5],[7,3,7,5],[8,3,8,5],[9,3,9,5],[10,3,10,5],[9,7,9,11],[9,12,9,13],[7,7,7,11],[8,7,8,11],[7,12,7,13],[8,12,8,13],[12,12,12,13],[13,7,13,11],[14,7,14,11],[13,12,13,13],[14,12,14,13],[19,12,19,13],[20,12,20,13],[21,0,21,13],[23,7,23,8],[15,7,15,11],[15,12,15,13],[5,6,20,6],[18,7,18,11],[18,12,18,13],[16,12,16,13],[17,12,17,13],[16,7,16,11],[17,7,17,11],[10,7,10,11],[11,7,11,11],[12,7,12,11],[17,1,17,2],[18,1,18,2],[19,1,19,2],[20,1,20,2],[19,7,19,11],[20,7,20,11],[2,6,2,13],[2,0,3,5],[23,14,25,14],[13,3,13,5],[14,3,14,5],[15,3,15,5],[16,3,16,5],[17,3,17,5],[18,3,18,5],[19,3,19,5],[20,3,20,5],[12,1,12,2],[13,1,13,2],[14,1,14,2],[15,1,15,2],[16,1,16,2]]}
["Safer Care Victoria - Ligature Point Audit Tool",null,null,null,null,null,null,null,null,null,null,null,null,"UNCONTROLLED WHEN DOWNLOADED"]
["Part 2: Ligature point identification walkaround"]
["Refer to the following Safer Care Victoria documents for guidance and support in completing Part 2:",null,null,null,null,null,"1. Improving Safety for consumers at risk of harm of ligature - Clinical Guidance document"]
[null,null,null,null,null,null,"2. Ligature Assessment Tool - Supporting Guidance Document"]
[]
["6) Audit location and audit panel members",null,null,null,null,null,null,"7) Questions to be asked by the audit team: Asking the multidisciplinary staff (including clinical and non-clinical workforce) on shift at the time the physical audit is being conducted"]
["6a)  Type of Service (e.g. PICU, Older Adult):",null,null,null,null,null,null,"a) Question 1: Are you aware of the local protocol / policies on how to respond to a ligature event?",null,null,null,null,"Follow up / actions based on clinician response"]
["6b)  Ward/Unit/Area Name:"]
["6c)  Ward/Unit/Area Location or Campus:"]
["6d)  Ward/Team Manager:",null,null,null,null,null,null,"b) Question 2: Do you know the location and type of ligature cutters on your ward?",null,null,null,null,"Follow up / actions based on clinician response"]
["6e)  Date ligature point risk assessment completed:"]
["6f)  Date of last ligature point risk assessment:"]
["6g)  Names and roles of assessor(s)","Name",null,"Role / Job Title",null,null,null,"c) Question 3: Do you know the location of resus equipment on your ward?",null,null,null,null,"Follow up / actions based on clinician response"]
[]
[]
[null,null,null,null,null,null,null,"d) Question 4: Are you aware of incident debrief / supprt / learning arrangements available to staff and patients following a ligature event?",null,null,null,null,"Follow up / actions based on clinician response"]
[]
[]
[null,null,null,null,null,null,null,"e) Question 5: Do you know how to report a potential ligature risk? (e.g. damaged room / area, new risk identified, following a ligature event)",null,null,null,null,"Follow up / actions based on clinician response"]
[]
[]
[]
["8) Ligature point identification walkaround template"]
[null,null,null,null,null,null,null,"8h)  Existing mitigating controls"]
["8a) Room / Area name / Identification Code","8b) Is the risk internal or external?","8c) Room/Area description","8d) Tiers","8e) Location of identified ligature point","8f) Description of ligature point","8g) Is this an old or new risk?","Existing mitigating controls, based on ISO controls 45001\n(select all that apply)","Existing mitigating controls, based on Care Quality Commission Risk mitigation actions\n(select all that apply)","8i) Recommendation from assessment","8j) Action required","8k) How will actions be taken forward?","8l) Are there any outstanding actions from previous audit?","8m) What were the outstanding actions?"]
[null,"Internal",null,"Tier 1",null,null,"New","Elimination","Environmental",null,null,null,"Yes"]
[null,"External",null,"Tier 2",null,null,"Old","Substitution","System/Process",null,null,null,"No"]
[null,null,null,"Tier 3",null,null,null,"Elimination","Individualised"]
[null,null,null,null,null,null,null,"Engineering Controls","Environmental"]
[null,null,null,null,null,null,null,"Administrative Controls"]

{"sheet":"Part3 PostAssessment ActionPlan","index":2,"n_rows":17,"n_cols":12,"rows_kept":17,"cut":false,"hidden":false,"merged":[[12,12,24,12],[3,5,3,11],[8,0,8,11],[10,6,10,9],[2,0,3,4],[10,2,10,5],[4,0,4,11],[6,0,6,11],[5,0,5,11],[2,5,2,11],[7,1,7,2],[7,6,7,11]]}
["Safer Care Victoria - Ligature Point Audit Tool",null,null,null,null,null,null,null,null,null,null,"UNCONTROLLED WHEN DOWNLOADED"]
["Part 3: Post-assessment action plan"]
["Refer to the following Safer Care Victoria documents for guidance and support in completing Part 3:",null,null,null,null,"1. Improving Safety for consumers at risk of harm of ligature - Clinical Guidance document"]
[null,null,null,null,null,"2. Ligature Assessment Tool - Supporting Guidance Document"]
["This post-assessment action plan has been produced following an intensive assessment of potential ligature point risks and review of local ward level information.\nContinued vigilance should be maintained to identify potential risks to patient, staff and visitor safety across all areas of the ward/service.\nThis post-assessment action plan contains only known information specific to (add name of ward) Ward and is not limited to ligature risks that may emerge that have not been previously identified.\n"]
[]
["9) Action plan for staff to minimise harm from ligature points within:"]
["9a) Ward / Service:",null,null,"9b)  Date of issue:",null,"9c) Completed by:"]
[]
["10) Actions identified in audit"]
[null,null,"10c)  Audit team's recommendation",null,null,null,"10d)  For completion by executive level personel"]
["10a) Risk identified\n(including previous existing continued risks)","10b) Is this an old or new risk?","Based on ISO controls\n(select all that apply)","Based on Care Quality Commission Risk mitigation actions\n(select all that apply)","Recommendation Comments / Rationale\n(i.e. rationale on why we are proposing to accept risks / rationale on why a replacement is required / rationale on immediate action)","Responsibility assigned to (i.e.. executive / engineering / OHS team etc.)","Endorsement","If not endorsed, what is the follow-up required?","Allocation of responsibility (i.e..specific department or persons)","Expected Completion Date","10e) Status","10f) Progress comments or notes"]
[null,"New","Elimination","Environmental",null,null,"Endorsed",null,null,null,"Not Started"]
[null,"Old","Substitution","Individualised",null,null,"Not-Endorsed",null,null,null,"In-Progress"]
[null,null,"Engineering Controls","System/Process",null,null,null,null,null,null,"Completed"]
[null,null,"Administrative Controls",null,null,null,null,null,null,null,"Abandoned"]
[null,null,null,null,null,null,null,null,null,null,"Risk Accepted"]

{"sheet":"Sheet1","index":3,"n_rows":10,"n_cols":6,"rows_kept":10,"cut":false,"hidden":true,"merged":[]}
["Yes","New","Endorsed","Not Started","Elimination","Environmental"]
["No","Old","Not-Endorsed","In-Progress","Substitution","Individualised"]
[null,null,null,"Completed","Engineering Controls","System/Process"]
[null,null,null,"Abandoned","Administrative Controls"]
[null,null,null,"Risk Accepted","PPE"]
[]
[]
["Internal","Tier 1"]
["External","Tier 2"]
[null,"Tier 3"]