Form – Dignity Audit PAC – Dignity Audit – Staff observation PAC – Dignity Audit – Staff observation Client Name Client Name First First Last Last Client Address Client Address Client Address Client Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Name of assessor Name of assessor First First Last Last Name of carer under observation Name of carer under observation First First Last Last Date of observation * Time of observation * 121234567891011 : 0030 AMPM Carer arrival time * 121234567891011 : 0030 AMPM Carer departure time * 121234567891011 : 0030 AMPM Scoring Criteria Paragraph The audit score ratings must be populated by Passionate About Care Limited. These must be based on the local risks associated with this audit theme. An Action Plan to be completed for any section scoring 0 Audit Area There is evidence the staff member has had training in dignity and respect. * 01 Comment The staff member has read and understood the policies and procedures at Passionate About Care Limited in relation to maintaining the dignity of a Service User. * 01 Comment The staff member knocks before entering the Service User’s property * 01 Comment The staff member calls the Service User by their preferred name? * 01 Comment The staff member ensures that choice is given to the Service User in the tasks being carried out, i.e. choice of what to eat, what clothes to wear and whether they need the toilet, etc. * 01 Comment The staff member seeks consent from the Service User in relation to the tasks being carried out, i.e. when moving items to clean, etc. * 01 Comment The staff member ensures the dignity of the Service User by maintaining their privacy, dignity, and modesty, when required. For example, closing curtains, door or preserving their modesty with a towel * 01 Comment The staff member communicates to the Service User in a dignified way. For example, they are attentive, ready to help and support the Service User * 01 Comment The communication used by the staff member is the preferred method of the Service User. * 01 Comment Choice is given to the Service User at all stages of the visit. * 01 Comment The Service User’s Care Plan is followed in relation to how they require the tasks to be carried out. * 01 Comment Upon leaving, the staff member respects the dignity of the Service User, i.e. communicates that they are leaving, ensures nothing else is required, etc. * 01 Comment The staff member is the preferred gender of carer for the Service User for the tasks being carried out. * 01 Comment Action plans Action Points Recorded Date Expected Comnpletion Action Points Recorded Date Expected Completion Action Points Recorded Date Expected Completion Action Points Recorded Date Expected Completion Action Points Recorded Date Expected Completion Carer email for copy of assessment If you are human, leave this field blank. Submit
