GM Spasticity - Service Organisation Audit Tool: Community

(Please complete one form only per service)

Team(Required)

What kind of team are you?(Required)

Stroke/Neuro/Joint?

Is spasticity routinely considered for all patients with neurological motor weakness?

If compliant, what process is in place to provide assurance?

Please select all that apply

Training

GM Spasticity Proforma

Supervision

Local Audit

Which members of the locality MDT are involved in spasticity management?

Rehab Medicine Doctor

Non-Medical Injector

Physiotherapist

Occupational Therapist

Nurse

Orthotist

Other (Please State)

If other........ Please indicate

Is the MDT able to provide first-line interventions in the community:

Self-Management

Full Compliance

Partial Compliance because - limited access to trained staff, limited capacity, limited access to support self-management

None Compliance because- no capacity to provide support for self-management, no trained staff able to support self-management, no access to resources to support self-management

If Partial or none recorded. Please indicate reasons why.....

Trigger Management

Choose multiple as required

Full Compliance

Partial compliance because - access to some professions for trigger management, limited access to all professions for trigger management,

None compliance because - no specialists within the team, no capacity within the team, no pathway in place for access to specialists

If Partial or none recorded. Please indicate reasons why.....

Postural Management

Choose multiple as required

Full Compliance

Partial compliance because - limited capacity within the team, limited pathway in place for access to HCPs trained in postural management, limited access to equipment to manage posture

None compliance because - no capacity within the team, no pathway in place for access to HCPs trained in postural management, no access to equipment to manage posture

If Partial or none recorded. Please indicate reasons why.....

Therapeutic Management

Full Compliance

Partial compliance because - limited capacity within the team

None compliance because - no capacity within the team

If Partial or none recorded. Please indicate reasons why.....

Is the MDT able to provide or access second-line interventions in the community?

Orthoses

Choose multiple as required

Full Compliance

Partial compliance because - resource is available but pathway is not coordinated, Limited stock options, limited capacity, limited resource, waiting time to access service

None compliance because - no capacity within the team, workforce not trained to provide orthoses, no orthotic resource within the team, no referral pathway in place to access orthotics

If Partial or none recorded. Please indicate reasons why.....

Oral Anti-Spasticity Agents

Choose multiple as required

Full Compliance

Partial compliance because - available but pathway not coordinated, limited due to timescales, waiting time to access services

None compliance because - no capacity within the team to offer review/assessment, no prescribers within the workforce, no pathway in place to access prescribers such as Rehab Medicine Doctors or GP

If Partial or none recorded. Please indicate reasons why.....

Botulinum Toxin

Choose multiple as required

Full Compliance

Partial compliance because - available but pathway not coordinated, administration of toxin offered on a goodwill basis, limited capacity to provide toxin., waiting time to access services

None compliance because - no capacity within the team, workforce not trained to provide botulinum toxin, no pathway in place to access trained medical or non-medical injector for botulinum toxin

If Partial or none recorded. Please indicate reasons why.....

Which healthcare professionals deliver botulinum toxin in your locality?

Choose all that apply

Rehab Medicine Doctor

Non-Medical Injector

Rehab medicine specialist trainee

If Partial or none recorded. Please indicate reasons why.....

Is this delivered within the locality spasticity clinic or within patients homes?

Spasticity Clinic

Patients homes

Both

Nerve Block

Full Compliance

Partial compliance because - discoordinated or ad hoc pathway in place to access nerve block

None compliance because - no referral pathway in place to access nerve block

If Partial or none recorded. Please indicate reasons why.....

Are there pathways in place to access third line interventions?

Intrathecal baclofen service

Full Compliance

Partial compliance because - limited pathway in place to access ITB clinic, waiitng time to access service

None compliance because - no referral pathway in place to access neurosurgical services

If Partial or none recorded. Please indicate reasons why.....

Neurosurgical options

Full Compliance

Partial compliance because - limited referral pathway in place to access neurosurgical services

None compliance because - no referral pathway in place to access neurosurgical services

If Partial or none recorded. Please indicate reasons why.....

Orthopaedic/Plastic surgery

Full Compliance

Partial compliance because - limited referral pathway in place to access orthopaedic surgical services , waiting time to access service

None compliance because - no referral pathway in place to access orthopaedic surgical services

If Partial or none recorded. Please indicate reasons why.....

Sativex Clinic

Choose all that apply

Full Compliance

Partial compliance because - limited referral pathway in place to access sativex service, no sativex service in place

None compliance because - no referral pathway in place to access sativex service, no sativex service in place

If Partial or none recorded. Please indicate reasons why.....

Does the locality service routinely provide written information to patients and carers on managing spasticity?

Choose all that apply

Full Compliance

Partial compliance because - written information is provided some of the time

None compliance because - no resource available, written information is never provided

If Partial or none recorded. Please indicate reasons why.....

Is there a pathway in place with inpatient services to manage patients with spasticity needs moving out into the community?

Choose all that apply

Full Compliance

Partial compliance because - limited pathway in place

None compliance because - no pathway in place

If Partial or none recorded. Please indicate reasons why.....

Thank you for completing the survey

Phone

This field is for validation purposes and should be left unchanged.

GM Spasticity - Community Service Organisation Audit

Is the MDT able to provide first-line interventions in the community:

Is the MDT able to provide or access second-line interventions in the community?

Are there pathways in place to access third line interventions?

Thank you for completing the survey