Back to Standards/Criterion 09D.3.1.19
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorPartially met
Mr Ganesh PillaiRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

09D.3.1.19
Special requirements

Child Safety Safeguards Protocol 3.1

The Paediatric Services department establishes, implements and monitors documented operational procedures ensuring quality, clinical safety and regular compliance audits for child safety safeguards.

Compliance Criteria

  • 1Approved standard operating procedure for child safety safeguards reviewed within the last 3 years
  • 2Designated qualified personnel assigned to monitor day-to-day child safety safeguards compliance
  • 3Regular documentation audits and evidence of corrective action implementation
  • 4Staff training records and competency assessments maintained in the department

Hospital Self-Rating

Rated by Dr. Wong Wei Jun on 19 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"The department has established comprehensive operational policies for child safety safeguards. Regular self-assessments and internal quality checks demonstrate consistent compliance across all operational shifts."

Evidence Documents (0)

A criterion with no document reads as unevidenced to the survey team.

Attach relevant hospital policies, registers, audit reports, or training records.

WW
Person-in-ChargeConsultant Paediatrician
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority PaneAssigned: Mr. Ganesh Pillai (Engineering & Facilities Surveyor)

Surveyor Rating

Committed 15 Apr 2026

Staff interviews during tracer challenge indicated uneven adherence to child safety safeguards protocols during weekend coverage, despite available departmental guidelines.

Establish continuous supervisory sign-off audits and enforce documented shift compliance for child safety safeguards.

Implement monthly documentation audits and review adherence rates during departmental quality meetings.