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					   NHS NORTH LANCASHIRE QUALITY ASSURANCE ASSESSMENT FRAMEWORK

   Name of Provider                                                                    Date of Self Assessment:

   Name of Commissioning Assessor(s):                                                    Date of Assessment Visit


   Levels of compliance: Red - not compliant, Amber - partially compliant Green - fully compliant

                                                     Level of
   Description of Standard                           compliance   Evidence available             Action and timescale
                                                Infection Control and Prevention

   Complaince to CQC Outcome 8 : Cleanliness
 1 and Safety

 2 Infection Control
                                                       Health and Safety
   Compliance to CQC Outcome 10 : Safety and
 3 suitability of premises
   Compliance to CQC Outcome 11 : Safety,
 4 availability and suitability of equipment
 5 PEAT compliance - good quality furniture

 6 Health & Safety arrangements
   Service specific environment - functional
 7 suitability
 8 Disable access
 9 Waste disposal (clinical and non-clinical)

10 Medical devices and safety alerts
11 Compliant with DSSA




                                                                       Page 1
12 Harrassment and Bullying
13 Aggression and violence

                                                     Medicine Management
   Compliance to CQC Outcome 9: Management
14 of Medicine

15 Medicine management
   Aspiration for self medicating for appropraite
16 clients
                                                         Safeguarding

   Compliance to CQC Outcome 7: Safeguarding
17 people who use services from abuse

18 Money management according to clients' need
19 Protection from abuse

                                                     Equality and Diversity
   Compliance to CQC Outcome 1: Respecting
20 and involving people who use services
   Discrimination / equal opportunity in line with
21 Equality Act 2006
   Information can be accessed in an appropriate
22 format by clients.

                                                     Information Governance
23 Information Governance Toolkit
24 Compliance to CQC Outcome 21: Records
25 Confidentiality / access to records

26 Record keeping




                                                                        Page 2
   Compliance to CQC Outcome 6: Cooperating
27 with other providers

                                                     Quality Assurance
     External Audit
28
   Compliance to CQC Outcome 16: Assessing
29 and monitoring the quality of service provision

     Internal and Clinical Audit
30

31 Risk Assessment / Management
                                                       Governance

32 Leadership - clinical and corporate
   Corporate / individual objectives setting and
33 performance management
     Compliance to CQC Outcome 17: Complaints
34

35 Complaints procedures
     Governance
36
   Compliance to CQC Outcome 20: Notification
   of other incidents (NOT included in the Quality
37 and Safety core standard)
     Service development - participation processes
38
     Independent Advocacy
39
                                                        Workforce

40 Compliance to CQC Outcome 13: Staffing




                                                                    Page 3
41 Induction
   Compliance to CQC Outcome 14: Supporting
42 workers
     Supervision
43
   Compliance to CQC Outcome 12:
44 Requirements relating to workers

45 Recruitment and Retention
     Registration and CRB
46

47 Staff Appraisal, PDP

48 Staffing levels and skill mix
     Sickness rates and cover arrangements
49

50 Volunteers
                                                Care Planning and Review
   Compliance to CQC Outcome 4: Care and
51 welfare of people who use services
   Care Planning and Review of care including
52 service user participation
     Assessment process
53
   Compliance to CQC Outcome 2: Consent to
54 care and treatment

     Appeal process
55
                                                       Outcomes

56 Outcomes focus and monitoring




                                                                  Page 4
57 Education, Training and Employment
58 Daily living skills

59 Religious and Cultural needs
   Compliance to CQC Outcome 5: Meeting
60 nutritional needs

61 Food
62 Social Interaction
     Healthy lifestyle and Health Promotion
63
64 Leisure activities




                                              Page 5
Page 6
    Guidance to Self Assessment for NHS North Lancashire Quality Assurance Framework




    Description of the standard      Fully compliant                             Partly complaint                   Not compliant
                                                          Infection Control
                              Evidence for all the reguirements of
                              regulation 12 of the Health and Social     Some evidence on the                       Minimal evidence to support the
                              Care Act 2008 (Regulated Activities)       requirements of regulation 12 with         requirements of regulation 12 with
  Compliance to CQC Outcome 8
1                             Regulations 2009 with regard to the Code regard to the Code of Practice for           regard to the Code of Practice for
  : Cleanliness and Safety
                              of Practice for health and adult social    health and adult social care in the        health and adult social care in the
                              care in the prevention and control of      prevention and control of infections       prevention and control of infections
                              infections and related guidance.           and related guidance.                      and related guidance.
                                     Policy in place and complied with good
                                     practice standards addressed. Audited       Policy in place. Some evidence of Policy in place, no evidence of
2 Infection Control                  and reviewed on the implementation of       staff training                    implementation.
                                     the policy. Hand hygiene given
                                     importance.
                                                              Health and Safety
                                     Evidence for all the reguirements of
                                     regulation 15 of the Health and Social
                                     Care Act 2008 (Regulated Activities)
                                     Regulations 2009. Design and layout of
3                                    the premises are suitable, adequately       Some evidence of compliance        Minimal evidence of compliance
                                     maintained and safe for people who use
    Compliance to CQC Outcome        the service, including staff and others.
    10 : Safety and suitability of   Measures in place to ensure security.
    premises                         Compliance with legal requirements.




                                                                        Page 7
                                      Evidence for all the reguirements of
                                      regulation 16 of the Health and Social
                                      Care Act 2008 (Regulated Activities)
                                      Regulations 2009. Equipment that is
 4                                                                                  Some evidence of compliance           Minimal evidence of compliance
                                      suitable for its purpose, is avaiable,
     Compliance to CQC Outcome        properly maintained, use correctly and
     11 : Safety, availability and    safely, promotes independence and is
     suitability of equipment         comfortable.

                                                                                    Some information re activities,
                                    Reviewed and agreed activities                  users information. Meets minimum
                                    programme. Up to date information on                                                    Poor quality and quantity of
 5                                                                                  requirements but shabby, stained
                                    notice boards. Furnishings and high                                                     furniture. No activity programme.
                                                                                    furniture, fittings. Little evidence of
   PEAT compliance - good quality standard decorations, environment                 maintenance programme.
   furniture (level of compliance). suitably maintained.
                                    Policies in place, reviewed and adhered
                                                                                    Up to date policies in place, notice
                                    to by all. H & S noticeboard up to date.
 6 Health & Safety arrangements                                                     board information not up to date.    Policy not in date or not developed
                                    Designated H & S staff rep. Practices and
                                                                                    Some staff awareness of policy.
                                    procedures tested.

                                      Fit for purpose - all aspects of care         Some aspects to a good enough
     Service specific environment -
 7                                    treatment, environment of a high              standard. Evidence of                 Not suitable for the service function
     functional suitability
                                      standard and any clinical areas compliant     improvement plan.
                                      with clinical standards requirements
                                      External and internal compliance with      Ramps outside. Some aids.                Few inprovements in situ. Not
 8 Disable access
                                      legislation                                Adaptations insitu                       compliant with legislation
   Waste disposal (clinical and non- Policy in place. Evidence of staff training Policy in place. Little evidence of
 9                                                                                                                        Polciy not developed
   clinical)                         that policy is followed                     staff training
     Medical devices and safety       Policy in place. Evidence of staff training   Policy in place. Little evidence of
10                                                                                                                        Polciy not developed
     alerts                           that policy is followed                       staff training
                                      Undertaken self assessment. Have a
   Compliant with DSSA                DSSA action plan as required. Have a          Undertaken self assessment.
                                                                                                                          No evidence of self assessment
11 (Delivering Same Sex               process in place for recording breachess      Action in place but not
                                                                                                                          and action plan.
   Accomadtion)                       DSSA guidance. Process in place for           implemented.
                                      monitoring of complaints.




                                                                           Page 8
                                        Up to date policy or policies in place.    Policy or policies in place.
                                                                                                                             No policy in place. Whistle blowing
12 Harrassment and Bullying             Staff training programme. Induction.       Covered at induction. Whistle
                                                                                                                             not encouraged
                                        Whistle blowing encouraged.                blowing encouraged.
                                        Up to date policy or policies in place.    Policy or policies in place.
                                                                                                                             No policy in place. Whistle blowing
13   Aggression and violence            Staff training programme. Induction.       Covered at induction. Whistle
                                                                                                                             not encouraged
                                        Whistle blowing encouraged.                blowing encouraged.
                                                                 Medicine Management
                                        Evidence for all the requirements stated
                                        for regulation 13 of the Helath and Social
                                        Care Act 20078 (Regulated Activities)
     Compliance to CQC Outcome 9: Regulations 2009. Handle medicines
14                                                                                 Some evidence of compliance               Minimal evidence of compliance
     Management of Medicine             safely, securely and appropriately.
                                        Follow published guidance. Information
                                        about medicine prescribed are available
                                        to the clients.
                                        Up to date policy in place- covering
                                        storage, administration and accurate
15   Medicine management                                                           Policy in place                           Policy not developed
                                        recording. Staff training, evidence of
                                        implementation of policy through audit.
                                        Up to date policy in place- covering
     Aspiration for self medicating for storage, administration and accurate
16                                                                                 Policy in place                           Policy not developed
     appropraite clients                recording. Staff training, evidence of
                                        implementation of policy through audit.
                                                                      Safeguarding
                                        Evidence for all the requirements stated
     Compliance to CQC Outcome 7:
                                        for regulation 11 of the Health and Social
17   Safeguarding people who use                                                   Some evidence of compliance               Minimal evidence of compliance
                                        Care Act 20078 (Regulated Activities)
     services from abuse
                                        Regulations 2009.
                                        Clients have full control over all their
                                                                                   A policy has been established to
                                        finances with their own bank account and                                             No clear policy exists for clients to
                                                                                   clients to having full control over all
                                        are supported with access to external                                                manage their own finances or for
                                                                                   of their finances with their own
                                        advice agencies for any assistance with                                              external appointeeship
                                                                                   bank account OR
                                        financial matters. OR

     Money management according
18
     to clients' need




                                                                             Page 9
                                   A system of external appointeeship is in
                                                                             A system of external appointeeship
   Money management according      place for clients who cannot manage their
18                                                                           is in place for clients who cannot
   to clients' need                own monies
                                                                             manage their own monies
                                   A policy for management of finances
                                   within the service is in plac. There is a
                                                                               A policy is about to be
                                   clear and accountable audit trail for the
                                                                               implemented
                                   management of finances within the
                                   service.
                                   Up to date safeguarding policy, including
                                   MCA and DOLs in place in responding to
                                   safeguarding concerns. Induction            Policy in place. Induction
                                   programme. Appropraite levels of            programme. Lack of evidence of
19 Protection from abuse                                                                                              No policy in place.
                                   safeguarding training for staff. Evidence   appropraite level of staff training of
                                   of policy being implement                   the implmentation of the policy


                                                          Equality and Diversity

                                   Evidence for all the requirements stated
                                   for regulation 17 of the Health and Social
                                   Care Act 20078 (Regulated Activities)
                                   Regulations 2009. Recognise the
                                   diversity, values and human rights of
   Compliance to CQC Outcome 1: people who use services. Uphold and
20 Respecting and involving people maintain the privacy, dignity and          Some evidence of compliance            Minimal evidence of compliance
   who use services                independence; put them at the centre of
                                   their care and treatment and support
                                   them with decision making, provide
                                   information that support decision making.
                                   Involve service user in how the service is
                                   run and be an active community
                                   participation in appropriate settings.




                                                                     Page 10
                                     Policy or polcies in place. Staff training /
   Discrimination / equal            induction. Evidence of policy being
21 opportunity in line with Equality implemented. Individualised apporach to Policy in place                               No policy in place
   Act 2006                          diversity in relation to clients needs
                                     demonstrated.
                                     Evidence in leaflets that similar
                                     information can be access in different                                                No mentioned that information is
   Information can be accessed in                                                 Some leaflets available in different
22                                   format. Service leaflet available if                                                  available in different format at
   an appropriate format by clients.                                              format.
                                     different format. Staff aware how to                                                  request
                                     access this at request.
     Information Governance
                                  Evidence to Level 2 compliance OR                 Registered for compliance with
                                  action Plan in place showing working              Information Governance Toolkit.
23 Information Governance Toolkit                                                                                          Not registered
                                  towards Level 2                                   No action plan in place if not at
                                                                                    Level 2
                                       Evidence for all the requirements stated
                                       for regulation 20 of the Helath and Social
     Compliance to CQC Outcome         Care Act 20078 (Regulated Activities)
24                                                                                   Some evidence of compliance           Minimal evidence of compliance
     21: Records                       Regulations 2009. Personal records are
                                       accurate, fit for purpose, held securely
                                       and remain confidential.
                                       Policy in place that complies with
                                       legislative requirements around DATA
     Confidentiality / access to       Protection and FOI and good practice
25                                                                                   Policy in place. Induction training   No policy
     records                           standards on sharing information.
                                       Induction and ongoing training. Evidence
                                       of implementation
                                       Policy in place, signatures, legible, entries
26 Record keeping                                                                    Polciy in place. Induction            No policy
                                       dated, time and timely. Audited




                                                                           Page 11
                                    Evidence for all the requirements stated
                                    for regulation 24 of the Health and Social
                                    Care Act 20078 (Regulated Activities)
                                    Regulations 2009. Cooperate with others
                                    involved in the care, treatment and
   Compliance to CQC Outcome 6:
27                                  support of the client who uses the         Some evidence of compliance    Minimal evidence of compliance
   Cooperating with other providers
                                    service. Shared information in a
                                    confidential manner with all relevant
                                    services. Support clients to access other
                                    health and social care services they
                                    need.
                                                            Quality Assurance
                                   Evidence of significant assurance that
                                   there is a robust system of control      Some evidence of significant
28 External Audit                  designed to meet the organisation's      assurance. Action plan to address Poor evidence of assurance.
                                   objectives.                              full assurance.




                                                                     Page 12
                                    Evidence for all the requirements stated
                                    for regulation 10 of the Health and Social
                                    Care Act 2008 (Regulated Activities)
                                    Regulations 2009. Monitor the quality of
                                    service people receive. Identify, monitor
                                    and manage risks to people who use,
                                    work or visit the service. Seek
                                    professional advice if do not have
                                    knowledge themselves on how to run the
    Compliance to CQC Outcome service safely. Take into account of
29 16: Assessing and monitoring     comments and complaints, investigat into     Some evidence of compliance       Minimal evidence of compliance
   the quality of service provision poor practice. Improve service from
                                    adverse events, incidents, errors and
                                    near misses that happen, the outcome
                                    from comments and complaints, and the
                                    advice of other expert bodies where the
                                    information show the service is not fully
                                    complaint. Arrangements in place on
                                    decisions that affect the health and
                                    welfare and safety of people who use the
                                    service.
                                    Framework in place. Clinical and other
                                    audit systems in place with evidence of
                                                                                 Framework in place. Some          No framework in place. Ad hoc
30 Internal and Clinical Audit      using audit to inform paractice and
                                                                                 evidence of audit.                processes
                                    service development via governace
                                    arrangements
                                    Ongoing attention paid to Risk
                                    Assessment - clinical and environmental.
                                    Training at induction and ongoing.           Framework in place and training   No framework in place. Ad hoc
31 Risk Assessment / Management
                                    Evidence of risk assessment and              covered at induction              processes
                                    management directly informing proactive
                                    and service delivery.
   Governance




                                                                       Page 13
                                     Means of communication with staff,
                                     users, carers, externally. Evidence of        Clear mission statement or
   Leadership - clinical and         collaborative working with CPA                objectives. Annual Business Plan.
32                                                                                                                   Minimal evidence of leadership
   corporate                         processes and CMHTs. Clear mission            Some evidence of collaborative
                                     statement or objectives. Annual               working
                                     Business Plan.
   Corporate / individual objectives Annual for unit, initial objectives for new
                                                                                   Performance Management              Minimal evidence of Performance
33 setting and performance           staff. Performance Management
                                                                                   Framework in place.                 Management
   management                        Framework
                                      Evidence for all the requirements stated
                                      for regulation 19 of the Health and Social
                                      Care Act 20078 (Regulated Activities)
                                      Regulations 2009. Systems in place to
     Compliance to CQC Outcome        deal with comments and complaints,
34                                                                               Some evidence of compliance           Minimal evidence of compliance
     17: Complaints                   including information to people about the
                                      system and not be discriminated against
                                      for making a complaint. Respond
                                      appropriately and resolve where possible
                                      any comments and compliants.
                                      Up to date policy in place. Monitoring of
                                      trends in % of complaints in a period.
                                      Timescale for response, outcome.
35 Complaints procedures              Lessons learnt. Transparency of dealings Policy in place. Induction training.    No policy. Ad hoc processes
                                      with compliants. Appropriate training for
                                      managers dealing with complaints.

                                      Up to date policy in place. Monitoring of
                                      trends in % of incidents in a period.
36 Governance                         Timescale for response, outcome.          Policy in place. Induction training.   No policy. Ad hoc processes
                                      Lessons learnt. Transparency of dealings
                                      with incidents.




                                                                          Page 14
                                  Evidence for all the requirements stated
    CQC compliance to Outcome
                                  for regulation 18 of the Health and Social
   20: Notification of other
37                                Care Act 2008 (Regulated Activities)           Some evidence of compliance      Minimal evidence of compliance
   incidents (NOT a Quality and
                                  Regulations 2009. Notify the CQC about
   Safety core standard)
                                  incidents that affect the health, safety and
                                  welfare of people who use the service.
                                  Evidence of Service Development Plan
                                  communicated, involvement of others re         Service Development Plan in
   Service development -          service collaboration. Service users           place. Involvement within the    No involvement in service
38
   participation processes        involvement. Community meetings take           organisation. Needs further      development
                                  place.                                         development.
                                  Policy for access access to advocacy.
                                                                                 Policy for access to advocacy.   No provision or access to
39 Independent Advocacy           Staff training . Evidence of effective use
                                                                                 Staff training at induction.     advocacy.
                                  of of advocacy by service users
                                                                 Workforce
                                  Evidence for all the requirements stated
                                  for regulation 22 of the Health and Social
     Compliance to CQC Outcome
40                                Care Act 2008 (Regulated Activities)       Some evidence of compliance          Minimal evidence of compliance
     13: Staffing
                                  Regulations 2009. Adequate staff to meet
                                  the needs of clients.
                                                                             All staff have gone through and      All staff have had induction training,
41 Induction                      All staff, including Bank staff have gone less than 80% of Bank staff have      less than 50% Bank staff had
                                  through induction training.                had induction training.              training.
                                  Evidence for all the requirements stated
                                  for regulation 23 of the Health and Social
     Compliance to CQC Outcome    Care Act 20078 (Regulated Activities)
42                                Regulations 2009. Staff are properly       Some evidence of compliance       Minimal evidence of compliance
     14: Supporting workers
                                  trained, supervised and appraised.
                                  Competent staff that meet the health and
                                  welfare need of the clients.
                                  Upe to date supervision policy. Schedule
                                  in place for all formal supervision and    Policy in place. Some evidence of
43 Supervision                                                                                                 No formal supervision or policy
                                  evidence. Peer support available.          compliance




                                                                      Page 15
                                   Evidence for all the requirements stated
                                   for Regulation 21 of the Health and Social
                                   Care Act 2008 (Regulated Activities)
                                   Regulations 2009. have effective
                                   recruitment and selection procedures in
   Compliance to CQC Outcome
                                   place. Carry relevant checks when they
44 12: Requirements relating to                                               Some evidence of compliance              Minimal evidence of compliance
                                   employ staff. Ensure staff are registered
   workers
                                   with relevant professional regulator or
                                   professional body. Refer staff who are
                                   not fit to work and meet the requirement
                                   for referral to the appropriate bodies.

                                   Systems and policies in place. Limited
                                   use of Bank / Agency staff. Limited
                                   vacancies. Demonstrable ethos of              Systems and policies in place.        High vacancy rates. Overtime time
45 Recruitment and Retention       valuing staff and prioritising inter personal Limited use of Bank / Agency staff.   off in lieu is uncontrolled. High use
                                   skills and values of staff in client care     Some vacancies.                       of Bank / Agency staff.
                                   within recruitment and retention
                                   processes.
                                                                                 System in place. All clinicians
                                   Systems and policies in place. All staff      have current professional             All clinicians have current
46 Registration and CRB            have appropriate and current level of         registration. Less than 75% of        professional registration. Less
                                   CRB check. All clinical staff have current frontline staff have current CRB         than 50% have current CRB check
                                   professional registration.                    check (every 3 years)..
                                   System and current policy in place for
                                                                                 System and process in place.
                                   staff training and development. Annual                                              Less than 50% of staff have annual
                                                                                 Less than 80% have annual
47 Staff Appraisal, PDP            appraisal for more than 80% of staff.                                               appraisal, CPD and training
                                                                                 appraisal, CPD and training
                                   Evidence of CPD and training                                                        programme
                                                                                 programme.
                                   programme.
                                   Appropriate staffing to meet identified
                                   needs - roles and functions documented. Adequate staffing on duty for unit          Inadequate staffing for unit to be
48 Staffing levels and skill mix
                                   Staffing levels permit active social          to be safe.                           safe.
                                   includsion work on a regular basis




                                                                       Page 16
                                  Sickness rates monitored and standards
                                                                           No monitoring of sickness rates.
   Sickness rates and cover       set. Adequate staff on duty. Check notes                                       Inadequate staffing for unit to be
49                                                                         Adequate staff on duty for unit to
   arrangements                   including waking nights if applicable                                          safe.
                                                                           be safe.
                                  Screening, training and ongoing support
50 Volunteers                     or supervision provided. Appropriate        Induction training and CRB check   No system in place.
                                  level of CRB check.
                                                       Care Planning and Review

                                  Evidence for all the requirements stated
                                  for Regulation 9 of the Health and Social
                                  Care Act 20078 (Regulated Activities)
                                  Regulations 2009. Reduce the risk of
                                  people receiving unsafe or inappropriate
                                  care, treatment and support by assessing
   Compliance to CQC Outcome 4: the needs of people who use the
51 Care and welfare of people who services, planning and delivering care,    Some evidence of compliance         Minimal evidence of compliance
   use services                   treatment and support that are safe, their
                                  welfare is protected and their needs are
                                  met. Using of published research and
                                  guidance. Making reasonable
                                  adjustments to reflect people's needs,
                                  values and diversity. Having
                                  arrangements for dealing with
                                  unforeseeable emergencies.
                                  Process is led by trained individuals and   Process is led by a trained
   Care Planning and Review of    include relevant people, is timely and      individuals, may not include
52 care including service user    undertaken in a thorough non threatening                                        Poor or no process
                                                                              relevant people. Little sevice user
   participation                  process. Service users take an active in    involvement.
                                  decision about their care and treatment.




                                                                    Page 17
                                                                          Process is led by a trained
                                                                          individuals, may not include
                                                                          relevant people. A recognised,
                               Process is led by trained individuals and evidence based tool used, timely Assessment process is not clear or
53 Assessment process          includes relevant people, using evidence and non threatening. Holistic     robust. Not timely or well recorded.
                               based assessment tool, conduct in a        needs of service users could be
                               timely and non threatening manner.         improved. Some involvement with
                               Service users take an active part and      service users.
                               meaning part in the process
                               Evidence for all the requirements stated
                               for Regulation 18 of the Health and Social
                               Care Act 2008 (Regulated Activities)
   CQC complaince with Outcome
                               Regulations 2009. Systems in place to
54 2: Consent to care and                                                 Some evidence of compliance     Minimal evidence of compliance
                               gain and review consent for people who
   treatment
                               use the services and act on them.
                               Confident that their human rights are
                               respected.
                                  Information is available to all regarding
                                  appeal processes (in relation to CPA        An approach exists. Inforamation
55 Appeal process                 reviews, clinical assessments, service      available is fragmented and        Lack of available information
                                  decisions, including MHA and MCA.). If      needed further development
                                  appropriate, an advocate is available.
                                                                Outcomes
                                 The focus is upon recovery; progress and
                                 move on; skill maintenance; social       Used of outcome measures
                                                                                                                 Minimal or No evidence of being
56 Outcomes focus and monitoring inclusion and quality of life. Evidenced explored. Limited focus on
                                                                                                                 outcome focussed
                                 based outcome measures used              progress.
                                 effectively.
                                                                          An approach exists, but
   Education, Training and                                                                                       No system in place to support
57                               Users are supported appropriately to     fragmented. Needs further
   Employment                                                                                                    service users
                                 meet their education needs               development




                                                                     Page 18
                                     Users are supported and supervised
                                     appropriately to meet their daily living skill   An approach existes, but          No system in place to support
58 Daily living skills
                                     needs. Evidence of this approach is              fragmented.                       service users
                                     recorded in Care Plan.
                                     Users are supported appropriately to             An approach exists, but           No system in place to support
59 Religious and Cultural needs
                                     meet their religious and cultural needs          fragmented.                       service users
                                  Evidence for all the requirements stated
                                  for Regulation 14 of the Health and Social
                                  Care Act 2008 (Regulated Activities)
     Compliance to CQC Outcome 5: Regulations 2009. Choice of food and
60                                                                                    Some evidence of compliance       Minimal evidence of compliance
     Meeting nutritional needs    drink for people to meet their diverse
                                  needs, making sure that the food and
                                  drink they provide is nutritionally balanced
                                  and supports their health.
                                  Given attention in assessment and
                                  review. Users are supported
                                                                                      Some choice of food. Users are
                                  appropriately to meet their food and
                                                                                      supported appropriately to meet   No systems in place. Little choice
61   Food                         nutritional needs. Service users can
                                                                                      their nutritional needs. Need     of menu.
                                  access snacks and drinks 24 hours a
                                                                                      further development
                                  day. Have choice of food for two hot
                                  meals a day. Menu on display.
                                  Users are supported appropriately to
                                                                                      An approach exists, although
62   Social Interaction           meet their needs surrounding social                                                   No systems in place.
                                                                                      fragmented.
                                  intergration / inclusion.
                                  Users are supported appropriately to
                                  meet their need to have a healthier
     Healthy lifestyle and Health lifestyle. Evidence of intervention are             An approach exists, although
63                                                                                                                      No systems in place.
     Promotion                    recording in individual care plan.                  fragmented.
                                  Smoking cessation work carried in house
                                  or accessed through local PCT.
                                  Users are supported appropriately to
                                  meet their need to have a healthier                 An approach exists, although
64   Leisure activities                                                                                                 No systems in place.
                                  lifestyle. Evidence of intervention are             fragmented.
                                  recording in individual care plan.




                                                                           Page 19
THRESHOLD OF COMPLIANCE TO NHS NORTH LANCASHIRE QUALITY ASSURANCE FRAMEWORK


                                             Score rating (points per standard /
Self Assessment Rating                       measure)                            Green       Amber              Red
Fully compliant     Green                    CQC 16 core standards                       3                  2           0
Partially compliant Amber                    PCT 48 measures                             2                  1           0
Not compliant       Red




                                             Overall Achievement Score
                              CQC measures   PCT Assurance measures                                             Result
Fully compliant       Green   All            > = 120 (e.g.100% CQC + 75% Green PCT measures)                    Excellent
Partially compliant   Amber   All            > = 96 (e.g 100% CQC + 50% Green PCT measures)                     Fair
Not compliant         Red     Any Fail       < 96 ( Any failed CQC and or failure to achieve required PCT       Poor

				
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