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summary - Welcome to the Royal Cornwall Hospitals Trust website

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									Royal Cornwall Hospitals Trust Standards for Better Health (Core ) Summary Level Not Met Insufficient Assurance (term not used for 06/07 declaration) Compliant Core Standard C1 Healthcare organisations protect patients through systems that: identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and Director of Nursing national experience and information derived from the analysis of Sharon Terry incidents ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales Acting Director of Delivery Valerie Howell At Re-submission 7 12 25 Executive Lead 21` PGST 13 At Re Submission March position 23 Declaration 31

Some core standards do not appear on this form since they are assessed through other components of the Annual Health Check

Agreed March 07 position

Lead Executive /EMT agreement

Not met SS Insufficient assurance Compliant
currently compliant but due to significant lapse must declare not met

a)

b)

DA/CB

Compliant

Compliant

Compliant

C2

Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations

Medical Director Rob Pitcher

DA/CB

Not Met

Not met

Not met

C3

Healthcare organisations protect patients by following NICE Interventional Procedures guidance Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that:

Medical Director Rob Pitcher

DB

Insufficient assurance

Compliant

Not met

C4

a)

the risk of healthcare acquired infection to patients is reduced, with Director of Nursing particular emphasis on high standards of hygiene and cleanliness, Sharon Terry achieving year-on year reductions in MRSA all risks associated with the acquisition and use of medical devices are minimised Acting Director of Delivery Valerie Howell

SS

Not Met

Not met

Not met

b)

DA/CB

Compliant

Not met

Not met

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Core Standard all reusable medical devices are properly decontaminated prior to use C4c) and that the risks associated with decontamination facilities and processes are well managed

Executive Lead Acting Director of Delivery Valerie Howell Acting Director of Delivery Valerie Howell

PGST

At Re Submission Compliant

Agreed March 07 position Not met

Lead Executive /EMT agreement Not met

DA/CB

Not met AH/BB Insufficient assurance Compliant
currently compliant but due to significant lapse must declare not met

d)

medicines are handled safely and securely

e) C5 a)

the prevention, segregation, handling, transport and disposal of waste is Director of Planning properly managed so as to minimise the risks to the health and safety of Mike Coupe staff, patients, the public and the safety of the environment Healthcare organisations ensure that: they conform to NICE technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care clinical care and treatment are carried out under supervision and leadership clinicians continuously update skills and techniques relevant to their clinical work clinicians participate in regular clinical audit and reviews of clinical services. Medical Director Rob Pitcher

SAS/JM

Not Met

Not met

Not met

DB

Insufficient assurance

Not met

Not met Not met

b)

Medical Director Rob Pitcher Medical Director Rob Pitcher Medical Director Rob Pitcher

SS

Not Met

Compliant

currently compliant but due to significant lapse must declare not met

c)

SS

Insufficient assurance Insufficient assurance

Not met

Not met Not met

d)

SS

Compliant

currently compliant but due to significant lapse must declare not met

C6

Healthcare organisations co-operate with each other and social care organisations to ensure that patients' individual needs are properly managed and met. Governance Healthcare organisations:

Acting Director of Delivery Valerie Howell

Not met SAS/JM Not Met Compliant
currently compliant but due to significant lapse must declare not met

C7

a) & C) apply the principles of sound clinical and corporate governance actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources

Director of Nursing Sharon Terry Director of Finance Ethna McCarthy

AH/BB

Insufficient assurance Compliant

Not met

Not met

b)

SS

Compliant

Compliant

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Core Standard Clinical & Cost Effectiveness C7e) challenge discrimination, promote equality and respect human rights C8 Healthcare organisations support their staff through: having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required.

Executive Lead Interim Director of HR Angela Huxham

PGST

At Re Submission

March position

Exec/EMT sign off

AH/BB

Compliant

Not met

Not met

a)

Interim Director of HR Angela Huxham

AH/BB

Compliant

Compliant

Compliant

b)

Interim Director of HR Angela Huxham

AH/BB

Not Met

Not Met

Not Met

C9

Acting Director of Delivery Valerie Howell

Not met SAS/JM Insufficient assurance Compliant
currently compliant but due to significant lapse must declare not met

C10 Healthcare organisations: undertake all appropriate employment checks and ensure that all employed or contracted professionally qualified staff are registered with the appropriate bodies require that all employed professionals abide by relevant published codes of professional practice. Healthcare organisations ensure that staff concerned with all aspects of the provision of health care: are appropriately recruited, trained and qualified for the work they undertake Interim Director of HR Angela Huxham All Compliant Not Met Not Met Interim Director of HR Angela Huxham Acting Director of Delivery Valerie Howell

a)

AH/BB

Compliant

Not Met

Not Met

b)

All

Compliant

Compliant

Compliant

C11

a)

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Core Standard b) participate in mandatory training programmes participate in further professional and occupational development c) commensurate with their work throughout their working lives. Health care organisations which either lead or participate in research C12 have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied. Patient Focus C13 Healthcare organisations have systems in place to ensure that: a) staff treat patients, their relatives and carers with dignity and respect appropriate consent is obtained when required for all contacts with patients and for the use of any confidential patient information staff treat patient information confidentially, except where authorised by legislation to the contrary Healthcare organisations have systems in place to ensure that patients, their relatives and carers:

Executive Lead Acting Director of Delivery Valerie Howell Interim Director of HR Angela Huxham Medical Director Rob Pitcher

PGST

At Re Submission Not Met

Agreed March 07 position Not met

Lead Executive /EMT agreement Not met

BB

Not Met

Not met

Not met

AH/BB

Compliant

Compliant

Compliant

Director of Nursing Sharon Terry Medical Director Rob Pitcher Medical Director Rob Pitcher

SS

Compliant

Not Met

Not Met

b)

DA/CB

Compliant

Not Met

Not Met

c)

DA/CB

Compliant

Compliant

Compliant

C14

a)

have suitable and accessible information about, and clear access to, Director of Nursing procedures to register formal complaints and feedback on the quality of Sharon Terry services are not discriminated against when complaints are made Director of Nursing Sharon Terry

TA

Compliant

Compliant

Compliant

b)

TA

Compliant

Compliant

Compliant

c)

are assured that organisations act appropriately on any concerns and, Director of Nursing where appropriate, make changes to ensure improvements in service Sharon Terry delivery Where food is provided, health care organisations have systems in place to ensure that: patients are provided with a choice and that it is prepared safely and Director of Planning provides a balanced diet Mike Coupe

TA

Compliant

Compliant

Compliant

C15 a)

SS

Compliant

Compliant

Compliant

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Core Standard

Executive Lead

PGST

At Re Submission Insufficient assurance

Agreed March 07 position Not Met

Lead Executive /EMT agreement Not Met

b)

patients' individual nutritional, personal and clinical dietary requirements Director of Nursing are met, including any necessary help with feeding and access to food Sharon Terry 24 hours a day.

AH/BB

Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible Director of Nursing C16 information on the care and treatment they receive and, where Sharon Terry appropriate, inform patients on what to expect during treatment, care and after care. Accessible and Responsive Care The views of patients, their carers and others are sought and taken into Director of Planning C17 account in designing, planning, delivering and improving health care Mike Coupe services.

DB

Compliant

Compliant

Compliant

DA/CB

Compliant

Compliant

Compliant

Healthcare organisations enable all members of the population to C18 access services equally and offer choice in access to services and treatment equitably Care Environment and Amenities C20 Healthcare services are provided in environments which promote effective care and optimise health outcomes by being:

Acting Director of Delivery Valerie Howell

All

Compliant

Not Met

Not Met

a)

a safe and secure environment which protects patients, staff, visitors Director of Planning and their property, and the physical assets of the organisation Mike Coupe supportive of patient privacy and confidentiality Director of Nursing Sharon Terry

SS

Insufficient assurance Compliant

Not Met

Not Met

b)

SS

Not Met

Not Met

Healthcare services are provided in environments which promote effective care and optimise health outcomes by being well Director of Planning C21 designed and well maintained with cleanliness levels in clinical and Mike Coupe non-clinical areas that meet the national specification for clean NHS premises.

SS

Compliant

Not Met

Not Met

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Core Standard Public Health Healthcare organisations promote, protect and demonstrably C22 improve the health of the community served, and narrow health inequalities by: co-operating with each other and with local authorities and other organisations making an appropriate and effective contribution to local a) & c) partnership arrangements including local strategic partnerships and crime and disorder reduction partnerships. b) ensuring that the local Director of Public Health's Annual report informs their policies and practices

Executive Lead

PGST

At Re Submission

Agreed March 07 position

Lead Executive /EMT agreement

Acting Director of Delivery Valerie Howell Medical Director Rob Pitcher

SAS/JM

Compliant

Not Met

Not Met

DA/CB

Compliant

Compliant

Compliant

Healthcare organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the National Service Frameworks and national C23 plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections.

Not met Medical Director Rob Pitcher DA/CB Insufficient assurance Compliant
currently compliant but due to significant lapse must declare not met

Healthcare organisations protect the public by having a planned, prepared and, where possible, practiced response to incidents and Director of Nursing C24 Sharon Terry emergency situations which could affect the provision of normal services.

SS

Insufficient assurance

Not Met

Not Met

Excludes, as measured separately, C7d Financial management is assessed through our use of resouces component C7f Existing performance requirements & C19 Access - emergency care are both picked up through our assessment of exisitng targets

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