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Mersey Care NHS Trust Standards for Better Health Declaration

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Mersey Care NHS Trust Standards for Better Health Declaration Powered By Docstoc
					Mersey Internal Audit Agency
                                                                                   n
                                                               MIAA Audit and Assurance
        Regatta Place
   Brunswick Business Park
       Summers Road
           Liverpool
      Tel: 0151 285 4500
      Fax 0151 285 4501




         1829 Building
                                           Mersey Care NHS Trust
Countess of Chester Health Park
        Liverpool Road
            Chester
      Tel: 01244 364473
      Fax: 01244 364471
                                  Standards for Better Health Declaration
                                              Opinion - Final
     HM Stanley Hospital
     Upper Denbigh Road
           St Asaph
        North Wales
      Tel: 01745 589735
                                                     2009-10
      Fax 01745 589796
                                      Report No. 401MERC_0910_002 - Draft Report


           Room 59
           1st Floor,                       Private and Confidential
      Summerfield House
     544 Eccles New Road
            Salford
      Tel: 0161 2061909




      WEB SITE
    WWW.MIAA.CO.UK
 401MERC_0910_002
 Mersey Care NHS Trust
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                                                                                                                                     MIAA Audit and Assurance

                                                                                       The Trust achieved a ‘good’ and ‘excellent’ rating for 2008-09 and are to
1.     Introduction                                                                    declare full compliance against the core standards.
The Standards for Better Health are a key aspect of the Annual Health Check and        The Trust was selected by the Healthcare Commission for a random
include core standards, which are “the basic standards of care which the Department    inspection in October 2009.
of Health says all healthcare organisations should be meeting at the moment” and       In April 2010, the Government will introduce some new regulations, which will
developmental (or improvement) standards.                                              bring the registration of the NHS, independent healthcare and adult social
The Care Quality Commission (CQC) confirmed in August that it will require all NHS     care into one system. These regulations will cover other areas of practice.
Trusts to carry out a self-assessment against Standards for Better Health in           The CQC will continue to take forward the development of registration
November 2009. The assessment will cover the period April - October 2009. Trusts       requirements during 2009-10. The CQC has indicated that the 2010
are required to comply with the core standards for the entire assessment year.         registration process will open January 2010 and close in February 2010. To
The CQC has amended the core standards in light of the 2009-10 registration            further assist NHS providers, the CQC intends to publish a guide to the links
requirements which are based on the compliance with the hygiene code.                  between registration requirements and Standards for Better Health.
For 2009-10, the CQC has retained the core processes of the Annual Health Check               Review Completed      Cath McKenna - Audit Manager
as previously applied in 2008-09 including an assessment of each organisation                 by:
against the national targets and priorities relevant to their healthcare sector. The                                Gary Baines - Audit Manager
2009-10 CQC assessment will inform the Comprehensive Area Assessment.                                               Tim Crowley - Director

                                                                                              Distributed to :      Neil Smith - Executive Director of Finance and
                                                                                                                    Performance
                                                                                                                    Andrea Chadwick - Deputy Director of Finance
                                                                                                                    Dave Fearnley - Medical Director
                                                                                                                    Anne Cleminson - Trust Secretary
                                                                                                                    Linda Chadburn - Governance Manager
                                                                                                                    Sarah Jennings - Compliance Analyst




Source: The annual health check 2008/2009 – Assessing and rating the NHS (Healthcare
Commission, June 2008)




 Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                            Page 1
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2.       Scope and Objectives
This review focuses on the systems and processes in respect of the organisation’s self assessment for core standards.
The overall objective of the review was to ensure that the Trust has utilised robust systems and processes to underpin its conclusions regarding the Standards for Better
Health self assessment declaration (2009-10).


3.       Overall Assessment
Levels of assurance are provided in respect of each individual Internal Audit review conducted. The levels of assurance, as defined below, have been applied against the
specific review objectives and should therefore be considered in this context.


    Level of                                                                                Description
   assurance
  High           Our work found some low impact control weaknesses which, if addressed would improve overall control. However, these weaknesses do not affect key controls and are
                 unlikely to impair the achievement of the objectives of the system. Therefore we can conclude that the key controls have been adequately designed and are operating
                 effectively to deliver the objectives of the system, function or process.
  Significant    There are some weaknesses in the design and/or operation of controls which could impair the achievement of the objectives of the system, function or process.
                 However, either their impact would be minimal or they would be unlikely to occur.
  Limited        There are weaknesses in the design and / or operation of controls which could have a significant impact on the achievement of the key system, function or process
                 objectives but should not have a significant impact on the achievement of organisational objectives.
  No             There are weaknesses in the design and/or operation of controls which [in aggregate] have a significant impact on the achievement of key system, function or process
                 objectives and may put at risk the achievement of organisational objectives.

The level of assurance at the time of this review is high, that there is a sound system of control designed to meet the review objectives. The Trust has identified key roles
and responsibilities and these are documented on the accountability framework. The Board and Clinical Governance Committee approved the process for the declaration.
The review found that the core standards were mapped to the Trust Assurance Framework. Testing of a sample of core standards identified that evidence was available as
stated to support the Trust declaration position. The declaration has been reviewed by the Clinical Governance Committee before being submitted to the Trust Board.
Note: This opinion is based on the process and not the level of compliance against standards.
         Detailed findings are provided in:
         Appendix A – Assessment of Self Assessment Declaration 2009-10.




 Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                              Page 1
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4.       Ongoing Developments
In order to further develop the systems and processes to support the declaration, the Trust needs to continue to progress and embed the following actions:
     To ensure that the Trust Board, Clinical Governance Committee and key leads receive the relevant training on the new standards and regime.
     Through completing a review of evidence available to support compliance, some gaps in evidence have been identified and these should be considered by the Trust and the evidence
     matrix updated accordingly.
     The evidence matrix includes a column for ‘Board Assurance’ although this column is not currently being utilised to specifically identify the assurance mechanisms, around compliance to
     the Board, i.e. commentary centred on information which has been submitted to the Board, i.e. policies for ratification rather than assurances being provided. The Assurance column
     should identify assurance mechanisms in place to ensure compliance with the standard.
     To ensure that the Clinical Governance Committee continually receive updates on SfBH and assess evidence available to support standards at each meeting.
     The Trust has an evidence matrix, which is maintained by the Compliance Analyst to identify evidence in place to support compliance against each standard. The Trust is looking to
     implement an electronic system, SharePoint, to collate evidence, this would mean that resources currently deployed in administratively supporting data entry can be targeted more on
     data quality and providing support to lead officers on interpretation of guidance. This system should be progressed.
     The Trust is to put in place a strategy to reflect quality standards and CQC requirements.




 Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                                    Page 2
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Appendix A - Assessment of Self Assessment Declaration (2009-10)
                                                                                                                                                                       Overall Opinion
                                                                      Key Components
                                                                                                                                                                       Agree Disagree
1. Roles and responsibilities are clearly defined

        The Medical Director / Assistant Chief Executive has Lead Executive responsibility, supported by the Head of Service Governance & Risk/Trust Secretary, the
        Governance Manager, the Compliance Analyst and the Service Governance Support Team.
        The Clinical Governance Committee is responsible for reviewing and monitoring the Trust’s compliance with the core standards. The Trust Board has as part
        wider reviews of ratified the revised terms of reference for the committee in February 2009. The terms of reference states that the committee are to ensure
        organisational and CBU level compliance in relation to SfBH.
        The Trust has assigned Executive Leads as ‘Accountable Director’ for each of the standards. This has been set out in the Accountability Framework.
        CBUs are responsible for compliance against specific core standards identified in their Integrated Governance Framework.

2. Awareness raising has been undertaken with key groups

        Updates to the Trust Board have been provided through Clinical Governance Committee papers and briefings, support to Executive Leads and Directorates /
        Clinical Business Units by the Governance Support Team. It was highlighted by the Trust secretary that updates around the new standards and regime will be
        provided to the Trust Board as required.
  Board/ Group            Date (s)                    Briefing subject area                          Completed by                             Attendees
Non Executives        Ongoing           Non Executive Resource Pack – part of induction      Trust Secretary                       Non Executives
                                        for new Chairman and Non Executive.       This
                                        includes a section on performance framework,
                                        including SfBH.
Trust Board           Ongoing           •    Receives minutes of Clinical Governance         Clinical Governance Committee         Trust Board Members
                                             Committee                                       Chair
                                        • Integrated Corporate Performance Reporting
                                             gives an overall evaluation on compliance
                                             against the core standards as part of the
                                             reporting against the CQC indicators.
Clinical Governance   11 Aug 2009       Paper outlining proposed approach on Standards       Trust Secretary                       Clinical Governance Committee
Committee                               for Better Health – Annual Declaration for 2009/10                                         members
                                        (paper approved).       This highlighted the new
                                        registration standards being introduced and the
                                        process to be undertaken for the declaration.




Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                        Appendix A.1
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                                                                                                                                                                           Overall Opinion
                                                                        Key Components
                                                                                                                                                                           Agree Disagree
Clinical Governance   Ongoing            Through the SfBH reporting framework and work         N/A                                 Clinical Governance Committee
Committee                                programme of the CGC:                                                                     members.
                                         • Focused review by domain and supporting
                                              evidence (last submission April 2009);
                                         • Consideration of the Assurance Framework;
                                         • Evaluation of variance reports received;
Directorates          Various            Establishment      of    Integrated     Governance
                                                                                               Governance Manager
                      throughout the     Frameworks – this has sought to make the
                      year               linkages with Clinical Business Units to core
                                         standards with framework showing lead officers,
                                         how the CBU meets the standard and relevant
                                         indicators.
Executive Team        Monthly            Consideration of key risks to organisation also                                           Executive Team
                                                                                               Assigned Executive Leads
                                         considers the position against the core standards.
                                                                                               ‘Accountable Directors’

Further Action: To ensure that the Trust Board, Clinical Governance Committee and key leads receive the relevant training on the new standards and regime.

3. Standards have been mapped to the organisation’s objectives

Core standards have been mapped to the organisation’s objectives through the assurance framework.
Additionally at a CBU level the standards relevant to CBUs are mapped to the organisations objectives through the Integrated Governance Frameworks.

4. Sound processes underpin the completion of the assessment and production of the declaration
4.1 Process
        A paper outlining the process for the declaration was approved by the Clinical Governance Committee in August 2009.
        The statement on compliance was submitted to the Clinical Governance Committee in October 2009, prior to this members of the committee were able to
        review the evidence portfolios in place. The outcome of this was reported to the Board through the minutes of the committee.
        The core standard evidence was collated by the Compliance analyst and is being reviewed by the associated Executive Lead, as identified on the accountability
        framework and a statement of compliance is to be produced against each standard.
        The draft declaration will be submitted to the Board in December 2009. It is proposed that the declaration will be signed by all Board members at this meeting.
        The Board has also received a summary of the Trust position for compliance as part of the Performance Report.
        As with previous years the Trust is proposing to make the declaration public through the December Board meeting and publication on the Trust website by the
        communicated deadline.



Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                            Appendix A.2
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                                                                                                                                                                            Overall Opinion
                                                                       Key Components
                                                                                                                                                                            Agree Disagree
4.2 Constructive Challenge
        MIAA undertook constructive challenge of 2 standards. This involved assessing the robustness of the Trusts evidence matrix for each standard, identifying the
        assurances and evidence as documented and requesting/reviewing this evidence. Generally robust systems were in place and evidence was available to
        support the position. However some action / gaps were identified to further support the Trust position – this has been detailed below. The Trust has
        arrangements for the monitoring / reporting of actions in support of the Standards Declaration processes through the Clinical Governance Committee.
Further Action: Where gaps in evidence have been identified these should be included in the evidence matrix.
The evidence matrix includes a column for ‘Board Assurance’ although this column is not currently being utilised to specifically identify the assurance mechanisms,
around compliance to the Board, i.e. commentary centred on information which has been submitted to the Board, i.e. policies for ratification rather than assurances
being provided. The Assurance column should identify assurance mechanisms in place to ensure compliance with the standard.
        Standard            Declaration    Assurance Mechanism                                Evidence Provided                                       Comments
 C1b - Healthcare           Compliant      • Health & Safety          • H&S Committee minutes January 09 (no update noted), March 08            • To include H&S
 organisations protect                     Committee (sub             (system changes) and June 09 (Policy updates required),                   Committee terms of
 patients through                          committee of the Board)    • Risk Management Policy Strategy – no specific reference to              reference.
 systems that ensure                       - SABs issues              SABs but the document includes areas such as roles and                    • To include all TNA by
 that patient safety                       considered.                responsibilities for risk and training requirements.                      staff groups.
 notices, alerts and                       • Monitored through the    • Minutes of Trust Board (13 November 07) where Risk                      • To include training
 other communications                      Clinical Governance        Management Policy Strategy was submitted.                                 materials to support
 concerning patient                        Committee.                                                                                           training around alerts.
                                                                      • Health & safety Policy – this includes a section on ‘central alerting
 safety which require
                                                                      system guidance and responsibilities’.                                    • To include Assurance
 action are acted upon
                                                                      • Health & Safety Manager Job description – ‘to ensure Trust –            Framework.
 within required time-
 scales.                                                              wide systems are in place for the management of SABs’.                    • To include
                                                                      • Policy for Management of Medical Devices – details                      Safeguarding Annual
                                                                      responsibilities of the MHRA Liaison Officer and Health & Safety          Report, submitted to
 Element one                                                                                                                                    April 2009 Trust Board.
                                                                      Manager around disseminations of publications.
 All relevant
                                                                      • Board minutes (12 February 2008) where Policy for Management            • To include more up to
 communications
                                                                      of Medical Devices was approved.                                          date minutes as
 requiring action
                                                                      • Minutes of CGC were Trust’s policy and procedure for induction          evidence, i.e. H&S
 concerning patient
                                                                      of staff was approved.                                                    Committee minutes.
 safety issued on behalf
 of the Medicines and                                                 • Health & safety workplan which includes reviewing systems               • To consider whether
                                                                      regarding the management of safety alerts.                                Board receives further
 Healthcare products
                                                                                                                                                assurances, i.e. through
 Regulatory Agency                                                    • Example of Safety Partnership Agreement which is in each
                                                                                                                                                H&S Annual Report or
 (MHRA), the National                                                 service. This includes a section on DoH alerts management.
                                                                                                                                                Assurance Framework.
 Patient Safety Agency                                                • Example of alert being received by the Trust,
 (NPSA), and the                                                      • Example report on compliance by relevant service, includes detail
 Department of Health



Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                             Appendix A.3
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                                                                                                                                                   MIAA Audit and Assurance

                                                                                                                                                                    Overall Opinion
                                                                 Key Components
                                                                                                                                                                    Agree Disagree
(DH) via national                                                on SAB, aim, objectives, findings, risk assessment and action plan.
distribution systems,                                            • Example report on the working group on implementation of the
including the Central                                            alert and corresponding audit of compliance.
Alert System (CAS),                                              • Example e-mails from H&S Officer chasing actions from alerts not
are implemented within                                           actioned.
the required timescales.
                                                                 • Training needs analysis – completed by staff group, identifies
                                                                 training around child protection. (These are being updated to reflect
                                                                 CBUs).
                                                                 • Update on MIAA review on SABs - Trust Health & Safety
                                                                 Committee agenda Nov 09
                                                                 • Induction Policy – outlines requirement for staff to attend
                                                                 induction training.
                                                                 • Example report from SABs database – details alert title, origin,
                                                                 issue date, status, response and deadline.
C11b – Healthcare          Compliant   • Monitored through the   • Risk management Policy & Strategy – outlines risk management          • To include Mandatory
organisations ensure                   Clinical Governance       training requirements.                                                  Training Policy and the
that staff concerned                   Committee.                • Supporting minutes of Risk management policy & Procedure              supporting minutes of
with all aspects of the                                          being submitted to the Board.                                           approval.
provision of healthcare                                          • Training Needs Analysis by staff group – mandatory training           • Where possible more
participate in                                                   programme is included.                                                  up to date examples
mandatory training                                                                                                                       should be included as
programmes.                                                      • Supporting agenda of CGC for approval of Trust induction policy.
                                                                                                                                         evidence, i.e. e-mails
Element 1                                                        • Link to Learning Zone on Trust internet in relation to ‘Corporate
                                                                                                                                         prompting staff of
                                                                 Essential Mandatory Learning’, this details the programme content
Staff participate in                                                                                                                     mandatory training
                                                                 of training which includes a section on risk management. It is also
relevant mandatory                                                                                                                       occurrences.
                                                                 stated that all staff should have mandatory training.
training programmes as                                                                                                                   • Report to CGC should
defined by the relevant                                          • PDP template document - used to identify training need.
                                                                                                                                         be identified as an
sector-specific NHSLA                                            • Policy and Procedure for induction of staff,                          assurance mechanism.
Risk Management                                                  • Link to Learning Zone on Trust internet, sets out aim and
Standards.                                                       programme content of corporate induction, which includes
                                                                 handouts.
                                                                 • Report to CGC on Mandatory training – provision and attendance
                                                                 (13 Oct 2009, bi-annual report).
                                                                 • HR Policy for Learning & development, identifies that Mandatory
                                                                 training requirements must be met before other training is offered.
                                                                 • Minutes of Trust Board ratifying the HR Policy for Learning &
                                                                 development (7 March 2007).



Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                     Appendix A.4
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                                                                                                                                                      MIAA Audit and Assurance

                                                                                                                                                                       Overall Opinion
                                                                   Key Components
                                                                                                                                                                       Agree Disagree
                                                                   • Dates for Corporate Essential Learning June to December 2009.
                                                                   • Communication briefing sent to all staff, highlighting that online
                                                                   mandatory training modules are available (30/03/09).
                                                                   • Example of e-mail sent out with details of the mandatory training
                                                                   occurring (March 2009).
Element 2                    Compliant   • Monitored through the   • Timetable of Corporate Induction dates.                               • Include induction
Staff and students                       Clinical Governance       • HR Policy for the Induction of newly employed staff, dated            materials.
participate in relevant                  Committee.                October 2009, includes a section on the Induction process and           • Where possible more
induction programmes.                                              includes an induction checklist.                                        up to date examples
                                                                   • Link to Trust Internet with details of High Secure, 2 day essential   should be included as
                                                                   induction.                                                              evidence, i.e. record of
                                                                   • Example of e-mail sent out with details of the mandatory training     corporate induction
                                                                   occurring (March 2009).                                                 attendance.
                                                                   • Record of corporate induction attendance (March 2009).                • Examples of HR
                                                                                                                                           department chasing on
                                                                   • Supporting agenda of CGC for approval of Trust induction policy.
                                                                                                                                           non returns of induction
                                                                   • Link to Trust internet, employee service section, section on          checklist.
                                                                   recruitment and includes the induction checklist.
Element 3                    Compliant   • Monitored through the   • HR Policy for the induction of newly employed staff, dated            • Include induction
The healthcare                           Clinical Governance       October 2009, includes a section monitoring arrangements.               materials.
organisation verifies                    Committee.                • Supporting agenda of CGC for approval of Trust induction policy.
that staff participate in                                          • Minutes of Trust Board ratifying the HR Policy for Learning &
those mandatory                                                    Development (7 March 2007).
training programmes
                                                                   • Record of corporate induction attendance (March 2009).
necessary to ensure
probity, clinical quality                                          • Report to CGC on mandatory training – provision and attendance
and patient safety                                                 (13 Oct 2009, bi-annual report).
(including that referred                                           • Example of e-mail sent out with details of the mandatory training
to in element one).                                                occurring (March 2009).
Where the healthcare                                               • Policy and procedure for the development and training of staff,
organisation identifies                                            due for review March 2010, outlines managers responsibilities in
non-attendance,                                                    ensuring staff attendance.
action is taken to rectify                                         • Non attendance form template which is sent to managers
this.




Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                        Appendix A.5
401MERC_0910_002
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                                                                                                                                                           MIAA Audit and Assurance

                                                                                                                                                                            Overall Opinion
                                                                          Key Components
                                                                                                                                                                            Agree Disagree
5. There is a sound approach to identify the Board’s assurance, including utilisation of existing assurance mechanisms

         The core standard evidence was collated by the Compliance analyst and is being reviewed by the associated Executive Lead, as identified on the accountability
         framework and a statement of compliance is to be produced against each standard, this is to be reviewed by the Chair of the Clinical Governance Committee
         before the declaration is submitted to the Board.
         The draft declaration will be submitted to the Board in December 2009. It is proposed that the declaration will be signed by all Board members at this meeting.
         The Clinical Governance Committee considers a range of external and internal assurances through out the year such as Clinical Audit outcomes, Patients
         Survey etc. The committee is composed of staff from a range of services including support services within the Trust and has both Executive and Non Executive
         representation. This has enabled the Clinical Governance Committee to challenge position against the standards against a range of sources.
         The Corporate Performance Report received by the Trust Board at each meeting includes a summary of position against each standard.
        Additionally SfBH core standards are mapped through the objectives in the Integrated Governance Framework of CBUs.
Further Action: To ensure that the Clinical Governance Committee continually receive updates and assess evidence available to support standards at each meeting.
The Trust has an evidence matrix, which is maintained by the Compliance Analyst to identify evidence in place to support compliance against each standard. The Trust
is looking to implement an electronic system, SharePoint, to collate evidence, this would mean that resources currently deployed in administratively supporting data
entry can be targeted more on data quality and providing support to lead officers on interpretation of guidance. This system should be progressed.
The Trust is to put in place a strategy to reflect quality standards and CQC requirements.




Internal Audit Report 2009-10 – SfBH Declaration Opinion 09-10                                                                                                             Appendix A.6

				
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Description: Mersey Care NHS Trust Standards for Better Health Declaration