THE CLINICAL GOVERNANCE PERFORMANCE FRAMEWORK HEALTH STANDARDS DELIVERY PLAN The

THE CLINICAL GOVERNANCE PERFORMANCE FRAMEWORK 2005/06 - HEALTH STANDARDS DELIVERY PLAN The guidance requiring organisations to produce a clinical governance development plan, outturn reports and an annual report is still in place but these need to be consistent with “ Assessment for Improvement The Annual Health Check – Measuring what matters” and Creating a Patient –led NHS. Therefore the SHA Clinical Governance Performance Framework has been adjusted to take account of the policy changes, reflect the key priority of compliance with the core standards and enable the SHA to provide informed comment in support of Trust and PCT declarations of compliance. To facilitate the process electronic proforma have been created. The framework consists of 4 elements An outline plan of the strategic clinical governance objectives and corporate arrangements to achieve compliance and board assurance. A . . . . self-assessment against the Standards for Better Health Core Standards. The submission date is 30th June 2005. A Delivery Plan for the Standards for Better Health and Clinical Governance based on the self-assessment. The submission date is 30 August 2005. An out turn report on progress submitted by January 31st 2006 A review visit between September 2005 and February 2006 Part 1 – The Strategic Clinical Governance Objectives, Corporate Arrangements and Self-Assessment The Objectives and self-assessment need to be signed off and approved by the NHS Trust/PCT Board. However given the timescales draft self assessments will be accepted by 30 June 2005 and the final copies forwarded once they have been ratified by the PCT or Trust Board. In the Clinical Governance Strategic Objectives and Corporate Arrangements Section • Outline the organisation’s response to the introduction of the Standards for Better Health and include the organisational arrangements in place, any changes or Board development needs, and the systems and processes in place or required in the organisation to ensure it is fit for purpose in ensuring the Board is able to complete an informed declaration of assurance to the Healthcare Commission. • Identify key strategic objectives, actions and expected outcomes. These can include any additional objectives such as Healthcare Commission action plans for example. We anticipate that there will be no more than five key objectives. Use the SHA Template/Spreadsheet for the self-assessment to identify the anticipated position for October 2005 (Interim declaration) and April 2006 (Declaration) against the standards using the following traffic light criteria. Red: The information received by the Board made it clear that there have been significant lapses in meeting the core standards Amber: There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards Green: The Board has reasonable assurance that there have been no significant lapses in meeting the Core Standards A brief narrative should be provided indicating the risks/nature of the lapse. CLINICAL GOVERNANCE STRATEGIC OBJECTIVES AND CORPORATE ARRANGEMENTS 2005/06 North Cumbria Acute Hospitals NHS Trust Clinical Governance Strategic Objectives and Corporate Arrangements This return addresses the Trust's approach to addressing the entirety of the Healthcare Commissions Core Standards. The attached documents show: I) The Trust's key principles, strategic objectives and key annual objectives for 2005/06 ii) The Trust's new proposed Governance and management structure. All these documents are in draft form and as yet have not been formally ratified within the organisation. GLOSSARY CNST NPSA MHRA RIDDOR HSE RPST SABs PEAT MRSA 1 2 3 4 5 Clinical Negligence Scheme for Trusts National Patient Safety Agency Medicines and Healthcare Products Regulatory Agency Reporting of Injuries, Disease and Dangerous Occurences Regulation Health and Safety Executive Risk Pooling Scheme for Trusts Safety Action Bulletins Patient Environment Action Team Methicillin Resistant Staphylococcus Aureus Corporate Objectives Actions Date Accountability Outcome STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 1. SAFETY Anticipated Position / Risk Area Core Standards October 2005 CNST level 1, reporting to NPSA, reporting to MHRA, reporting RIDDOR to HSE, root cause analysis awareness, Maternity CNST, RPST, evidence of changes due to complaints & incidents, Risk Management policies, zero tolerance & harrasment policy SABs etc reported to Board via Assurance report but not all SABs have been closed in an acceptable timescale. Child protection audit reported to Board, policy on recruitment includes CRB checks (to be presented at September Board), + 2004/5 Clinical Governance Development Plan feedback. Issues specific to Children's Act, Section 11 (2004) to be addressed. Monitored by Clinical Effectiveness Facilitator. CNST level 1 & maternity CNST. Monitoring report of receipt and implementation in Assurance report. Evidence required to ascertain that all applicable IPGs have been implemented. PEAT, Infection Control Reports, MRSA rates, Clean Hospital Standards Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C1 a Green C1 b Red C2 Green C3 C4 a Red Green STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 1. SAFETY Anticipated Position / Risk Area Core Standards October 2005 Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C4 b Policies in place for procurement and acquisition of medical devices. CNST level 1 review including training, monitoring of Infection Control standards, action plan for year on year reductions in MRSA. Register to be managed and training plan to be developed. Amber Policies in place on decontaminating equipment. Monitoring of implementation required. Amber CNST level 1, policy on storage, supply and administration of medicines. Drug errors recorded via Risk Management systems and processes. D&T Committee minutes. Medicines Management Group. Green PEAT. Waste Management policy. Annual report required. Amber C4 c C4 d C4 e Self Assessment Criteria Red Amber Green The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 2. Clinical and Cost Effectiveness Anticipated Position / Risk Area Core Standards October 2005 Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C5 a Insufficient information available as yet. Audits of NICE implementation undertaken. CNST level 1. Performance monitoring of Day Case procedures. Annual report required. Red Leadership programme and structures reported to Board. Nursing and Midwifery staff, medical staff and associate medical staff have undergone Leadership Development Programmes. Preceptorship programme available for nursing and midwifery staff. CNST level 1. Training & Development programme available. Annual report required for Trust Board to verify training undertaken. Programme of audit & research undertaken and included on website on intranet. Evidence of audit: NSFs. Framework for Research Governance. Annual reports required to verify to Board. Discharge policies and procedures in place. Development of single assessment in progress. Corporate objectives 2005/06 include pathway development. C5 b Amber C5 c Amber C5 d Amber C6 Amber Self Assessment Criteria STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 2. Clinical and Cost Effectiveness Anticipated Position / Risk Area Core Standards October 2005 Red Amber Green Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 3. Governance Anticipated Position / Risk Area Core Standards October 2005 C7a CNST level 1/RPST, structures, Assurance framework, IWL, Audit Reports Whistle blowing and raising concerns policy. Need to verify managers are aware of code of conduct and follow its principles. Report on compliance with Controls Assurance to Trust Board Monthly financial reports to Trust Board. Audit Committee Management letter. Equality scheme, diversity training. Performance Report. Meet existing targets. Processes in place. Policies to Board. IWL - practice Plus Assessment December 2005, staff survey, no evidence of discrimination. Training & Development plan to Board, applicable to all staff. Meet CNST level 1. Policies/procedures on creating & disposing of Medical Records. Action plan for Information governance - self assessment amber Evidence on employment checks being undertaken. Revised Recruitment policy to Board in September 2005. Policy on protecting vulnerable adults presented. Self Assessment Green Anticipated Position / Risk Area March 2006 Self Assessment C7 b C7 c C7 d C7 e C7 f C8 a Amber Green Green Amber Green Green C8 b Amber C9 Amber C10 a Green C10 b C11 a C11 b C11 c C12 Included in revised Recruitment policy and job descriptions. Policy on Disciplinary procedure. CNST, verification of registration, policy on professional registration includes action when registration has lapsed. Revised recruitment policy includes checking registration. Induction available, IWL, Training & Education programme. Mandatory training on H&S is provided but there is poor attendance. Action being taken to address this Trust-wide. Induction training provided for ALL new employees. Staff accessing clinical skills training to be included in annual report. Research Governance framework implemented. Projects on website. Green Green Red Amber Green Self Assessment Criteria Red Amber Green The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 4. Patient Focus Anticipated Position / Risk Area Core Standards October 2005 Essence of Care, evidence of action taken to maintain privacy in wards in feedback 2003/04. Inpatient & outpatient surveys. Young person survey - results to be presented. Complaints reviews and action. PEAT. Audit to review compliance on scope of Human Rights Act etc to be undertaken. Policy and CNST level 1. Cumbria Deaf Association & interpreters available. Patient information to CNST standards. Information on disclosure & use of information for patients available. Policy on confidentiality. Systems in place should staff disclose information. Comprehensively addressed within training. Appropriate policies and procedures in place. Information on complaints procedure and PALS available. Opportunities for feedback - see PCPI report. System in place in that medical records and complaints files are stored separately. No reports of complaints of discrimination. Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C13 a Amber C13 b Green C13 c Green C14 a Green C14 b Amber C14 c Meet standards. Feedback/changes see PCPI reports, however this will be improved 2005/06. Green STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 4. Patient Focus Anticipated Position / Risk Area Core Standards October 2005 Better Hospital Food not fully implemented. Varied menu for preferences and choices. Food for different faiths & cultures is available. Food hygiene courses available - need attendance monitored. Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C15 a Amber C15 b C16 Access to 24hr snacks and drinks available. Individual nutritional assessments undertaken & care planned to improve nutritional status. Complaints on catering reviewed and action taken. Catering surveys with action plans undertaken - positive outcomes. Green Available but requires review and improvement. Patient information available and process to review information in place to ensure it conforms to Trust, CNST & Toolkit for producing information. Interpreters and Cumbria Deaf Association sign language interpreters available. Inpatient booklets currently being recorded on to tape. Range of leaflets to be extended. Amber Self Assessment Criteria Red The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 4. Patient Focus Anticipated Position / Risk Area Core Standards October 2005 Amber Green Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 5. Accessible and Responsive Care Anticipated Position / Risk Area Core Standards October 2005 Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C17 C18 C19 See PCPI annual report. PCPI strategy and action plan. Objectives of Governance Plan 2005/06. Involvement in strategic options: Healthcare in North Cumbria Green No data/information available. Choice currently being developed. DDA reviewed and report on part 3 requirements available. Locally, multiracial population limited. Red NHS targets met - monthly performance report. Green Self Assessment Criteria Red Amber Green The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 6. Care Environment and Amenities Anticipated Position / Risk Area Core Standards October 2005 Reports for PEAT, IWL and RIDDOR data are submitted. ERIC reporting to be formalised. More verifying data required to cover all standard elements. Information on current position rquired. Estates strategy underway. Work at West Cumberland Hospital underway, linked to outcome of strategic options. Capital programme includes refurbisment etc. PEAT reports. Monitoring of cleaning standards. Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment C20 a C20 b Amber Amber C21 Amber Self Assessment Criteria Red Amber Green The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 7. Public Health Anticipated Position / Risk Area Core Standards October 2005 C22 a C22 b Evidence of working with agencies via Partnership Board. A more systematic approach required for Trust Board. Self Assessment Amber Anticipated Position / Risk Area March 2006 Self Assessment C22 c Currently no policies applicable to this standard. Red Other than with health and social services partnerships with other agencies to be established eg crime and disorder. Red Data available on current and future health & healthcare needs of the local population via Public Health. Requirements of NSFS to be reviewed and reported upon. The Trust liaises with the Health Protection Agency and Public Health on Infection Control. The Trust has been involved in working groups on Obesity, Stopping Smoking, Substance Abuse and STD strategies. Has identified lead. Amber Major incident plans at WCH & CIC but CIC needs review to be completed. Liaises with key partners, organisations etc, including the Emergency Planning Team. Green C23 C24 Self Assessment Criteria Red The information received by the Board made it clear that there have been significant lapses in meeting the Core Standards STANDARDS FOR BETTER HEALTH - SELF ASSESSMENT 2005/06 North Cumbria Acute Hospitals NHS Trust 7. Public Health Anticipated Position / Risk Area Core Standards October 2005 Amber Green Self Assessment Anticipated Position / Risk Area March 2006 Self Assessment There is insufficient information/assurance leaving the Board unclear as to whether there has been significant lapses in meeting the Core Standards The Board has reasonable assurance that there has been no significant lapses in meeting the Core Standards