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					                                                                                          Standards for Better Health 07/08                                                                                    Appendix B

Core standards - Assessment of compliance 07/08      key: The 9 shaded standards compliant at year area
How we should consider the elements?
Trust board should consider the level of compliance required by each of the elements when considering the extent to which they meet a core standard. They
should consider whether they are compliant with a standard by assessing whether they have reasonable assurance that they have been meeting it, without
significant lapse for the whole year.
Reasonable assurance
Reasonable assurance must be based on documentary evidence that can stand up to internal and external challenge.
Domain Core Standard             Element                      Lead   Assessment                                   Evidence

                1a) identify and learn from    1. Incidents are reported locally and to   G.C   Processes embedded for reporting incidents within the          Incident Reporting policy; 3 examples of SUI reports on
                all patient safety incidents   the National Patient Safety Agency               trust and externally to:.SHA (SUIs reported via STEISS);       STEISS; emails to PCT from IC; Example of upload of
                and other reportable           (NPSA) via the National Reporting and            MHRA; SHOT; HSE (RIDDOR); NRLS (weekly) and as                 incidents to NRLS;
   1 - Safety

                incidents, and make            Learning System                                  required to inform National Audit and confidential enquiry
                improvements in practice                                                        processes.
                based on local and national
                experience and information
                derived from the analysis of

                1a) identify and learn from 2. Reported incidents are analysed to         G.C   Incidents are reported via PRISM risk management system        Risk Management and Incident Reporting Policies; PRISM
                all patient safety incidents seek to identify root causes, relevant             and graded according to the grading matrix in the trust risk   system available to view if required at inspection for
                and other reportable         trends and likelihood of repetition                management policy. The Senior Clinical Risk Manager            evidence of incidents reported and incidents investigated
   1 - Safety

                incidents, and make                                                             meets monthly with the Divisional Risk Coordinators to         and closed; Framework for SUI Process of Maternity
                improvements in practice                                                        review the incidents, close those investigated and to          Deaths; RCA of MRSA bacteraemia;
                based on local and national                                                     identify emerging themes. A full RCA of the more serious
                experience and information                                                      incidents is undertaken.
                derived from the analysis of

                1a) identify and learn from    3. Demonstrable improvements in            G.C   Risk Management forums are held monthly with Divisional        M&CS Divisional Gov minutes
                all patient safety incidents   practice are made to prevent                     Risk Coordinators, Head of Legal Services and consider         to add
                and other reportable           reoccurrence of incidents as a result of         links with the complaints received. NRLS feedback report       Divisional IGC reports; Minutes from Divisional Governance
   1 - Safety

                incidents, and make            information arising from the analysis of         circulated to PS committee and analysed by Senior Risk         meetings and RMF in maternity; Copy of WEHT NRLS
                improvements in practice       local incidents and from the NPSA's              Manager. Emerging themes shared with IGC and PS                feedback report; IGC minutes and papers for 2 months;
                based on local and national    national analysis of incidents                   Committee for discussion within Divisions.
                experience and information
                derived from the analysis of

                1b) ensure that patient        1. All communications, including drug      A.H   SABS officer assigned - Head of Patient Safety and             PSC Minutes, Agendas and Terms of Ref
                safety notices, alerts and     alerts, issued by the Safety Alert               Healthcare Governance. All alerts have accountable leads       SABS list/spreadsheet (hyperlink); Risk Management Policy;
                other communications           Broadcast System (SABS) are                      at Corporate, Divisional and Departmental level as per         Copies of IGC agendas and mins; Divisional IGC reports;
   1 - Safety

                concerning patient safety,     implemented within the defined                   Trust protocol. SABS alerts listed on trust intranet.
                which require action, are      timescales, in accordance with Chief             Progress towards compliance monitored via Patient Safety
                acted upon within required     executive's bulletin article (Gateway            Committee and IGC (Divisional Reports).
                timescales                     2326)

                                                                                                       Page 1 of 26
                                                                                          Standards for Better Health 07/08                                                                                 Appendix B

Domain Core Standard                          Element                                    Lead   Assessment                                                    Evidence

               2) Healthcare organisations    1. Effective processes are in place for    C.H    The WEHCT Policy and Guidance for Safeguarding                Child protection training report Jan - June 07.
               protect children by            identifying, reporting and taking action          Children has been updated as a consequence of routine         CP training report July - Dec07.
               following national child       on child protection issues in accordance          review of all policies, which complies with National, and     Correlation of inter-agency working audits WEHTCSD.
               protection guidelines within   with Working together to safeguard                Hampshire guidance and includes effective processes to        HCG Paediatric structure
               their own activities and in    children (HM Government, 2006)                    identify, report and take action on Child Protection issues   Midwives CP training course info on intranet.
               their dealings with other                                                        and support for staff throughout. The document has been       Presentation charts audit
               organisations                                                                    presented to the Designated professionals for                 Report re presentation charts Jan -Sept 07
                                                                                                Safeguarding Children in Hampshire Safeguarding               Risk structure in Paediatric Dept 07
                                                                                                Children's Board (HSCB) for advice and recommendations        SHA Safeguarding audit 29/12/07 update
                                                                                                on the document. HSCB policy and guidance available on        Final report LSCB (Hants & IOW).
  1 - Safety

                                                                                                our Intranet for consultation as required. Training for       Lessons learned from IMRs.
                                                                                                Safeguarding Children is now mandatory for all staff.         Midwives case conference audit
                                                                                                Safeguarding developments presented to WEHCT board.           Report re inter-agency working audit (July 07).
                                                                                                Appointed a Specialist Midwife for Vulnerable Women and       Report re safeguarding children's info audit.
                                                                                                Children. Whilst training in Safeguarding Children has        SHA safeguarding audit 6/11/07update.
                                                                                                been made mandatory, as yet, all staff have not been           WEHT Safeguarding Children Policy. (awaiting final
                                                                                                enabled to access the training. Training is to be offered     approval)
                                                                                                within other fora than dedicated 'training sessions' e.g.     Powerpoint presentation used by CP named nurse on Trust
                                                                                                Clinical Governance protected time sessions, Ward/Dept        induction programme.
                                                                                                meetings, e-learning availability, one-to-one sessions as     Powerpoint paediatric governance
                                                                                                requested, supervision sessions in high risk areas.
                                                                                                Monitoring of training levels are ongoing. A business case
                                                                                                for appointment of a liaison nurse has been prepared and
                                                                                                is going forward.

               2) Healthcare organisations    2. The healthcare organisation works       C.H    The Safeguarding Children's Committee has                    Correlation of inter-agency working WEHTCSD.
               protect children by            with partners to protect children as set          representatives from all partner organisations. The           Inter-agency working audit 07.
               following national child       out in Working together to safeguard              WEHCT Policy and Guidance document has been                   Hants inter-agency SCB training calendar Apr 07 - Mar 08.
               protection guidelines within   children (HM Government, 2006)                    presented to the Designated professionals for                Hants SCB training information.
               their own activities and in                                                      Safeguarding Children in Hampshire Safeguarding              Lessons learned from IMRs.
               their dealings with other                                                        Children's Board (HSCB) for advice and recommendations         Final 4LSCB procedures.
               organisations                                                                    on the document. Training is available with partner          Revised and updates WEHT Safeguarding Children Policy,
                                                                                                organisations and professionals from those organisations
                                                                                                attend and input on our 'Basic Awareness' sessions.
                                                                                                Named Doctor and Nurse represent the WEHCT on the
  1 - Safety

                                                                                                Multi-Agency Safeguarding Forum, which is a sub-
                                                                                                committee of the HSCB. Supervision for the named
                                                                                                professionals is accessed via the Designated
                                                                                                professionals on the HSCB. Documentation for
                                                                                                Safeguarding Children has been developed in conjunction
                                                                                                with reresentatives from partner agencies. All service level
                                                                                                agreements with the PCT will include the requirement for
                                                                                                effective Safeguarding Children's processes to be in place.
                                                                                                Annual audit of interagency working undertaken with co-
                                                                                                terminous Children's Services Departments.

                                                                                                       Page 2 of 26
                                                                                                Standards for Better Health 07/08                                                                                    Appendix B

Domain Core Standard                           Element                                         Lead   Assessment                                                      Evidence

               2) Healthcare organisations     3. Criminal Records Bureau (CRB)                J.W    Policy and Procedures in place and audited                      CRB paper
               protect children by             checks are conducted for all staff and                 CRB checks are currently undertaken to the level required       Policy regarding Criminal Records Bureau disclosures
  1 - Safety

               following national child        students with access to children in the                by DOH
               protection guidelines within    normal course of their duties, in                      We plan to implement repeat checking (in excess of
               their own activities and in     accordance with CRB disclosures in the                 current standard) over a 3 year period.
               their dealings with other       NHS (NHS Employers, 2004)

               3) Healthcare organisations     1. The healthcare organisation follows          A.R    Process is carried out via the Deputy Medical Director and      NICE spreadsheet
               protect patients by following   NICE interventional procedures                         checking if the new procedures are applicable to the Trust      reports to CPC
  1 - Safety

               National Institute for Health   guidance in accordance with The                        with the relevant clinicians. NICE distributed via Clinical     letter to clinicians
               and Clinical Excellence         interventional procedures programme                    Governance and records kept and available on intranet. If       Introduction of new procedures policy
               (NICE) interventional           (Health Service Circular 2003/011)                     the procedures are relevant then they are presented to the      NICE flow chart and Implementation of National Best
               procedures guidance                                                                    Clinical Policy Group in line with policy on 'Introduction of   Practice Guidance Policy
                                                                                                      New Procedures'

               4a) Healthcare                  1. The healthcare organisation has              R.P    Health Act compliance Action plan completed during 2007         annual reports
               organisations keep              systems to ensure the risk of healthcare               so processes in place. Work continues to ensure this is         antibiotic management guidance & protocols
               patients, staff and visitors    associated infection is reduced in                     sustained and embedded throughout the organisation.             audit & cephalosporin restriction
               safe by having systems to       accordance with The Health Act 2006                    Divisional and clinical/ward ownership of infection control     audits
               ensure that: a) the risk of     Code of Practice for the Prevention and                issues is critical to the success of Health Act compliance.     decontainmination figures
               healthcare acquired             Control of Healthcare Associated                       Training & Development Policy now includes Infection            education - newsletters, talks & training
               infection to patients is        Infections (Department of Health, 2006)                Control Training as a mandatory requirement for all staff.      HAI surveillance
               reduced, with particular                                                               Unannounced HCC inspection in January 2008 confirmed            HCAI improvement
                                               note the measurement of the MRSA target is             compliance to this standard.                                    HCA 2006
               emphasis on high
  1 - Safety

                                               undertaken through the new 'national targets'
               standards of hygiene and                                                                                                                               IC div leads
                                               component in the annual health check.
               cleanliness, achieving year                                                                                                                            monitoring
               on year reductions in                                                                                                                                  networking
               Methicillin-Resistant                                                                                                                                  occupational health
               Staphylococcus Aureus                                                                                                                                  pandemic influenza planning
               (MRSA)                                                                                                                                                 patient information leaflets
                                                                                                                                                                      Saving lives
                                                                                                                                                                      training and development policy

                                                                                                             Page 3 of 26
                                                                                         Standards for Better Health 07/08                                                                                   Appendix B

Domain Core Standard                          Element                                   Lead   Assessment                                                    Evidence

               4b) Healthcare                 1. The healthcare organisation has        B.C    Internal Audit completed and attached to the evidence file.   audit report
               organisations keep             systems in place to minimise the risks           Management and procurement policies currently under           IRMER
               patients, staff and visitors   associated with the acquisition and use          review.                                                       Management policy
               safe by having systems to      of medical devices in accordance with             Interim Chair remains in place pending formal appointment    Procurement policy
  1 - Safety

               ensure that: all risks         guidance issued by the MHRA                      of substantive chair. Work ongoing to strengthen central      MGD TOR & minutes
               associated with the                                                             co-ordination of the procurement of medical devices.
               acquisition and use of                                                          Requirement to ensure review of competency of
               medical devices are                                                             ward/divisional staff to use devices

               4b) Healthcare                 2. The healthcare organisation has        Di.B   A Trust IR(ME)R policy which includes all relevant locally    IRMER procedures
               organisations keep             systems in place to meet the                     interpreted IRMER procedures and Local Rules has been         example of incident reporting for any non-compliance of
               patients, staff and visitors   requirements of the Ionising Radiation           drawn up and implemented. A revised version has been          policy
  1 - Safety

               safe by having systems to      (Medical Exposure) Regulations                   approved and ratified and is available on the Trust intranet.
               ensure that: all risks         2000[IR(ME)R]                                    All new Imaging Users have been issued with a personal
               associated with the                                                             copy of the policy.
               acquisition and use of
               medical devices are

               4c) all reusable medical       1. Reusable medical devices are           B.C    CSSD full compliance achieved (Oct 2007) against ISO          Signed agreements
               devices are properly           properly decontaminated in appropriate           13485 and MDD.                                                SLA for CSSD
               decontaminated prior to        facilities, in accordance with the               ENT outpatients at RHCH and Ophthalmic Outpatients at         ISO certificate issued Oct 2007
  1 - Safety

               use and that the risks         relevant requirements of The Health Act          AWMH not centralised. All other decontamination               decontamination action plan
               associated with                2006 Code of Practice for the                    processes now centralised.                                    sets processed 06/07
               decontamination facilities     Prevention and Control of Health Care            Procurement of ENT instrumentation completed Jan 2008,
               and processes are well         Associated Infections (Department of             awaiting commencement of service. Ophthalmic
               managed                        Health, 2006)                                    instruments at AWMH - procurement and centralisation by
                                                                                               April 2008.

                                                                                                      Page 4 of 26
                                                                                         Standards for Better Health 07/08                                                                     Appendix B

Domain Core Standard                         Element                                    Lead   Assessment                                                    Evidence

               4d) medicines are handled     1. Medicines are safely and securely       M.I    Core policies for Acquisition of medicines including          Adverse drug group
               safely and securely           procured, prescribed, dispensed,                  unlicensed have been in place all year & the development      District prescribing committee
                                             prepared, administered and monitored,             of PGDs. The Prescribing Policy, Identification & Approval    D & T committee
                                             including in accordance with the                  of Non-medical prescribers, have beed approved and            Medicines evaluation committee
                                             statutory requirements of the Medicines           ratified. NPSA Alerts published since Mar-07 have been        Patient group directions
                                             Act 1968                                          achieved within the recommended timescales at present         Trustwide policies & procedures
                                                                                               work ongoing to produce corporate prescribing guidance        Chief Pharmacy job description
                                                                                               on anti-coagulation. Adverse Drugs Events Group being         CD audits
  1 - Safety

                                                                                               reviewed to strengthen membership. Pharmacy staffing          Minutes of CD review group
                                                                                               based on FFtF bed model.

               4d) medicines are handled     2. Controlled drugs are handled safely     M.I    Wards & Departments have been regularly audited by
               safely and securely           and securely in accordance with the               Pharmacy Staff, Clinical Governance & Internal Audit have
                                             Misuse of Drugs Act 1971, the Misuse              also reviewed the processes. New procedures have been
  1 - Safety

                                             of Drugs Act 1971 (Modification) Order            approved and ratified and are available on the intranet. CD
                                             2001 and Safer management of                      accountable Officer Director of Nursing and Patient Care.
                                             controlled drugs: Guidance on                     CD review group meet quarterly to review compliance and
                                             strengthened governance                           idenitfy actions if required.
                                             arrangements (Department of Health,

               4e) the prevention,           1. The prevention, segregation,            B.C    Up stream audit completed by Stericycle. Audit rating         Audit & action plan
               segregation, handling,        handling, transport and disposal of               awarded was 'Adequate' and attached to evidence file.         waste policy
               transport and disposal of     waste is properly managed to minimise             Policy has been revised to account for changes in             waste clearing
               waste is properly managed     the risks to patients, staff, the public          legislation and practice. Waste Disposal Policy available     clinical waste spreadsheet
  1 - Safety

               so as to minimise the risks   and the environment in accordance with            on the Trust intranet.                                        weight invoice
               to the health and safety of   Environment and sustainability Health              Audit points to need for training of staff in duties and     weight costs
               staff, patients, the public   Technical Memorandum 07-01: Safe                  responsibilities. Training package has been sourced and
               and the safety of the         management of healthcare waste                    being assessed by Trust on 24/1/07.
               environment                   (Department of Health, November 2006)             ACTION Attached as evidence from audit report
                                                                                               recommendations and action plan.

                                                                                                      Page 5 of 26
                                                                                                                                                                                     Standards for Better Health 07/08                                                                                      Appendix B

Domain Core Standard
  2 - Clinical & Cost Effectiveness 2 - Clinical & Cost Effectiveness 2 - Clinical & Cost Effectiveness
                                                                                                                                        Element                                     Lead    Assessment                                                     Evidence

                                                                                                          5a) Healthcare                1. The healthcare organisation              AR      Process is carried out via the Medical Director and            NICE spreadsheet
                                                                                                          organisations ensure that:    conforms to NICE technology                         checking compliance with the relevant clinicians. NICE         reports to D & T & IGC
                                                                                                          they conform to National      appraisals where relevant to its services           distributed via Clinical Governance and records kept and       letter to clinicians
                                                                                                          Institute for Health and                                                          available on intranet. Progress reported to IGC via            relevant audit reports
                                                                                                          Clinical Excellence (NICE)                                                        divisional reports. Any non- compliance is recorded on         NICE flow chart & policy
                                                                                                          technology appraisals and,                                                        Trust Corporate Risk Register, and notified to Trust Board.    NICE audits completed and audit report
                                                                                                          where it is available, take                                                       Audit of NICE guidance are included in annual clinical         Policy for the Implementation of National Best Practice
                                                                                                          into account nationally                                                           audit programme, managed by Clinical Audit Committee.          Guidance
                                                                                                          agreed guidance when
                                                                                                          planning and delivering
                                                                                                          treatment and care

                                                                                                          5a) Healthcare                2. The healthcare organisation can          J.B & Clinical Governance department records statements of             NICE spreadsheet
                                                                                                          organisations ensure that:    demonstrate how it takes into account       K.S   compliance with NICE technology assessments. D&T                 NICE audits completed and audit report
                                                                                                          they conform to National      nationally agreed best practice as                  Terms of Reference – includes focus on requirements of         NSF action plan & related audits
                                                                                                          Institute for Health and      defined in national service frameworks              NICE guidance where drug related                               Policy for the review and implementation of national best
                                                                                                          Clinical Excellence (NICE)    (NSFs), NICE clinical guidelines,                   Best practice guidance received via membership of              practice guidance.
                                                                                                          technology appraisals and,    national plans and nationally agreed                networks, Royal Colleges and national audits: Network
                                                                                                          where it is available, take   guidance, when commissioning and                    Peer Reviews (Cancer, Haematology), contribution to
                                                                                                          into account nationally       when delivering services, care and                  National or regional Audits and Databases in Stroke,
                                                                                                          agreed guidance when          treatment                                           Myocardial Infarction, Intensive Care, Neonatology, Breast
                                                                                                          planning and delivering                                                           screening, Maternity, national hip register etc. Process for
                                                                                                          treatment and care                                                                for receipt and review of guidance received incoporated
                                                                                                                                                                                            into a new trust policy for teh review and implementation of
                                                                                                                                                                                            national best practice guidance.

                                                                                                          5b) Healthcare                1. Appropriate supervision and clinical     JB &    Through supervision, job planning and appraisal, and an       Infusion devices study days & workbooks
                                                                                                          organisations ensure that:    leadership is provided to staff involved    KS      annual performance development review that highlights         Training courses evaluation
                                                                                                          clinical care and treatment   in delivering clinical care and treatment           skills requirements relevant to their clinical work.          to add:
                                                                                                          are carried out under         in accordance with guidance from                    Individuals are expected to be personally accountable for     Personnel development plan documents
                                                                                                          supervision and leadership    relevant professional bodies                        their professional practice. Training records of all doctors  Example of self assessment competency statements
                                                                                                                                                                                            in training supervised by Director of Postgraduate Medical    Trust induction policy
                                                                                                                                                                                            Educational and the local deanery.                            Records of appraisals
                                                                                                                                                                                                                                                          Preceptorship competency book
                                                                                                                                                                                            Educational supervision of junior doctors is in the job plans Return to practice programme
                                                                                                                                                                                            of all relevant consultants.

                                                                                                                                                                                            Nurses subject to KSFs and annual appraisal.
                                                                                                                                                                                            Midwifery supervision in place.

                                                                                                                                                                                                   Page 6 of 26
                                                                                                                        Standards for Better Health 07/08                                                                                     Appendix B

Domain Core Standard                                                     Element                                       Lead   Assessment                                                      Evidence

                                          5c) Healthcare               1. Clinicians from all disciplines              JB &   Through CPD, clinical governance arrangements and               Monthly clinical skills cluster timetable
                                          organisations ensure that: participate in activities to update the           KS     appraisal. Trainee medcial staff have supervsion and            Statutory & mandatory training for clinicians
                                          clinicians continuously      skills and techniques relevant to their                regulation of training by Director of Postgraduate Medical      Statutory & mandatory training for Doctors
                                          update skills and            clinical work                                          Education, the Deanery and PMETB. Permanent medical             Divisional/specialty specific training
      2 - Clinical & Cost Effectiveness

                                          techniques relevant to their                                                        staff have minumum requirement for annual CPD overseen
                                          clinical work                                                                       by relevant Royal College and reportable to the Medical
                                                                                                                              Director through the appraisal process.

                                                                                                                              KSFs introduced and new appraisal policy; Clinical skills
                                                                                                                              and other in-house education have been mapped against
                                                                                                                              KSF and posted on intranet.

                                                                                                                              Competencies development - New framework has been
                                                                                                                              approved for registered clinical staff for self assessment of
                                                                                                                              competencies for: Clinical skills which are an expansion of
                                                                                                                              role, infusion devices. The competencies support personal
                                                                                                                              accountability for an individuals professional practice and
                                                                                                                              ensure feedback to line manager at appraisal re areas for
                                                                                                                              development and supervision

                                                                                                                              Committees supporting development of skills and
                                                                                                                              knowledge of staff: Practice and Professional development
                                                                                                                              committee; Interprofessional learning group; Education
                                          5d) Healthcare                 1. Clinicians are involved in prioritising,   S.S.   Monthly Clinical Governance rolling (protected) half days.      Clinical Audit Programme
                                          organisations ensure that:     conducting, reporting and acting on                  Trust clinical audit is overseen by the Clinical Audit          Rolling audit half day minutes
                                                                         clinical audits                                      Committee (CAC), with representation from consultants           Clinical Audit Reports
 2 - Clinical & Cost

                                          clinicians participate in

                                          regular clinical audit and                                                          and senior nurses of multiple disciplines. The Trust has a      Clinical Proposal form
                                          reviews of clinical services                                                        clinical audit programme which includes both local and          Clinical Audit minutes & ToR
                                                                                                                              national priorities ie. NICE, CNST. Audits within the Trust     NICE policy & framework
                                                                                                                              are reported to the CAC. Clinicians are actively involved in
                                                                                                                              conducting, presenting and acting on audits. This is
                                                                                                                              supported by the Clinical Governance Unit. Progress is
                                                                                                                              fed back to the Integrated Governance Committee as

                                          5d) Healthcare                 2. Clinicians participate in reviewing the    S.S.   The Trust clinicians review effectiveness through a number      Research database
                                          organisations ensure that:     effectiveness of clinical services                   of pathways. The Clinical Audit Committee oversees              Clinical Audit database
                                          clinicians participate in      through evaluation, audit or research                progress in implementing national targets and guidance          NICE database
 2 - Clinical & Cost

                                          regular clinical audit and                                                          such as NICE and prioritises their audit. The clinical          clinicians logbooks

                                          reviews of clinical services                                                        strategy continues to engage clinicians in rigorous             M & M meetings
                                                                                                                              evaluation of present services, including benchmarking          Rolling audit half day minutes
                                                                                                                              against national data (eg Length of stay etc). Trust
                                                                                                                              research is targeted on multicentre trials.regular, well
                                                                                                                              discussed and attended, mortality and morbidity meetings
                                                                                                                              in many specialties throughout the Trust. Global Trigger
                                                                                                                              Tool introduced and trustwide implementation plan under

                                                                                                                                     Page 7 of 26
                                                                                                              Standards for Better Health 07/08                                                                                   Appendix B

Domain Core Standard                                                 Element                                 Lead   Assessment                                                     Evidence

                                      6) Healthcare organisations    1. Staff work in partnership with       MO     Regular meetings re emergency admissions, managed          Reduced delayed discharge by 20% by Jonah discharge
  2 - Clinical & Cost Effectiveness

                                      cooperate with each other      colleagues in other health and social          care, intermediate care, delayed discharges, mental health project.
                                      and social care                care organisations to meet the                 and delayed discharges. Also meetings with PCT,            Timely referral of patients to continuing healthcare to PCT.
                                      organisations to ensure        individual needs of patients.                  neighbouring trusts and social services re specific issues
                                      that patients’ individual                                                     e.g. Provider Services Development Group, New Ways of
                                      needs are properly                                                            Working, Unscheduled Care meetings with PBC groups.
                                      managed and met
                                                                                                                    Joint action plans for mental health and delayed

                                      7ac) Healthcare                1. The healthcare organisation has      A.H    Clinical Governance activity is included in the Trust annual   PSC Agendas, Minutes and Terms of Reference
                                                                     effective arrangements in place for            report and the core component of Integrated Governance         Revised CGU structure; Policy for the implementation and
                                      organisations: a) apply the
                                                                     clinical governance                            Committee's (IGC) monthly agenda. IGC reports to the           review of National Guidance; Job descriptions of CGU;
  3 - Governance

                                      principles of sound clinical
                                                                                                                    Trust Board. Clinical professionals are involved in the        Divisional IGC reports; Clinical Audit TOR
                                      and corporate governance
                                                                                                                    decision making processes across the Trust with Clinical
                                      and c) undertake                                                              Directors leading the Divisions, from January 2008. The
                                      systematic risk assessment                                                    Patient Safety Committee and Clinical Audit Committee
                                      and risk management                                                           report progress, learning and evaluation of clinical
                                                                                                                    processes, reporting to IGC. The Clinical Governance Unit
                                                                                                                    provide support and advice to the Divisions.

                                      7ac) Healthcare              2. There are effective corporate          P.J.   Standing Orders and SFIs in place governing the way the        Standing Orders, SFIs and Scheme of Delegation approved
                                                                   governance arrangements in place that            Board operates and delegated authority levels. Board           March 2007.
                                      organisations: a) apply the
                                                                   accord with Governing the NHS: A                 members sign up to Code of Conduct (NEDs via                   Register of interests for Board members.
  3 - Governance

                                      principles of sound clinical
                                                                   guide for NHS boards (Department of              Appointments Commission) and Trust maintains a Register        Policy on Gifts and Hospitality.
                                      and corporate governance
                                                                   Health and NHS Appointments                      of Interests for Board members. Board discussion August        Job description for Head of Corporate Services (Company
                                      and c) undertake             Commission, 2003), Corporate                     2007 regarding purpose of the Board and roles of NEDs /        Secretary).
                                      systematic risk assessment governance framework manual for                    Execs - Part 2 minutes                                         Appointment of NEDs due January 2007.
                                      and risk management          PCTs (Department of Health, April 2003)                                                                         Board discussion re purpose of board and board sign-up to
                                                                                                                                                                                   working principles. (Part 2 minutes).
                                                                                                                                                                                   Board approval of Principles of public conduct.
                                                                                                                                                                                   Assurance Framework

                                                                                                                           Page 8 of 26
                                                                                             Standards for Better Health 07/08                                                                                     Appendix B

Domain Core Standard                              Element                                   Lead   Assessment                                                      Evidence

                   7ac) Healthcare                3. The healthcare organisation            A.H    Each Division holds a monthly risk management forum             to add Revised CGU structure; Policy for the implementation
                                                  systematically assesses and manages              where the Divisional risk register is reviewed and updated      and review of National Guidance; Job descriptions of CGU;
                   organisations: a) apply the
                                                  its risks                                        according to the progress made in minimising the risks          Divisional IGC reports; PS committee minutes; Clinical Audit
                   principles of sound clinical
                                                                                                   identified. Each risk is graded according to the risk grading   TOR; PS Com TOR;
  3 - Governance

                   and corporate governance
                                                                                                   matrix. A process is in place for escalating Divisional risks
                   and c) undertake                                                                to the Corporate Risk Register. The Corporate Risk
                   systematic risk assessment                                                      Register is reviewed monthly at IGC. The Divisional
                   and risk management                                                             Governance/Risk facilitators work closely with the Senior
                                                                                                   Clinical Risk Manager who oversees and coordinates the
                                                                                                   Risk assessment processes. The key Corporate risks are
                                                                                                   identified at IGC and mitigation reported to the Trust Board
                                                                                                   for information.

                   7b) Healthcare                 1. The healthcare organisation actively   J.W    Management Code of Conduct issued to all new and                fraud matters newsletters
                   organisations actively         promotes openness, honesty, probity              existing staff. Counter fraud management is well                audit committee annual report
                                                  and accountability to its staff and              established in the organisation                                 fraud corruption policy
  3 - Governance

                   support all employees to
                   promote openness,              ensures that resources are protected                                                                             how to report concerns
                   honesty, probity,              from fraud and corruption in accordance                                                                          LCFS paper reviewed
                   accountability, and the        with the Code of conduct for NHS                                                                                 webpage
                   economic, efficient and        Managers (Department of Health, 2002)                                                                            workplan
                   effective use of resources     and NHS Counter Fraud and Corruption
                                                  Manual Third Edition (NHS Counter
                                                  Fraud Service, 2006).

                   7e) Healthcare                 1. The healthcare organisation            J.W    The Trust has developed a Single Equalities Scheme              Equal opportunies minutes
                   organisations challenge        challenges discrimination and respects           which has engagement from Board Staff Groups and local          Equality impact assessment tool
                   discrimination, promote        human rights in accordance with the              minority representatives                                        Single equality scheme
                   equality and respect human     Human Rights Act 1998, No Secrets:               The Equalities Forum to be reviewed and relaunched in
                   rights                         Guidance on developing and                       2008. NED appointed to 'buddy' Director of HR to optimise
                                                  implementing multi-agency policies and           assurance in HR systems.
  3 - Governance

                                                  procedures to protect vulnerable adults
                                                  from abuse (Department of Health,
                                                  2000), The Sex Discrimination (Gender
                                                  Reassignment) Regulations 1999, The
                                                  Employment Equality (Religion or
                                                  Belief) Regulations 2003, The
                                                  Employment Equality (Sexual
                                                  Orientation) Regulations 2003, and The
                                                  Employment Equality (Age) Regulations

                                                                                                          Page 9 of 26
                                                                                              Standards for Better Health 07/08                                                                                 Appendix B

Domain Core Standard                               Element                                   Lead   Assessment                                                  Evidence

                   7e) Healthcare                  2. The healthcare organisation            J.W    The Single Equalities Scheme has a been published and is
                   organisations challenge         promotes equality, including by                  available via the home page on the Trust internet.
                   discrimination, promote         publishing information specified by
                   equality and respect human      statute, in accordance with the general
                   rights                          and specific duties of the Race
                                                   Relations Act 1976 (as amended), the
                                                   Code of practice on the duty to promote
                                                   race equality (Commission for Racial
  3 - Governance

                                                   Equality 2002),the Disability
                                                   Discrimination Act 1995, the Disability
                                                   Discrimination Act 2005, the Code of
                                                   practice on the duty to promote
                                                   disability equality (Disability Rights
                                                   Commission, 2005), the Equality Act
                                                   2006, Gender Equality Duty Code of
                                                   Practice (Equal Opportunities
                                                   Commission, November 2006) and
                                                   Delivering Race Equality in Mental
                                                   Health Care (Department of Health,

                   8a) Healthcare                  1. Staff are supported, and know how,     J.W    The Trust has a well established "Whistle blowing" policy   Policy for managers on resolving concerns
                   organisations support their     to raise concerns about services                 which is reviewed annually.                                 Minutes of doctors & dentists negotiating sub committee
                   staff through having access     confidentially and without prejudicing                                                                       Staff handbook
                   to processes which permit       their position, including in accordance                                                                      Sample employment contract
                   them to raise, in confidence    with the Public Disclosure Act 1998:
  3 - Governance

                   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

                                                                                                          Page 10 of 26
                                                                                                Standards for Better Health 07/08                                                                                    Appendix B

Domain Core Standard                               Element                                     Lead   Assessment                                                   Evidence

                   8b) Healthcare                  1. The healthcare organisation              J.W    The Trust has achieved Practice Plus standard for IWL.       Staff survey
                   organisations support their     supports and involves staff in
                   staff through organisational    organisational and personal
  3 - Governance

                   and personal development        development programmes as defined
                   programmes which                by the relevant areas of the Improving
                   recognise the contribution      Working Lives standard at Practice Plus
                   and value of staff, and         level
                   address, where
                   appropriate, under-
                   representation of minority

                   8b) Healthcare                  2. Staff from minority groups are offered   J.W    All staff have access to annual appraisal and Personal       Single equality scheme & action plan
                   organisations support their     opportunities for personal development             Development Planning. Minority groups are well
                   staff through organisational    to address under-representation in                 represented at all levels of the organisation.
  3 - Governance

                   and personal development        senior roles
                   programmes which
                   recognise the contribution
                   and value of staff, and
                   address, where
                   appropriate, under-
                   representation of minority

                   9) Healthcare organisations     1. The healthcare organisation has          L.K    Health Records Policy in place and updated regularly.        Medical records online business case.
                   have a systematic and           effective systems for managing clinical            Monitoring is undertaken (this is detailed in the policy).   Casenote audit Orthopaedics
                   planned approach to the         records in accordance with Records                 The Trust undertakes annual I.G. Toolkit assessment.         Casenote audit Paediatrics
                   management of records to        management: NHS code of practice                   Medical Records Sub-Committee in place to review and         Casenote audit Surgery
                   ensure that, from the           (Department of Health, April 2006)                 agree any changes / impacting issues                         Casenote audit Medicine
                   moment a record is created                                                         Implementation of plans to improve accommodation for         Data Quality (Staff guidance)
                   until its ultimate disposal,                                                       storage of Health Records at both RHCH & AWMH sites          Health Records Police
  3 - Governance

                   the organisation maintains                                                         underway.                                                    LKDP Information Gov presentation
                   information so that it serves                                                      Use of 'Off Site Storage' has been extended. A review of     Medical records report to IGC
                   the purpose it was                                                                 warehousing options is being undertaken.                     Audit tool - Discharge management
                   collected for and disposes                                                         Consideration is being given to undertake an Electronic      Offsite storage requirements mail & spreadsheet
                   of the information                                                                 Document System using a discrete area as a pilot site.       Records Management Policy
                   appropriately when no                                                                                                                           EDM presentation
                   longer required                                                                                                                                 Intranet Confidentiality NHS Code of Practice
                                                                                                                                                                   LK Record Keeping presentation
                                                                                                                                                                   Medical records missing flowchart
                                                                                                                                                                   Audit tool documentation - Care Planning
                                                                                                                                                                   Preceptorship programme 2007-08

                                                                                                            Page 11 of 26
                                                                                                                Standards for Better Health 07/08                                                                                Appendix B

Domain Core Standard                                               Element                                     Lead   Assessment                                                    Evidence

                                  10a) Healthcare                  1. The necessary employment checks          J.W    Well established procedures are in place for checking the     Policy for validation
  3 - Governance 3 - Governance

                                  organisations undertake all      are undertaken for all staff in                    registrations of new staff and managing registration          recruitment selection & employment records
                                  appropriate employment           accordance with Safer recruitment - A              renewals.
                                  checks and ensure that all       guide for NHS employers (NHS
                                  employed or contracted           Employers, 2006) and CRB disclosures
                                  professionally qualified staff   in the NHS (NHS Employers, 2004)
                                  are registered with the
                                  appropriate bodies

                                  10b) Healthcare                  1. The healthcare organisation              J.W    Meeting codes of professional conduct is an express term      disciplinary procedure
                                  organisations require that       explicitly requires staff to abide by              of the employment contract. Any breaches are reported to
                                  all employed professionals       relevant codes of professional conduct             the professional body.
                                  abide by relevant published      and takes action when codes of
                                  codes of professional            conduct are breached

                                  11a) Healthcare                  1. The healthcare organisation recruits     J.W    Policies and Procedures are in place governing the            recruitment & selection policy
                                  organisations ensure that        staff in accordance with relevant                  recruitment process and to provide equality of opportunity.
                                  staff concerned with all         legislation and with particular regard to
                                  aspects of the provision of      the Sex Discrimination (Gender
  3 - Governance

                                  healthcare are                   Reassignment) Regulations 1999, The
                                  appropriately recruited,         Employment Equality (Religion or
                                  trained and qualified for the    Belief) Regulations 2003, The
                                  work they undertake              Employment Equality (Sexual
                                                                   Orientation) Regulations 2003, The
                                                                   Employment Equality (Age) Regulations
                                                                   2006, Race Relations Act 1976 (as
                                                                   amended), the Disability Discrimination
                                                                   Act 2005 and the Equality Act 2006

                                  11a) Healthcare                  2. The healthcare organisation              J.W    The Trust participates in local and national workforce        Annual business plan
  3 - Governance

                                  organisations ensure that        undertakes workforce planning which                planning initiatives and has a workforce plan which is        Foundation Trust HR strategy
                                  staff concerned with all         aligns workforce requirements to its               monitored monthly.                                            HR focus group
                                  aspects of the provision of      service needs                                                                                                    Annual plan presentation slides
                                  healthcare are
                                  appropriately recruited,
                                  trained and qualified for the
                                  work they undertake

                                                                                                                            Page 12 of 26
                                                                                          Standards for Better Health 07/08                                                                                   Appendix B

Domain Core Standard                             Element                                 Lead   Assessment                                                      Evidence

                   11b) Healthcare               1. Staff participate in relevant        Div    Over the past 6 months significant improvements have            Position statement & action plan from - Family Services ,
                   organisations ensure that     mandatory training programmes as        C.D    been made in the provision and attendance at statutory          Anaesthetics & Surgery overall attendance 52% (Feb 2008)
                   staff concerned with all      defined by the NHSLA's risk                    and mandatory training. The Training and Developemnt            Medicine 69% (Feb 2008)
                   aspects of the provision of   management standards for acute trusts          Policy has been updated with the Trust requirements for         CAD's
  3 - Governance

                   healthcare participate in                                                    clinical and non clinical staff listed within the appendices.   Mandatory courses
                   mandatory training                                                           These were approved by IGC. The Divisions have                  Trust corporate induction programme
                   programmes                                                                   implemented systems for monitoring. IGC have monitored          Trust corporate induction Doctors
                                                                                                the trusts position on a monthly basis since Oct 2007. The      T & D policy
                                                                                                expansion of the OLM to incorporate local monitoring of
                                                                                                staff training is planned for April 2008 alongside
                                                                                                supernumery status for all new starters to accommodate
                                                                                                corporate and local induction and madatory and statutory
                                                                                                training required.

                   11b) Healthcare               2. Staff and students participate in    Div
  3 - Governance

                   organisations ensure that     relevant induction programmes           C.D
                   staff concerned with all
                   aspects of the provision of
                   healthcare participate in
                   mandatory training

                                                                                                      Page 13 of 26
                                                                                               Standards for Better Health 07/08                                                                                    Appendix B

Domain Core Standard                             Element                                      Lead   Assessment                                                      Evidence

                   11c) Healthcare               Staff have opportunities to participate in   S.B    The Trust's commitment to this standard is evidenced by         A - Z of courses in the Trust
                   organisations ensure that     professional and occupational                       successful achievement of IWL Practice Plus in 2005 with        IPL programme Sept 07
                   staff concerned with all      development at all points in their career           a commendation in Training and Development.                     Date order set year 2
                   aspects of the provision of   in accordance with Working together -               The Trust has a purpose built multi professional Education      E-KSF administration home page
                   healthcare participate in     learning together: a framework for                  Centre and Healthcare Library                                   Guidelines for use of e-KSF
                   further professional and      lifelong learning for the NHS                       The teams who form the Education Service are based in           H & GS NVQ New Starters June '07
                   occupational development      (Department of Health, 2001)                        the Education Centre but many specialist leads for clinical     H & GS NVQ New Starters July '07
                   commensurate with their                                                           teaching (e.g. Tissue Viability) teach from their service       L & D structure - Jan '08
                   work throughout their                                                             base.                                                           Learning agreement for training final
                   working lives                                                                     The yearly Appraisal cycle includes PDP and KSF planning        'Spotlight' Mandatory training
                                                                                                     The Trust has begun implementation of e- ksf                    Monthly clinical skills timetable
                                                                                                     The Trust has begun implementation of OLM (the Training         NVQ awards database '07
                                                                                                     module of the Electronic Staff Record) which enables            NVQ evidence of study
                                                                                                     better monitoring of take up of development opportunities       NVQ nomination form
                                                                                                     and properly planned attendance on training programmes          NVQ registration form - candidate ethnicity
  3 - Governance

                                                                                                     The Trust's Lifelong Learning team achieved Matrix              NVQ Step into Learning monitoring info
                                                                                                     accreditation for giving staff Information Advice and           PER11 personal development review Appraisal Policy
                                                                                                     Guidance on learning and development                            PER 09 Trust induction Policy (Updated Jan 08)
                                                                                                     Until mid 2007 the Trust had its own accredited NVQ             Plan for future NVQs
                                                                                                     Centre for healthcare, housekeeping and administrative          Provision of national vocational qualifications
                                                                                                     NVQs. This is now run through local colleges but                Short guide to NVQ
                                                                                                     approximately the same number of NVQs are achieved              Short guide to NVQ in care
                                                                                                     The Trust offers a range of management development              Intranet 'Spotlight' statutory courses
                                                                                                     programmes including the Certificate in Management              Statutory & Mandatory training for clinicians
                                                                                                     The Executive lead for Education is the Director of HR but      Statutory & Mandatory training for non-clinical staff
                                                                                                     all directors are active in giving and receiving mentorship -   Support worker development strategy
                                                                                                     and the Chief Executive leads monthly Induction as well as      Trust Training Policy
                                                                                                     hosting learning awards ceremonies.                             Trust web 'Spotlight' on training 'should do' courses
                                                                                                     In 2007 Appraisal, Induction and Training Policies were all     WEHT Final validation report
                                                                                                     updated.                                                        Course List
                                                                                                     In partnership with University of Southampton the Trust         Corporate induction for Doctors
                                                                                                     hosts the prestigious fast track bachelor of Medicine 4 year    Corporate Trust Induction programme
                                                                                                     degree.                                                         LEO Poster
                                                                                                     The Trust has thriving postgraduate medical education           CMS WEHT handout (Cert Mgt Studies)
                                                                                                     The Trust has a specialist IT training team who handle
                   12) Healthcare                1. The healthcare organisation has an               courses such as ECDL.
                                                                                                     Research Governance framework in place coordinated by           Link to Research database; Research Governance
                   organisations which either    effective research governance                       the Head of Patient Safety and Governance. Process              flowchart; CLRN minutes and agendas and funding allocated;
  3 - Governance

                   lead or participate in        framework in place which complies with              strengthened through appointment of Clinical Lead for
                   research have systems in      the requirements of the Research                    Research and Development, R&D Manager (Acting) and
                   place to ensure that the      governance framework for health and                 review of infrastructure in January 2008. Trust active
                   principles and requirements   social care, second edition (Department             member of Comprehensive Local Research Network.
                   of the research governance    of Health, 2005)                                    Monies awarded from CLRN to support infrastructure and
                   framework are consistently                                                        work of research supporting national portfolio. R&D office
                   applied                                                                           to be based in Education Centre from April 2008. R&D

                                                                                                           Page 14 of 26
                                                                                                 Standards for Better Health 07/08                                                                                     Appendix B

Domain Core Standard                                Element                                     Lead   Assessment                                                      Evidence

                      13a) Healthcare               1. The healthcare organisation ensures      P.S    Trust has benchmarked EoC standard so staff engaged              GL23 chaperoning policy for patients with confusion
                      organisations have            that staff treat patients, carers and              with process.                                                   privacy & dignity presentation
                      systems in place to ensure    relatives with dignity and respect at              Discrimination training available within the Trust and          privacy & dignity policy
  4 - Patient Focus

                      that staff treat patients,    every stage of their care and treatment            monitored.                                                      policy on safe management of obese patients
                      their relatives and carers    and takes action where dignity and                 Through EoC benchmarking asking patients their views            links to factors
                      with dignity and respect      respect has been compromised                       and opinion and via admission assessment with the
                                                                                                       Marsden manual used as the reference to other faiths and
                                                                                                       culture with regards to end of life care and death
                                                                                                       There is a list of appropriate interpreters available via
                                                                                                       Maintenance of Privacy and Dignity Policy CP006
                                                                                                       Care Environment in A&E improvements

                      13a) Healthcare               2. The healthcare organisation meets        P.S    There is a committee which has replaced the DDA, called         briefing sessions mental capacity act
                      organisations have            the needs and rights of different patient          'The single equality scheme steering group', this is in the     learning disabilities week launch
                      systems in place to ensure    groups with regard to dignity including            early stages.                                                   planning notes and timetable
                      that staff treat patients,    by meeting the relevant requirements of            DDA training continues to be offered to Trust staff             minutes of practice & innovation committee
                      their relatives and carers    the Human Rights Act 1998, the Race                This year the Practice and Innovations committee                report of event
                      with dignity and respect      Relations Act 1976 (as amended), the               undertook a large project looking at the needs of people
  4 - Patient Focus

                                                    Disability Discrimination Act 1995, the            with learning disabilities when they come into Hospital, this
                                                    Disability Discrimination Act 2005, and            was done in partnership with local voluntary and statutory
                                                    the Equality Act 2006                              agencies, users of the service and PCT's. It culminated in
                                                                                                       an event, held in learning disabilities week, which
                                                                                                       consisted of a series of awareness raising events and
                                                                                                       seminars for staff and the launch of patient information
                                                                                                       leaflets aimed at people with LD.
                                                                                                       The education service runs briefing sessions on the Mental
                                                                                                       capacity act and vulnerable adults

                      13b) Healthcare               1. Valid consent, including from those      R.M    Revised Trust Consent Policy for Consent approved and           consent policy
                      organisations have            who have communication or language                 ratified in February 2008.                                      consent to surgery audit
                      systems in place to ensure    support needs, is obtained by suitably             Re-audit of consent to surgery completed and the report
                      that appropriate consent is   qualified staff for all treatments,                shows that the actions agreed at the last audit have been
  4 - Patient Focus

                      obtained when required, for   procedures (including post-mortem) and             implemented. Re-audit later in 2008 against revised
                      all contacts with patients    investigations in accordance with the              Consent Policy.
                      and for the use of any        Reference guide to consent for
                      confidential patient          examination or treatment (Department
                      information                   of Health, 2001) and Families and post
                                                    mortems: a code of practice
                                                    (Department of Health, 2003) and Code
                                                    of Practice to the Mental Capacity Act
                                                    2005 (Department of Constitutional
                                                    Affairs 2007

                                                                                                             Page 15 of 26
                                                                                                   Standards for Better Health 07/08                                                                                         Appendix B

Domain Core Standard                                   Element                                    Lead   Assessment                                                       Evidence

                      13b) Healthcare                  2. Patients, including those with          L.K    Your Healthcare Information' leaflets are available across       Access to communications contact details
                      organisations have               language and/or communication                     the Trust & posters indicating this are displayed.               CCN Survey letter to patients
                      systems in place to ensure       support needs, are provided with                  Information is also included in the Outpatient Information       Data Quality (Staff Guidance)
                      that appropriate consent is      information on the use and disclosure of          Booklet. The Trust subscribes to 'Language Line' and also        Health records Policy
  4 - Patient Focus

                      obtained when required, for      confidential information held about them          accesses the 'Southampton Interpreter Service'. Details of       Intranet confidentiality NHS Code of Practice
                      all contacts with patients       in accordance with Confidentiality: NHS           these services are held with the Patient Support Services        OPD Handbook
                      and for the use of any           code of practice (Department of Health,           Department, Duty Managers instruction book and the               Staff Confidentiality Code of Conduct
                      confidential patient             2003)                                             Consent Policy 'Appendix G'. Revised Patient Information         Appendix G Language Line
                      information                                                                        Policy approved and ratified in February 2008.                   Consent Audiology statement of patient
                                                                                                                                                                          Going home consent form
                                                                                                                                                                          IG information leaflet
                                                                                                                                                                          Northbrook Ward survey patient letter
                                                                                                                                                                          Patient information poster
                                                                                                                                                                          Patient Information Policy

                      13c) Healthcare                  1. Staff act in accordance with            L.K    Trust Health Records and Information Security policies           E-mail intranet link IG information
                      organisations have               Confidentiality: NHS code of practice             reinforce staff responsibilities. Staff responsibilities are     Going Home Consent form (info sharing)
                      systems in place to ensure       (Department of Health, 2003), the Data            reiterated at Trust Induction & local induction. Refresher       Information security book
                      that they treat patient          Protection Act 1998, Protecting and               training on Confidentiality, Data Protection, F.o.I. available   Intranet Confidentiality NHS Code of Practice
                      information confidentially,      using patient information: a manual for           to staff on request through Medical Records department.          LKDP Outpatients presentation
                      except where authorised by       Caldicott guardians (Department of                Responsible Officers have D.P., F.o.I & Caldicott roles          Lyn's IG Quiz
  4 - Patient Focus

                      legislation to the contrary      Health, 1999), the Human Rights Act               within their Job Descriptions. NHS Code of Practice on           Non-disclosure agreement (Temp Service desk)
                                                       1998 and the Freedom of Information               Confidentiality adopted by the Trust (IGC October 2005).         Reporting breaches e-mail
                                                       Act 2000 when using and disclosing                Any breaches in confidentiality are reported through the         Template response for opt-out requests
                                                       patients’ personal information                    Trusts risk Management system.                                   Final WEHT guidance releasing info to Police
                                                                                                                                                                          Health records Policy approved
                                                                                                                                                                          Information security flyers
                                                                                                                                                                          LKDP Data protection presentation
                                                                                                                                                                          LK Record Keeping presentation (Preceptorship)
                                                                                                                                                                          Non-disclosure agreement
                                                                                                                                                                          Preceptorship programme
                                                                                                                                                                          Reporting of breaches in patient confidentiality

                      14a) Healthcare                  1. Patients, relatives and carers are      M.P    Information is available on the website, via complaints          Information is available on the website, via complaints
                      organisations have               given suitable and accessible                     leaflets, (Tel Website PALS). Revised Complaints and             leaflets, (Tel Website PALS).
                      systems in place to ensure       information about, and can easily                 raising informal concerns policy apporved and ratified.          Complaints and Informal Concerns Policy.
  4 - Patient Focus

                      that patients, their relatives   access, a formal complaints system
                      and carers have suitable
                      and accessible information
                      about, and clear access to,
                      procedures to register
                      formal complaints and
                      feedback on the quality of

                                                                                                               Page 16 of 26
                                                                                                    Standards for Better Health 07/08                                                                                   Appendix B

Domain Core Standard                                   Element                                     Lead   Assessment                                                      Evidence

                      14a) Healthcare                  2. Patients, relatives and carers are       M.P    At the end of response the complainant is offered meeting       Details of the gold standard week
                      organisations have               provided with opportunities to give                with CEO and/or Trust CHAIR. To date this has occurred          examples of visits
                      systems in place to ensure       feedback on the quality of services                about ten times and on all occasions the outcome has            WEHT Complaints Policy
  4 - Patient Focus

                      that patients, their relatives                                                      been very positive and no further action required. Patients     Examples of letter responses from the CEO to complainants
                      and carers have suitable                                                            have been involved in the Trust Governance Week with a          Footage of interviews with complainants (Gold Standard)
                      and accessible information                                                          focus on learning from compliants and inviting them to
                      about, and clear access to,                                                         share their stories and experience.
                      procedures to register
                      formal complaints and
                      feedback on the quality of

                      14b) Healthcare                  1. The healthcare organisations has         M.P    Complaints and Informal Concerns policy available on the        WEHT Complaints and informal concerns policy.
  4 - Patient Focus

                      organisations have               systems in place to ensure that patients,          intranet and included in staff corporate and local induction.   Available on Intranet
                      systems in place to ensure       carers and relatives are not treated                                                                               The Single Equality Scheme
                      that patients, their relatives   adversely as a result of having
                      and carers are not               complained
                      discriminated against when
                      complaints are made

                      14c) Healthcare                1. The healthcare organisations acts          M.P    We work to 25 days but if complaint is complex an               SPC chart - analysis of complaints received
                      organisations have             on, and responds to, complaints                      extension is negotiated with the family.                        example of letters
                      systems in place to ensure appropriately and in a timely manner                                                                                     Complaints flowchart showing process
                      that patients, their relatives                                                                                                                      Complaints comparison report
  4 - Patient Focus

                      and carers are assured that
                      the organisation acts
                      appropriately on any
                      concerns and where
                      appropriate, make changes
                      to ensure improvements in
                      service delivery

                                                                                                                Page 17 of 26
                                                                                                               Standards for Better Health 07/08                                                                                  Appendix B

Domain Core Standard                                               Element                                    Lead   Assessment                                                     Evidence

                                  14c) Healthcare                  2. Demonstrable improvements are           M.P    From 1 Jan more local action will be taken. Complaints         SPC chart - analysis of complaints received
                                  organisations have               made to service delivery as a result of           Manager to attend the Div Meeting re Action Plans . Also to    Customer care training programme.
                                  systems in place to ensure       concerns and complaints from patients,            attend Consultant meetings To discuss Medical                  Customer Care Strategy
                                  that patients, their relatives   relatives and carers                              Complaints and Action Plan. Complaints Manager to attend       Complaints and Informal Concerns policy
  4 - Patient Focus

                                  and carers are assured that                                                        Exec Board Bi monthly to provide an overview of the
                                  the organisation acts                                                              complaints received and themes emerging. Clinical areas
                                  appropriately on any                                                               with increase in complaints will be required to produce
                                  concerns and where                                                                 action plan which will be monitored to ensure
                                  appropriate, make changes                                                          improvement. All staff are to attend Customer Care training
                                  to ensure improvements in                                                          Recent changes to Taunton ward environment - nurses
                                  service delivery                                                                   station removed providing better staff/patient accessibility

                                  15a). Where food is              1* Patients are offered a choice of food   M.L    The Trust conforms to this standard and the requirements       Meal service requirements
                                  provided healthcare              in line with the requirements of a                of the Better Hospital Food Programme.                         Policy food safety
  4 - Patient Focus

                                  organisations have               balanced diet, reflecting the needs and                                                                          Patient meal survey & restaurant survey
                                  systems in place to ensure       preferences and rights (including faith                                                                          Patient meal audit
                                  that patients are provided       and cultural needs) of its service user
                                  with a choice and that it is     population
                                  prepared safely and
                                  provides a balanced diet

                                  15a). Where food is              2* The preparation, distribution,          M.L    The Trust conforms to this standard. HACCP Procedures          RHCH & AWMH HACCP policy
              4 - Patient Focus

                                  provided healthcare              handling and serving of food is carried           are in place. Compliance is measured by the
                                  organisations have               out in accordance with food safety                Environmental Health Department.
                                  systems in place to ensure       legislation and national guidance
                                  that patients are provided       (including the Food Safety Act 1990, the
                                  with a choice and that it is     Food Safety (General Food Hygiene)
  4 - Patient Focus

                                  prepared safely and              Regulations 1995 and EC regulation
                                  provides a balanced diet         852/2004

                                  15b) Where food is               1* Patients have access to food and        M.L    The Trust conforms to this standards through the provision     Dietary requirements
                                  provided healthcare              drink 24 hours a day                              of dietary coded menus, dietetic input and provision of        Provision 24 hour meal service
                                  organisations have                                                                 special diets.
                                  systems in place to ensure
                                  that patients’ individual

                                                                                                                           Page 18 of 26
                                                                                                Standards for Better Health 07/08                                                                           Appendix B

Domain Core Standard                               Element                                     Lead   Assessment                                                       Evidence

                      15b) Where food is           2* The nutritional, personal and clinical   A.Mc   The trust has benchmarked EoC standards.                         Nutrition policy
                      provided healthcare          dietary requirements of individual                  Patient care plans are informed of nutritional requirements     3 day food fluid chart
                      organisations have           patients are assessed and met,                     via a formal nutritional screening tool and score on             Nutritional screening tool
                      systems in place to ensure   including the right to have religious              admission to hospital and appropriate follow up as               Referral criteria
                      that patients’ individual    dietary requirements met                           indicated in the nursing action plan providing guidance on:      Nutrition audit
                      nutritional, personal and                                                       • when to refer to the dietitian,                                Audit of assessment tool
                      clinical dietary                                                                • when to start high protein diet or supplements.                EoC questionnaires
                      requirements are met,                                                           • When to start a food fluid chart (see attached)
                      including where necessary                                                        Within the last year the food chart has been adapted to
                      help with feeding and                                                           completion and calculation of nutrition requirements easier
                      access to food 24 hours a                                                       (see attached)
  4 - Patient Focus

                                                                                                      Education on nutrition screening given at monthly Trust
                                                                                                      core training sessions
                                                                                                      Advice on healthy eating promoted via dietitians as well as
                                                                                                      by nursing staff.
                                                                                                       Nutrition team in place for patients with complex nutritional
                                                                                                      enteral or parenteral needs.
                                                                                                      Registered nurses work within their code of professional
                                                                                                      conduct as regards to competence to undertake basic
                                                                                                      Red tray scheme has been implemented and protected
                                                                                                      meal times on the wards.
                                                                                                      Quality and nutritional content of food is monitored at least
                                                                                                      weekly by the dietetic and catering department and
                                                                                                      problems fed back to the hospital kitchens.
                                                                                                      Protocols in place for referral to dietitians for an in depth
                                                                                                      assessment of nutrition requirements (see attached)
                                                                                                      Special dietary needs are recorded on menu cards
                                                                                                      Wards have a named chef to assist in communication

                      15b) Where food is           3* Patients requiring assistance with       A.Mc   Assistance level to eat is identified and recorded on menu       to add protected meal times poster
                      provided healthcare          eating and drinking are provided with              cards.                                                           Nutrition policy
                      organisations have           appropriate support                                Red tray scheme has been implemented and protected               EoC questionnaires
                      systems in place to ensure                                                      meal times on the wards.                                         Nutrition audits
  4 - Patient Focus

                      that patients’ individual                                                       Looking at implementing a Red Glass initiative to assist         Action plans from Matrons meetings
                      nutritional, personal and                                                       patients with their drinking.
                      clinical dietary                                                                Positioning of patient to eat part of general nursing role.
                      requirements are met,                                                           Equipment available via occupational therapies
                      including where necessary                                                       consultation and then ordered.
                      help with feeding and                                                           Support given to promote independence.
                      access to food 24 hours a                                                       Practical feeding sessions provided by the Nutrition Nurse
                      day                                                                             Specialist for care assistants and qualified nurses
                                                                                                      attending the mandatory pressure ulcer training study day.

                                                                                                            Page 19 of 26
                                                                                                                 Standards for Better Health 07/08                                                                                    Appendix B

Domain Core Standard                                                  Element                                   Lead   Assessment                                                     Evidence

                                       16) Healthcare                 1. The healthcare organisation provides   L.H    Translation and braille service available upon request.        Trust news 2007
                                       organisations make             suitable and accessible information on           Medica (print and broadcast) poster, leaflets, Trust news      Examples of media coverage
                                       information available to       the services it provides and in                  2007 in use.
                                       patients and the public on     languages and formats relevant to its
  4 - Patient Focus

                                       their services, provide        service population which accords with
                                       patients with suitable and     the Disability Discrimination Act 1995,
                                       accessible information on      the Disability Discrimination Act 2005
                                       the care and treatment they    and the Race Relations Act 1976 (as
                                       receive and, where             amended)
                                       appropriate, inform patients
                                       on what to expect during
                                       treatment, care and after

                                       16) Healthcare                 2. Patients and, where appropriate,       L.H    Individual teams are responsible for the information they    Patient Information Policy
                                       organisations make             carers (including those with                     produce referring to the Policy of producing patient written Minutes of steering group
                                       information available to       communication or language support                information. There is a Patient Steering Group which is a    examples of patient information leaflets
                                       patients and the public on     needs) are provided with sufficient and          sub group of Integrated Governance and a key role is to
  4 - Patient Focus

                                       their services, provide        accessible information on care,                  review new patient information. The Trust has access to
                                       patients with suitable and     treatment and after care, where                  interpreters and can make information available in different
                                       accessible information on      appropriate in accordance with the               formats (tapes, large print etc) Complainants can be
                                       the care and treatment they    Code of Practice to the mental Capacity          signposted to advocacy services e.g ICAS for additional
                                       receive and, where             Act 2005 (Department of Constitutional           support. The website has been relaunched which includes
                                       appropriate, inform patients   Affairs 2007)                                    accessibility standards and conforms to WCAG level A
                                       on what to expect during
                                       treatment, care and after

                                       17) The views of patients,     1. The healthcare organisation seeks      L.H    PALS, Complaints, comments cards, website -                    Views from patient's User involement projects including,
  5 - Accessible and Responsive care

                                       their carers and others are    the views of patients, carers and the            (, feedback from PPIFs               childrens community nurse team questionnaire
                                       sought and taken into          local community, including those from            PPI strategy in place which includes various methods for       Outcome of women who had surgery for prolapse
                                       account in designing,          disadvantaged and marginalised                   gaining feedback e.g. 1 to 1 interviews, focus groups, talks   Views of patients from the treatment centre
                                       planning, delivering and       groups, when planning, commissioning,            to community groups etc.
                                       improving healthcare           delivering and improving services in             PALS in place since Sept 2001. PALS leaflets and posters
                                       services                       accordance with Strengthening                    widely displayed. Awareness raising with public in various
                                                                      Accountability, patient and public               localities, also self help groups, voluntary groups, parish
                                                                      involvement policy guidance – Section            magazines etc. Often give talks to groups mentioned
                                                                      11 of the Health and Social Care Act             above.
                                                                      2001 (Department of Health, 2003)                PPI strategy in place which includes various methods for
                                                                                                                       gaining feedback e.g. 1 to 1 interviews, focus groups, talks
                                                                                                                       to community groups etc.
                                                                                                                       Foundation Trust database of 8,000 members has been
                                                                                                                       used to update the local community on Trust ‘news’ and to
                                                                                                                       gain feed back re proposed service change.

                                                                                                                             Page 20 of 26
                                                                                                                                                              Standards for Better Health 07/08                                                                              Appendix B

                                              5 - Accessible and Responsive care                                                                             Lead   Assessment                                                  Evidence
Domain Core Standard                                                                                             Element

                                                                                   17) The views of patients,    2. The healthcare organisation              L.H    Regular trust attendance at Overview & Scrutiny meetings Trust clinical strategy
                                                                                   their carers and others are   demonstrates to patients, carers and               (e.g. December 2007) and consultation re where public wristband & baby labelling audits
                                                                                   sought and taken into         the local community how it has taken               consultation required. Infection Control Presentation in Nov
                                                                                   account in designing,         their views into account when planning,            07 and the Trust Clinical Strategy will be presented in Feb
                                                                                   planning, delivering and      commissioning delivering and improving             08. NPSA advised on the redesign of ward areas to be
                                                                                   improving healthcare          services for patients in accordance with           improvement to enhance patient safety and enviornment.
                                                                                   services                      Strengthening Accountability, patient
                                                                                                                 and public involvement policy guidance
                                                                                                                 – Section 11 of the Health and Social
                                                                                                                 Care Act 2001 (Department of Health,
  5 - Accessible and Responsive care Responsive care


                                                                                   18) Healthcare                1. The healthcare organisation ensures      L.H    The healthcare organisation consults with the local         Capital programme
                                                                                   organisations enable all      that all members of the population it              community to get advice on how best to ensure equal         Estates plans
                                                                                   members of the population     serves are able to access its services             access for all of the population.
                                                                                   to access services equally    on an equitable basis including acting in          The Trust works hard to optimise the facilities in
                                                                                   and offer choice in access    accordance with the Sex Discrimination             accordance with the DDA. However, due to the age of
                     5 - Accessible and

                                                                                   to services and treatment     Act 1975, the Disability Discrimination            some bulidings and the site position on a hill, full
                                                                                   equitably                     Act 1995, the Disability Discrimination            compliance has not been achieved. Where this occurs
                                                                                                                 Act 2005, the Race Relations Act 1976              reasonable alternatives are offered. All new estates
                                                                                                                 (as amended) and the Equality Act 2006             planning includes compliance to the DDA.

                                                                                   18) Healthcare                2. The healthcare organisation offers       A.T    Choose and book programme implemented at the Trust.         example of booking process
                                                                                   organisations enable all      patients choice in access to services              Revised waiting list and access policy to be ratified, Care geriatric,cardiac,diabetic,gastro pathways
                                                                                   members of the population     and treatment, where appropriate, and              pathways have been developed. Choice of maternity           waiting list evidence list
                                                                                   to access services equally    ensures that this is offered equitably             services provided, nurse led at Andover. Evening and one
                                                                                   and offer choice in access                                                       stop clinics are provided.
                                                                                   to services and treatment

                                                                                                                                                                          Page 21 of 26
                                                                                                                                     Standards for Better Health 07/08                                                                                     Appendix B

Domain Core Standard                                                                 Element                                        Lead   Assessment                                                       Evidence

                                                     20a) Healthcare services        1. The healthcare organisation                 B.C    Annual 'Statement of Fire Safety' indicates Trust              Fire- Annual fire report 2006
                                                     are provided in                 effectively manages the health, safety                compliance with the Regulatory Reform Order and that risk           Fire contingency nightingale
                                                     environments which              and environmental risks to patients,                  assessments have been undertaken. Capital investment                Fire policy revision 2007
                                                     promote effective care and      staff and visitors, including by meeting              required to further improve fire safety status in place. No         Fire code statement 2007
                                                     optimise health outcomes        the relevant health and safety at work                notices served during the period                                    Fire action plan Dec 2007
  6 - Care Environment & Amenities

                                                     by being a safe and secure      and fire legislation and The                                                                                              Fire letter to CEO 2007
                                                     environment which protects      Management of Health, Safety and                      It is evident that the Trust is committed to reducing its           Fire return for DGM to return to CE
                                                     patients, staff, visitors and   Welfare Issues for NHS staff (NHS                     overall incident and accident rates and providing an           H&S
                                                     their property, and the         Employers, 2005) and the Disability                   evironement which is safe for our staff, patients and               Assessments
                                                     physical assets of the          Discrimination Act 1995                               visitors. Those Incidents requiring reports to the enforcing        Memos
                                                     organisation                                                                          authority, Health and Safety Executive                              Reports
                                                                                                                                           (HSE) have significantly reduced and are below the                  Estates contract leaflet
                                                                                                                                           national average for an organisation of this size with only         Policies
                                                                                                                                           11 for the reporting period. NPSA advised on the redesign           Training
                                                                                                                                           of ward areas to be improvement to enhance patient safety Security
                                                                                                                                           and enviornment.                                                    Audit report Jan 08
                                                                                                                                                                                                               Security policy
                                                                                                                                           The annual slips, trips and falls report demonstrated a             FP security report
                                                                                                                                           significant reductino in the number of patient falls.               Alarm FST
                                                                                                                                           However, the trust maintains its committment to continue
                                                                                                                                           this trend in reduction and remains favourably comaparble
                                                                                                                                           to like size trusts. The number of reportable incidents to the
                                                                                                                                           HSE has also decreased to 7 for falls in this reporting
                                                                                                                                           period and is the lowest for 5 years.                          .
                    6 Care Environment & Amenities

                                                     20a) Healthcare services        2. The healthcare organisation                 P.T    Trust Security Policy 07/08 (for ratification 29 Jan 08)
                                                     are provided in                 provides a secure environment which            D.B    outlines Trust responsibilities in respect of staff and users'
                                                     environments which              protects patients, staff, visitors and their          safety, premises and property. Wards and departments
                                                     promote effective care and      property, and the physical assets of the              take account of security risks and have local procedures in
                                                     optimise health outcomes        organisation                                          place to minimise risks identified. Security Management
                                                     by being a safe and secure                                                            Specialist employed to ensure work is undertaken in areas
                                                     environment which protects                                                            specified by Counter Frad and Security Management
                                                     patients, staff, visitors and                                                         service. A Security Manager and manned Security Service
                                                     their property, and the                                                               is employed 24hrs/day 365 days/year. Service provides
  6 - Care Environment -& Amenities

                                                     physical assets of the                                                                immediate incident response, investigation reporting and
                                                     organisation                                                                          advisory services. CCTV systems operate at RHCH and

                                                     20b) Healthcare services        1.The healthcare organisation provides         B.C    Ongoing ward upgrading programme has enhanced the                Daily monitoring of single sex accommodation
                                                     are provided in                 services in environments that are                     patient environment by providing additional single room          privacy & dignity presentation
                                                     environments which              supportive of patient privacy and                     and en-suite facilities.                                         privacy & dignity policy
                                                     promote effective care and      confidentiality, including the provision of           There is daily monitoring and review of mixed sex                EoC standard on privacy & dignity
                                                     optimise health outcomes        single sex facilities and accommodation               accommodation and will be included in board reports.
                                                     by being supportive of
                                                     patient privacy and

                                                                                                                                                 Page 22 of 26
                                                                                                                                         Standards for Better Health 07/08                                                                                 Appendix B

                          - Care Environment & Amenities                                                                                Lead   Assessment                                                   Evidence
Domain Core Standard                                                                        Element

                                                           21) Healthcare services are      1. The healthcare organisation has          BC     The 2006/07 PEAT inspection resulted in an overall 'Good'    Cleaning specs
                                                           provided in environments,        taken steps to provide care in well         PS     status for the patient environment. Good progress has        Housekeeping procedures
                                                           which promote effective          designed and well maintained                       been achieved on the associated action plan                  Housekeeping monitoring reports
                                                           care and optimise health         environments including in accordance
                                                                                                                                        MO                                                                  Patient survey reports
                                                           outcomes by being well           with Building Notes and Health                                                                                  Housekeeping evidence summary
  6 - Care Environment &6Amenities

                                                           designed and well                Technical Memorandum, the Disability                                                                            Housekeeping staff allocation
                                                           maintained, with                 Discrimination Act 1995 and the                                                                                 National standards of cleanliness meeting minutes
                                                           cleanliness levels in clinical   Disability Discrimination Act 2005 and
                                                           and non-clinical areas that      associated code of practice
                                                           meet the national
                                                           21) Healthcare clean NHS
                                                           specification forservices are    2. Care is provided in clean                M.L    The Trust confirms to this standard in respect of cleaning
                                                           provided in environments,        environments, in accordance with the               service provision. Laundry and Linen conforms to the
                                                           which promote effective          National specification for clean linen in          necessary HTM requirements
                                                           care and optimise health         the NHS (National Patient Safety
                                                           outcomes by being well           Agency 2007) and the relevant
                                                           designed and well                requirements of The Health Act 2006
                                                           maintained, with                 Code of Practice for the Prevention and
                                                           cleanliness levels in clinical   Control of Health Care Associated
                                                           and non-clinical areas that      Infections (Department of Health, 2006)
                                                           meet the national
                                                           specification for clean NHS
                                                           22a) Healthcare                  1. The healthcare organisation works        M.O    PCT developing commissioning intentions based on health Local Delivery Plan and PCT contracts with performance
                                                           organisations promote,           with local partners to deliver the health          need and delivery of national target and quality.         indicators included.
                                                           protect and demonstrably         and well being agenda, such as by                                                                            Commissioning meetings.
                                                           improve the health of the        working to improve care pathways for               LDP and Business Plan process specify the Trusts          Monthly teleconferences with SHA, DH and PCT in relation
                                                           community served, and            patients across the health community               contribution to collaborative commissioning               to Infection Control.
                                                           narrow health inequalities       and participating in equity audits to                                                                        Smoking cessation advice
                                                           by cooperating with each         identify population health needs                   Communication with other local healthcare organisations
  7 - Public Health

                                                           other and with local                                                                about national and local health priorities and concerns –
                                                           authorities and other                                                               Trust participation in NSF working groups.
                                                           organisations c) making an
                                                           appropriate and effective                                                           Senior representation in joint planning arrangements with
                                                           contribution to local                                                               the local authority and other partners – JR is Trust
                                                           partnership arrangements                                                            representative for the Test Valley, Winchester City and
                                                           including local strategic                                                           Eastleigh Borough LSPs, and CE is on the Local Area
                                                           partnerships and crime and                                                          Agreement board. Trust involvement in local partnership
                                                           disorder reduction                                                                  initiatives such as Sure Start, LSP, Andover Vision

                                                                                                                                                     Page 23 of 26
                                                                                              Standards for Better Health 07/08                                                                             Appendix B

Domain Core Standard                             Element                                     Lead   Assessment                                                        Evidence

                      23) Healthcare             1. The healthcare organisation collects,    Div    Trust works to PCT Commissioning intentions which are             McKinsley data and reports
                      organisations have         analyses and shares data about its          C.D    based on local health and local healthcare needs                  NSF action plan
                      systematic and managed     patients services, including with its              Limited compliance to data sets covering disease
                      disease prevention and     commissioners, to influence health                 prevention and health promotion requirements of NSFs
                      health promotion           needs assessments and strategic                    and national and local plans
                      programmes which meet      planning to improve the health of the              Trust contributes information to local PCT health needs
  7 - Public Health

                      the requirements of the    community served                                   assessments.
                      national service
                      frameworks (NSFs) and                                                         Trust representation on NSF groups (Older Persons,
                      national plans with                                                           Children's’, Cardiac, Cancer.
                      particular regard to
                      reducing obesity through                                                      Information on smoking, ethnic status, breast-feeding and
                      action on nutrition and                                                       control of infection available through Clearnet (submitted
                      exercise, smoking,                                                            via STEIS).
                      substance misuse and
                      sexually transmitted

                      23) Healthcare             2. Patients are provided with advice and    Div    PCT commissioning intentions and LDP process                      leaflets in OP
                      organisations have         support along their care pathway in         C.D                                                                      smoking etc information on intranet
                      systematic and managed     relation to public health priority areas,          Initiatives to improve nutrition and health whilst in hospital.   NSF Action plans
                      disease prevention and     including through referral to specialist           Use of community teams to promote health.
                      health promotion           advice and services
                      programmes which meet                                                         Information leaflets and referral mechanisms for drug
  7 - Public Health

                      the requirements of the                                                       dependency and smoking.
                      national service
                      frameworks (NSFs) and                                                         Departmental information boards (e.g. Orthodontics re
                      national plans with                                                           importance of dental hygiene
                      particular regard to
                      reducing obesity through
                      action on nutrition and
                      exercise, smoking,
                      substance misuse and
                      sexually transmitted

                                                                                                          Page 24 of 26
                                                                                                                     Standards for Better Health 07/08                                                                         Appendix B

Domain Core Standard                                                     Element                                    Lead   Assessment                                                       Evidence
                      7 - Public Health
                                          23) Healthcare                 3. The healthcare organisation             J.W    The Trust has pro-active Occupational Health and Infection       Celebrating success awards
                                          organisations have             implements policies and practices to              Control departments who work to improve the health and           flu vac adverts and updates
                                          systematic and managed         improve the health and well being of its          well-being of the workforce.                                     OH annual report
                                          disease prevention and         workforce                                         Staff fast musculoskeletal service                               staff physio evaluation
                                          health promotion                                                                 Counselling                                                      counselling stats
                                          programmes which meet                                                            Occ H&S services SLA                                             improving health and well being
                                          the requirements of the                                                          Annual report July 06 - July 07                                  OHS business plan
                                          national service                                                                 Flu vaccination programme                                        staff fast tract MS service
                                          frameworks (NSFs) and                                                            Promote Smoke Free Policy                                        trust SLA
                                          national plans with                                                              Provide a staff nutrition workshop on site                       staff stress project
                                          particular regard to                                                             Review of substance abuse policy
                                          reducing obesity through                                                         Health Promotion
                                          action on nutrition and                                                          Trial of subsidised therapies / exercise taster sessions
                                          exercise, smoking,                                                               Stress Audit
                                          substance misuse and                                                             Improving Working Lives
                                          sexually transmitted
                                          24) Healthcare                 1. The healthcare organisation has a       JD     The RHCH has a plan for use in the event of a major              Major incident policy.
                                          organisations protect the      planned, prepared and, where possible,            incident occurring in our region, or in support of another       Flu pandemic strategy.
                                          public by having a planned,    practised response to incidents and               hospital experiencing difficulties due to excessive demand       Business Continuity Plan.
                                          prepared and, where            emergency situations (including control           for its services. This plan now includes a policy specifically
                                          possible, practised            of communicable diseases), which                  designed for use in the event of a Chemical Biological,          All available on Trust Intranet.
  7 - Public Health

                                          response to incidents and      includes arrangements for business                Radioactive or Nuclear (CBRN) incident, as well as an
                                          emergency situations,          continuity management, in accordance              internal major incident plan designed to allow the Trust to
                                          which could affect the         with The NHS Emergency Planning                   cope with an incident which does not require this
                                          provision of normal services   Guidance (Department of Health, 2005)             implementation of the full plan but which does require
                                                                         and UK influenza pandemic                         immediate decisions to be made centrally.
                                                                         contingency plan (Department of                   Board approval for the MI plan was due in September;
                                                                         Health, 2005)                                     however, the imminent MI test and its subsequent review
                                                                                                                           delayed this until early in the New Year. The revised plan
                                                                                                                           has been through IGC and goes to the board April 2008.

                                                                                                                                 Page 25 of 26
                                                                                                  Standards for Better Health 07/08                                                  Appendix B

Domain Core Standard                                 Element                                     Lead   Assessment                                                        Evidence

                      24) Healthcare                 2. The healthcare organisation works        JD     The current MI plan was revised in 2005 and draws on
                      organisations protect the      with key partner organisations, including          lessons learned from a test of its CBRN component earlier
                      public by having a planned,    through Local Resilience Forums, in the            that year. The full plan was tested in October 2007 and
                      prepared and, where            preparation of, training for and annual            lessons learned are currently being used to inform a further
                      possible, practised            testing of emergency preparedness                  revision which is due out early in 2008; this will also reflect
                      response to incidents and      plans, in accordance with the Civil                changes to both management and site structure. To
                      emergency situations,          Contingencies Act 2004, The NHS                    ensure that the plan considered multi agency working, the
  7 - Public Health

                      which could affect the         Emergency Planning Guidance 2005,                  recent test involved the police, ambulance service and
                      provision of normal services   Beyond a major incident (Department of             local PCT. In addition, the Trust has a detailed Flu
                                                     Health, 2004) and UK influenza                     pandemic strategy which is continually being updated in
                                                     pandemic contingency plan                          light of ongoing DOH guidance. Again this plan is multi-
                                                     (Department of Health, 2005)                       agency and representatives from the Trust are heavily
                                                                                                        involved in working closely with surrounding Hospital
                                                                                                        Trusts, PCTs, HPA, SHA, County Council, and Ambulance
                                                                                                        Trust.A Business continuity plan is in place to deal with
                                                                                                        unforeseen external problems affecting the smooth running
                                                                                                        of the Trust. All the above plans are available on the trust's

                                                                                                              Page 26 of 26

Description: Sample Flu Shot Consent Form document sample