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Evidence - Patient safety_ safety patient

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					                                                                Draft Position Using Compliance with Prompts for Provided Services
          KEY          No issues, full compliance
                       Non compliance either in April or now
                       Unknown at moment waiting for further information




                                                                                                                                      prompts April 2005



                                                                                                                                                           prompts Oct 2005
                                                                                                                                                             Compliant all
                                                                                                                                         Compliant all




                                                                                                                                                                              Significant
            Standard




                                                                                                                                                                               Breach?
Colour




                                                                                                                    Director
                           Description of Core Standard Element                   Areas of Concern                                                                                                    Action Plan
                                                                                                                  Responsible



         Safety
                       Healthcare organisations protect patients through
                       systems that identify and learn from patient safety
Green




                       incidents or other reportable incidents based on                                        Nursing and Clinical
          C01a         local and national experience and information                     None                                               Y                   Y                N                        N/A
                                                                                                                  Governance
                       derived from the analysis of incidents

                       Ensure that patient safety notices, alerts and other
Green




                       communications concerning patient safety which                                          Nursing and Clinical
          C01b                                                                             None                                             Y                   Y                N                        N/A
                       require action are acted upon within required                                              Governance
                       timescales
                       Healthcare organisations protect children by
Green




                       following national child protection guidelines within                                     Integrated and
           C02                                                                             None                                             Y                   Y                N                        N/A
                       their own activities and in their dealings with other                                      Primary Care
                       organisations
                       Healthcare organisations protect patients by          New NICE policy in place in                                                                                    Communicate with staff through
                       following National Institute for Clinical Excellence June 2005. Requires publicity to   Nursing and Clinical                                                         web, newsletter and emails to
                       (NICE) interventional procedures guidance             ensure that staff know and are       Governance                                                                ensure awareness.
                                                                             acting according to the policy
           C03                                                                                                  Medical Directors
Green




                                                                                                                                           N                    Y                N
                                                                                                                  Director of
                                                                                                                   Service
                                                                                                               Modernisation and
                                                                                                                 Partnership




                                                                                                  Page 1 of 16                                                                                                         8/20/2011
                                                                                                                                     prompts April 2005



                                                                                                                                                          prompts Oct 2005
                                                                                                                                                            Compliant all
                                                                                                                                        Compliant all




                                                                                                                                                                             Significant
          Standard




                                                                                                                                                                              Breach?
Colour




                                                                                                                    Director
                         Description of Core Standard Element                      Areas of Concern                                                                                                   Action Plan
                                                                                                                  Responsible



                     Healthcare organisations keep patients, staff and      Although there is microbiology                                                                                 Discover a source of professional
                     visitors safe by having systems to ensure that the     laboratory support, there is no                                                                                support. The SHA is aware that
                     risk of healthcare acquired infection to patients is   access to an Infection Control                                                                                 this is a sector wide issue.
Green




                     reduced, with particular emphasis on high              Doctor.                           Nursing and Clinical                                                         December 2005.
         C04a                                                                                                                             N                    N                N
                     standards of hygiene and cleanliness, achieving                                             Governance
                     year on year reductions in MRSA

                     Healthcare organisations keep patients, staff and
                     visitors safe by having systems to ensure that all
Green




                                                                                                                  Primary and
         C04b        risks associated with the acquisition and use of                      N/A                                             Y                   Y                N                          N/A
                                                                                                                Integrated Care
                     medical devices are minimised

                      Healthcare organisations keep patients, staff and
                     visitors safe by having systems to ensure that all                                                                                                                    Explore options for obtaining
                     reusable medical devices are properly              No decontamination lead with a
                                                                                                                                                                                           professional support in this area.
                     decontaminated prior to use and that the risks     formal qualification in
                     associated with decontamination facilities and     decontamination.
                                                                                                                                                                                           Possible sector wide
                     processes are well managed                                                                                                                                            decontamination resource to be
                                                                        PCT has no access to a
                                                                                                                                                                                           developed but no plans at the
                                                                        specialist decontamination unit.
                                                                                                                  Primary and                                                              moment.
Red




         C04c                                                                                                                             N                    N                Y
                                                                                                                Integrated Care
                                                                            Not all clinics have separate
                                                                                                                                                                                           Lack of facilities being addressed
                                                                            rooms for decontamination.
                                                                                                                                                                                           through new build and ongoing
                                                                                                                                                                                           improvement plans.
                                                                            Not all GP surgeries have
                                                                            adequate facilities.




                                                                                                   Page 2 of 16                                                                                                         8/20/2011
                                                                                                                                  prompts April 2005



                                                                                                                                                       prompts Oct 2005
                                                                                                                                                         Compliant all
                                                                                                                                     Compliant all




                                                                                                                                                                          Significant
          Standard




                                                                                                                                                                           Breach?
Colour




                                                                                                                Director
                         Description of Core Standard Element                  Areas of Concern                                                                                                    Action Plan
                                                                                                              Responsible



                     Healthcare organisations keep patients, staff and Audits have not taken place on a                                                                                 Regular audits coupled with
                     visitors safe by having systems to ensure that    regular basis and those that                                                                                     ongoing training in this area
                     medicines are handled safely and securely         have show some areas of
                                                                       concern in terms of chill chain                                                                                  Develop programme starting in
                                                                       procedures.                                                                                                      December 2005.

                                                                        Drug administration training has
                                                                                                             Integrated and
Red




         C04d                                                           not been taking place.                                         N                    N                Y
                                                                                                              Primary Care




                     Healthcare organisations keep patients, staff and Waste Management Policy is in                                                                                    Produce policy - November 2005
                     visitors safe by having systems to ensure that the draft form waiting for approval by
                     prevention, segregation, handling, transport and November 2005.
Green




                     disposal of waste is properly managed so as to                                        Nursing and Clinical
         C04e        minimise the risks to the health and safety of staff,                                                             N                    N                N
                                                                                                              Governance
                     patients, the public and the safety of the
                     environment




                                                                                              Page 3 of 16                                                                                                              8/20/2011
                                                                                                                                          prompts April 2005



                                                                                                                                                               prompts Oct 2005
                                                                                                                                                                 Compliant all
                                                                                                                                             Compliant all




                                                                                                                                                                                  Significant
            Standard




                                                                                                                                                                                   Breach?
Colour




                                                                                                                        Director
                            Description of Core Standard Element                     Areas of Concern                                                                                                      Action Plan
                                                                                                                      Responsible



         Clinical and Cost Effectiveness
                   Healthcare organisations ensure that they                  NICE policy and procedures not
                   conform to National Institute for Clinical                 in place until June 2005.            Nursing and Clinical
                   Excellence (NICE) technology appraisals and,                                                       Governance
                   where it is available, take into account nationally
Green




                                                                                                                    Medical Directors
          C05a agreed guidance when planning and delivering                                                                                    N                    Y                N                         N/A
                   treatment and care
                                                                                                                       Service
                                                                                                                   Modernisation and
                                                                                                                     Partnership

                        Healthcare organisations ensure that clinical care There is no formal policy on                                                                                         Develop formal policy -
                       and treatment are carried out under supervision     clinical supervision and there is       Nursing and Clinical                                                         December2005
                       and leadership                                      no way of knowing whether                  Governance                                                                Develop accountability
Red




          C05b                                                             managers are picking up all                                         N                    N                Y          arrangements in line with the
                                                                           clinical supervision with staff           Organisational                                                             policy - December 2005
                                                                                                                     Modernisation

                        Healthcare organisations ensure that clinicians   According to the 2004 Staff                                                                                           Implement the KSF programme to
Orange




                       continuously update skills and techniques relevant Survey, not all staff have had a           Organisational                                                             ensure that all staff have had a
          C05c                                                                                                                                 N                    N                 ?
                       to their clinical work                             PDP.                                       Modernisation                                                              KSF linked PDP by December
                                                                                                                                                                                                2005
                       Healthcare organisations ensure that clinicians        Support for audits is available                                                                                   To ensure that new PCT structure
                       participate in regular clinical audit and reviews of   through the Supporting                                                                                            enables collection of GP
                       clinical services                                      Improvement Group but there is                                                                                    information for auditing purposes
                                                                              a lack of dedicated resource to
                                                                              collect data from GP practices .
Orange




                                                                                                                       Primary and
          C05d                                                                                                                                 N                    N                 ?
                                                                              Don't know if clinical reviews are     Integrated Care
                                                                              informed by comparable clinical
                                                                              data or if this process is
                                                                              documented.




                                                                                                     Page 4 of 16                                                                                                           8/20/2011
                                                                                                                                  prompts April 2005



                                                                                                                                                       prompts Oct 2005
                                                                                                                                                         Compliant all
                                                                                                                                     Compliant all




                                                                                                                                                                          Significant
         Standard




                                                                                                                                                                           Breach?
Colour




                                                                                                                  Director
                        Description of Core Standard Element                    Areas of Concern                                                                                                   Action Plan
                                                                                                                Responsible



                    Healthcare organisations cooperate with each         Not all partners have been                                                                                     Renegotiate financial components
                    other and social care organisations to ensure that   identified and for those that                                                                                  of section 31 agreements without
                    patients’ individual needs are properly managed      have, the process is in it's early                                                                             affecting integration of services.
                    and met                                              stages.                                                                                                        Continue with project plans around
                                                                                                                                                                                        emergency care and Rapid
                                                                         Potential renegotiation of                                                                                     Referral and Discharge.
                                                                         financial elements of Section 31                                                                               Work ongoing at regional level to
                                                                         agreements may impact on                                                                                       develop IT approach for single
Orange




                                                                                                                  Service
         C06                                                             services.                            Modernisation and        N                    N                 ?         assessment processes. Where
                                                                         Some projects are in the early         Partnerships                                                            possible roll out Framework
                                                                         stages - too soon to evaluate                                                                                  system (Social Services IT
                                                                         results.                                                                                                       system) to NHS users. Continue
                                                                         Lack of common IT systems                                                                                      pilot approach using manual
                                                                         hinders development of single                                                                                  systems where necessary.
                                                                         assessment processes.




                                                                                                 Page 5 of 16                                                                                                       8/20/2011
                                                                                                                                    prompts April 2005



                                                                                                                                                         prompts Oct 2005
                                                                                                                                                           Compliant all
                                                                                                                                       Compliant all




                                                                                                                                                                            Significant
            Standard




                                                                                                                                                                             Breach?
Colour




                                                                                                                  Director
                           Description of Core Standard Element                  Areas of Concern                                                                                         Action Plan
                                                                                                                Responsible



         Governance
                Healthcare organisations apply the principles of
                                                                                                               Chief Executive
                sound clinical and corporate governance
Green




          C07a                                                                         None                                               Y                   Y                N             N/A
                                                                                                             Nursing and Clinical
                                                                                                                Governance
                       Healthcare organisations actively support all
                                                                                                               Chief Executive
Green




                       employees to promote openness, honesty,
          C07b                                                                         None                      PCT Chair                Y                   Y                N             N/A
                       probity, accountability, and the economic, efficient
                                                                                                                 PEC Chair
                       and effective use of resources
                       Healthcare organisations undertake systematic
Green




                                                                                                             Nursing and Clinical
          C07c         risk assessment and risk management                             None                                               Y                   Y                N             N/A
                                                                                                                Governance
                       Healthcare organisations challenge discrimination, Diversity Statement and Dignity
Green




                       promote equality and respect human rights          at Work Policy were not in place     Organisational
          C07e                                                                                                                           N                    Y                N             N/A
                                                                          in April. In place September         Modernisation
                                                                          2005.
                       Healthcare organisations support their staff
                       through having access to processes which permit
                       them to raise, in confidence and without
Green




                       prejudicing their position, concerns over any                                           Organisational
          C08a         aspect of service delivery, treatment or                           None                                            Y                   Y                N             N/A
                                                                                                               Modernisation
                       management that they consider to have a
                       detrimental effect on patient care or on the
                       delivery of services




                                                                                                Page 6 of 16                                                                                            8/20/2011
                                                                                                                                   prompts April 2005



                                                                                                                                                        prompts Oct 2005
                                                                                                                                                          Compliant all
                                                                                                                                      Compliant all




                                                                                                                                                                           Significant
          Standard




                                                                                                                                                                            Breach?
Colour




                                                                                                                    Director
                          Description of Core Standard Element                      Areas of Concern                                                                                                 Action Plan
                                                                                                                  Responsible



                     Healthcare organisations support their staff            The staff survey 2004 shows                                                                                  Project underway to improve the
                     through organisational and personal development         only 68% of staff have had a                                                                                PDP process and link it closer to
                     programmes which recognise the contribution and         PDP agreed within the last 12                                                                               the PCT objectives and strategy -
                     value of staff, and address, where appropriate,         months.                                                                                                     September 2005. as part of the
                     under-representation of minority groups                                                                                                                             KSF. . Deadline for all staff to
                                                                                                                                                                                         have personal development plans
Green




                                                                                                                  Organisational                                                         linked to their KSF outline by
         C08b                                                                                                                           N                    N                N
                                                                                                                  Modernisation                                                          December 05. TDS to provide
                                                                                                                                                                                         reports to the Diversity Facilitator
                                                                                                                                                                                         enabling access to training and
                                                                                                                                                                                         development to be scrutinised by
                                                                                                                                                                                         ethnic group.


                     Healthcare organisations have a systematic and          February 2004 self assessment                                                                               Action plans underway to risk
                     planned approach to the management of records           showed the PCT achieving 43%                                                                                assess and improve the lowest
                     to ensure that, from the moment a record is             (THIS WAS THE HIGHEST                                                                                       scoring areas by April 2006.
Green




                     created until its ultimate disposal, the organisation   SCORE IN THE SECTOR)
         C09         maintains information so that it serves the                                                     Finance            N                    N                N
                     purpose it was collected for and disposes of the
                     information appropriately when no longer required

                     Healthcare organisations undertake all
                     appropriate employment checks and ensure that
Green




                                                                                                                  Organisational
         C10a        all employed or contracted professionally qualified                  None                                           Y                   Y                N                          N/A
                                                                                                                  Modernisation
                     staff are registered with the appropriate bodies

                     Healthcare organisations require that all employed
Green




                                                                                                                  Organisational
         C10b        professionals abide by relevant published codes                      None                                           Y                   Y                N                          N/A
                                                                                                                  Modernisation
                     of professional practice
                     Healthcare organisations ensure that staff
                     concerned with all aspects of the provision of
Green




                                                                                                                  Organisational
         C11a        healthcare are appropriately recruited, trained and                  None                                           Y                   Y                N                          N/A
                                                                                                                  Modernisation
                     qualified for the work they undertake




                                                                                                   Page 7 of 16                                                                                                        8/20/2011
                                                                                                                            prompts April 2005



                                                                                                                                                 prompts Oct 2005
                                                                                                                                                   Compliant all
                                                                                                                               Compliant all




                                                                                                                                                                    Significant
          Standard




                                                                                                                                                                     Breach?
Colour




                                                                                                             Director
                         Description of Core Standard Element                Areas of Concern                                                                                     Action Plan
                                                                                                           Responsible



                     Healthcare organisations ensure that staff       Fire training was now
                     concerned with all aspects of the provision of   incorporated into the overall PCT
                     healthcare participate in mandatory training     reporting system.
                     programmes
                                                                      Risk Assessment of reducing
                                                                      requirements within the
Green




                                                                      Mandatory Training Policy            Organisational
         C11b                                                                                                                    N                    Y                N             N/A
                                                                      underway.                            Modernisation

                                                                      Non attendees for core
                                                                      mandatory courses now being
                                                                      chased up and reported to
                                                                      managers.




                                                                                            Page 8 of 16                                                                                        8/20/2011
                                                                                                                                    prompts April 2005



                                                                                                                                                         prompts Oct 2005
                                                                                                                                                           Compliant all
                                                                                                                                       Compliant all




                                                                                                                                                                            Significant
          Standard




                                                                                                                                                                             Breach?
Colour




                                                                                                                  Director
                         Description of Core Standard Element                    Areas of Concern                                                                                                    Action Plan
                                                                                                                Responsible



                     Healthcare organisations ensure that staff           The staff survey 2004 shows                                                                                     The PCT is still awaiting to hear if
                     concerned with all aspects of the provision of       only 68% of staff have had a                                                                                    funds are available from the SHA
                     healthcare participate in further professional and   PDP agreed within the last 12                                                                                   for the current financial year.
                     occupational development commensurate with           months.                                                                                                         Uncertain whether historical
                     their work throughout their working lives                                                                                                                            streams of funding will continue
                                                                          Funding has been restricted to                                                                                  beyond 01-04-06
                                                                          only essential clinical external                                                                                Co-ordinate the TNA with Annual
                                                                          courses.                                                                                                        Development Plans. Refine
                                                                                                                                                                                          systems for identifying and
                                                                                                                                                                                          collating training needs. Develop
                                                                                                                                                                                          integrated plans which are
                                                                                                                                                                                          appraised by the Management
                                                                                                                                                                                          Team. Linking to systems related
Green




                                                                                                                Organisational                                                            to the KSF and ESR Apr 2006
         C11c                                                                                                                            N                    N                N
                                                                                                                Modernisation                                                             Change culture to increasingly
                                                                                                                                                                                          value and exploit both formal and
                                                                                                                                                                                          informal development routes.
                                                                                                                                                                                          opportunities. This will help
                                                                                                                                                                                          people appreciate development
                                                                                                                                                                                          opportunities which do not require
                                                                                                                                                                                          hard cash as in an external
                                                                                                                                                                                          training course.




                     Healthcare organisations which either lead or
                     participate in research have systems in place to
Green




                                                                                                             Nursing and Clinical
         C12         ensure that the principles and requirements of the                 None                                              Y                   Y                N                          N/A
                                                                                                                Governance
                     research governance framework are consistently
                     applied




                                                                                                 Page 9 of 16                                                                                                           8/20/2011
                                                                                                                                            prompts April 2005



                                                                                                                                                                 prompts Oct 2005
                                                                                                                                                                   Compliant all
                                                                                                                                               Compliant all




                                                                                                                                                                                    Significant
            Standard




                                                                                                                                                                                     Breach?
Colour




                                                                                                                          Director
                           Description of Core Standard Element                       Areas of Concern                                                                                                       Action Plan
                                                                                                                        Responsible



         Patient Focus
                  Healthcare organisations have systems in place               No policy or guidance in place                                                                                     Write policy in line with Essence of
                  to ensure that staff treat patients, their relatives         for treating patients with dignity,                                                                                Care guidance
                                                                                                                       Organisational
Red




          C13a and carers with dignity and respect                             privacy and respect.                                              N                    N                Y          Training to be incorporated into
                                                                                                                       Modernisation
                                                                                                                                                                                                  Communications Training

                       Healthcare organisations have systems in place          Training was not in place in April,
                       to ensure that appropriate consent is obtained          starting Autumn 2005. No audits
                                                                                                                   Nursing and Clinical
Red




          C13b         when required, for all contacts with patients and       of who has taken consent from                                     N                    Y                Y                          N/A
                       for the use of any confidential patient information     patients.                              Governance


                       Healthcare organisations have systems in place          February 2004 self assessment                                                                                      To improve score by April 2006.
                       to ensure that staff treat patient information          showed the PCT achieving 71%
Green




                       confidentially, except where authorised by              for confidentiality in the            Nursing and Clinical
          C13c         legislation to the contrary                             Information Governance toolkit.                                   N                    Y                N
                                                                                                                        Governance


                       Healthcare organisations have systems in place No information on the prompts,
                       to ensure that patients, their relatives and carers but scored as 1 out of 5 on the
Orange




                       have suitable and accessible information about,     Assurance Framework.                      Nursing and Clinical
          C14a         and clear access to, procedures to register formal                                                                         ?                   ?                 ?
                                                                                                                        Governance
                       complaints and feedback on the quality of
                       services
                       Healthcare organisations have systems in place
Green




                       to ensure that patients, their relatives and carers                                           Nursing and Clinical
          C14b                                                                                None                                                Y                   Y                N                          N/A
                       are not discriminated against when complaints are                                                Governance
                       made
                       Healthcare organisations have systems in place
                       to ensure that patients, their relatives and carers )
Green




                       are assured that organisations act appropriately                                              Nursing and Clinical
          C14c         on any concerns and, where appropriate, make                           None                                                Y                   Y                N                          N/A
                                                                                                                        Governance
                       changes to ensure improvements in service
                       delivery




                                                                                                       Page 10 of 16                                                                                                           8/20/2011
                                                                                                                                      prompts April 2005



                                                                                                                                                           prompts Oct 2005
                                                                                                                                                             Compliant all
                                                                                                                                         Compliant all




                                                                                                                                                                              Significant
          Standard




                                                                                                                                                                               Breach?
Colour




                                                                                                                    Director
                          Description of Core Standard Element                      Areas of Concern                                                                                                  Action Plan
                                                                                                                  Responsible



                     Where food is provided, healthcare organisations
                     have systems in place to ensure that patients are
Green




                                                                       Wards did not have                          Primary and
         C15a        provided with a choice and that it is prepared                                                                        N                    Y                N                        N/A
                                                                       housekeepers in April 2005.               Integrated Care
                     safely and provides a balanced diet

                     Where food is provided, healthcare organisations
                     have systems in place to ensure that patients’
Green




                     individual nutritional, personal and clinical dietary                                         Primary and
         C15b        requirements are met, including any necessary                        None                                              Y                   Y                N                        N/A
                                                                                                                 Integrated Care
                     help with feeding and access to food 24 hours a
                     day
                     Healthcare organisations make information               Not all prompts have been                                                                                      Once guidance on providing
                     available to patients and the public on their           completed for this standard.                                                                                   patient information is fully
                     services, provide patients with suitable and            Scored as 3 out of 5 on                                                                                        embedded, begin auditing patient
                     accessible information on the care and treatment        Assurance Framework.                Chief Executive                                                            information
Orange




                     they receive and, where appropriate, inform
         C16         patients on what to expect during treatment, care       No central system for monitoring   Director of Nursing         ?                   ?                 ?
                     and after care                                          quality, availability and              and Clinical
                                                                             accessibility of information          Governance
                                                                             provided to patients




                                                                                                  Page 11 of 16                                                                                                        8/20/2011
                                                                                                                           prompts April 2005



                                                                                                                                                prompts Oct 2005
                                                                                                                                                  Compliant all
                                                                                                                              Compliant all




                                                                                                                                                                   Significant
            Standard




                                                                                                                                                                    Breach?
Colour




                                                                                                             Director
                       Description of Core Standard Element                  Areas of Concern                                                                                               Action Plan
                                                                                                           Responsible



         Accessible and Responsive Care
                 The views of patients, their carers and others are   Not all prompts have been                                                                                  Include patient views in next
Orange




                                                                                                          Service
                 sought and taken into account in designing,          completed for this standard.                                                                               edition of the Annual Prospectus
           C17                                                                                        Modernisation and          ?                   ?                 ?
                 planning, delivering and improving healthcare        Scored as 2 out of 5 on                                                                                    of provided services- April 2006
                                                                                                        Partnerships
                 services                                             Assurance Framework.
                 Healthcare organisations enable all members of       Not all prompts have been        Integrated and                                                            Regular assessment and reporting
                 the population to access services equally and        completed for this standard.      Primary Care                                                             by the DPH on equality.
                 offer choice in access to services and treatment     Scored as 2 out of 5 on
Orange




                 equitably                                            Assurance Framework.                Service                                                                Improve Guide to Local Services -
           C18                                                                                                                   ?                   ?                 ?         May 2006
                                                                                                      Modernisation and
                                                                                                        Partnership

                                                                                                           Public Health




                                                                                           Page 12 of 16                                                                                                     8/20/2011
                                                                                                                         prompts April 2005



                                                                                                                                              prompts Oct 2005
                                                                                                                                                Compliant all
                                                                                                                            Compliant all




                                                                                                                                                                 Significant
            Standard




                                                                                                                                                                  Breach?
Colour




                                                                                                          Director
                           Description of Core Standard Element             Areas of Concern                                                                                   Action Plan
                                                                                                        Responsible



         Care Environment and Amenities
                 Healthcare services are provided in environments
                 which promote effective care and optimise health                                 Nursing and Clinical
                                                                                                     Governance
Green




                 outcomes by being a safe and secure
          C20a environment which protects patients, staff, visitors              None                                          Y                   Y                N             N/A
                 and their property, and the physical assets of the                                   SSP Chief
                 organisation                                                                      Operating Officer

                       Healthcare services are provided in environments                           SSP Chief Operating                                                             N/A
                       which are supportive of patient privacy and                                     Officer
Green




          C20b         confidentiality                                           None                                          Y                   Y                N
                                                                                                      Primary and
                                                                                                    Integrated Care
                       Healthcare services are provided in environments
                       which promote effective care and optimise health
                       outcomes by being well designed and well
Green




                       maintained with cleanliness levels in clinical and                         Nursing and Clinical
           C21                                                                   None                                          Y                   Y                N             N/A
                       non-clinical areas that meet the national                                     Governance
                       specification for clean NHS premises




                                                                                        Page 13 of 16                                                                                        8/20/2011
                                                                                                                                 prompts April 2005



                                                                                                                                                      prompts Oct 2005
                                                                                                                                                        Compliant all
                                                                                                                                    Compliant all




                                                                                                                                                                         Significant
            Standard




                                                                                                                                                                          Breach?
Colour




                                                                                                                 Director
                           Description of Core Standard Element                Areas of Concern                                                                                                    Action Plan
                                                                                                               Responsible



         Public Health
                  Healthcare organisations promote, protect and         Information on Public Health is
                  demonstrably improve the health of the                not widely distributed in the
                  community served, and narrow health inequalities      community.
                  by) cooperating with each other and with local
                  authorities and other organisations) making an        National and local healthcare
                  appropriate and effective contribution to local       concerns are not discussed with                                                                                Improve distribution, possibly
                  partnership arrangements including local strategic    the acute trusts.                                                                                              using the website.
                  partnerships and crime and disorder reduction
          C22a partnerships
Red




                                                                        Resources limit the possibility of     Public Health          N                    N                Y          Improve links with acute trusts.
          C22c                                                          giving monies to joint working
                                                                        projects.                                                                                                      Strengthen monitoring from the
                                                                                                                                                                                       SHA.
                                                                        Ad hoc external monitoring by
                                                                        the SHA as opposed to regular
                                                                        reviews.



                       Healthcare organisations promote, protect and     SLA with providers are not                                                                                    Include Public Health report
                       demonstrably improve the health of the            based on Public Health data.          Public Health                                                           findings in future service level
                       community served, and narrow health inequalities                                                                                                                agreements
Red




          C22b         by ensuring that the local Director of Public                                                                  N                    N                Y
                                                                                                             Modernisation and
                       Health’s annual report informs their policies and                                       Partnership
                       practices




                                                                                               Page 14 of 16                                                                                                         8/20/2011
                                                                                                                               prompts April 2005



                                                                                                                                                    prompts Oct 2005
                                                                                                                                                      Compliant all
                                                                                                                                  Compliant all




                                                                                                                                                                       Significant
         Standard




                                                                                                                                                                        Breach?
Colour




                                                                                                                 Director
                        Description of Core Standard Element                     Areas of Concern                                                                                               Action Plan
                                                                                                               Responsible



                    Healthcare organisations have systematic and          Contracts, SLAs and direct                                                                                 Strengthen links with
                    managed disease prevention and health                 provision do not meet the                                                                                  commissioning.
                    promotion programmes which meet the                   disease prevention and health
                    requirements of the national service frameworks       promotion aspects of NSFs and
                    (NSFs) and national plans with particular regard to   national plans, as not based on
                    reducing obesity through action on nutrition and      local need.
                    exercise, smoking, substance misuse and
                    sexually transmitted infections                       Not including a requirement to
                                                                          support healthy lifestyles among
Red




         C23                                                              staff employed by it's               Public Health        N                    N                Y
                                                                          commissioned providers.

                                                                          Links between public health
                                                                          specialists and the
                                                                          commissioning department
                                                                          within the PCT are not strong
                                                                          enough.


                    Healthcare organisations protect the public by
                    having a planned, prepared and, where possible,
Green




                                                                                                               Primary and
         C24        practised response to incidents and emergency                      None                                          Y                   Y                N                         N/A
                                                                                                             Integrated Care
                    situations which could affect the provision of
                    normal services




                                                                                               Page 15 of 16                                                                                                  8/20/2011
Standard                    Evidence Required           From Whom
C04e     SLA with SSP to handle waste was agreed when

				
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