Webforms Output: Core standards declaration 2007/2008 May 2008

Transcription

1 Inspecting Informing Improving Webforms Output: Core standards declaration 2007/2008 May 2008 Generated 01/05/08 by Neil Carr Form: FRM-12, Response: FRR-6BC - Page 1 -

2 Confirmation * Please enter the postcode for your organisation. This must be in capital letters and be in the format EC1Y 8TG. This is the information that we have for your organisation. If this information is incorrect please contact the Healthcare Commission at forms@healthcarecommission.org.uk Organisation Name: South Staffordshire And Shropshire Healthcare NHS Foundation Trust Chief Executive's First Name: Neil Chief Executive's Surname: Carr Chief Executive's neil.carr@ssh-tr.nhs.uk Organisation Code: RRE If your organisation is any of the following please select the option PCT or Community Trust: PCT Community Trust PCT with Mental Health Care Trust with PCT If your organisation is any of the following please select the option Mental Health or Learning Disability Mental Health Learning Disability Care Trust with Mental Health * Please enter your type of organisation O Acute O Mental Health/Learning Disability O PCT O Ambulance O Isle of Wight NHS PCT O NHS Direct O Health Protection Agency O NHS Blood and Transplant - Page 2 -

3 Guidance General Guidance You might find it helpful to print the following instructions (a printable version is available here) so you can refer to them easily while you are completing the declaration form. The declaration form is divided into the following sections: 1. General statement of compliance 2. Statement on measures in place to meet the provisions of the Hygiene Code 3. Domain pages for core standards 4. Sign off 5. Comments from third parties Your declaration will be the basis of your score for the assessment of core standards. For core standards, your declaration should cover the period from April 1st 2007 to March 31st The statement on the Hygiene Code should set out whether the appropriate measures are in place to ensure that the provisions of the Hygiene Code were being observed during 2007/2008. There will not be a specific developmental standards assessment as part of the 2007/2008 annual health check. Instead, we will issue a small set of comparative, or benchmark, indicators to trusts to show their position relative to similar trusts within specific domains (safety, clinical and cost effectiveness or public heath). We expect that trust boards will use this information along with the local data that trusts already use when reviewing their performance and considering their compliance with the core standards. Please note you are only able to access sections applicable to your trust type. 1. General statement of compliance The general statement is an opportunity for trusts to place in context the detail of the domain pages and the comments received from the specified third parties. Each trust should use the general statement of compliance to present a summary of its declaration. It is important for the statement to be consistent with the detail presented in the rest of the declaration. 2. Statement on measures in place to meet the Hygiene Code Trusts are asked to provide a short statement outlining whether the trust considers it has appropriate measures in place to ensure that the provisions of the Hygiene Code were being observed during March 2007/ This year, we have been inspecting acute trusts as part of our duty under the Hygiene Code. If you have the results of a Hygiene Code inspection, you must include a short summary of the findings and any actions taken as a result of the inspection. This statement is also intended to provide assurance to patients and the public that trusts have taken due account of their new duties under the Code. Please note - the Health Protection Agency and NHS Direct are not required to provide a statement on measures in place to meet the Hygiene Code. 3. Domain pages for core standards Separate sections have been set up for each domain. For each part standard (for example, C7b), you must categorise your trust under one of the following headings: Compliant - a declaration of 'compliant' should be used where a trust's board determines that it has had 'reasonable assurance' that it has been meeting a standard, without significant lapses, from April 1st 2007 to March 31st Not met - a declaration of 'not met' should be used where the assurances received by the trust's board make it clear that there has been one or more significant lapses in relation to a standard during the year. Insufficient assurance - a declaration of 'insufficient assurance' should be used where a lack of assurance leaves the trust's board unclear as to whether there have been any significant lapses during 2007/2008. Please note, in circumstances where a trust is unclear about compliance for a whole year but has good evidence about the occurrence a significant lapse during the year, the trust should consider whether a declaration of 'not met' is more appropriate. For each standard, the boards of trusts need to decide whether any identified lapses are significant or not. In making this decision, we anticipate that boards will consider any potential risks to patients, staff and the public, and the duration and impact of the lapse. The declaration should not be used for reporting isolated, trivial or purely technical lapses in respect of the core standards. If one or more standards within a domain is declared as 'not met' or 'insufficient assurance', please record the details for each of these standards, including the following items of information: Start date - the date at the start of the period for which the trust has: - identified a lack of assurance to determine whether there have been any significant lapse(s) or - identified one or more significant lapses which means that the trust has not met the standard End date (planned or actual) - the date by which the trust plans to have: - assurances in place to enable it to determine whether the standard has been met or - addressed the issues identified as one or more significant lapse(s) Issue - a statement detailing: - why the trust does not have assurance to determine their level of compliance or - the details of the significant lapse(s) that have been identified - Page 3 -

4 Guidance Action plan - an outline of the steps the trust is taking, or has taken, to: - address an issue of 'insufficient assurance' (that is, the actions in place to gain assurances of whether or not the trust is meeting the standard) or - address an issue of 'not met' (that is, the actions in place to address the areas for which the trust has identified one or more significant lapse(s)) This year, where applicable, we will ask you for additional information where: - the standard was declared as 'not met' or insufficient assurance' in 2006/2007 and - there was an action plan with an end date before 31st March 2007 and - the standard has again been declared as 'not met' or 'insufficient assurance' for 2007/08. Please describe the circumstances for this second consecutive declaration of non-compliance in light of the action plan. Some standards are not included in the declaration, as separate assessments for them are being undertaken elsewhere in our overall assessment process or where these have been judged to not be applicable to the trust type. These standards are: C7d - this relates to financial management and will be measured through the use of resources assessment for which we will rely on the findings of the Audit Commission or Monitor. C7f - this relates to existing performance requirements and will be measured through the existing targets assessment. C19 - this relates to access to services with nationally agreed timescales and will be measured through the existing targets and new national targets assessments. In addition there are standards which are not applicable for certain trust types and as such will only be shown on the declaration form where applicable: C3 - regarding NICE interventional procedures, we are not assessing ambulance trusts, mental health services, primary care trusts and learning disability services on this standard for 2007/2008. C4c - regarding reusable medical devices, we are not assessing ambulance trusts, mental health services and learning disability services on this standard for 2007/2008. C15a and C15b - regarding provision of food for patients, we are not assessing ambulance trusts on these standards. C22b - regarding local health needs, we are not assessing acute trusts, ambulance trusts, mental health services and learning disability services on this standard for 2007/2008 HPA / NHSD and NHSBT - Some standards are not included in the declaration for your trust. These will have been agreed with you and the reasons for their exclusion are documented on our website 4. Sign off The Healthcare Commission recommends that all members of the trust board, including the non-executive directors (for foundation trusts this should be the board of directors), should sign off the declaration in the space provided below. Here, sign off is achieved by recording the name(s) and position(s) of the individual(s) concerned. We do not require scanned signatures. As a minimum, we require the declaration to be signed off by an appropriate officer(s) with delegated authority from the board. The completion of the sign off page will be taken as verification that the individual(s) who are recorded as signing off the declaration have reviewed the contents of the declaration form and are certifying that: - the general statement of compliance, and information provided for each standard, are a true representation of the trust's compliance for the core standards - the statement of the measures in place to meet the requirements of the Hygiene Code are a true representation of the trust's position - any commentaries provided by specified third parties have been reproduced verbatim. Specific third parties are: strategic health authority, and foundation trust board of governors, where relevant, and patient and public involvement forums and overview and scrutiny committees - they are signing off the declaration form on their behalf and with delegated authority on behalf of all members of the trust board as referred to above 5. Comments from specified third parties Trusts are required to invite comments on their performance against the core standards, from specified third parties. These comments must be reproduced verbatim in the relevant sections of the form. The specified partners are: - for all NHS trusts, except foundation trusts, third parties must include the strategic health authority, the local authority's overview and scrutiny committee, the trust's patient and public involvement forum and the local safeguarding children board - for foundation trusts, third parties must include the local authority's overview and scrutiny committee, the patient and public involvement forum and the local safeguarding children board. We also encourage foundation trusts to seek, if they wish, comments from their board of governors and strategic health authority - Page 4 -

5 Guidance - for the Health Protection Agency, NHS Direct and the NHS Blood and Transplant, organisations are required to invite comments on their performance against the core standards from specified third parties. These have been agreed with you. These comments must be reproduced verbatim in the relevant sections of the form. At the top of the section, please record the name of the commentator. A trust may have more than one overview and scrutiny committee within its catchment area. If this is the case, it should invite comments from those committees it deems most relevant. In addition, a committee may specifically ask to comment on the performance of a trust against core standards. Where this is the case, the trust should accept comments from such a committee and include them on their declaration form. In some locations, overview and scrutiny committees will have joint working arrangements. Where this is the case, the trust may wish to use those arrangements to gain comment. Where a specified local partner declines to comment, a statement to this effect must be included in the declaration, along with any reasons cited by the local partner for their lack of comment. Please note that Frequently Asked Questions are available by clicking the link within the 'Completer Information' section. - Page 5 -

6 General statement of compliance General statement of compliance * Please enter your general statement of compliance in the text box provided. There is no word limit on this answer. The Board of South Staffordshire and Shropshire Healthcare NHS Foundation Trust is very pleased to declare full compliance with all core standards in its first year of operation after integrating its services across two counties. You will read in the following section that we are taking full account of our duties under the Hygiene Code, and in later sections that our Board has determined it is satisfied that there have been no significant lapses against any core standard during the year. (Please note, the year represents 1st Aril 2007 to 1st June 2007 as South Staffordshire Healthcare NHS Foundation Trust and 1st June 2007 to 31st March 2008 as South Staffordshire and Shropshire Healthcare NHS Foundation Trust.) The year of integration has generated much creativity and hard work from everyone. Integration has provided many opportunities to take a long hard look at what best practice might mean by using the experiences in all our geographical areas to develop what being "Better Together" actually means. Working on a development agenda at the same time as sustaining core standards has been a challenging balancing act with many positive outcomes. Our declaration is just one of them. Our Oversee and Scrutiny Committee feedback is pleasing to us and provides evidence of continued engagement. Their contributions to debates about broad strategic issues facing the development of services across the health economies have been welcomed by the Board, and it is encouraging to note they will be picking up some of our member governors priority planning issues for wider debate. Additionally, interest in specific projects to give service users more meaningful choice has given a boost to our processes. We maintain a developmental approach to performance management in the Trust and work with our partners to improve wherever we can. As South Staffordshire Healthcare NHS Foundation Trust, we scored a positive rating from our external PEAT assessment on food quality, but we took seriously last year's public and patient involvement forum commentary expressing concerns over the consistency of food quality or choice between our services. This has been referred to in our feedback from PPI partners in the section "Comments from specified third parties". We acknowledged their concerns and worked with PPI partners, service users and staff to explore different options which have been agreed by the Board. Now both staff and service users are looking forward to greater consistency in quality and choice of menu. This year, although not required to comment, our membership council has taken a strong lead in developing their own feedback approach to us. Members input a huge amount of time into championing a range of improvements to our current and potential services. We are keen that their roles allow them to be both a support and a realistic challenge for us: their commentary, recorded at the end of this submission does both these. We are positive that their commentary will enable us to continue focusing our energies in the right places and to work in partnerships with commissioners and other providers to explore how our local community plans to meet needs for further specialist service developments. Specialist services such as for people with autistic spectrum disorder (particularly Asperger's syndrome), as mentioned in the member governor commentary, are not currently provided by the Trust. In terms of improving access to psychological therapies, we were recently pleased to have been successful in our partnership bid with Shropshire County PCT to resource exploration of a joint way forward. Our new Director of Psychological Services will join us in the summer and will take a lead role in improving access to psychological therapies across all our services. If you would like any further information about the assurance processes we have in place to enable us to declare ourselves fully compliant, please contact us through the Chief Executive's office. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 6 -

7 Hygiene code Statement on measures to meet the Hygiene Code * Please enter this statement in the box provided. There is no word limit on this answer. The Trust has adopted the commitments of A Matrons's Charter. The 10 broad commitments and responsibilities are undertaken by senior sisters and charge nurses in the organisation. This work is supported through the Clinical Standards monthly meeting which include representatives from clinical areas and Facilities and Estates. The Trust has implemented the duties of the Health Act 2006 Code of Practice for the Prevention and Control of Healthcare Associated Infections. Duty 4 of the Code and the associated lines of enquiry are met. The Trust's audit programme and action plans are addressed at the Infection Control Committee, the Clinical Standards and Facilities and Estates Infection Control group meetings. Matters concerning decontamination are addressed at the Medical Devices meeting and the Infection Control Committee. The Director of Infection Prevention and Control (DIPCI) is an Executive member of the Trust Board. The Trust Board receives monthly reports on incidents of infections and mandatory training attendance data. The Trust reviewed its management of infection control against the recommendations in the Investigation into Outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust. The Trust's action plan following this review is also submitted monthly to the Board. The Trust has had no cases of Clostridium difficile or MRSA bacteraemia and as a result does not have a local Strategic Health Authority target to meet. High standards of hygiene and cleanliness are maintained across the organisation and are monitored through audit programmes. These include the infection control annual audit, hand hygiene audit, PEAT assessments and audits of national cleaning standards. Only single use items are used throughout the Trust. Decontamination facilities are therefore not required. All matters relating to medical devices including training and purchase of items are addressed at the Medical Devices meeting. Representatives from the Medical Devices meeting are members of the Infection Control Committee. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 7 -

8 Safety domain Please note some standards may not appear on the declaration form as they are not applicable to your trust type. Please refer to the guidance for further information. Safety domain - core standards (C1a - C3) Please declare your trust's compliance with each of the following standards: * C1a: Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents. * C1b: Healthcare organisations protect patients through systems that ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales. * C2: Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations. Safety domain - core standards (C4a - C4e) Please declare your trust's compliance with each of the following standards: * C4a: Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA). - Page 8 -

9 Safety domain * C4b: Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised. * C4d: Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely. * C4e: Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 9 -

10 Clinical and cost effectiveness domain Clinical and cost effectiveness domain - core standards (C5a - C6) Please declare your trust's compliance with each of the following standards: * C5a: Healthcare organisations ensure that they conform to National Institute for Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care. * C5b: Healthcare organisations ensure that clinical care and treatment are carried out under supervision and leadership. * C5c: Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work. * C5d: Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services. * C6: Healthcare organisations cooperate with each other and social care organisations to ensure that patients' individual needs are properly managed and met. - Page 10 -

11 Clinical and cost effectiveness domain There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 11 -

12 Governance domain Governance domain - core standards (C7a - C9) Please note some core standards do not appear on the declaration form as they are assessed through other components of the annual health check: Standard C7f is assessed through the existing targets component of the annual health check. Standard C7d is assessed through our use of resources component which uses information from assessments undertaken by the Audit Commission and Monitor. Standards C7f and C7d are not applicable to the Health Protection Agency, NHS Direct or NHS Blood and Transplant. Please declare your trust's compliance with each of the following standards: * C7a and C7c: Healthcare organisations apply the principles of sound clinical and corporate governance and Healthcare organisations undertake systematic risk assessment and risk management. * C7b: Healthcare organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources. * C7e: Healthcare organisations challenge discrimination, promote equality and respect human rights. * C8a: Healthcare organisations support their staff through having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services. - Page 12 -

13 Governance domain * C8b: Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups. * C9: Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required. Governance domain - core standards (C10a - C12) Please declare your trust's compliance with each of the following standards: * C10a: Healthcare organisations undertake all appropriate employment checks and ensure that all employed or contracted professionally qualified staff are registered with the appropriate bodies. * C10b: Healthcare organisations require that all employed professionals abide by relevant published codes of professional practice. * C11a: Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare are appropriately recruited, trained and qualified for the work they undertake. - Page 13 -

14 Governance domain * C11b: Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in mandatory training programmes. * C11c: Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in further professional and occupational development commensurate with their work throughout their working lives. * C12: Healthcare organisations which either lead or participate in research have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 14 -

15 Patient focus domain Please note some standards may not appear on the declaration form as they are not applicable to your trust type. Please refer to the guidance for further information. Patient focus domain - core standards (C13a - C14c) Please declare your trust's compliance with each of the following standards: * C13a: Healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect. * C13b: Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all contacts with patients and for the use of any confidential patient information. * C13c: Healthcare organisations have systems in place to ensure that staff treat patient information confidentially, except where authorised by legislation to the contrary. * C14a: Healthcare organisations have systems in place to ensure that patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services. * C14b: Healthcare organisations have systems in place to ensure that patients, their relatives and carers are not discriminated against when complaints are made. - Page 15 -

16 Patient focus domain * C14c: Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery. Patient focus domain - core standards (C15a - C16) Please declare your trust's compliance with each of the following standards: * C15a: Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet. * C15b: Where food is provided, healthcare organisations have systems in place to ensure that patients' individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day. * C16: Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care. - Page 16 -

17 Patient focus domain There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 17 -

18 Accessible and responsive care domain Accessible and responsive care domain - core standards (C17 - C18) Some core standards do not appear on the declaration form as they are assessed through other components of the annual health check. Standard C19 is assessed through the existing targets component of the annual health check. Please declare your trust's compliance with each of the following standards: * C17: The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services. * C18: Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 18 -

19 Care environment and amenities domain Please note some standards may not appear on the declaration form as they are not applicable to your trust type. Please refer to the guidance for further information. Care environment and amenities domain - core standards (C20a - C21) Please declare your trust's compliance with each of the following standards: * C20a: Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation. * C20b: Healthcare services are provided in environments which promote effective care and optimise health outcomes by being supportive of patient privacy and confidentiality. * C21: Healthcare services are provided in environments which promote effective care and optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 19 -

20 Public health domain Please note some standards may not appear on the declaration form as they are not applicable to your trust type. Please refer to the guidance for further information. Public health domain - core standards (C22a - C24) Please declare your trust's compliance with each of the following standards: * C22a and C22c: Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organisations and healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by making an appropriate and effective contribution to local partnership arrangements including local strategic partnerships and crime and disorder reduction partnerships. * C23: Healthcare organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the national service frameworks (NSFs) and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections. * C24: Healthcare organisations protect the public by having a planned, prepared and, where possible, practised response to incidents and emergency situations, which could affect the provision of normal services. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 20 -

21 Electronic sign off page Electronic sign off page The Healthcare Commission recommends that all members of the trust board, including the non-executive directors (for foundation trusts this should be the board of directors) should sign off the declaration in the space provided below. Here, sign off is achieved by recording the name(s) and position(s) of the individual(s) concerned. We do not require scanned signatures. As a minimum, we require the declaration to be signed off by an appropriate officer(s) with delegated authority from the board. The completion of the sign off page will be taken as verification that the individual(s) who are recorded as signing off the declaration have reviewed the contents of the declaration form and are certifying that: - the general statement of compliance, and information provided for each standard, are a true representation of the trust's compliance - the statement on measures to meet the Hygiene Code are a true representation of the trust's position - any commentaries provided by specified third parties have been reproduced verbatim. Specified third parties are: strategic health authority, foundation trust board of governors (where relevant), patient and public involvement forums, overview and scrutiny committees and local safeguarding children boards - they are signing off the declaration form on their behalf and with delegated authority on behalf of all members of the trust board as referred to above. Electronic sign off - details of individual(s) Title: Full name: Job title: 1 Mr Neil Carr Chief Executive Officer 2 Ms Jayne Deaville Director of Finance & Performance 3 Mr Richard Beeken Chief Operating Officer 4 Dr Simon Smith Medical Director 5 Dr Neil Brimblecombe Director of Nursing, Research & Development 6 Mr Steve Jones Chair 7 Ms Eleanor Chumley-Roberts Non-Executive Director 8 Mr Roger Craven Non-Executive Director 9 Mr Peter Woolrich Non-Executive Director 10 Ms Susie Green Non-Executive Director 11 Professor Roger Evans Non-Executive Director There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 21 -

22 Comments from specified third parties Comments from specified third parties Please enter the comments from the specified third parties below. * Please enter the name of the strategic health authority that has provided the commentary West Midlands Strategic Health Authority * Strategic health authority comments. There is no word limit on this answer. Our SHA was invited to comment if they would so wish. At the time of submission, no comment had been received. * Please enter the name of the patient and public involvement forum that has provided the commentary South Staffordshire Public and Patient Involvement Forum * Patient and public involvement forum comments. There is no word limit on this answer. - Page 22 -

23 Comments from specified third parties Staffordshire PPI Forum Comments on S4BH 2008 C1a: The Trust has taken action by suspending staff when an incident was reported on an Older Adult Ward in September Forum members and the general public were unaware of the issues surrounding the incident and suspensions, as it was a matter subject to police investigation. Members have asked for information at regular intervals. There has been a briefing note in Trust Board minutes and newspaper articles C1b: A press release was issued on the 1st February which made assurances that an internal investigation would be carried out. Members anticipate that any changes in practice (if required) following this investigation, will be made known to the public and carers. C4a: Forum members were involved in PEAT inspections in February 2008 which enabled them to inspect wards with staff to access whether wards were clean. Outcomes from these visits will be contained in the report which will be published after 31st March C13a: Forum members visited wards and talked to patients as part of the Care Watch survey in March The Final report was issued in April 2007 and included the findings from this survey, although it did not include specific comments from patients from South Staffordshire Healthcare NHS Foundation Trust C14a: Members have seen evidence that the PALS complaints system has been used by patients who were not satisfied with food on the Stafford site when they have visited wards. These issues were reported to the Trust Board. There is also a complaints system of reporting food concerns in Coton House using a book. This system was incomplete and may have meant that all issues were not followed up appropriately. C15a: Forum members have visited all wards on the three Staffordshire sites following the publication of the Food Watch Report in September The Forum continued to look at food provision on each of them during Examples of excellent provision have been found on a small number of wards with major concerns on others. Patients and staff have contributed when members have visited the wards. There are many examples of a lack of choice for certain patients with spilt or spoilt food, this often adds to an already unbalanced diet because items were missed when food was delivered. This may improve because of the introduction of Cook and Chill food on the Stafford site from April. Members do however have concerns that at least one example of food service may be lost if all sites are made to standardize the way food is prepared and served from 1st April Members of staff on one ward visited in January had not been told officially that the food would change to Cook and Chill from the 1st April 2008 and if this does not happen better choice is likely to continue for patients. Members have attended Food meetings where there should have been an attempt to rectify food concerns. These meetings have often been poorly attended by staff and patients. They have been cancelled without prior notice. Minutes have not been prepared and distributed, and follow up actions not always completed. The monitoring of the contract with Mid Staffordshire Hospitals Trust and the follow up of any missing food items has not been carried out efficiently by the staff from the Estates department. The introduction of Cook and Chill food on the Stafford site from 1st April 2008 will only work if action is taken to tighten up on daily issues before they become PALS issues or formal complaints. Balanced diets will only happen if patients receive what they order. This has not consistently happened in the past. C15b: Some changes are still needed on the Older Adult Ward in Burton which have been receiving Cook and Chill food for many years. These have been discussed in staff and patient meetings, which are minuted with the requests for changes being known by senior staff on the ward. A recent change that has benefited patients is that Cook and Chill purã ed food is now sent from Queens Hospital when required, with some now stored on ward. Previously staff had to purã e the meal that the patient ordered before they could eat. One major request which had not been considered when Members visited was patient and staff requests to have a similar meal service to the Acute Ward where they are served from a heated trolley instead of having a plated meal. This would allow for larger portions for some patients, all patients would be able to make a choice when they were at the trolley and this would allow for a second portion if required. Food items on existing menus are not always appropriate for Older Adults. Forum members assume that this will be addressed on the new Cook and Chill me... - Page 23 -

24 Comments from specified third parties...nus from 1st April Members have eaten food in the Cedar Canteen at Shelton Hospital in Shrewsbury, and noted that there was access to this facility for patients who wished to eat in the canteen rather than on the ward. This enabled individual choice to be made just before eating a meal. Many patients seemed to be taking advantage of these facilities. Food was available from a refrigerated cabinet for patients 24 hours a day which could be reheated if required. These facilities are not available on any of the Stafford sites. C17: Members are aware that South Staffordshire and Shropshire Healthcare NHS Foundation Trust have consulted on Delivering Service User and Carer Involvement across the area. The deadline has been extended to the 28th February to allow an extended feedback from those patients and carers who had concerns over the initial short consultation period. Members have also been part of a number of events which show how the Trust intends to make changes by consultation with patients and carers now that the Foundation Trust covers both Staffordshire and Shropshire. * Please enter the name of the local child safeguarding board that has provided the commentary Staffordshire Safeguarding Children Board * Local child safeguarding board comments. There is no word limit on this answer. The following commentary is made with reference to the following standards: C2, C6 and C22c. OVERVIEW The Trust plays a central and critical role in the activity of Staffordshire Safeguarding Children Board (SSCB). The engagement of the Designated Doctor and Designated Nurse for Child Protection is consistently pro-active and substantial and contributions made have had a direct impact upon forwarding a range of objectives in the SSCB Business Plan. Actions agreed by staff from 'The Trust' are conducted in a timely manner. SPECIFIC ISSUES 1) 'The Trust' is a statutory member of SSCB and is represented by Dr G Patel. Attendance is regular and consistent. The Trust's Designated Nurse for Child Protection acts as an Officer of the Board, an advisory role which is subject to an agreed job description. 2) 'The Trust' provide consistent and active representation to the full range of Sub-Groups of SSCB; Serious Care Review; Professional Development and Training; Prevention; Performance Management, Policy and Procedures; Communications and Child Death Review. This representation extends to proactively undertaking actions on behalf of the sub-groups. 3) Financial contribution to SSCB for Health Trust in South Staffordshire is received via South Staffordshire PCT, not directly from this Trust. 4) The Designated Nurse for Child Protection and her team are actively engaged in the delivery of the Inter-Agency Training and the development of the SSCB Training Strategy. 5) 'The Trust' completed the SSCB audit of compliance with S11 of the Children Action Out of 51 objectives measured, 42 were assessed as 'green', (everything in place according to standards), 4 were assessed as 'amber', (an element requires improvement or review) and 5 objectives were not rated. No objectives were rated as 'red' (something needs to be done as a matter of urgency). The SSCB will be conducting a review of actions taken in relation to red/amber rating later in Please enter the name of the organisation that has provided the first commentary Please enter the first commentary for this organisation - Page 24 -

25 Comments from specified third parties Please enter the name of the organisation that has provided the second commentary Please enter the second commentary for this organisation Please enter the name of the organisation that has provided the third commentary Please enter the third commentary for this organisation Please enter the name of the organisation that has provided the fourth commentary Please enter the fourth commentary for this organisation Please enter the name of the organisation that has provided the fifth commentary Please enter the fifth commentary for this organisation Please enter the name of the organisation that has provided the sixth commentary Please enter the sixth commentary for this organisation Please enter the name of the organisation that has provided the seventh commentary Please enter the seventh commentary for this organisation Please enter the name of the organisation that has provided the eighth commentary Please enter the eighth commentary for this organisation Please enter the name of the organisation that has provided the ninth commentary Please enter the ninth commentary for this organisation Please enter the name of the organisation that has provided the tenth commentary Please enter the tenth commentary for this organisation - Page 25 -

26 Comments from specified third parties Please enter the name of the organisation that has provided the eleventh commentary Please enter the eleventh commentary for this organisation Please enter the name of the organisation that has provided the twelth commentary Please enter the twelth commentary for this organisation Please enter the name of the organisation that has provided the thirteenth commentary Please enter the thirteenth commentary for this organisation Please enter the name of the organisation that has provided the fourteenth commentary Please enter the fourteenth commentary for this organisation Please enter the name of the organisation that has provided the fifteenth commentary Please enter the fifteenth commentary for this organisation There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 26 -

27 Overview and scrutiny committee comments Overview and scrutiny committee comments * How many overview and scrutiny committees will be commenting on your trust? (maximum of 10) O 1 O 2 O 3 O 4 O 5 O 6 O 7 O 8 O 9 O 10 Overview and scrutiny committee comments Name of overview and scrutiny committee 1 Staffordshire Health Scrutiny Committee Comments. There is no word limit on this answer. - Page 27 -

28 Overview and scrutiny committee comments Following correspondence and initial feedback in January 2008, in February 2008 the Trust enabled the SHSC to follow up on previous scrutiny activity through the Chief Operating Officer reporting on the results of their internal review of their community Child and Adolescent Mental Heath Service (CAMHS). The SHSC have asked to consider the implementation plan arising from the review, once this has been to the Trust Board, and for some example patient journeys to help them understand the nature of the service. The SHSC will maintain an overview of strategic developments across the county in regard to the various tiers of CAMHS (and will ask South Staffordshire Primary Care Trust about their commissioning intentions with regard to services for people with autistic spectrum disorders). The implementation relates to Core Standard C18 in respect of tackling inequities in service; C7a in respect of revising governance arrangements; and C7f in respect of reducing waiting times (for this year team targets had been set at a maximum of 11 weeks waiting time from first assessment to treatment. At the time of the presentation, Burton and Stafford Teams had already achieved this with the remaining teams very close to attaining the goal.) The working relationship between the Trust and the SHSC relates most closely to compliance with Core Standards 17 and 22 as evidenced below. Communication from the Trust has enabled the SHSC to maintain an overview of developments. In April 2007, the SHSC learned that Neil Carr had been appointed Chief Executive of the former South Staffordshire Healthcare NHS Foundation Trust. In June 2007, the SHSC were made aware that Monitor had approved the integration of mental health and learning disability services across South Staffordshire and Shropshire. In October 2007, the SHSC Chair, Vice-Chair and Scrutiny and Performance Manager met with Mr Steve Jones (Chair) and the Chief Executive, receiving an update on developments since the Trust had become a Foundation Hospital Trust and discussing learning disabilities respite care from the Trust's perspective. The SHSC had been pursuing (discussion and) consultation on the transfer of responsibility for commissioning some learning disability services from South Staffordshire Primary Care Trust to the County Council and had written to the PCT, the County Council and the Trust, as a provider of services to people with learning disabilities, to ensure the highest level commitment to this process. The Trust had provided supplementary information to the SHSC to assist them in their consideration of this matter. Also, the Scrutiny and Performance Manager was invited to act as an observer in the Choice 4U project. This project was facilitated by the Centre for Innovation and Involvement and explored ways in which the Trust could deliver its commitment to giving service users choice in respect of the services they delivered. In December 2007, the SHSC were made aware that the Trust had been named as Foundation Trust of the Year in the national Healthcare Financial Management Association awards. A further meeting with the Chair, Chief Executive and Susan Cassidy, Head of children's services, took place on 30 January 2008 meeting. This provided the opportunity to discuss: integration of services with Shropshire, CAMHS; and Learning Disbility services. There are no further questions in this section. Please press either the Save and Quit button or the Finish button to return to the main section list - Page 28 -

29 Board of governors' comments Please enter the comments from the board of governors in the box below. There is no word limit on this answer. - Page 29 -

30 Board of governors' comments C5c: Concern expressed about lack of clinicians with experience of high functioning autism/asperger's Syndrome especially in CMHT's. Lack of training cited as reason for resisting access to services for people with ASDs in some parts of Shropshire. 'Clinicians from all disciplines have access to and participate in activities to update the skills and techniques relevant to their clinical work' This has been denied to some clinicians in area of Talking Therapies. C6: ASD is not generally available although planning for such a service is in its early stages. (Possibility of some housing for people with Asperger's syndrome under review, some employment support available but long waiting lists, some group support available but long waiting lists). A seamless transition from CAMHS services or Learning Disability Services to an adult service is not possible, and almost no services for adults currently receiving a diagnosis who are not previously known to services. General lack of expertise to make community care assessments for people with ASD. Individuals going out of county to obtain assessments. "Proper individual assessments, based on eligibility criteria as set down in 'Fair Access to Care' are the starting point for people getting the services they need...& quot; 'Better Services for People with an Autistic Spectrum Disorder' DOH November 2006 (Continued overleaf) Serious shortcomings with regard to regular carers' assessments being completed particularly in the Shrewsbury area, which prejudice the carer's input into the care programme. Attempts are being made to rectify this situation and a review of the CPA documentation has taken place which will, amongst other things, it is hoped make the carer's voice more easily heard. Opportunities for carers for engagement and involvement have recently been greatly improved in the Shropshire/ Telford and Wrekin area, including access to an Involvement website and newsletter. Concern expressed about lack of clarity between responsibilities of various teams and third sector organisations where each provide elements of care e.g. between crisis resolution and assertive outreach Concern expressed about the transition from children's to adult services for people with learning disabilities. 'Seamless services' do not as yet exist. Residents of care home in Shropshire on enhanced CPA (in receipt of services from local CMHT) whose individual needs are not properly managed or met e.g. 1) personal clothing lost in laundry process, random clothing provided in replacement 2) no structured day 3) no encouragement to participate in social activities or input from occupational therapist 4) no programme of regular health checks 5) no consistent encouragement with personal hygiene Irregular contact with CMHT sometimes with gaps of several weeks C7e: Limited experience of particular client groups leads to discrimination, e.g. adults with an ASD. C8a: There are some lessons to be learnt from an on going whistleblowing investigation and the Trust should take these on board as per of staff training and development. C9: The move to integrated case notes across the trust is welcomed and seen as a positive move offering advantages to service users, clinicians and carers. C11a: Concern expressed over level of training and experience of some STR workers called on to interact with difficult or extremely needy service users. Lack of training cited as reason for resisting access to services for people with ASDs in some parts of Shropshire. C13a: Concern expressed that a carer's potential contribution to the care programme is not always acknowledged and respected and encouraged by staff e.g. at first admission, review or relapse. Carer of resident on enhanced CPA, in Shrewsbury care home, refused information on physical and mental health of resident, by CMHT on grounds of confidentiality, despite resident's regular contact with carer and resident's willingness to share information with carer. Challenge by CMHT of carer status. C13b: Concern expressed with regard to valid consent if suitable interpreters or advocacy workers are not available at all times (for say Polish speakers or people with a learning disability), in the hospital setting, at outpatient appointments e... - Page 30 -