Document 2. Service Specification NHS Continuing Healthcare East Midlands Clinical Commissioning Groups

Transcription

1 Document 2 Service Specification NHS Continuing Healthcare East Midlands Clinical Commissioning Groups Authors: East Midlands CCG Commissioners, Clinicians, & GEM CSU Date Authorised: 30/01/2014

2 Table of contents 1. Introduction Strategic Relevance Scope Core principles and approach to services Service User admission into care Pre-placement assessment On Placement Service Users transfer to Service Provider care Activity upon admission Service User needs and outcomes General End of Life The Service Provider is expected to deliver End of Life care services to help all those with advanced, progressive, incurable illness to live as well as possible. The requirements stipulated in Appendix A must be met, in addition to those listed in other sections of this service specification Learning Disabilities If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Learning Disability services, then the additional requirements set out in Appendix B must be met, together with those listed in other sections of this service specification Mental Health (incorporating Dementia) If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Mental Health services, then the additional requirements set out in Appendix C must be met, together with those listed in other sections of this service specification Physical Disabilities (including Brain Injury) If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Physical Disability services, then the additional requirements set out in Appendix D must be met, together with those listed in other sections of this service specification Enhanced observation / support Challenging behaviour Infection Prevention and Control Tissue viability Risk management, incident recording, and outcomes Health reviews Equipment Bespoke equipment Clinical governance Medication Service User death Safeguarding of Service Users Access to primary healthcare services Service User s external appointments and social outings Transport The Service Provider will ensure that all staff that drive their private vehicles in the course of their work hold a full current drivers licence and hold business use insurance cover of 49

3 Where the Service Provider uses a minibus or any company vehicle to transport Service Users, the Service Provider must comply with all statutory requirements and local guidelines for the operation of such vehicles Outpatient or other appointments Hospitalisation of a Service User (elective and emergency treatment) Activity supporting Service User admission into hospital Activity supporting discharge from hospital of a known Service User Absence from accommodation Holiday/agreed leave for more than 1 day Unplanned absence Accommodation General Monies STAFFING Staff training Responsibilities of staff General Registered nurses Key worker FEEDBACK ON SERVICE PROVISION Survey and forums Complaints Raising concerns ADMINISTRATION Record keeping Service User Health Records Policy requirements Care Plan Top-Up Fees APPENDICES Appendix A - End of Life Appendix B Learning Disabilities Appendix C - Mental Health (incorporating Dementia) Appendix D Physical Disabilities (incorporating Brain Injury) Appendix E Individual Placement Agreements INDIVIDUAL PLACEMENT AGREEMENT Service User Name QA reference (* for invoice purposes) Previous Address DOB: NHS NO: Last Known GP Name of Care Home Start Date: End Date (if applicable) Review Date Agreed Weekly Rate: Band A B/FT C D Based upon DST Levels of 49

4 In such cases no period of notice is required Appendix F Notifiable Events Appendix G Legislation/guidance to be adhered to Appendix H Policies/procedures of 49

5 1. Introduction This document has been prepared by the Commissioning teams in East Midlands Clinical Commissioning Groups (CCGS). It is a specification for placements funded by the NHS, either in full or in part, for adults who are eligible for NHS Continuing Healthcare or under certain provisions of the Mental Health Act 1983 and as further amended by the Mental Health Act Service Users placed using this specification will have needs that may include End of Life, Learning Disabilities, Mental Health (including Dementia), Physical Disabilities, including Brain Injury. CCGs are required to demonstrate that investment decisions will be made in an informed and considered way, ensuring that improvements are delivered within available resources. CCGs will work with others to optimise effective care. Where an individual qualifies for a NHS continuing healthcare the package to be provided is that which the CCG assesses is appropriate to meet the individuals needs, taking into account safety and assessed risk. 1.1 Strategic Relevance National Framework for NHS CHC funded care (revised Nov 12) The Government White Paper, Our Health, Our Care, Our Say, framework for local authority and health to achieve a new direction for community based services. 1.2 Scope The services commissioned under this specification are to provide NHS Continuing Healthcare for individuals who have complex health care needs. The individuals will be registered within the region of the Responsible Commissioner. NHS Continuing Healthcare means, a package of Care that is arranged and funded solely by the NHS where the individual has found to have a primary health need. Such care is provided to an individual aged 18 years or over to meet needs that may include End of Life, Learning disabilities, Mental Health (including dementia), Physical Disabilities including Brain Injury 2. Core principles and approach to services Aims & Objectives The aim of this service is to provide a responsive high quality patient focused domiciliary and or nursing care service for individuals identified as eligible for NHS Continuing Healthcare. The Service Provider will deliver care in accordance with the following principles: Respect for capacity: Each Service User should be treated as able to make their own decisions. A Service User's capacity to make a decision will be established at the time that a decision needs to be made, as per the definition of capacity set out in the Mental Capacity Act 2005; 5 of 49

6 Equality of opportunity: The service will be organised and provided in a way which does not negatively discriminate against Service Users and staff in respect of race, gender, disability, sexuality, culture, language, religion or age; Individuality: Each Service User will be recognised and respected as an individual person; Rights: The maintenance of all entitlements associated with UK citizenship (subject to any authorised Deprivation of Liberty Safeguards ; Choice: The opportunity to select independently from a range of appropriate options; Independence: The opportunity to act and think without reference to another person, including willingness to incur an acceptable degree of risk; Fulfilment: The realisation of personal aspirations and abilities in all aspects of daily life; Privacy: The right of individuals to be left alone undisturbed and free from intrusion of public attention into their affairs providing that this does not conflict with any identified Mental Health Need; Dignity: Recognition of the intrinsic value of Service Users, regardless of circumstances, by recognising their uniqueness and their personal needs and treating them with respect, in line with DoH Dignity in Care policy and End of Life guidelines, e.g. Gold Standards Framework; Confidentiality: The sharing of any and all kinds of information concerning a Service User will always be consistent with the principles of consent and data protection as well as choice and privacy; Protection: Service Users shall be protected from risk of harm that arises from abuse or neglect; Service User engagement: The Service Provider should actively engage with Service Users so that they are consistently contributing, where possible, to the structuring and delivery of their care; Person centred care: The Service User s goals, targets and objectives should remain the focus of care at all times; and Cultural awareness: Service Providers shall ensure that the religious, cultural and spiritual needs and wishes of all Service Users are identified, respected and wherever possible met. The Service Provider, on behalf of the Commissioner will: Meet Service User s mental and physical health, social, personal and cultural needs as identified through their individual Care Plan; Provide services that take in to account the Service User s mental capacity and their personal circumstances, e.g. safeguarding issues with relatives and carers; 6 of 49

7 Ensure that Service Users are supported so that they are able to access local health and social care services, where this is identified as appropriate to their needs; Ensure that Service User s mobility is optimised, within a risk assessed framework; Provide a range of treatment and care, to promote, maximise, and wherever possible, sustain quality of life for Service Users; Provide access to social, occupational, vocational and meaningful activities as appropriate, in line with the Service User s care needs, which enhance the quality of life of Service Users; Provide a living environment where Service Users feel involved, comfortable and secure and are able to live with dignity and respect; Provide an equitable and sensitive service that meets the needs of Service Users from different cultural and religious backgrounds and one that takes positive action in removing any discrimination that may deny them equal opportunities; and Facilitate involvement of Service Users and their representatives (if appropriate), so that they make informed choices. 3. Service User admission into care 3.1 Pre-placement assessment Prior to admission the Service Provider will assess a potential Service User to determine whether they can meet the Service User s needs and aspirations. The Service Provider s assessment and outcome will be reported back to the Commissioner within the following timescales from date of referral: Care Group End of Life Learning Disabilities Mental Health (including Dementia) Brain Injury Physical Disabilities Timescale Within one (1) working day Within five (5) working days Within five (5) working days Within five (5) working days Within five (5) working days This assessment will detail any additional care/equipment required which is not covered by this specification and therefore the standard weekly rate. Additional care/equipment will only be required in exceptional circumstances and will be agreed with the Commissioner prior to Service User placement. The Service Provider will have the opportunity to talk to the potential Service User, their representatives and relevant health and social care professionals prior to admission, if appropriate. 7 of 49

8 3.2 On Placement The Commissioner will complete an Individual Placement Agreement for the Service User as soon as the Commissioner has been advised that the person has been admitted and send it to the provider for signature and return The Commissioner will inform the Service Provider of the Service User s unique NHS identification number, which will be used by the Service Provider in the provision of performance management information and invoices. The Service Provider will provide the Service User and their representatives with a copy of the service user guide which will include the complaints procedure, and access to a copy of the Service Provider s statement of purpose on request. 3.3 Service Users transfer to Service Provider care Service Users may be referred to Service Providers from a range of locations, e.g. Acute hospital environment, Service User s own home or other Service Providers. Alternatively the Service User may be an existing resident of the home and require an increased/decreased level of health care. Where the Service User is transferred to a new service provision, to ensure safe transfer, the discharging organisation will ensure that access to all relevant assessment documentation is made available provided. This may include, but is not limited to: Any clinical discharge notes or summaries; Care Plans and care transfer form; All other documentation which will assist the Service Provider in caring for the Service User e.g. Advance Care Plan Advanced Decision to Refuse Treatment; and Deprivation of Liberty Safeguarding issues. 3.4 Activity upon admission Upon Service User admission the Service Provider will: Develop a preliminary plan of care within 24 hours (including risk assessment) for, and in conjunction with, the Service User and/or family representative. A copy of the Care Plan (and any subsequent iterations) should also be shared with the Service User. The Care Plan will identify, in detail, the care required, must be person centred and incorporate all of the principles as stipulated in Section 2 of the document. The plan of care will indicate the following but not be limited to: How care needs will be met and expected outcomes; Frequency of interventions; Date when the Care Plan will next be reviewed/evaluated; The personal information will include: Named Registered Nurse or, where appropriate, Key Worker, responsible for writing the Care plan and supervising care delivery; Social Worker (if applicable); 8 of 49

9 Registered GP, and details of any other clinicians involved in their care; Details of Allergies; Relevant Medical History; and Service User details including but not limited to:- - Name - Preferred Name Previous address Previous GP - Gender - Date of Birth - Next of Kin - NHS number - Sexual Orientation - Ethnicity - Religion - Power of Attorney - Court of Protection Upon admission the Commissioner will notify the Service Provider of the date by which the Service User s eligibility for Continuing Healthcare will next be due to be assessed. The Commissioner will also advise the Service Provider of the circumstances that may necessitate an earlier review. 4 Service User needs and outcomes 4.1 General The Service Provider will support the needs and required outcomes detailed in Table 1 and will carry out an assessment of the Service User s needs on admission. These will be monitored and reviewed by the Service Provider as appropriate. Indicative activities to support Service Users in achieving the required outcomes are also detailed in Table 1. Note: this is not an exhaustive list of activity the Service Provider is expected to carry out duties beyond those listed. The Service Provider will refer Service Users to specialist care as appropriate, e.g. specialist continence nurse. Table 1: Indicative list of needs, outcomes and activities the Service Provider must support/undertake which include but will not be limited to: Need Outcomes Indicative Activity Ensure a strategic prevention approach to behaviour deterioration Behaviour Service user s capability towards positive behaviours is maximised Establish communication points and reporting lines to ensure expectations of both Service User and carer are clear where possible Ensure care plans and records accurately reflect positive behavioural strategies Ensure access to services as appropriate 9 of 49

10 Need Outcomes Indicative Activity Ensure a cognitive assessment is completed on admission (*). Monitor and review as appropriate Ensure staff understand individual Service User s cognitive needs Cognition Service User s cognitive capability is maximised Ensure staff utilise cognitive support tools for individual Service Users such as access to a clock and calendar (TV / radio if possible) as appropriate Encourage Service User s representatives to visit and bring in Service User s personal possessions, e.g. photographs Ensure the Service User s individual activity programme is tailored to meet the Service User s needs and prevents isolation Ensure access to specialist services, as appropriate Need Outcomes Indicative Activity Provide links to social facilities and arrangements Emotional & psychological needs Communication Mobility and Falls Nutrition food & drink Service Users are supported in achieving optimal level of psychological and emotional wellbeing. There is Service User opportunity for meaningful occupation and engagement Privacy and dignity is maintained at all times Service User has the opportunity to express needs and choices through their preferred or an appropriate method Optimisation of verbal and nonverbal communication skill Privacy and dignity is maintained at all times Mobility is maximised at a level which is appropriate relative to the ability of the Service User To minimise the risk of falls Privacy and dignity is maintained at all times Service User enabled to maintain a balanced and nutritious diet in accordance with NICE guideline CG32 Service User is enabled to maximise their own potential to feed themselves (i.e. not assisted solely in order to save time) Privacy and dignity is maintained at all times Provision of an appropriate activities plan and equipment to support activities Actively consult Service Users as part of activity planning Regularly review Service User engagement in activities and provide additional support to facilitate Service User involvement as required Support Service User with life changing events as required Ensure staff have the skills to recognise depression and its effects on behaviour and refer to GP Support and promote Service Users existing and new relationships, including partners, families and friends Support shopping / purchases as required, e.g. family gifts, clothes Ensure a communication assessment is completed on admission. Monitor and review as appropriate Ensure staff have communication skills relevant to meeting Service User needs Ensure information is provided to Service Users in the appropriate format Ensure staff are able to respond to verbal and non-verbal cues and make best use of relevant communication aids Ensure a mobility assessment (including a falls risk assessment) is completed on admission. Monitor and review as appropriate Implement fall prevention strategies as appropriate Ensure a manual handling risk assessment is completed and reviewed as appropriate Enable safe Service User moving and Service Provider handling provision Ensure access to a range of suitable equipment, that is maintained and replaced as appropriate Ensure an assessment of nutritional needs is completed on admission using the Malnutrition Universal Screening Tool (MUST) or equivalent recognised tool. Monitor and review as appropriate Support Service User by offering nutritious diet Ensure adequate hydration is maintained at all times Ensure that a policy is in place which ensures that any change in Service Users weight or dietary intake is responded to appropriately, and in a timely manner Manage the use of enteral feeds as appropriate Ensure that food/drink is available at flexible times and locations and is in accordance with Service User preferences Ensure request for referral to specialist services is made where appropriate Elimination & continence management Continence is promoted and optimised Privacy and dignity is maintained at all times Skin integrity is maximised Ensure appropriate supervision and assistance as necessary Undertake a continence assessment on admission (*), develop a continence plan and monitor and review as appropriate Ensure request for referral specialist continence services as appropriate Recognise normal patterns and act on abnormal occurrences seeking specialist advice as required 10 of 49

11 Need Outcomes Indicative Activity Risk of infection is minimised Monitor for and act on any infection Need Outcomes Indicative Activity Skin (including tissue viability) Skin integrity is optimised with active Service User input as appropriate Privacy and dignity is maintained at all times Ensure an assessment of skin integrity is completed on admission (*), and include any care required to maintain healthy skin. Monitor and review as appropriate Ensure an assessment of pressure ulcer risk is undertaken on admission and is reassessed regularly and prompt recognition of and action as a result of any changes to pressure ulcer risk factors according to local guidance. If a Service User is at risk of pressure ulcer development a pressure ulcer prevention plan must be devised, implemented and evaluated Ensure that skin care and wound management is evidence based and in line with current wound and skin care formularies and treatment/management regimes are clearly recorded in care plans Ensure that all wound and skin lesions are assessed and documented Ensure request for referral to specialist services using the identified referral criteria Ensure that staff access pressure ulcer prevention training Breathing General Well Being/Clinical Condition Medication and Symptom Control Airway integrity is maintained and breathing is optimised Respiratory risk is minimised Negative impacts of respiratory dysfunction on daily living are minimised Privacy and dignity is maintained at all times To ensure existing and emerging clinical conditions are managed appropriately To ensure Service User lives well until they die Medication is provided in a safe and timely manner in order to optimise the care and clinical condition of the Service User Service Users are advised of the purpose of medication and actively engaged in the decision making and review of it Privacy and dignity is maintained at all times Service User s pain levels are reduced and comfort optimised The negative impacts of pain on the Service User s daily life is minimised Where appropriate, ensure a breathing assessment is completed on admission. Monitor and review as required Utilise appropriate equipment to support Service User breathing as prescribed, e.g. nebulisers and tracheotomy equipment Ensure an assessment is carried out in conjunction with the information from GP and other services on admission Ensure regular review is carried out or as symptoms change Ensure that any changes in condition (physical and psychological ) are responded to appropriately and that actions taken are clearly recorded in care records Ensure a pain assessment is completed on admission. Monitor and review as appropriate Ensure a range of communication skills are utilised to assess the characteristics of pain, e.g. location, severity on a scale of 1 10, type, descriptors frequency, precipitating factors, relief factors Administer analgesia as prescribed and monitor effect using pain assessment tool Utilise appropriate non-pharmacological methods to reduce pain and discomfort Maintain prompt access to all required medication, including self-medication where appropriate Ensure appropriate recording of medication and escalation of noncompliance Inform the Service User and their representatives (as appropriate) of any likely side effects of medication Monitor the side effects of medication and refer to the appropriate prescriber. Work with the specialist care teams to anticipate Service User requirements prior to immediate need The provider must have a robust medication policy in place Ensure that medication information is available in an accessible format focused on the Service User e.g. pictorial, tape, Braille, translated Ensure that medication administration is in accordance with prescriptions and in line with the medication policy Need Outcomes Indicative Activity End of life planning and care To ensure that Service Users die with dignity in the manner and setting of their choice in accordance with local policy Privacy and dignity is maintained If a valid Do Not Attempt Resuscitation (DNAR) status has been recorded in the Service User s medical notes, ensure that staff are aware of and act in accordance with the DNAR status Ensure staff are aware of the content of any advance decision to refuse treatment orders (ADRT) and ensuring they are applied when appropriate 11 of 49

12 at all times Ensure the Advance Care Plan (including preferred place of death) has been completed within 1 month of admission Offer Service Users and their representatives (as appropriate) in devising an Advance Care Plan in order to record end of life choices and preferences. Adapt and review as needed Provide appropriate end of life planning and care communication skills training for relevant staff Engage with specialist palliative care teams and other Healthcare professionals, as applicable Ensure principles of the Gold Standards Framework (GSF) are applied to residents in the last year of life including use of End of life tools such as preferred priority of care (PPC) Ensure for all expected deaths that the end of life pathway e.g. Liverpool, care Pathway (LCP) is followed (*) Manage care of Service Users with syringe drivers (*) Ensure compliance with local Commissioner guidelines regarding syringe driver use (*) Ensure appropriate clinical supervision, consistent with occupational standards (*) Signpost relatives and other residents to appropriate after death support Recognise normal patterns and act on abnormal occurrences seeking specialist advice as required Altered State of Consciousness To identify fluctuations in state of consciousness and manage according to need Privacy and dignity is maintained at all times Ensure access to referral to specialist services as appropriate Monitor for and act on any fluctuations Undertake an assessment on admission, develop a care plan and monitor and review as appropriate Complete full and regular assessments and reviews as appropriate * Note In care homes that are not registered to provide nursing care, activities marked (*) will be the responsibility of the community nursing services. 4.2 End of Life The Service Provider is expected to deliver End of Life care services to help all those with advanced, progressive, incurable illness to live as well as possible. The requirements stipulated in Appendix A must be met, in addition to those listed in other sections of this service specification. 4.3 Learning Disabilities If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Learning Disability services, then the additional requirements set out in Appendix B must be met, together with those listed in other sections of this service specification. 4.4 Mental Health (incorporating Dementia) 12 of 49

13 If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Mental Health services, then the additional requirements set out in Appendix C must be met, together with those listed in other sections of this service specification. 4.5 Physical Disabilities (including Brain Injury) If the Service Provider wishes to be selected onto the Approved Provider list as a provider of Physical Disability services, then the additional requirements set out in Appendix D must be met, together with those listed in other sections of this service specification. 5 Enhanced observation / support It is recognised that a service user may develop an acute condition which results in their care needs fluctuating. It is expected that the Service Provider will respond flexibly to ensure that any such changes in need are met. However, in some cases, the change will be so great that the provider will not be able to meet the needs of the service user without a significant increase in the resources that have previously been employed. Circumstances can change rapidly, and this section aims to address the procedure to be followed to ensure that the Commissioner is notified promptly and that a request for a change in care plan is responded to in a timely manner. If a Service User requires enhanced observations or staff input during an episode of care the Service Provider will telephone the Case Manager or Commissioner. Where there is evidence to support the request, the Case Manager or Commissioner will give verbal authorisation. The Service Provider must confirm this request in writing within 24 hours, confirming the nature of the change in need, the level of increased observation / staff input being put into place, and the associated costs involved. The Commissioner will respond and confirm the funding. If the Service User has required enhanced observation / support continuously for 7 days, the Commissioner will require a report from the appropriate professional(s) indicating the increased need. This must be approved by the Case Manager/Commissioner in writing and supporting evidence must then be provided upon request. Where the Case Manager/Commissioner decides that the additional support is not required, they must confirm this to the provider giving the clinical basis for their decision. 6 Challenging behaviour Challenging behaviour must be considered in the context of the environment in which it occurs, the way the Service is organised and the needs of the Service User. The Service Provider must have a policy to positively engage and support Service Users who show challenging behaviour. This policy will take account of all relevant legislation, guidance and good practice including the Human Rights Act 1998, the Mental Capacity Act 2005 including the Deprivation of Liberty Safeguards. 13 of 49

14 Persistent behaviour of a disruptive nature will require a consistent response by staff. The Service Provider must be aware of and have plans for known challenging behaviour in the Service User s Care Plan. All reasonable endeavours will be undertaken to mitigate discontinuation of placement for the Service User. The Service Provider will work with the Commissioner to take steps to resolve issues as and when they arise. Discontinuation of service will only occur if all other demonstrable efforts to resolve issues have been unsuccessful. However, the Service Provider will have the final say in whether or not they can continue to meet a Service User s needs. Where a Service User exhibits behaviour that cannot be managed in such a way as to safeguard them or other Service Users, the provider may need to access emergency support as available under the Mental Health Act. 7 Infection Prevention and Control The Service Provider will: Meet the requirements detailed in the Essential standards of quality and safety (CQC) Health and Social Care Act 2012 (Department of Health); Ensure that all policies and procedures have regard to current NICE guidelines regarding Infection Control 1 ; Ensure all staff for which this forms part of their duties in the care home are aware of their role in infection prevention and control. Designated staff will be aware of the Health Protection Agency and local resources/arrangements for accessing advice on the prevention and control of infection; Ensure that the staff responsible for the day-to-day organisation of the home have the knowledge and skills and equipment to manage and ensure good hygiene standards; Ensure each care home has a nominated Infection Control Lead. The Infection Control Lead, most likely a senior nurse or other responsible person, will be responsible for infection control in the care home; Ensure the Infection Control Lead undertakes additional training in infection control to enable them to recognise problems as they occur and seek specialist advice; Ensure that the nominated Infection Control Lead attends an annual training/link clinician session and disseminates information/training to other care staff in the care home; Co-operate with and support screening procedures and any prescribed decolonisation procedures, in particular Service Users at high risk of contracting healthcare acquired infections; Adopt any of the Essential Steps to safe, clean care: reducing healthcare-associated infections, July with the high impact interventions specific to their service; Participate with the Infection Prevention and Control Team s annual programme of audit; Ensure that Service Users who require isolation have their personal dignity and physical needs met; dance/dh_ of 49

15 Collaborate with the Commissioner Community Infection Control Nurse to undertake root cause analysis of all healthcare associated infections and take action to prevent further incidences; Co-operate in decontamination procedures, when instructed that it is necessary by the Commissioner Infection Control Specialist; and Ensure safe disposal of hazardous and non-hazardous waste according to National Health Technical Memorandum (2006). 8 Tissue viability The Service Provider will: Ensure that all policies and procedures have regard to current NICE guidelines regarding tissue viability, in particular NICE clinical guideline CG 29 and European Pressure Ulcer Advisory Panel (EPUAP) Guidelines 2009; HSE National Best Practice and evidence based guidelines for wound management 2009; Ensure all staff are aware of their role in maintaining healthy skin, pressure ulcer prevention and management; Ensure that all staff for whom this forms part of their duties are aware of procedures for reporting the development of pressure ulcers including where appropriate, reporting of pressure ulcers grade 3 and above as well as per local safeguarding agreements and/or CQC reporting; Ensure that all staff for whom this forms part of their duties are aware of infection control practices relating to wound management to prevent wound infection; Ensure that all staff for whom this forms part of their duties are aware of up to date practice regarding wound assessment and treatments using local wound care formularies, local and national guidance; Collaborate with the Commissioner/ Tissue Viability Service to undertake root cause analysis in line with local policy of all pressure ulcer and wound care clinical incidents; Ensure access to link worker who will act as a resource for the staff of the home; Ensure that all pressure relieving equipment owned by the provider is maintained and is in good working order, decontaminated appropriately and is suitable for use; Service Users are referred appropriately to tissue viability specialist services following local referral criteria and that any advised care is implemented; and Ensure that staff, for whom this forms part of their duties, receive Pressure Ulcer Prevention and wound management training. 9 Risk management, incident recording, and outcomes Service User s wishes regarding their personal care must be respected, and risks managed subject to the consent of the Service User, where possible in regard to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Known and predictable risks will be explained to Service Users and their representatives in an understandable manner and recorded in their Care Plan. 15 of 49

16 Risks shall be regularly reviewed, recorded and documented within the Care Plan together with agreed strategies for addressing them. Reviews will include consultation with the Service User or their representative and all other relevant professional and organisational representatives. The Commissioner recognises that situations may arise where a Service User s decision to exercise their rights may result in an unacceptable threat to the health and safety of either themselves or others. In such circumstances, the Service Provider must discuss concerns with the Service User and contact the Commissioner within 24 hours where this is not resolved. The Service Provider must record all concerns and outcomes in the Service User s records. In order to ensure continued safety it may be necessary to make a best interest decision which does not accord with the Service User s wishes. The Service Provider will have in place formal written policies and procedures to ensure that an assessment of risk is conducted on all aspects of tasks to be carried out by care staff. This will lead to the production of clear guidance for all care staff on safety precautions to be taken. This will form part of the staff induction process. Where the care provided to a Service User requires manual handling or hoisting the Service Provider will ensure that risk assessments are reviewed regularly in accordance with regulatory requirement. The Service Provider will ensure all accidents and significant incidents are investigated and recorded. Notifiable Events will be reported immediately by the Service Provider (using the template attached within Appendix F) to the relevant authorities, e.g. Police, CQC, and the Health & Safety Executive where required in accordance with the Reporting of Injuries, Diseases & Dangerous Occurrences (RIDDOR) Regs The Service Provider will notify the relevant organisation (Site Lead Commissioners or Commissioner) of the Notifiable Events within the timescales given. 10 Health reviews Reviews The Commissioner will ensure Service Users are reviewed for their ongoing eligibility for NHS funded care (in accordance with the DoH National Framework for Continuing Healthcare 3 or the provisions of the relevant section of the Mental Health Act 1983 and the 2007 Amendment and any associated Good Practice Guidance) three months after admission and at a minimum, annually thereafter. Service Users / and or their representative, the service provider and any professionals involved in the service user s care will be invited to attend the assessment and outcome discussion. The Service Provider will contribute to the review by reporting progress against the Care Plan and any issues that have arisen since the last Commissioner review. If, as a result of the review the Service User no longer meets the eligibility criteria for NHS funded care the Service User may be referred to the appropriate Local Authority. Local Authority funding of 49

17 is subject to a financial assessment of the Service User. It should be noted that Local Authorities may not be prepared to accept the NHS contract price. Reassessments Notwithstanding the above, the Service User, their representatives, the Commissioner or the Service Provider may request a re-assessment at any time. In the event of a significant change in the Service Users needs or if the requirements of the existing Care Plan change significantly, the Service Provider will notify the Commissioner as soon as is reasonably practicable and take any immediate necessary action in order to ensure the safety of the Service User. The reassessment should be held within 10 operational days of the request being made. Where any immediate action is required that involves an increase in the amount of support given that is over and above the standard care package, see section Equipment The Service Provider will provide all equipment required to meet assessed ongoing needs as detailed in the local ICES (Integrated Community Equipment Services) Policy which is in accordance with CQC registration requirements. The Service Provider will ensure that equipment is subject to regular safety checks and maintenance/replacement as necessary in line with manufacturer s instructions. It is expected that the MHRA (Medicines and Healthcare Products Regulatory Agency) guidance DB2006 (05) Managing Medical Devices is also being followed. Any incidents with medical devices should be reported to the MHRA. 12 Bespoke equipment The Service Provider will ensure that any bespoke equipment provided for the Service User by the Commissioner is: Managed safely and securely; Operated in line with the manufacturer s instructions; Made available for maintenance by the Commissioner; Kept clean and decontaminated as per infection control policies and procedures. Where necessary, items of equipment which need to undergo specialist decontamination, the Commissioner will provide instructions to the Service Provider; and Only for use in relation to the named Service User. If the Service Provider identifies a potential requirement for bespoke equipment to be loaned by the Commissioner or nominated other, then the Service Provider will make a referral to the relevant assessment service. The Commissioner retains title for any equipment loaned for the Service User but the liability for the safe use and maintenance remains with the Service Provider. The Service Provider is responsible for looking after any loaned equipment and if it is found to have been mistreated, 17 of 49

18 abused or adapted in any way, the Service User will be liable for the replacement cost and/or cost of repairs. In the event of the Service User s condition changing and the equipment no longer being necessary, the Service Provider must advise the local ICES within 1 working day by fax in order that arrangements can be made for the equipment s collection. Failure to return equipment to the equipment store, upon Service User death, or when the equipment is no longer required by the Service User, will result in a charge for the replacement cost of the item to the Service User. 13 Clinical governance The Service Provider will: Work with the Commissioner to establish systems and procedures of clinical governance to promote continuous improvement in the quality of health and social care services and to safeguard high standards of care by creating an environment in which health and social care will continually develop. Maintain on an ongoing basis a care record, which details, in English, all the nursing care provided to a Service User to confirm that the Care Plan has been implemented. This record must be standardised and include, but not be limited to: - The date and time care was provided; - The type and frequency of care provided; - Observations which may be relevant to nursing / care need; - Action to be taken and the name of the person responsible; and - The name(s), designation(s), signature(s) of the staff members writing the record. Ensure that a signatory register is maintained which includes the names, designations and signatures of all staff involved in the provision of care. Ensure that a named registered nurse or residential support worker is identified for each Service User, regardless of their level of care needs, who will have nursing / care management responsibility. The registered nurse / care manager will maintain direct contact with Service Users as well as overseeing the care delivered by staff. Care home (residential homes) without nursing will need to ensure they maintain adequate links with a Community Nurse or Consultant. 14 Medication The Service Provider will ensure that (a) there are policies and procedures in place and (b) staff adhere to those policies and procedures, for obtaining supplies of medicines, receipt, recording (on MAR sheets and care plans), storage (including controlled drugs and refrigerated items), handling, administration and disposal of medicines in accordance with: The Handling of Medicines in Social Care Settings by The Royal Pharmaceutical Society of Great Britain 2007 or subsequent revisions; Professional advice documents produced by the Care Quality Commission, (or its predecessor, the Commission for Social Care Inspection), including The Administration of Medicines in Care Homes, Medicine Administration Records (MAR) In Care Homes and Domiciliary Care, and the Safe Management of Controlled Drugs in Care Homes or subsequent revisions; and 18 of 49

19 The Misuse of Drugs Act 1971 (Modification) Order The Service Provider s policy for medicines administration will include procedures to ensure that Service Users are able to take responsibility for and self-administer their own medication if they wish, within a risk management framework and the Service Provider s policies and procedures will protect Service Users in doing so. Prescribed medication will be administered in a format suitable for the Service User, with the Service User s consent who has the capacity to do so. The Service Provider's policies and procedures for medicine management will include the management of homely remedies. The Service Provider s policies and procedures for medicine management will, wherever possible, be agreed by all GP's providing services to the home. The Service Provider will seek information and advice from a pharmacist regarding medicines policies within the home and medicines dispensed for individuals in the home. The Service Provider, where appropriate will have a system in place to ensure that anticipatory end of life drugs can be prescribed and stored in the home for Service Users who have reached the last days of life. The Service Provider will ensure that staff monitor the condition of the Service User on medication and will prompt a medication review with the GP if there are concerns relating to use of medicines. The Service Provider will have a system in place to ensure that Service Users over the age of 75 have an annual medication review, Services Users taking four or more medicines have a six monthly medication review, and those taking less than 4 medicines have an annual medication review. Medicines prescribed for individual Service Users will not be supplied or dispensed to any other person. The Service Provider will ensure that staff adhere to controlled drugs procedures. The Service Provider will make the necessary arrangements in accordance with regulatory requirements for the disposal of medical waste. The Service Provider will have procedures for the transfer of medicines when a Service User transfers to another health / social care setting; returns from hospital stays or is newly admitted. The Service Provider will have procedures for dealing with verbal orders from prescribers; giving medicines to Service Users with difficulties in swallowing; for covert administration and crushing tablets; expired medicines and for adverse drug reactions. The Service Provider will have procedures in place to deal with errors or incidents relating to any aspect of medicines management. Safe procedures should be put into place to ensure security with regard to keys to medicines cupboards, trolleys and controlled drugs cabinets. 19 of 49

20 The Service Provider must ensure that staffs are appropriately trained in all aspects of safe handling and use of medicines appropriate to their role. Appropriate competency assessments must be in place. Staff training must be documented. 15 Service User death In the event of the death of a Service User, the Service Provider will notify: The Service User s next of kin/their representative as soon as is reasonably practicable, so that suitable arrangements can be made, including the collection of personal effects; The Commissioner verbally or by fax within 24 hours; and The regulator (CQC) where required to do so by Law. In the cases of a sudden or unexpected death the Service Provider will notify the Commissioner as soon as is reasonably practicable. The Service Provider will provide the Service User s representatives with a quiet area where they can sit and grieve when the Service User has died. The Service Provider will contact the Service User s representatives so they can collect the Service User s personal effects. Where no Service User representative exists the Service Provider will contact the host Local Council, who will make the necessary arrangements for both removing the Service User s possessions and arranging their burial/cremation. The Service Provider will permit reasonable access to the relatives and friends of the Service User, to enable funeral and other necessary arrangements to be made. The Service Provider will ensure that the Service User s medicines are retained for a period of seven days in case there is a coroner s inquest. The Commissioner shall pay the full agreed fee for three days including the date of death. 16 Safeguarding of Service Users The Service Provider will follow locally agreed procedures for the detection and response to suspected Adult Abuse in line with locally agreed procedures and the Safeguarding Vulnerable Groups Act 2006 (and any subsequent acts/ guidance). All staff involved in caring for Service Users must be aware of the laws and guidance protecting Service Users as outlined in Appendices G and H. Any suspected abuse or neglect of a Service User by anyone must be recorded and reported immediately to the Commissioner, Safeguarding Team, and CQC. 17 Access to primary healthcare services 20 of 49

21 The Service Provider will ensure that Service Users have access to the full range of local primary healthcare services including ensuring/enabling a Service User to get to and take up any annual health checks as available and inform the Commissioner if they experience any difficulties in securing these services. The Service Provider will ensure that Service User referrals are made in a timely manner and are followed up when a referral is not accepted or actioned. 18 Service User s external appointments and social outings 18.1 Transport The Service Provider will ensure that all staff that drive their private vehicles in the course of their work hold a full current drivers licence and hold business use insurance cover. Where the Service Provider uses a minibus or any company vehicle to transport Service Users, the Service Provider must comply with all statutory requirements and local guidelines for the operation of such vehicles Outpatient or other appointments The Service Provider will where necessary arrange transport for Service Users attending hospital outpatient or similar specialist care appointments or court appearances. The Service Provider will ensure the Service User has an escort if required appropriate to the level of risk and care need associated with the appointment. In instances when the Service Provider is providing the escort, the first four hours of escorting will be not be charged as an additional cost to the Commissioner. Escorting required beyond the first four hours will be charged and determined on a case by case basis. The Service Provider will alert the appointment service provider of any Service User language requirements prior to the appointment. 19 Hospitalisation of a Service User (elective and emergency treatment) 19.1 Activity supporting Service User admission into hospital When an admission to hospital is required the Service Provider will ensure that the hospital receives all the relevant information regarding the Service User including but not limited to:- Contact details and address of Service Provider; The Care Plan / or a précis of care needs (including risk assessment, communication requirements, infection control status / issues); and Service User details including but not limited to:- - Name - Preferred Name - Gender - Date of Birth - Next of Kin 21 of 49