Regulatory and Review Bodies Tracking Report - Reports Received and Inspections/Visits Undertaken - 1 July 2014 to 31 January 2015

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1 Regulatory and Review Bodies Tracking Report - Reports Received and Inspections/Visits Undertaken - 1 July 2014 to 31 January Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) Cardiff Council Standard 3 - Health Promotion, Protection & Improvement Standard 22 - Managing Risk and Health and Safety 1 July June 2014 Ward based catering at the University Hospital of Wales and the Teddy Bear Trust Nursery (both areas combined in one report) Annual Environmental Health Officer (EHO) Review of catering facility in accordance with Food Safety legislation Ward kitchens and Teddy Bear Trust Nursery was given a score of 5 out of 5 in the National Food Hygiene Rating Scheme. Action plan developed by the Operational Services Manager to address the issues raised. This will be monitored by the PFI/Compliance Manager on behalf of the the Head of Operational Services. N/A Senior EHO'S do not intend to check compliance with the report. A copy will be kept on file and will be referred to during the next routine inspection. Completed Health and Safety - Martyn Waygood 21 October August August 2014 Rookwood Hospital Periodic EHO Review of catering facility in accordance with Food Safety legislation Catering areas scored 4 out Action plan was of 5 in the National Food developed by the Hygiene Rating Scheme. NB: Some recommendations under Schedule A (work needed to comply with the law) and Schedule B (matters which, though not legally required, are considered to be good working practice) Operational Services Manager (South) to address the issues raised. To be monitored by the PFI/Compliance Manager on behalf of the Assistant Director and Head of Operational Services. N/A Senior EHO'S do not intend to check compliance with the report. A copy will be kept on file and will be referred to during the next routine inspection. Completed Health and Safety - Martyn Waygood 21 October 2014 Vale of Glamorgan Council Standard 3 - Health Promotion, Protection & Improvement Standard 22 - Managing Risk and Health and Safety 8 July June 2014 University Hospital Llandough (UHL) Main Kitchen and Restaurants Annual EHO Review of catering facility in accordance with Food Safety legislation 4 out of 5 in the National Food Hygiene Rating Scheme. NB: Some recommendations under Schedule A (work needed to comply with the law) and Schedule B (matters which, though not legally required, are considered to be good working practice) Action plan was developed by the Operational Services Manager (South) to address the issues raised. To be monitored by the PFI/Compliance Manager on behalf of the Assistant Director and Head of Operational Services. N/A Senior EHO'S do not intend to check compliance with the report. A copy will be kept on file and will be referred to during the next routine inspection. Completed Health and Safety - Martyn Waygood 21 October 2014 Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 1 of 24

2 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 14 July July 2014 Barry Hospital Main Kitchen Annual inspection of catering facility in accordance with Food Safety legislation 4 out of 5 in the National Food Hygiene Rating Scheme. NB: Some recommendations under Schedule A (work needed to comply with the law) and Schedule B (matters which, though not legally required, are considered to be good working practice) N/A Senior EHO'S do not intend to check compliance with the report. A copy will be kept on file and will be referred to during the next routine inspection. Completed Health and Safety - Martyn Waygood 21 October 2014 Natural Resources Wales Standard 1 - Governance and Accountability Framework Standard 12 - Environment inspections during period Health Inspectorate Wales Standard 1 - Governance and Accountability Framework Standard 2 - Equality, Diversity and Human Rights Standard 5 - Citizen Engagement and Feedback Standard 7 - Safe and Clinically Effecive Care Standard 10 - Dignity and Respect Standard 11 - Safeguarding Children and Vulnerable Adults Standard 12 - Environment Standard 13 - Infection, Prevention and Control Standard 22 - Managing Risk and Health and Safety Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 2 of 24

3 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 11 July & 19 June 2014 Wards 7 and 8, Rookwood Hospital Dignity and Essential Care Inspection The anticipated date of publication is 10 September 2014 Action plan in preparation Executive Nurse Director N/A To provide update to QSE Committee at its next. Ongoing Quality, Safety and Experience 16 December 2014 ############### 30 June 2014 Cardiff and Vale Orthopeadic Centre (CAVOC), UHL Surgical Services Clinical Board Dignity and Essential Care Inspection Awaiting report Executive Nurse Director N/A To provide update to QSE Committee at its next. Ongoing Quality, Safety and Experience 16 December July /23 July Ward B6, UHW Trauma and Otthopaedics Dignity and Essential Care Inspection Urgent action was taken to address some immediate feedback. An action plan has been submitted to HIW Executive Nurse Director Follow up visit undertaken on 20th January. Feedback was positive whilst accepting that some areas still required action. Deadlines for actions vember 2014 at the latest Quality, Safety and Experience 16 December vember August 2014 Sam Davies Ward, Barry Hospital Older Persons' Acute and Intermediate Services Dignity and Essential Care Inspection HIW felt that the public could be confident that the service was well run and attention was being paid to delivering a safe service to patients. Executive Nurse Director Improvement plan has been submitted to HIW and is being monitored Ongoing but deadline for most actions is January Quality, Safety and Experience 16 December 2014 t received t known - information provided to QSE Committee as part of a composite report. dates provided. Wards inspected were E4, E7, W2, Stroke Rehabilitation Ward at UHL, A1, C7 Dignity and Essential Care Inspection Handwritten notes of each A bid for funding to Executive Nurse visit were shared at the end of support the necessary Director each inspection. Some findings required urgent environmental upgrading works across the Health action e.g. a keypad as found Board has been to be faulty on a treatment room door; a controlled drug cupboard was found to be in submitted to Welsh Government as part of the capital planning a poor state of repair and was process. work is being replaced immediately. Other actions will require a longer timescale for completion, undertaken to identify opportunities to reshape services notably the environmental issues and 24/7 working practices. (Formal report not yet received.) Quality, Safety and Experience 23 September 2014 Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 3 of 24

4 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 3 vember and 22/10/14 B1 UHW Cardiology Dignity and Essential Care Inspection The immediate feedback was extremely positive although two areas which required immediate assurance were identified. These related to completion of Deprivation of Liberty paperwork on one patient; environmental issues related to the kitchen area on the ward. Executive Nurse Director A comprehensive action plan has been submitted to address the areas of noncompliance. Quality, Safety and Experience 16 December 2014 t received 12 vember 2014 W1 UHL General Medicine Dignity and Essential Care Inspection Immediate feedback was extremely positive. There were no areas that required immediate assurance. (Formal report not yet received) action required. Executive Nurse Director Quality, Safety and Experience 16 December vember vember 2014 W3 Whitchurch Mental Health MH Act Monitoring Visit MHA managed well. Increased OT and gym supervision provision necessary. Some Estates maintenance issues. Evidence of strong teamwork and empowering clinical leadership. Executive Nurse Director 05 December 2014 Mental Health and Capacity Legislation Prof Marcus Longley Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 4 of 24

5 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 2 September June 2014 A4 UHW General Medicine Dignity and Essential Care Inspection Overall patients felt the Detailed action plan quality of their experience provided. was high,staff aware of the need to protect the privacy&dignity of all patients & had measures in place to ensure that this happened. Lack of communication aids for those patients who may have some form of sensory impairment. Some environmental factors need attention. Nursing & medical leadership provided to the ward appeared good. One key issue relating to the fragmented & occasionally incomplete nature of the documentation relating to patient care. This area was not subject to detailed review during this inspection & it was recommended that the UHB look at this in more depth. Also recommended introduction of a tool for the consistent assessment & evaluation of pain management. Executive Nurse Director Quality, Safety and Experience Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 5 of 24

6 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) Health and Safety Executive Standard 1 - Governance and Accountability Framework Standard 12 - Environment Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety inspections during period Human Tissue Authority (HTA) visits during period Medicines and Health Care Regulatory Agency (MHRA) Standard 1 - Governance and Accountability Framework Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety Standard 1 - Governance and Accountability Framework Standard 7 - Safe and Clinically Effecive Care Standard 16 - Medical Devices, Equipment and Diagnostic Systems Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety 5-7 Feb 2013 UHB Wide Research & Development Good Clinical Practice (GCP) in the conduct and management of noncommercial clinical trials sponsored or hosted by the UHB. Two major findings identified during this inspection relating to: Trial Management Quality Systems As at only one Medical Director action outstanding, relating to UHB IT Policy which should receive approval in September Outstanding action regarding the updating of the UHB Information Technology (IT) Policy. The Information Governance Policy which is a related document was approved by the PPD Committee in January. Following this the IT Policy will be progressed. In progress Ongoing Quality, Safety & Experience - Research Governance Group Quarterly 23 September 2014 Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 6 of 24

7 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) South Wales Cancer Network Standard 1 - Governance and Accountability Framework Standard 2 - Equality, Diversity and Human Rights Standard 7 - Safe and Clinically Effecive Care Standard 8 - Care Planning and Provision Standard 9 - Patient Information and Consent Standard 10 - Dignity and Respect Standard 11 - Safeguarding Children and Safeguarding Vulnerable Adults Standard 12 - Infection Prevention and Control and Decontamination Standard 15 - Medicines Management Standard 17 - Blood Management Standard 18 - Communicating Effectively Standard 19 - Information Management and Communications Technology Standard 20 - Records Management Standard 21 - Research, Development and Innovation Standard 23 - Dealing with concerns and managing incidents t on CE post log - formal report is issued by Peer Review Panel to Multi Disciplinary Team (MDT) (Reported to QSE in September 2014) Lung Cancer MDT Peer review for quality assurance against a framework of standards of care. Several areas of excellent practice were noted. Concern raised at the lack of an acute oncology service within C&V. Lung - lack of management engagement The Health Board has instigated the formation of the Cancer Performance Steering Group, chaired by the Chief Operating Officer and attended by the Medical Director and Cancer Services team. This Group meets weekly to address cancer services quality, safety and performance issues in the round. Clinicians and managers involved at all steps along the patient journey are invited to attend; these include diagnostic services such as pathology and radiology on addition to clinical leads for the site specific cancer teams. Medical Director Complete Quality, Safety and Experience 23 September 2014 Annual review will be undertaken Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 7 of 24

8 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) t on CE post log - formal report is issued by Peer Review Panel to Multi Disciplinary Team (MDT) Urology Peer review for quality assurance against a framework of standards of care. Several areas of excellent practice were noted. Concern raised at the lack of an acute oncology service within C&V. Appointment of a senior clinical lead for Acute Oncology and 2 full time clinical nurse specialists (funded by Macmillan). Medical Director The AOS Lead Clinician was appointed in vember The 2 AOS nurse posts have been advertised and the interviews are scheduled for 6 February. Quality, Safety and Experience 23 September 2014 Annual review will be undertaken t on CE post log - formal report is issued by Peer Review Panel to Multi Disciplinary Team (MDT) (Reported to QSE Committee in September 2014) Upper GI MDT Peer review for quality assurance against a framework of standards of care. Several areas of excellent practice were noted. Concern raised at the lack of an acute oncology service within C&V. Upper gastrointestinal - age of the endoscopic ultrasound. Appointment of a senior clinical lead for Acute Oncology and 2 full time clinical nurse specialists (funded by Macmillan). The AOS Lead Clinician was appointed in vember The 2 AOS nurse posts have been advertised and the interviews are scheduled for 6 February. Quality, Safety and Experience 23 September 2014 Annual review will be undertaken South Wales Fire and Rescue Standard 1 - Governance and Accountability Framework Standard 12 - Environment Standard 22 - Managing Risk and Health and Safety 27 February February 2014 Cardiff and Vale Orthopaedic Centre, UHL Regulatory Reform Order Enforcement tice issued All issues now (ENH-280). Issues with compartmentation, fire doors propped open, staff who have not received fire training. addressed and SWFRS will be invited back to confirm they are satisfied with the improvements and to lift the Enforcement tice Enforcement tice lifted on following re-inspection by SWFS Completed Health and Board -21 October 2014 Safety - Martyn 1 July 2014 Waygood ############### 3 September 2014 Wards B7 and A7UHW Audit Informal tice issued. Management actions required and some capital issues. Completed. Health and Estate and Safety - Martyn Capital issues Waygood reported to Informal notices not reported in detail to Health and Safety Committee. ############### 3 September 2014 Ward C7 UHW Audit Informal tice issued. Management actions required and some capital issues. Completed. Health and Estate and Safety - Martyn Capital issues Waygood reported to Informal notices not reported in detail to Health and Safety Committee. ############### 18 September 2014 A5 UHW?? Audit Informal tice issued. Management actions required. Complete Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. 2 October September 2014 Ward B5 UHW Audit Informal tice issued. Management actions required and some capital issues. Completed. Health and Estate and Safety - Martyn Capital issues Waygood reported to Informal notices not reported in detail to Health and Safety Committee. 3 October October 2014 Toxicology UHL Audit Management issues and a lot of capital work required Capital issues out to tender Tender results awaited Ongoing Health and Safety - Martyn Waygood Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 8 of 24

9 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 10 vember October 2014 A6 UHW Audit Informal tice issued. Management actions required. Complete Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. 3 October October 2014 A4 UHW Audit Informal tice issued. Management actions required. Complete Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. 6 October September 2014 Ward B4 UHW Audit Informal tice issued. Management actions required and some capital issues. Completed Health and Estate and Safety - Martyn Capital issues Waygood reported to Informal notices not reported in detail to Health and Safety Committee. 7 October September 2010 Ward C5 UHW Audit Informal tice issued. Management actions required and some capital issues. Completed Health and Estate and Safety - Martyn Capital issues Waygood reported to Informal notices not reported in detail to Health and Safety Committee. 3 December vember 2014 Anwen Ward, UHL Order - Enforcement notice Capital, management issues Task and Finish Group established to address the issues. First due on 8 January. Health and Estate and Safety - Martyn Capital issues Waygood reported to 13 January 3 December vember 2014 Day Surgery, UHL Order - Enforcement notice Capital, management issues Task and Finish Group established to address the issues. First due on 8 January. Health and Estate and Safety - Martyn Capital issues Waygood reported to 13 January Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 9 of 24

10 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) 3 December vember 2014 Main Theatres, UHL Order - Enforcement notice Capital, management issues Task and finish group established to address the issues. First due on 8 January. Health and Estate and Safety - Martyn Capital issues Waygood reported to 13 January 4 December vember 2014 B6 Delivery Unit UHW Informal tice issued. Management actions required. Complete Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. 15 December December 2014 Theatres UHW Informal tice issued. Management actions required. Complete Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. 6.January 1 December 2014 Wards E10, 12, 14, 16 and 18 (MHSOP UHL) Informal tice issued. Management actions required. Awaited Estate and Capital issues reported to Informal notices not reported in detail to Health and Safety Committee. Wales Audit Office Reports monitored via separate tracking report ACCREDITATION VISITS Home Office Standard 1 - Governance and Accountability Framework Standard 7 - Safe and Clinically Effecive Care Standard 16 - Medical Devices, Equipment and Diagnostic Systems Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety Annual application made for licence to hold and test controlled drugs in the Toxicology laboratory. Licence applied for in February 2014 and received in July Licence has never been refused and there are no actions for the UHB to undertake as long as compliance is maintained. report centrally captured. British Standards Institute reports received Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 10 of 24

11 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) UK Accreditation Service (UKAS) Standard 1 - Governance and Accountability Framework Standard 7 - Safe and Clinically Effecive Care Standard 16 - Medical Devices, Equipment and Diagnostic Systems Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety reports centrally captured. However, evidence of visits within Clinical Board reports to QSE. General Medical Council (GMC) Standard 26 - Workforce Training and Organisational Development reports captured. Deanery Training Report reports captured. SGS United Kingdom Ltd reports captured. WELSH RISK POOL Standard 1 - Governance and Accountability Framework Standard 7 - Safe and Clinically Effecive Care Standard 11 - Safeguarding Children and Vulnerable Adults Standard 12 - Environment Standard 13 - Infection, Prevention and Control Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety Standard 23 - Dealing with Concerns and Managing Incidents 4-6 Mar 2014 Surgical Pathways Assessment The Welsh Risk Pool Assessment for 2013/2014 Scored 80% overall. Overall score for documentation = 87% Overall score for staff interview = 72% 6 areas were scored at 100% 4 areas were scored at 80% or over 3 areas were scored between 50 and 79% On receipt of the interim report an appeal was lodged with WRP and the assessment was reevaluated and the score increase from 77% to 80%. Final report presented to QSE Committee on 23 September Ongoing Quality, Safety and Experience 17/06/2014 and 23/09/14 Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 11 of 24

12 Date of Report Date of Visit/Review Site/Location Clinical Board/Directorate/ Specialty Brief Description of reason for visit/review Summary of Findings/Recommendations Management Response Executive/Operational Lead Due Date Position as at 31 January Status Assurance (Ongoing/Compl Committee & Chair ete) If reported to another group state here Date Reported to Assurance Committee Date Next Scheduled Visit/Renewal of Licence/ Accreditation (if applicable) JACIE (Joint Accreditation Committee-ISCT (Europe) & EBMT) Standard 1 - Governance and Accountability Framework Standard 3 - Health Promotion, Protection & Improvement Standard 6 - Participating in Quality Improvement Activities Standard 7 - Safe and Clinically Effecive Care Standard 8 - Care Planning and Provision Standard 9 - Patient Information and Consent Standard 12 - Environment Standard 13 - Infection, Prevention and Control and Decontamination Standard 16 - Medical Devices, Equipmetn and Diagnostic Systems Standard 17 - Blood Management Standard 20 - Records Management Standard 22 - Managing Risk and Health and Safety reports captured for this period. Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 12 of 24

13 Contained within CE Important Documents Log Regulatory and Review Bodies Tracking Report - 1 July 2014 to 31 January 13 of 24

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