DECLARATION OF COMPLIANCE WITH THE CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY & SAFETY (The Hygiene Code can be found in Outcome 8)

Transcription

1 DECLARATION OF COMPLIANCE WITH THE CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY & SAFETY (The Hygiene Code can be found in Outcome 8) FOR SOUTHPORT AND ORMSKIRK HOSPITAL NHS TRUST INTEGRATED CARE ORGANISATION Regulated Activities for Southport and Ormskirk Hospital NHS Trust Treatment of disease, disorder or injury Surgical Procedures Diagnostic and screening procedures Maternity and midwifery services Family planning Assessment or medical treatment for patients detained under the Mental health Act 1983 Management and supply of blood and blood derived products Termination of pregnancies ACUTE SERVICES PAGE 3 COMMUNITY SERVICES PAGE 99 ADULT SEUAL HEALTH SERVICES PAGE 185 To be fully understood this document should be read with the Guidance about compliance document for the Essential Standards of Quality and Safety, produced by the CQC 1

2 Please refer to our guidance document Provider Compliance Assessment: Guidance for providers before completing the assessment. Provider details Provider name Provider ID Location Location ID Address line 1 Address line 2 Town/city County Postcode Southport and Ormskirk NHS Hospital Trust RVY Southport General Hospital and Ormskirk General Hospital RVY01 and RVY02 Trust Management Office Town Lane, Kew Southport Merseyside PR8 6PN (if applicable) Website Main telephone Fa

3 Acute Services Involvement and information Outcome 1 (Regulation 17): Respecting and involving people who use services What should people who use services eperience? People who use services: Understand the care, treatment and support choices available to them. Can epress their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. Have their privacy, dignity and independence respected. Have their views and eperiences taken into account in the way the service is provided and delivered. Those acting on behalf of people who use services: Understand the care, treatment and support choices available to the people who use services. Can represent the views of the person using the service by epressing these on their behalf, and are involved appropriately in making decisions about their care, treatment and support. This is because providers who comply with the regulations will: Recognise the diversity, values and human rights of people who use services. Uphold and maintain the privacy, dignity and independence of people who use services. Put people who use services at the centre of their care, treatment and support by enabling them to make decisions. Provide information that supports people who use services, or others acting on their behalf, to make decisions about their care, treatment and support. Support people who use services, or others acting on their behalf, to understand the care, treatment and support provided. Enable people who use services to care for themselves where this is possible. Encourage and enable people who use services to be involved in how the service is run. Encourage and enable people who use services to be an active part of their community in appropriate settings. 3

4 Ensure personalised care, treatment and support through involvement 1A Provide evidence to demonstrate that people who use services are involved in and receive care, treatment and support that respects their right to make or influence decisions. Summary of evidence to support the outcomes described in 1A Clin Corp 61 Mental Capacity Act Policy and appendicies Clin Corp 20 Policy for written patient information Clin Corp 58 Policy for the care of people with learning difficulties within Southport and Ormskirk hospital NHS Clin Corp 04 Policy for Consent to eamination or treatment Corp 33 Policy on the Confidelntiality and Security of person identifiable information Corp 30 Policy for the use of the Interpretator service Pers 06 Dignity at work policy Blank Patient assessment form highlighting MCA section Screen shot of MCA/DOLS database Various assessment from learning disability passport Blank MCS care plan Patient leaflet - Information for Inpatients, day cases amd visitors Patient leaflet - Informaiton for Outpatients Patient information offered in range of other formats Customer Care presentation at Corporate Induction Equality and Diversity E-learning course Risk Management Committee agenda showing training is an discussd Trust Board Agena showing Risk Management is discussed Consent form and risks eplained PPISG Membership list PPISG Minutes April 2011 to June 2011 Nursing and Midwifery Advisory Group (NMAG) Minutes April 2011 to August 2011 Including TOR Senior Nurses Advancing Practice (SNAP) Minutes April 2011 to August 2011 Trust Board Agenda showing Matrons Checklist is an Agenda Item including Matrons Checklist Trust Board agenda showing Essence of Care as Aganda item including Essence of Care Report Trust Board aganda showing National Outpatient Survey as aganda item including National Outpatient surveypatient survey Choose and Book data for Southport and Ormskirk Update on choose and book performance Blank Learning Disabilities Health Passport PAS Screen shot showing Medical Alert PAS Screen shot ahowing further details of Medical Alert Single Equality Scheme Equality and Diversity Steering Group Minutes Agenda April 2011 to September 2011 Minutes April 2011 to December 2011 Risk Management agenda showing Equality and Diversity report to Risk Complaints Information available on the Internet Risk Management Committee Agenda showing Corporate trends and Incidents are discussed Trust Board agenda showing Risk Management report to Trust 4

5 The Caldicott Guardian Manual 2010 Interpretor spread sheet Interpretor invoices Maternity Liaison Committee Maternity Care Forum Annual consent audit Training figures for Mental Capacity Act 2005 e-learning Training figures for Mental Capacity Act Equality and Diversity Training records Incident reports on Breach of Patient Information ODGH Incident reports on Breach of Patient Information SDGH Training figures for Customer care attendance Patient eperience Measures (PEMS) monthly compliance reports Patient Related Outcome Measures (PROMS) monthly compliance reports Risk Management Trend reports Quality report submitted to DOH Inpatient survey National inpatient survey and action plan Maternity Inpatient survey and action plan National Staff Survey results AED CQI Patient Feedback October Southport and Ormskirk - Patient Eperience Report - August 2011 Implementing a Duty of Candour ; a new contractual requirement on providers GAP analysis RM 24 Policy Being open when a patient is harmed 1B Provide evidence to demonstrate that people who use services have their care, treatment and support needs met. Summary of evidence to support the outcomes described in 1B Clin Corp 10 Admission Policy Clin Corp 61 Mental Capacity Policy and appendices Clin Corp 64 Policy for the transfer of patients Pers 6 Dignity at Work Policy Clin Corp 58 Policy for the care of people with Learning Difficulties within Southport & Ormskirk NHS Trust Patient Assessment document Care plans Trust Board Agenda showing Matrons Checklist is discussed at Trust Including Matrons Checklist Patient and Public Involvement Strategy PPISG Minutes April 2011 to June 2011 Trust Quality Minutes showing Link representation Trust Board Agenda showing Quality reports to Trust Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR 5

6 Trust Board agenda showing Risk Management reports to Trust Coronary Heart Disease Minutes showing patient representation Equality and Diversity Steering Group Agenda and Minutes Agenda April 2011 to September 2011 Minutes April 2011 to December 2011 Risk Management Committee Agenda showing Corporate trends and Incidents are discussed Trust Board Agenda showing Risk report to Trust Screen shot of the DOLS, Safeguarding and LD Database MCA Care plans Learning Disabilities Health Passport Record of Restrictive Practice Leaflet on how to refer to the Liverpool/Sefton IMCA Manage risk through effective procedures about involvement 1C Provide evidence to demonstrate that people who use services receive care, treatment and support where clear procedures are followed in practice, monitored and reviewed. Summary of evidence to support the outcomes described in 1C Clin Corp 4 Policy for Consent to Eamination or Treatment Patient Assesment Document Southport and Ormskirk Choose and Book Services How to Make a Complaint leaflet Electronic Communication Tablets (THESE ARE AVIALABLE ON THE WARDS AND WILL BE AVAILABLE FOR ASSESSOR TO VIEW) Information for Outpatients booklet Information for Inpatients, Day Cases and Visitors Safeguarding Adults Care Plan Safeguarding Children Care Plan Maternity CNST 1D Provide evidence to demonstrate that people who use services benefit from a service that takes into account relevant guidance. Summary of evidence to support the outcomes described in 1D Clin Corp 58 Policy for Care of People with Learning Difficulties within Southport and Ormskirk Hospital NHS DOH Equal Access document showing trust named as eample of good practice Meeting Schedule and agenda for Access Advisory group Meetings PPISG Minutes April 2011 to June 2011 NICE Guidance benchmarking/action plans 6

7 Promote rights and choices 1E Provide evidence to demonstrate that people who use services, or others acting on their behalf, are supported to make informed choices about their care, treatment and support. Summary of evidence to support the outcomes described in 1E Clin Corp 58 Policy for Care of People with Learning Disabilities within Southport and Ormskirk Trust Clin Corp 3 Discharge Policy Clin Corp 10 Admission Policy Information for Outpatients booklet Information for Inpatients, Day Cases and Visitors MDT Minutes various minutes where a trust member has attended Blank Consent forms Completed Consent forms Blank Patient Assessment showing referral to Smoking Cessation Completed and Blank Patient Assessment showing referral to Smoking Cessation Patient Information leaflets for Alcohol abuse support List of Patient Information leaflets available in GUM Patient Information leaflets for Seual Health Advice Emergency Contraception advice Choices in Childbirth leaflet Genitourinary Medicine Fast Track referal form Smoking Cessation posters that are on the wards Smoking Cessation Care Plan Trust Board agenda showin Matrons Checklist reports to Trust Including Matrons Checklist 1F Provide evidence to demonstrate that people who use services receive care, treatment and support that is provided in a way that ensures their independence is promoted. Summary of evidence to support the outcomes described in 1F Risk Management No 26 - Risk Profiling Policy Pathways and Care Plans available on the Intranet Nursing and Midwifery Documentation Group Terms of Reference Nursing and Midwifery Documenation Group Agenda May 2011 to September 2009 Minutes May 2011 to September G Provide evidence to demonstrate that people who use services receive care, treatment and support that is provided in a way that ensures their human rights and diversity are respected. Summary of evidence to support the outcomes described in 1G Patient Admission Document showing section for Chaplaincy visit 7

8 Information available on chapel facilities in Southport and Ormskirk Hospitals Equlity and Diversity information available on the intranet Equality and Diversity Training records Single Equity Scheme Information available on the intranet about training and development Equality and Diversity Steering Group Agenda April 2011 to September 2011 Minutes April 2011 to December 2011 Risk Management Committee agenda showing E&D Steering group is discussed Trust Board Agenda showing Risk is discussed at trust End Of Life Strategy meeting agenda showing chaplaincy is discussed Trust Quality Meeting Annual cycle showing EOL is discussed Trust Board Agenda showing Quality report to trust 1H Provide evidence to demonstrate that people who use services are provided with information as outlined in section 1H. Summary of evidence to support the outcomes described in 1H Risk Management 19 - Complaints Policy/Procedure Corp 55 Administration of Private Patients Quality Strategy Complaints Leaflet List of policies available on both the intranet and internet 1I Provide evidence that demonstrates that people who use services, or others acting on their behalf, are given encouragement, support and opportunities as described in section 1I. Summary of evidence to support the outcomes described in 1I Clin Corp 3 Discharge Policy Clin Corp 10 Admission Policy CLIN CORP 58 Care of Patients with Learning Disabilities Clin Corp 61 Mental Capacity Policy and appendices Patient assessment documents Discharge questionnaire July 2010 Matrons checklist Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 Single-Equality-Scheme safeguarding children annual report safeguarding audit report safeguarding adults annual report Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR 8

9 Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR 1J Provide evidence that demonstrates that people who use services, can influence how the service is run as they are given opportunities to take part in decision making. Summary of evidence to support the outcomes described in 1J Inpatient Survey Outpatient Survey Matrons checklist National Cancer Survey End of Life GSF Survey Care as Care should be Survey Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 PPISG Minutes April 2011 to June 2011 Additional prompts for specific service types ACS AMB CHC DCS DEN DSS DTS HPS LDC LTC MBS MHC MLS PHS RCA RHS UCS 1K Provide evidence that demonstrates that people who use services can be confident that the outcome of diagnostic tests and assessments will be eplained and discussed with them in a way which they are able to understand and which enables them to make informed choices about their care, treatment and support, where this is the role or responsibility of the service undertaking the test. Summary of evidence to support the outcomes described in 1K Consultant timetable 1 consultant timetable 2 Consultant rotas Medicine Rotas Aug 10-Aug 11 and Aug 12 to date Consultant ward rounds 9

10 RSM MLS SMC 1L Provide evidence that demonstrates that people using rehabilitation or treatment services for substance misuse can be confident that restrictions which may be placed upon them achieve outcomes outlined in section 1L. n/a CHN CHS DCC EC LDC LTC MHC MLS RHS SHL SLS SMC 1M Provide evidence that demonstrates that people who use services are enabled to participate in the activities of the local community so that they can eercise their right to be a citizen as independently as they are able to. n/a Involvement and information Outcome 2 (Regulation 18): Consent to care and treatment What should people who use services eperience? People who use services: Where they are able, give valid consent to the eamination, care, treatment and support they receive. Understand and know how to change any decisions about eamination, care, treatment and support that has been previously agreed. Can be confident that their human rights are respected and taken into account. This is because providers who comply with the regulations will: Have systems in place to gain and review consent from people who use services, and act on them. 10

11 Manage risk through effective consent procedures 2A Provide evidence that where they are able, people who use services receive the eamination, care, treatment and support they agree to. This is because clear procedures to get valid consent are followed in practice, monitored and reviewed. Summary of evidence to support the outcomes described in 2A Clin Corp 04 Policy for Consent to Eamination or Treatment Including appendicies (Showing Frazer Gillick included) Clin Corp 20 Policy for Written Patient Information Clin Corp 61 Mental Capacity Policy Clin Corp 58 Policy for the Care of People with Learning Disabilities within Southport and Ormskirk Hospital NHS Clin Corp 5 Policy on Advance Directives Consent Committee Agenda April 2012 Minutes October 2011 Consent presentation Including TOR Risk Management Committee agenda showing Consent Commttee report to Risk Risk management Annual Cycle showing Consent Committee report to Risk Trust Board Agenda showing Risk Manangement report to Trust Diagnostic and support Agenda April 2011 September 2011 Minutes April 2011 September 2011 Changes its name in October 2011 to Service Improvement and Support Agenda October 2011 March 2012 Minutes October 2011 February 2012 Screen shot of Consent Database Interpretor spread sheet Interpretor invoices Screen shot of DOLS,Safeguarding and LD database MCA Care plans Patient assessment document highlighting MCA section Blank Learning Disability Health Passport Completed Learning Disability Health Passport IMCA services Record of restrictive practice Mental Capacity Act Deprivation of Liberty Safeguards Various MDT meeting where member of the trust attended Patient leaflet - Information for outpatients Patient leaflet - Information for Inpatients, Day cases and visitors safeguarding children annual report safeguarding adults annual report DOL Code of Practice 11

12 2B Provide evidence which demonstrates that people who use services benefit from staff who understand about consent as outlined in section 2B. Summary of evidence to support the outcomes described in 2B Clin Corp 58 Policy for the care of people with learning disabilities within Southport and Ormskirk Hospital NHS Clin Corp 09 Policy for the Decisions relating to a Do Not Attempt to Resuscitate (DNAR) Order Clin Corp 05 policy on Advance Directives (Also known as Living Wills) Single Equity Scheme Consent Annual report Patient Assessment document Condition specific Patient information leaflet Consent training records ALL FURTHER EVIDENCE FOR SECTION 2B CAN BE FOUND IN 2A 2C Provide evidence that demonstrates that the service has clear procedures that are followed in practice, monitored and reviewed about decision making for people who are unable to give, or choose to withhold, consent for each individual care, treatment and support activity. Summary of evidence to support the outcomes described in 2C Clin Corp 61 Mental Capacity Policy including apendicies Clin Corp 05 Policy on Advance Directives (Also know as Living Wills) Clin Corp 04 Policy for Consent to Eamination or Treatment MCA care plans Patient assessment document showing MCA section Annual list of mental health sectioned patients 2D Provide evidence that demonstrates that people who use services benefit from a service that takes into account relevant guidance, including that from the Care Quality Commission s Schedule of Applicable Publications. Summary of evidence to support the outcomes described in 2D Reference guide to Consent for Eamination or Treatment (DH 2001) - Clin Corp 04 Policy for Consent to Eamination or Treatment - Consent form 1 and 3 Good practice in consent: achieving the NHS plan commitment to patient centred consent pratice (Health Service Circular HSC 2001/023) referenced in Clin Corp 04 policy for consent to Eamination or Treatment Seeking consent working with children (DH 2001) referenced in Clin Corp 04 policy for consent to Eamination or Treatment - Consent form 2 Research governance framework for health and social care: second edition (DH, 2005) Procedures for the approval of Independent Sector Places for the Termination of Pregnancy (DH) Relevant guidance and codes of conduct relating to consent published by professional registration 12

13 councils such as the General Medical Council - Clin Corp 04 Nursing and Midwifery Council General Social Care Council and the Health Professionals Council Mental Health Act Code of Practice (2007) referenced in Clin Corp 04 Policy for Consent to Eamination or Treatment Mental Capacity Act Code of Practice (2008) referenced in Clin Corp 04 Policy for Consent to Eamination or Treatment 2E Provide evidence that demonstrates that people are able to make a decision about whether or not to give consent because they have information about the alternative options for their care, treatment and support and the risks and benefits of each. Summary of evidence to support the outcomes described in 2E Clin Corp 20 Policy for written patient information Patient leaflet - Information for Inpatients, day cases and visitors Patient leaflet - Information for Outpatients Additional prompts for specific service types ACS DCS DTS MBS 2F Provide evidence that demonstrates that people who use services give valid consent because arrangements are followed to ensure that cosmetic surgery does not take place on the same day as the consultation n/a ACS DCS DSS DTS MBS 2G Provide evidence that demonstrates that people who use imaging services who do not have symptoms indicating that imaging is required receive information regarding the risks and benefits prior to the procedure being carried out as outlined in section 2G. Summary of evidence to support the outcomes described in 2G -ray department letter eplaining the procedure 1 Bone Densitometry DEA -ray department letter eplaining the procedure 2 Barium Enema -ray department letter eplaining the procedure 3 MRI Small bowel study -ray department letter eplaining the procedure 4 CT Abdomen Colon Enhanced -ray department letter eplaining the procedure 5 US Abdomen 13

14 -ray department letter eplaining the procedure 6 R Intravenous urogram Patient information - Hysteroscopy under General Anaesthetic Diagnostic and support Agenda April 2011 September 2011 Minutes April 2011 September 2011 Changes its name in October 2011 to Service Improvement and Support Agenda October 2011 March 2012 Minutes October 2011 February 2012 ACS LDC MHC MLS PHS RSM SMC 2H Provide evidence that demonstrates that people who use services are supported to make a decision about whether or not to give consent when this is not in conflict with any restrictions set by the courts, Mental Health Act 1983, Mental Capacity Act 2005 or criminal justice system. Summary of evidence to support the outcomes described in 2H Clin Corp 20 Policy for written patient information Clin Corp 61 Mental Capacity Policy including apendicies Clin Corp 04 Policy for Consent to Eamination or Treatment Patient information - Hysteroscopy under General Anaesthetic 14

15 Personalised care, treatment and support Outcome 4 (Regulation 9): Care and welfare of people who use services What should people who use services eperience? People who use services: Eperience effective, safe and appropriate care, treatment and support that meet their needs and protect their rights. This is because providers who comply with the regulations will: Reduce the risk of people receiving unsafe or inappropriate care treatment and support by: o assessing the needs of people who use services o planning and delivering care, treatment and support so that people are safe, their welfare is protected and their needs are met o taking account of published research and guidance o making reasonable adjustments to reflect people s needs, values and diversity o having arrangements for dealing with foreseeable emergencies. Ensure effective, safe and appropriate, personalised care, treatment and support through coordinated assessment, planning and delivery 4A Provide evidence that demonstrates that people who use services have safe and appropriate care, treatment and support because their individual needs are established from when they are referred or begin to use the service. Summary of evidence to support the outcomes described in 4A Clin Corp 10 Admission policy Clin Corp 3 Discharge policy including appendicies Clin Corp 61 Mental Capacity policy including appendicies Clin Corp 64 Policy for the Transfer of Patients Screen shot of A&E flagging system A&E card showing flagging alert Nursing care plans Completed nursing care plans Blank Learning disability passport 15

16 Completed Learning disability passport Menu card showing healthy options available Menu card showing a red tray system is available Eamples of diatery advice in notes Dietary consultation Various completed menu cards Quality Dashboard Trust Quality Committee Agenda April 2011 to November 2011 Minutes April 2011 to November 2011 Including TOR Trust board agenda showing quality report to trust VTE Assessment form VTE working party Minutes April 2011 to July 2011 Including TOR Quality Minutes showing VTE is discussed Diatition Referal form Patient assessment form showing referal to smoking cessation team Advancing Quality Report AMI showing smoking cessation Advancing Quality Report Heart Failure showing smoking cessation Advancing Quality Report Pneumonia showing smoking cessation Manage risk through effective procedures 4B Provide evidence that demonstrates that people who use services benefit from a service that has effective procedures and arrangements in place which have outcomes described in section 4B. Summary of evidence to support the outcomes described in 4B Risk Man 6 Policy for Reporting and Management of Incidents Risk Man 24 Policy for Being Open when patients are harmed Corp 61 policy for Emergency, Contingency and Business Continuity Planning Risk Man 22 Policy for Central Alert System (CAS) Medical CBU governance Agenda April 201 to January 2012 Minutes April 2011 to December 2011 CBU Changing in November 2011 to Urgent Care Surgical CBU Governance April 2011 to January 2012 Minutes April 2011 to January 2012 CBU Changing in November 2011 Planned Care Changes to Women and children s CBU Governance in October 2010 Agenda April 2011 to September 2011 Minutes April 2011 to September 2011 CBU Changing in November 2011 Maternity Care Forum and Paediatric Dept Meeting Minutes Diagnostic and Support Services CBU Governance Agenda April 2011 to March 2012 Minutes April 2011 to February

17 Including TOR CBU Changing in November 2011 to Service Improvement and Support Business Unit Governance Committee Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR Trust Board Agenda and Minutes showing Risk Management report to Trust Risk Management Strategy C Provide evidence that demonstrates that people who use services can be confident that wherever possible, they have information and plans outlined in section 4C. Summary of evidence to support the outcomes described in 4C Training figures for Customer care attendance Equality and Diversity E-learning course Equality and Diversity Training records Feedback to matron 4D Provide evidence that demonstrates that people who use services can be confident that staff will quickly recognise and immediately respond to their needs when their condition deteriorates or they become seriously ill, transferring them to another service as quickly and as safely as possible, if this is deemed to be necessary. Summary of evidence to support the outcomes described in 4D Clin Corp 81 Early warning Track and Trigger policy Clin Corp 22 Transfer critically ill Patient Internal transfer of critically ill patients Audit report Internal Transfer Audit action plan Critical care minutes showing Internal transfer audit is discussed SNAP Minutes April 2011 to August 2011 Including TOR NMAG Minutes April 2011 to August 2011 Including TOR EWS and fluid balance charts EWS and fluid balance action plans Maternity Services transfer of care guidelines 17

18 Promote rights and choices 4E Provide evidence that demonstrates that people who use services are involved in or supported to make informed decisions about their care, treatment and support options as outlined in section 4E. Summary of evidence to support the outcomes described in 4E Inpatient Leaflet Outpatient Leaflet Additional prompts for specific service types ACS HPS MLS 4F Provide evidence that demonstrates that people who use services know that they will receive care, treatment and support in single se accommodation wherever it is available. Summary of evidence to support the outcomes described in 4F Care as care should be leaflet Care as care should be report Trust Board agenda showing care as care should be is discussed LD Questionnaire Care as Care should be Same Se accommodation information Feedback to Matron ACS MLS 4G Provide evidence that demonstrates that people who use services know that their length of stay will be as short as possible in order to meet their needs, or as required by legal restrictions and that their accommodation will not limit their freedom any further than is agreed in their plan of care. Summary of evidence to support the outcomes described in 4G Clin corp 03 discharge policy and appendices Clin Corp 61 mental capacity act policy and appendices Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR Trust Board 18

19 Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 SNAP Minutes April 2011 to August 2011 Including TOR NMAG Minutes April 2011 to August 2011 Including TOR 160 Mental Capacity Care Plan ACS AMB CHC DCS DEN DSS DTS LTC MBS MHC MLS PHS RCA RHS RSM SMC UCS 4H Provide evidence that demonstrates that people who use services can be confident that diagnostic tests are carried out in lines with section 4H of the Guidance about compliance: Essential standards of quality and safety. Summary of evidence to support the outcomes described in 4H Clin Corp 28 Policy to monitor and Ensure Competency in Carrying out procedures and in the use of clinical equipment Pers 25 capability Policy Corp 34 Medical Devices Policy Screen shot of competency database HR Strategy Committee minutes April 2011 to October 2011 Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 MDT - Cancer services meeting where member of the trust attended ACS AMB CHC DCC DCS DEN DSS DTS HPS LTC MBS MHC MLS PHS RCA UCS 4I Provide evidence that demonstrates that children who use services benefit the outcomes described in section 4I. Summary of evidence to support the outcomes described in 4I Corp 74 Safeguarding and Child protection policy Welcome to the children s ward booklet Medical CBU governance Agenda April 201 to January 2012 Minutes April 2011 to December

20 CBU Changing in November 2011 to Urgent Care Surgical CBU Governance April 2011 to January 2012 Minutes April 2011 to January 2012 CBU Changing in November 2011 Planned Care Changes to Women and children s CBU Governance in October 2010 Agenda April 2011 to September 2011 Minutes April 2011 to September 2011 CBU Changing in November 2011 Diagnostic and Support Services CBU Governance Agenda April 2011 to March 2012 Minutes April 2011 to February 2012 Including TOR CBU Changing in November 2011 to Service Improvement and Support Business Unit Governance Committee Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 Safeguarding Children Steering Group Agenda April 2011 to November 2011 Minutes April 2011 to November 2011 SNAP Minutes April 2011 to August 2011 Including TOR NMAG Minutes April 2011 to August 2011 Including TOR Blank paediatric admission document ACS DTS 4J Provide evidence that demonstrates that women undergoing termination of pregnancy know that the service and arrangements in place to meet their individual needs and preferences reflected in the outcomes described in section 4J. Summary of evidence to support the outcomes described in 4J Clin corp 21 disposal of fetal remains Pregnancy loss form Inpatient Leaflet Outpatient Leaflet Referral into Trust via GP / Family planning Dr / Nurse Pregnancy Advisory Service Pathway Self referral being discussed at following groups Abortion Group North West Abortion network group 20

21 Clinics on ODGH Site For 13 week + links with BPAS ( Merseyside Clinic) 24 hr advice available via ward phone afterwards ACS CHC CHN CHS DCC EC HPS LDC LTC MLS RSM SHL SLS SPC UCS 4K Provide evidence that demonstrates that people who use services who are at the end of their life will have their care, treatment and support needs met because wherever possible the outcomes in section 4K are met. Summary of evidence to support the outcomes described in 4K clin corp 24 policy for the early release of the deceased patient clin corp 77 policy for care of the dying and deceased patient Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR Inpatient Leaflet Outpatient Leaflet ACS LDC MHC MLS PHS RSM SMC 4LProvide evidence that demonstrates that people who use services, who are thought to present a risk of suicide and homicide or harm to themselves or others have an ongoing, multi-disciplinary assessment and plan of care made to determine whether they have a history of harm to themselves or others, including environmental risks, and how these can be minimised. Summary of evidence to support the outcomes described in 4L Corp 58 standards and clinical guidance policy including national institute for clinical ecellence guidance nsfs confidential enquiries and high level enquiries Quality Dashboard Screen shot of A&E flagging system A&E card showing flagging alert A+E PEG BO guideline Maternity Services referral pathways 21

22 ACS AMB BTS CHC CHN CHS DCC DCS DEN DSS DTS HBC HPS LDC LTC MBS MHC MLS PHS RCA RHS RSM SLS SMC SPC UCS 4M Provide evidence that demonstrates that people who use services benefit from a service that ensures that patient safety alerts, rapid response reports and patient safety recommendations issued by National Patient Safety Agency (NPSA) and which require action are acted upon within required time-scales. Summary of evidence to support the outcomes described in 4M RM policy no 22 - central alert system Cas Alerts April 2011 to December 2011 Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 MLS RSM SMC 4N Provide evidence that demonstrates that people who use rehabilitation or treatment services for substance misuse have their care, treatment, and support options eplained before they start to use the service. These include any restrictions identified, and the alternatives, risks and benefits. In addition a risk assessment is completed that includes the risk of drug related death. n/a MLS RSM SMC 4O Provide evidence that demonstrates that people using rehabilitation or treatment services for substance misuse benefit from clear procedures followed in practice, monitored and reviewed, for when they leave the service, in a planned or unplanned way. n/a 22

23 CHC CHN CHS LDC LTC MLS PHS RSM SHL SLS 4P Provide evidence that demonstrates that people with a learning disability who use services are supported to have a Health Action Plan developed by their primary care trust. n/a LTC MLS PHS 4Q Provide evidence that demonstrates that people who use services are only put in seclusion if it is in line and carried out in compliance with guidelines described in section 4Q. n/a ACS CHC CHN CHS DCC EC HPS LDC LTC MHC MLS PHS RSM SLS SMC 4R Provide evidence that demonstrates that people who use services have their needs met through the Care Programme Approach if they meet the criteria set out in Refocusing the Care Programme Approach: policy and positive practice guidance Summary of evidence to support the outcomes described in 4R Trust Quality Committee Agenda April 2011 to Nov 2011 Minutes April 2011 to Nov 2011 Including TOR Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 HBC 4S Provide evidence that demonstrates that people using services involving the use of a hyperbaric oygen chamber receive care treatment and support that follows clear procedures, that are monitored and reviewed and are prepared by a person who has sufficient eperience of hyperbaric oygen chambers and reflect the outcomes described in section 4S. n/a 23

24 RCA 4T Provide evidence that demonstrates that people who use services, receive care, treatment and support that is developed carefully and systematically where protocols or processes require rapid development in response to an unepected public health event. n/a RCA 4U Provide evidence that demonstrates that people who use remote clinical advice services are supported by arrangements, information and staff as described in section 4U. n/a BTS 4V Provide evidence that demonstrates that people who use services can be confident that blood, blood products and human tissue donated for transplantation are only taken from donors who do not present an unacceptable risk to the person. n/a ACS CHN CHS HPS LTC SHL SLS 4W Provide evidence that demonstrates that people who use services are able to visit the service, where it is practical or appropriate to do so, prior to using it so that they can decide whether or not they wish to use it, or to allow them to become familiar with it in order to allay aniety or fear. Summary of evidence to support the outcomes described in 4W Paediatric Standard Operating Procedure Trust open days Patients planned to attend ITU post theatre are invited to visit pre op information leaflet Access & Booking send letter to every child with operation date and invitation to attend with parents the Benny Bear Club held on Saturday mornings Offers the child and family a pre-op visit led by the play specialists where they re given a tour of the unit and eplained the process of going to theatre age appropriate for the child. Play specialists also attend the dental clinics to prep the children and their families pre-operatively 24

25 MLS PHS RSM 4 Provide evidence that demonstrates that people who use services can be confident that searches are conducted in line with nationally recommended practice and that the service will prevent and rapidly respond to incidents of illicit drug use and supply on or near the premises. n/a Personalised care, treatment and support Outcome 5 (Regulation 14): Meeting nutritional needs What should people who use services eperience? People who use services: Are supported to have adequate nutrition and hydration. This is because providers who comply with the regulations will: Reduce the risk of poor nutrition and dehydration by encouraging and supporting people to receive adequate nutrition and hydration. Provide choices of food and drink for people to meet their diverse needs making sure the food and drink they provide is nutritionally balanced and supports their health. Ensure personalised care by providing adequate nutrition, hydration and support 5A Provide evidence that demonstrates that where the service provides food and drink, people who use services have their care, treatment and support needs met because the outcomes referred to in section 5A are achieved. Summary of evidence to support the outcomes described in 5A Clin Corp 59 Guideline for Nutritional support in adults Clin Corp 53 Policy for protected mealtimes Patient Assessment documents showing Screening tool o BMI o Food and drink intake o Fluid Balance charts 25

26 o Food intake record Dietary consultation o High Protein/High Calorie o Food record chart o Feeding regime o Patient notes showing dictation o Patient consultation with dietician Nutrition Screening Committee o Minutes April 2011 to October 2011 Quality annual cycle showing Nutritional Screening Committee report to Quality Quality dashboard showing Nutritional at each CBU Selection of blank care plans Selection of completed care plans Catering staff training for food hygiene Food training course content Training records for food hygiene course Feedback to Matron Report showing food issues are items on report Nutrition screening pathway audit Nutrition screening pathway action plan Presentations Healthcare assistant training Acute dietetics Treating malnutrition in hospital providing oral and enteral nutritional support Nutritional screening and BMI Feeding tubes Facilities Hygiene Policy Control of Food Items Not Supplied By the Trust for Patient Consumption Cortrack competency forms & care plans Care plans PEG / TPN / PICC / RIG STAMP nutritional assessment paeds Medicines management Policy Eample of prescription for patient on TPN Swallowing screening protocol used by nurses 9a (+ competencies) Dysphagia criteria posters Dysphagia care plan Speech therapy SOP Pharmacy department compliance aid assessment Cheshire & Mersey Critical Care Network Nutrition Bundle Fridge temp monitoring MCL Catering trolley temp monitoring Kitchen SOP / food temp checks etc Maternity guidance re: BMI / Post C Section Feeding support signs e.g thickened fluids etc Dysphagia menu cards Diabetic eample of healthy option choice on menu cards FC2 policy control of food not supplied by Trusty for patient consumption 26

27 5B Provide evidence that demonstrates that where the service provides food and drink (but not when this is in the person s own home or shared lives arrangement), people have their care, treatment and support needs met because nutritional needs, choices and provision reflects the outcomes described in section 5B. Summary of evidence to support the outcomes described in 5B Selection of menus including Red tray Kosher Halal Snack bo options Food safety procedures Internal transfer form highlighting dietary assistance Eternal transfer form highlighting dietary assistance Promote rights and choices 5C Provide evidence that demonstrates that where the service provides food and drink, people who use services can make decisions about their food and drink because information, choices and provision of food and drink meet the outcomes described in section 5C. Summary of evidence to support the outcomes described in 5C Patient assessment document showing nutrition Information on treating malnutrition Malnutrition leaflet Blank and completed pre and post op care plans Additional prompts for specific service types ACS CHC DCS DEN DSS DTS HBC HPS LTC MLS PHS RHS UCS 5D Provide evidence that demonstrates people who use services who are requested to fast, benefit from clear procedures followed in practice, monitored and reviewed as described in section 5D. Summary of evidence to support the outcomes described in 5D Blank and completed Paediatric care plans Pre operative care and evaluation Discharge plan and assessment 27

28 ACS CHC DSS HPS MLS PHS RSM UCS 5E Provide evidence that demonstrates that people who use services have access to facilities for infant feeding, including facilities to support breastfeeding. Summary of evidence to support the outcomes described in 5E Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 Trust Quality Committee Agenda April 2011 to December 2011 Minutes April 2011 to December 2011 Including TOR Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR Equality and Diversity Steering group Agenda May 2011 to December 2011 Minutes May 2011 to December 2011 Equality and Diversity minutes showing breast feeding facilities was discussed MLS PHS RSM SMC 5F Provide evidence that demonstrates that people using rehabilitation or treatment services for substance misuse which provides them with food and drink, will have some limited choice about: When to eat. Where to eat. Whether to eat alone, or with company. n/a DCC EC LDC MLS RSM SHL SLS SPC 5G Provide evidence that demonstrates that people who use services are actively supported to plan and prepare their own meals, where this is safe and they are able to do so. n/a CHN CHS HPS LTC MHC MLS PHS SLS 5H Provide evidence that demonstrates that people who use services are able to make choices about: What to eat. n/a 28

29 When to eat. Where to eat. Whether to eat alone, or with company. Summary of evidence to support the outcomes described in 5H Personalised care, treatment and support Outcome 6 (Regulation 24): Cooperating with other providers What should people who use services eperience? People who use services: Receive safe and coordinated care, treatment and support where more than one provider is involved, or they are moved between services. This is because providers who comply with the regulations will: Cooperate with others involved in the care, treatment and support of a person who uses services when the provider responsibility is shared or transferred to one or more services, individuals, teams or agencies. Share information in a confidential manner with all relevant services, individuals, teams or agencies to enable the care, treatment and support needs of people who uses services to be met. Work with other services, individuals, teams or agencies to respond to emergency situations. Support people who use services to access other health and social care services they need. Ensure personalised care through adequate coordination of services 6A Provide evidence that demonstrates that people who use services can be confident that when their care, treatment or support is provided by more than one service, team, individual or agency, or is transferred from one service, team, individual or agency to another, this is organised to reflect the outcomes in section 6A. Summary of evidence to support the outcomes described in 6A Internal Transfer form 29

30 Eternal Transfer form Trust Board Agenda May 2011 to March 2012 Minutes May 2011 to January 2012 Paediatric Consultant to Consultant (trauma/tertiary referral) MDT blue sheet in nursing documentation Section 2 and 5 referrals Con 2 con referrals Handover documents between wards/ depts. Critical care transfer forms In utero transfer forms Documented evidence of referrals in maternity records which is audited (CNST) Robust guidelines for transfer of care between organisation, multiprofessional team and interdepartmental which are monitored and audited Handover of care proformas 6B Provide evidence that demonstrates that people who use services can be confident that when information about their care, treatment and support needs to be passed to another service, team, individual or agency, this is organised so that outcomes in section 6B are met. Summary of evidence to support the outcomes described in 6B Clin Corp 22 Transfer of Critically ill patients and appendices Clin Corp 64 transfer of patients Matrons checklist Internal Transfer form Eternal Transfer form Discharge summaries/ E discharge/ ascribe ICSD faes GP referrals to EAU GP letters Side room lists ( inf control to bed manager) Nursing assessments TTO s Discharge summaries Information sharing agreements Lead effectively to manage risk 6C Provide evidence that demonstrates that people who use services can be confident that when more than one service, team, individual or agency is involved at the same time in their care, treatment and support, or are planned to be in the future, the services provided are organised so that the outcomes in section 6C are met. 30

31 Summary of evidence to support the outcomes described in 6C Matrons checklist MDT cancer services meetings where a member of the Trust attended Continuing Care Health assessments Discharge planning processes and documentation. Medical records specialist nurse/medic/ahp involvement etc Maternity hand held records Risk assessments 6D Provide evidence that demonstrates that people who use services benefit from a service that wherever it is required, has in place a planned and prepared response to major incident and emergency situations which meet the outcomes in section 6D. Summary of evidence to support the outcomes described in 6D Contingency planning Agenda August 2011 to December 2011 Minutes August 2011 to December 2011 Risk Management Minutes Minutes April 2011 to January 2012 Agenda April 2011 to January 2012 Including TOR Escalation plans and procedures Contingency plans local and Trust wide MAJAC plan Fire response Fire escape routes Matrons checklists Fire doors Resus training records MIP training induction and ongoing E learning records Maternity/Neonatal unit closure guidelines and escalation plans 6E Provide evidence that demonstrates that people who use services, can be confident that when more than one service, team, individual or agency is involved at the same time in their care, treatment and support or are planned to be in the future, the transfer of information is organised so that outcomes in section 6E are achieved. Summary of evidence to support the outcomes described in 6E Corp 32 The Transportation of personal data Corp 33 The Confidentiality and Security of Person Identifiable Information Corp 77 Safeguarding adults policy 31

32 Corp 74 Safeguarding and Child protection policy Clin corp 4 Policy for Consent to eamination or treatment including appendices Risk Management Trend Reports Information Governance Steering Group Agenda May 2011 to January 2011 Minutes May 2011 to December 2011 Including TOR Safeguarding Children Steering Group Agenda April 2011 to December 2011 Minutes April 2011 to December 2011 Safeguarding Children Annual report Safeguarding Adults Agenda May 2011 to September 2011 Minutes May 2011 to September 2011 Including TOR Breach of confidentiality incident forms Safeguarding Adults Incident report Safeguarding Children incident report 6F Provide evidence that demonstrates that people who use services, can be confident that when more than one service, team, individual or agency are involved at the same time in their care, treatment and support, or are planned to be in the future, the services provided are organised so that the person who uses the service knows who to contact about their needs and if the needs are not being met. Summary of evidence to support the outcomes described in 6F Consultant timetable 1 Consultant timetable 2 6G Provide evidence that demonstrates that people who use services, can be confident that when information about their care, treatment and support is, or needs to be, passed to another service, team, individual or agency, this is organised so that the person or others acting on their behalf are aware of the information about them that is being transferred and that they can be provided with a copy of the information transferred if they want it. Summary of evidence to support the outcomes described in 6G Clin Corp 3 Discharge policy and appendices Discharge questionnaire Discharge plan assessment MDT Cancer services meetings where member of the Trust attended 32