Sources of evidence [note: you may reference other sources of evidence] Quarterly National Reporting Systems to the SHA on Waiting Times.

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1 PATIENT RIGHTS/PLEDGES Rights/pledges/Actions 1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the. The Primary Care Trust has a process in place to trigger referral to alternative providers if waiting times are exceeded. Quarterly National Reporting Systems to the SHA on Waiting Times. 2. You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. The Primary Care Trust has a process in place to ensure that NICE recommendations are implemented. Quarterly report to the SHA. 3. You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme. 4. The NHS commits to provide programmes as recommended by the UK Screening Committee The Primary Care Trust commissions a vaccination programme in line with the recommendations of the Joint Committee on Vaccination and Immunisation. The Primary Care Trust commissions a screening programme in line with the recommendations of the UK Screening Committee. Quarterly performance reports to the SHA on MMR and Flu vaccines and VSB10 (Immunisation). Monthly data to the Health Protection Agency on vaccines. Quarterly report to the SHA and VSA09 (Breast), VSA10 (Bowel), VSA15 (Cervical). 5. You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament. Fundamental NHS principle. Evidence not required but please confirm. 1

2 6. You have the right to access NHS services. You will not be refused access on unreasonable grounds. A formal policy for dealing with violent and abusive patients has been adopted. 7. You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary. The Primary Care Trust has undertaken a Joint Strategic Needs Assessment as part of the development and implementation of its Local Strategic Plan. 8. You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner. The Primary Care Trust has a process in place to manage the commissioning of treatments from European Economic Area countries. 9. You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age. A single equalities scheme has been adopted, implemented and is monitored. 10. The NHS commits to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered. Communications and engagement plans include actions to ensure decision making is communicated and understood. 11. The NHS commits to make the transition as smooth as possible when you are referred between services, and to include you in relevant discussions. Patient pathways include processes to ensure effective transitions between services and organisations. 2

3 12. You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality. Knowledge and Skills Frameworks for all staff are in place. The PCT only commissions from providers who have full CQC registration. 13. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. There is a health-economy agreed plan for further measureable improvement against these domains. Reporting to the SHA on: NPSA reporting system Annual Survey VSB 15 Reported against ambitions National Reporting Systems. No SHA reporting 14. The NHS commits to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice. Health services are provided in a clean and safe environment as reported to the Care Quality Commission and in accordance with the requirements of the Health and Safety Executive. Monthly reporting of HCA1 database to the Health Protection Agency VSA01 (MRSA) and VSA03 (CDiff). 3

4 15. The NHS commits to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. Reports to the SHA on: NPSA Reporting System Annual Survey VSB 15 Reporting against ambitions National reporting system. There is a health-economy agreed plan for further measureable improvement against these domains. No SHA reporting No plans to do so There is a clear programme for publicising progress against both existing quality improvement projections and plans for measureable quality improvement in the future. 16. You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you or your doctor feel would be right for you, they will explain that decision to you. A process to manage decisions concerning the provision of exceptional treatments is in place. A robust process is in place to make decisions on funding new medicines and other treatments. The PCT publishes clear information on the processes for local decision making, individual funding requests and the appeals process. 17. You have the right to be treated with dignity and respect, in accordance with your human rights. A privacy, dignity and respect policy/statement has been adopted. VSB15 (Patient experience) and VSB16 (public confidence). Reports on mixed sex accommodation. 4

5 18. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests. A policy on obtaining informed consent has been adopted. 19. You have the right to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing. Procedures are in place to ensure that patients are able to make informed decisions about proposed treatments. Patient information is regularly reviewed and updated. 20. You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure. 21. You have the right of access to your own health records. These will always be used to manage your treatment in your best interests. A records management policy has been adopted. The policy includes specific actions to ensure that confidential information is kept secure. Procedures are in place to provide access to health records on request. A process to manage complaints relating to access to health records is in place. Reports to the SHA on completion of the Information Governance Toolkit. No SHA reporting No plans to do so 22. The NHS commits to share with you any letters sent between clinicians about your care. Procedures are in place to ensure that clinician s letters are shared with patients. 23. You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons. There is a clear procedure in place for the public to register with the GP of their choice. VSA06 (GP Access). 5

6 24. You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply. Patient information on how to register with a GP includes this provision. 25. You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs. The Primary Care Trust has arrangements in place to: ensure that patients who need an elective referral are offered a choice of any clinically appropriate provider; National Choice Survey. Monthly Choose and Book information for 18 weeks reported to the SHA. ensure that where a patient has not been offered that choice, and notifies the Primary Care Trust that they have not been offered that choice, that patient may choose any clinically appropriate secondary care provider. 26. The NHS commits to inform you about the healthcare services available to you, locally and nationally. The Primary Care Trust communication plan includes actions to provide up to date information on healthcare services. 27. The NHS commits to offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available. The communications plan includes actions to ensure decision making is communicated and understood. 28. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this. Procedures are in place to ensure that patients are routinely involved in discussions and decisions about their healthcare. 6

7 29. You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services. Communications, engagement and stakeholder relations plans include actions to ensure appropriate and proportionate involvement of patients and the public in service planning, development or change. 30. The NHS commits to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services. 31. The NHS commits to work in partnership with you, your family, carers and representatives. Communications, engagement and stakeholder relations plans include the provision of clear and accessible information on planning and delivery of NHS services. Working in partnership with families, carers and representatives is part of the engagement plan. 32. You have the right to have any complaint you make about NHS services dealt with efficiently and to have it properly investigated. A complaints policy has been adopted. 33. You have the right to know the outcome of any investigation into your complaint. The complaints policy includes procedures to ensure the communication of the outcomes of complaints investigations. 34. You have the right to take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS. The complaints policy, complaints literature and letters to complainants provide information on how to take complaints to the Health Services Ombudsman. 35. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body. This is a legal right and as such does not require an assurance statement. Rating not required 7

8 36. You have the right to compensation where you have been harmed by negligent treatment. 37. The NHS commits to ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment. A procedure for managing compensation payments is in place. The complaints policy includes access to support and reassurance of the impact of a complaint on future treatments. Complaints handling is monitored. 38. The NHS commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. A clear process to provide timely information, feedback and apologies is in place. This is monitored and reported as part of the formal process for receiving and acting on lessons arising from complaints, claims or PALS. 39. The NHS commits to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services. A formal process to receive and act on lessons arising from complaints, claims or PALS is in place. This process links directly to the Board. 8

9 P1 Provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities. The organisation has an up-todate job description in place for all staff, which clearly outlines their roles and responsibilities; The organisation will introduce the in future Job Descriptions/person specifications. Job descriptions are and continue to be evaluated under the Agenda for Change Terms and Conditions for Job Evaluation [except Medical and dental staff]; The organisation has promoted the to all staff within the organisation. Board report confirming with the NHS Constitution for Staff rights and pledges. Confirmation of application of National Agenda for Change Job Evaluation, or equivalent Job Evaluation process for FTs. is incorporated into the organisations Induction arrangements; Compliant but no agreement to actions specified is incorporated into Staff Handbook; is promoted on Trust Intranet; The organisation has a Staff Charter, outlining staff rights, pledges and responsibilities. P2 Provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed. The organisation has in place for all staff a personal development pan, supported by an individual KSF outline [for Agenda for Change staff]; The organisation has in place a mechanism which defines the relevant mandatory and developmental training required for specific roles; Board report confirming with the NHS Constitution for Staff rights and pledges. Board report on CARE QUALITY COMMISSION standards and with staff receiving appraisal and personal development plans. As P1 The personal development plan clearly outlines appropriate development training to support Evidence of an Organisational Training Plan based on PDPs. 9

10 the employee; The organisation has in place appropriate training providers [internal /external] and training prospectus to satisfy individual and job requirements. Evidence of an organisational Training programme and/prospectus. P3 Provide support and opportunities for staff to maintain their health, wellbeing and safety. The organisation has arrangements in place either by internal or external agreements to provide Occupational Health and Wellbeing arrangements for staff; The organisation has in place an action plan to deal with the recommendations from the Boorman Report. An organisational SLA/Contract for Occupational Health and Wellbeing. Board Report responding to the Boorman Report, including an action plan to develop Health and Wellbeing of staff; As P1 Not signing up to actions set out Board level champion for Health and Wellbeing; An organisational Health and Wellbeing strategy and action plan. P4 Provide the opportunity for all staff to Engage in decisions that affect them and the services they provide. The organisation has a staff engagement strategy in place. The organisation engages with staff through appropriate Trades Union machinery ie Joint Staff Committee. The organisation has in place arrangements to engage with staff who are non-representatives of TU/Professional organisations. Recognition Agreement with Trades Unions and Professional Organisations. Joint Staff Committee Facilities agreement. Joint Staff Committee Terms of Reference. Organisational Engagement Strategy and Action Plan. R1 The NHS has a good record of fair employment and respecting the rights of staff. All Staff have a Contract of Employment based on National Terms and Conditions, and reflecting the rights of staff. Staff Charter incorporating the rights of staff and the NHS constitution. Contracts of Employment based on National Terms and Conditions. Not all staff have national terms and conditions The minimum statement is not well thought out 10

11 R2 Rights embodied in general employment and discrimination law. The organisation has in place arrangements to support Equality and Diversity and Equal Opportunities. The organisation has a framework of policies and procedures in place to comply with employment and discrimination legislation. Equal Opportunities Policy; Single Equality Scheme; Bullying and Harassment Policy; Violence and Aggression Policy; Grievance and Appeals Policy; Involvement/Engagement Policy; Health and Safety Policy; Flexible Working Policy; Whistle blowing policy. Staff Charter, setting out the responsibilities and expectations of staff. Board report satisfying with the NHS Constitution Staff rights and pledges. E1. Expectations and legal duties of Staff: The Constitution also includes expectations that reflect how staff should play their part in ensuring the success of the NHS and delivering High level of staff trained in Equality and Diversity. Arrangements to train all managers in key policies and procedures. The organisation has a framework which sets out the expectations of and makes clear the legal duties placed on staff. Staff Survey results; Care Quality Commission evidence; Human Resources/Workforce Board Reports; Care Quality Commission evidence; Human Resources/Workforce Board reports. An organisational Staff Charter; Evidence of discussion and promotion at Joint Staff Committee meetings; 11

12 high-quality care. Expectations: The highest quality of patient care is delivered by staff who are ambitious in their expectations of themselves and their colleagues, and strive to achieve beyond what is legally required of them. Legal duties: Accept professional accountability; Take reasonable care of health and safety at work; Act in accordance with the express and implied terms of the employment contract; Not to discriminate against patients or staff; Protect confidentiality; Be honest and truthful. Discussion and promotion at Staff Engagement meetings; Staff Newsletters; Staff Induction Programme; Staff Handbook; Promotion through the organisations intranet; Staff promotion material; Staff signed up to the NHS Code of Conduct; Staff Statement of Confidentiality ; Staff comply with Professional Codes of Conduct /Professional Regulatory Body registration. 12

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