CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY Outcome 6 Regulation 7 Cooperating with Other Providers CQC 6A Ensure personalised care through adequate coordination of services 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 so that: 6A(1) A lead is always identified who is responsible for coordinating the care, treatment and support of the person who uses services. 6A(2) The person who uses services is aware of who the lead is and how to contact them. Health Personalised Care Planning processes ensure that a lead is identified and depending on the social care needs of the patient this will either be within DCHS or Social Care. All patients are notified of their care planning lead. DCHS is committed to working in partnership with our local authority colleagues to support the personalised care agenda Clinical documentation used across a range of DCHS services has undergone to ensure a consistent and standardised approach across adult and children s services. Contact details detailed in Clinical case notes. Parent held records contain contact details. 1
6A(3) 6A(4) The plan of care includes arrangements for when a person who received care, treatment or support transfers between services. Each of their assessed needs is met by the service, team, individual or agency that is accountable for doing so; ensuring, in total, that all those needs are met. The patient s personalised care plan includes details of proposed transfers between services (NHS & Social Care). Patients who require care across health & social care have multidisciplinary / agency care plans in place. These are integral to the patient care plan and are detailed in the discharge summaries. A single assessment process (SAP) folder is held by the patient and has contributions from Health & Social Care, with Social Care being the initiator of the care plan. Common assessment framework (CAF) is the equivalent process for Children and Young People. 2
6A(5) All those involved in the care, treatment and support of the person who uses services: cooperate with the planning and provision of care, treatment and support have the documented plan of care available to them have relevant information about the person who uses services available, where it has a direct bearing on the quality and safety of the care, treatment and support being delivered record the key points of the care, treatment and support they have given enable relevant information to be accessed in time to ensure that the needs of the person who uses services continue to be met. As a part of the care planning process there is a requirement for multidisciplinary / multiagency team members to liaise or meet to evaluate the care plan. This is all recorded in the integrated care plan, which in adult services is held by the patient and in children services an equivalent is held by the parent or guardian. Patient Care Plan. Case conference and multidisciplinary meeting notes. Discharge summaries. CQC 6B 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: 3
6B(1) The information includes everything the other service, individual, team or agency will need to ensure the needs of the person who uses services are met safely, even when the transfer of information is urgently. As a minimum this includes: their name gender date of birth address unique identification number where one exists emergency contact details any person(s) acting on behalf the person who uses services, with contact details if available records of care, treatment and support provided up to the point of transfer assessed needs known preferences and any relevant diverse needs previous medical history that is relevant to the person s current needs, including general practitioner s contact details Cont d.. The background and contact assessment (BICA) is the main document that is used across health & social care services which gives all of this information. On initial assessment this document is checked for accuracy. Clinical documentation used across a range of DCHS services has undergone a review to ensure a consistent and standardised approach across adult and children s services. Information sharing protocols exist between health & social care. 4
any infection that needs to be managed homicide and harm to self and others any medicine they need to take any allergies they have key contact in the service the person is leaving reason for transferring to the new service any advance decision any assessed risk of suicide and homicide and harm to self and others. 6B(2) The information is transferred in time to make sure that there is no delay to the assessment of needs by the other service, team, individual or agency. The single assessment process (SAP) ensures that all patients have their own personalised care folder, which includes any information relevant to their care plan. The lead for introducing the SAP is Derbyshire County Council Social Services. All health partners were expected to participate and whilst this has happened across community service providers (NHS & Social Care), the Acute Care Providers, who were initially involved, have since taken a decision to withdraw. Med Poss Mod DCHS Admissions Policy and documentation that supports the transfer of patients from other health providers. Medical records from other healthcare providers can be obtained and transfer summaries. The SAP is not universally used across all health providers in Derbyshire, particularly if the patient has acute hospital care. 201112 5
6B(3) There are no interruptions to the continuity of care, treatment and support for the person who uses services. The transfer processes between health & social care providers aim to ensure continuity of care. The introduction of the JONAH discharge management system has helped to identify areas of delays in discharge which have been worked through and resolved with our social care providers. Home of Choice Policy. Complaints system. The introduction of JONAH has seen reductions in delays in discharge and average length of stay. 6C 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: 6C(1) All those involved understand which service has the coordinating role and who is responsible for each element of care, treatment and support to be delivered. 6C(2) Each service, team, individual or agency is involved when the plan of care is reviewed or brought up to date. 6C(3) Where appropriate, all those involved discuss together the plan of care for the person who uses services. The multidisciplinary / agency meetings will agree lead responsibilities for each element of care. Review dates will be agreed as part of the integrated care plan and leads expected to attend and contribute to reviews and key milestone dates. Multidisciplinary care conferences / mtg notes. Multidisciplinary care conferences / mtg notes. See 6C (1) and (2) above. Multidisciplinary care conferences / mtg notes. 6
6C(4) It takes into account relevant guidance, including that from the Care Quality Commission s Schedule of Applicable Publications (see appendix B CQC Guidance). 6D 6D(1) Wherever it is, has in place a planned and prepared response to major incident and emergency situations. This prepared response should include arrangements for sharing information with other providers, provision of mutual aid and arrangements for engagement with appropriate emergency planning and civil resilience partners across the local area. 6D(2) Is aware of and has arrangements in place to respond to any requirements made of the provider by the Civil Contingencies Act 2004. 6D(3) In partnership, practises, monitors and reviews all of the plans that are in place. The CQC Schedule of applicable publications is complied with and referred to in this report. People who use services benefit from a service that: DCHS Emergency Planning Lead Director in place and EP Officer. DCHS Local Security Management Specialist in place linked to the DoH Emergency Preparedness agenda. Gold / Silver and Bronze Commanders in place. This report detailing compliance to the regulatory framework. DCHS Major Incident Plan. DCHS Business Continuity Plan. Emergency Planning Leads meeting. As 6D(1) above As above An agreed timetable of emergency planning events is in place with our local stakeholders (Police, Fire, Social Care etc). Local Emergency Planning exercises. 7
6E 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: 6E(1) The confidentiality of people who use services is protected. 6E(2) 6E(3) Information is transferred safely and securely. Where appropriate, the way in which information is documented, copied, stored and transferred to the other service has been agreed previously between the services, in line with laws that relate to the safe handling of information. Our Information Governance arrangements ensure compliance to all aspects of data protection and confidentiality Information sharing protocols are in place with all local stakeholders. Robust processes are in place, tied into health records management standards. 8 Caldicott Guardian. Information Governance Committee. Information Governance Selfassessment Tool Kit. Information Governance Policies & Procedures. Information Governance Training of all DCHS staff. Information Governance forms an integral part of corporate induction and essential training of all staff. Information sharing protocols. Clinical Record Keeping Policy. Health Records Lifecycle Management Policy. Information sharing protocols. Clinical Record Keeping Policy. Health Records Lifecycle Management Policy.
6E(4) Staff know the ways that are acceptable for transferring information. 6E(5) Information is transferred that: is relevant to the continuing safe delivery of care, treatment and support is factual, correct and does not include subjective opinions about the person can be shared in line with the Data Protection Act 1998 and other relevant guidance. 6E(6) Staff notify their line manager if information has been lost or transferred incorrectly. 6E(7) There are clear procedures followed in practice, monitored and reviewed about the action to be taken when confidential information is inappropriately shared or stored or is lost. These procedures should include the requirement to inform the person who uses services if their information is transferred or shared inappropriately or lost. Information Governance Training arrangements Corporate Induction and Essential Training records. IG Toolkit self assessment process. Internal Audit reviews of IM&T reported to the Audit Committee. As 6E (1) to (4) above. IG Standards & Protocols in place. This forms an integral part of the DCHS Incident Reporting processes and the STEIS reporting systems with NHS East Midlands. DATIX Incident Reporting system. STEIS database with NHS East Midlands. Investigations and Action Plans. See 6E(6) above As 6E (6) above. 9
6E(8) When information relates to a safeguarding allegation, or where disclosure is in the wider public interest for another reason, the disclosure is made in accordance with relevant legislation and guidance. As far as possible the consent of the person(s) whose information is to be disclosed should be obtained. 6E(9) Where the service cannot obtain consent, it is clear about the reasons and the necessity for sharing. errals of this nature are dealt with in line with Data Protection / IG Governance Frameworks detailed above. In addition the Derbyshire Safeguarding Procedures require Derbyshire County Council to take a lead agency role in all safeguarding concerns / allegations. Issues regarding consent are tied into these procedures. DCHS will act in line with published protocols, procedures and guidelines in relation to best interest of the patient. There would be documented evidence in all health records as to the reasons why and what risk assessments were undertaken to support the decision. Derbyshire Safeguarding Procedures. Information Sharing Protocols. Serious Case Review (Safeguarding) notes of meetings. 6F 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: 6F(1) The person who uses the service knows who to contact about their needs and if the needs are not being met. It is the responsibility of all agencies to identify who their contacts are. Within DCHS this would form part of the information contained in the patient record. Clinical Records. Clinical Records Audits. 10
6G 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: 6G(1) Are aware of the information about them that is being transferred. 6G(2) Can be provided with a copy of the information transferred if they want it. This forms part of the care planning and consent processes. The Access to Health Records process and Single Assessment Process ensures that all relevant information is held through the patient held record. 6H People who use services know that they: 6H(1) Can request information to be National information sharing transferred to another service and protocols published by the NHSthat the service agrees to transfer DoH form an integral part of the information requested unless DCHS s compliance to the there is a good reason why they information governance toolkit. cannot. If so, that reason is fully National & local protocols ensure explained. that all internal and external transfers of confidential information comply with published guidance. 6I 6I(1) Clinical Records audits Patient requests for access to health records. SAP Process. Information Governance Toolkit compliance scores. Information Governance Committee monitoring. Clinical Records Committee monitoring. Information sharing protocols (inc MAPPA). People who use services are supported to access the care, treatment and support they need by a provider who: Makes them aware of other Patient Information Leaflets provide DCHS Public Website. available health and social care details of the integrated care Media Releases. services or support relevant to their pathways available to their specific care, treatment and support. needs. PALS information service. Staff awareness of health & social care services available as well as voluntary services. 11
6I(2) 6I(3) Helps them to approach, or make a formal referral to, any other health and social care service or support they want to access, and that are relevant to their needs. Enables them, as far as possible, to access other health and social care services or support relevant to their care, treatment and support needs, provided that their care, treatment and support will not be compromised. Local Managers in health and social care, as well as other local healthcare providers (Acute, Mental Health, Ambulance) work together to develop integrated care pathways. DCHS staff understand what these pathways are, which allows patients to access appropriate care. Clinical Care Pathways (End of Life, Stroke, Falls etc). CQUIN (section 3) indicators agreed with our commissioners require us to develop individual care plans for patients with Long Term Conditions and Learning Disabilities. As 6I(1) and (2) above See above 12
6J 6L * 6L(1) People who use rehabilitation or treatment services for substance misuse who are provided with accommodation when they use the service: This regulation does not apply to DCHS People with mental health needs who use services: This only applies to: Long Term Conditions & Hospital Services for People with Mental Health needs, and or Learning disabilities. Are, where necessary, supported by local multiagency public protection arrangements to protect themselves and others from harm. MultiAgency Public Protection Arrangements (MAPPA under the duty to cooperate arrangements in place under section 325 of the Criminal Justice Act 2003;) are in place for all DCHS inpatients. The MAPPA arrangements in place for our LDS offenders based in the community are being tracked and agreed with MAPPA stakeholders. Med Poss Mod MAAPA arrangements agreed locally with the Police, Prisons and Probation Services. Agree MAPPA arrangements for our community based LD Patients with local stakeholders. 6M When children who use services are moving to access adult services, these are organised so that: This only applies to: Community Healthcare Services, Dental Services, Community based Services for People with a * Learning Disability, Long Term Conditions Services, Hospital Services for People with Mental Health needs, and or Learning Disabilities & Rehabilitation Services. 6M(1) All those involved in the care, Ongoing care for children moving Case Reviews. treatment and support cooperate into adult services would be Case Conferences. with the planning and provision to planned as part of the local Healthcare Plans. ensure that the services provided transition planning processes continue to be appropriate to the agreed between health, education age and needs of the person who and social care. uses services. Jan 2011 13
6M(2) Children and those acting on their behalf are involved in and informed about the move to adult care, treatment and support. As above, this would form part of the transition planning process. As above 6N People who use rehabilitation or treatment services for substance misuse will benefit from teams, individuals and/or agencies who: This regulation does not apply to DCHS 14