Commissioning for Quality Assurance and Improvement using an Appreciative Enquiry Approach Policy/Procedure December 2014

Commissioning for Quality Assurance and Improvement using an Appreciative Enquiry Approach Policy/Procedure December 2014

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South Yorkshire & Bassetlaw Commissioning for Quality Assurance and Improvement using an Appreciative Enquiry Approach Policy/Procedure December 2014 3

Contents 1. Introduction... 5 2. Purpose... 6 3. Scope... 6 4. Accountabilities and Responsibilities... 7 5. Procedure... 8 6. Distribution and Implementation... 9 7. Equality Impact Assessment... 9 8. Associated Documents... 9 9. Policy review... 9 10. Version Control Tracker... 10 Appendix 1- Quality Assurance Framework... 11 Appendix 2... 16 a) Risk Assessment... 16 c) Risk Profile... 22 d) Risk Threshold Matrix... 24 Appendix 3- Toolkit... 25 Appendix 4 Confidentiality Agreement... 99 Appendix 5 Equality Impact Assessment... 101 Appendix 6 Principles for managing quality in specialised commissioning including the RASCI template... 108 Glossary... 118 References... 119 4

1. Introduction 1.1. South Yorkshire and Bassetlaw (SY&B) Area Team and its constituent Clinical Commissioning Group (CCG S) are committed to achieving high standards of patient care for the services it commissions. Furthermore, ensuring high standards of care is one of the core values within the NHS Constitution (DH 2013) and therefore places a requirement on all providers of health care to strive to deliver high quality and safe care to patients. In addition, commissioners of health care have an important role in securing continuous improvements in the quality of services provided to individuals. Improvements will be measured in terms of the actual outcomes achieved for patients including those that show the effectiveness of the services being provided, the safety of the services being provided and the quality of the experience undergone by patients. The National Health Service Act 2006 (as amended by the Health and Social Care Act 2012) also places a duty on the NHS England to exercise its functions effectively, efficiently and economically and a duty as to the improvement in quality of services provided to individuals. Clinical Commissioning groups (CCGs) are also under a duty to assist and support NHS England in discharging its duty so far as relating to securing continuous improvement in quality of primary medical services. CCGs are also under a similar duty as to improvement in quality of services. The principle of collaborative working is embedded to understand and support the quality improvement agenda across South Yorkshire & Bassetlaw with CCGs and the Area Team working in partnership to ensure high quality provision across the area and in it wider commissioning responsibilities. 1.2. Gaining Quality Assurance, places Commissioners in a specific dilemma, over how far they should check and validate Quality data and how far they should trust Providers to make available the Assurance as part of the contracting processes. The (Mid Staffordshire Inquiry 2010) exposed a number of failings for both providers and commissioners in how they gain assurance that high quality care is being delivered to patients. More recently the lessons learned following the review into the quality of care and treatment provided by 14 hospital Trusts in England (Keogh Jul 2013) has led to a number of developments to strengthen how we assess the standards of services provided. 1.3. Within SY&B a number of processes and checks are in place to triangulate evidence in order to help gain assurance across the footprint. We are working to a quality assurance framework (Appendix 1), which enables us to scrutinise Serious Incidents, Serious Case Reviews, Never Events, HSMR rates, complaints, staffing issues, CQC reports, patient and staff survey reports, clinical audit reports etc. Whilst each organisation may have different ways of demonstrating this level of scrutiny the principles remain the same across SY&B Quality is everyone s business and this is evident in our Board and Committee structures and is embedded into all of our contracting processes. 1.4. NHS England has in place in each of its Area Teams a Quality Surveillance Group (QSG) which in turn reports to the regional QSG The Quality Surveillance Groups are a place where all the regulatory and commissioning bodies come together locally, where shared concerns can be highlighted and action agreed. The role of Quality Surveillance Groups is principally about alignment, not accountability. The Quality Surveillance Groups enable all parties in the system to meet, share intelligence on current quality concerns, receive updates from participating organisations and provide co-ordinated feedback

1.5. Specifically the NHS Standard Contract for Acute, Ambulance, Community and Mental Health and Learning Disability Services states at that the Provider shall not restrict access to any Authorised Person for the purposes of auditing, viewing, observing or inspecting such premises and/or the provision of the Services. In addition, Section E, paragraph 47 (Contract Management) allows for issues to be escalated where performance is not meeting the contractual requirements. 1.6. When Quality concerns are raised or identified and they are not being addressed through the normal routes adequately, the commissioner may need to take specific actions to investigate the scale of the problem. Where serious concerns are being identified a structured and purposeful Quality Assurance Visit (Appreciative Enquiry) to the Trust may be required to enable further scrutiny to take place. 2. Purpose 2.1. To strengthen SY&B, routine quality assurance processes and drive continuous quality improvement by supporting providers and working in partnership with commissioners. 2.2. To formalise the process for escalation of quality concerns 2.3. To formalise the process that should be followed when there is a need to conduct a Quality Assurance Visit in the form of an Appreciative Enquiry. 2.4. Provide a structured process which ensures that the rationale to conduct a quality assurance visit is justified and it has Senior Leadership Team and executive sign up from a commissioning perspective. 2.5. To enable SY&B to better understand and proactively be involved in identifying quality concerns early and working supportively with providers to take actions promptly to prevent potential harm to patients. 2.6. To describe the escalation process to the Regional process 3. Scope 3.1. This policy is intended to provide a point of reference when a Quality Assurance Visit is being considered and can be used to aid that decision. 3.2. This policy describes the process of determining and conducting a Quality Assurance Visit to a provider organisation delivering patient care within SY&B. 3.3. The policy applies to NHS and Independent provider organisations. 3.4. The policy applies to all commissioning staff employed within NHS England SY&B and constituent CCG s

4. Accountabilities and Responsibilities 4.1. NHS England SY&B Senior Leadership Team has the responsibility to consider and ratify the content of this policy. It has the responsibility to make the decision when it is appropriate to conduct a Quality Assurance Visit in the form of an Appreciative Enquiry. This is in conjunction with the relevant CCG 4.2. The Quality Surveillance Group key role is the sharing information and intelligence about quality and risk within provider organisations across the system as part of a culture of open and honest cooperation. This will be key to spotting any quality problems at an early stage and the operation of an effective early warning system for quality in the NHS These groups will bring together commissioners, regulators and other parts of the system on the footprint of the NHS England local area and regional teams to share information on quality and to raise concerns where they arise. They are designed to foster collaborative working relationships and support a culture of open and honest cooperation between different parts of the system, without impinging on the statutory responsibilities and independence of member organisations. 4.3. NHS England Director SY&B has the overall accountability for gaining quality assurance for commissioned services within SY&B. 4.4. The Director of Nursing & Quality has the delegated responsibility from the Director SY&B to implement the policy in full across SY&B. 4.5. The Medical Director has the responsibility to support the Director of Nursing and Quality in implementing this policy. 4.6. Clinical Commissioning Groups have the responsibility to identify areas of concern and be actively involved in leading and implementing this policy 4.7. Chief Operating Officers have the responsibility to support the CCG Chief Nurses in implementing this policy. 4.8. Quality Leads have the responsibility to prepare a policy implementation plan which includes providing support and education regarding the use of the Appreciative Enquiry tools and will play a key role in supporting the visit.

5. Procedure 5.1. Data and Document Review In advance of any decision to undertake a Quality Assurance Visit a detailed data and document review should commence taking account of both qualitative and quantitative sources of information. A Risk Assessment (Appendix 2a) should be undertaken of each area of concern and this should be used to form an overall Risk Profile (Appendix 2b) of the organisation. The Risk Profile should be assessed against SY&B Risk Threshold (Appendix 2c) as this will help to determine the need and rationale for conducting a Quality Assurance Visit. 5.2. Senior Leadership Team Approval The Director of Nursing & Quality will prepare a Senior Leadership Team paper identifying the rationale and scope of the enquiry in order to seek Senior Leadership Team approval. The Director SY&B will inform the provider Chief Executive/Senior Manager of the decision to conduct Quality Assurance Visits and the process that this will involve. This conversation will be followed up in writing. CCG will be included in the decision making process The Director SY&B will inform Monitor and CQC of the intention to conduct the enquiry. 5.3. Enquiry Team The Director of Nursing & Quality and Medical Director will select appropriate individuals depending on the scope of the enquiry. It is expected that the Nurse Director, Medical Director and CCG representatives will be involved in these visits routinely. Consideration will be given to inviting Monitor and CQC representatives on the enquiry team. 5.4. Visit Preparation In preparation for the Quality Assurance Visits, packs containing key information will be prepared based on the Appreciative Enquiry Toolkit (Appendix 3). The enquiry team will meet to assess the information so far and use this to plan the site visits and prepare the questions that will need to be asked. The team will be appraised of the sensitive nature of this enquiry and the need to remain confidential at all times. A Confidentiality Agreement may need to be put in place for the purpose of the enquiry if one does not already exist. The Provider will be informed of the visit and a timetable will be prepared and shared in advance. The initial visit will be announced, however, further unannounced visits may be required and the Provider will be informed that this may be the case. 5.5. Quality Assurance Visit The site visits will consist of speaking to Managers, Staff, Patients and Visitors, observing practices and processes and examining pertinent records and documents. 5.6. Code of Conduct

The team will, at all times, act professionally, respectfully, confidentially, sensitively and supportively. The team will be courteous at all times and be mindful of the privacy and dignity of patients, relatives and staff during the visit. The team will ensure that it works within a formalised Confidentiality Agreement for the purpose of the visits (Appendix 4). 5.7. Feedback Immediate feedback will be given to the Chief Executive or most Senior Manager of the Provider Trust/Independent organisation at the end of day, detailing risks requiring immediate action or urgent attention. The CE/ Senior Manager will be informed of the headline findings and this will be followed up in writing in the form of a report within 7 days of completing the Appreciative Inquiry. 5.8. Monitoring The Provider will develop an action plan detailing any immediate and planned remedial actions within 72 hours following receipt of the inquiry findings. Monitoring against the delivery of the action plan will be done as part of the routine contract monitoring processes. 6. Distribution and Implementation o NHS England South Yorkshire & Bassetlaw Area Team o All CCG s in South Yorkshire and Bassetlaw 7. Equality Impact Assessment There is a legal requirement to pay due regard to equality in all new, existing or updated policies, strategies, services, projects, business cases and service specifications etc. This is done through Equality Impact Assessment (EIA). EIA s are designed to analyse equality impact, to identify potential or actual negative effects on specific groups or people and to evidence how the organisation has paid due regard to equality. The EIA in respect of this policy is attached (Appendix 5). 8. Associated Documents 9. Policy review This policy will be reviewed on an annual basis or sooner if appropriate guidance is published.

10. Version Control Tracker Version Number Date Author Title Status Comment/Reason for Issue/Approving Body 1.0 December 2013 Updated in light of NHS changing architecture 1.1 December 2014 Reviewed and dates updated Mental Health KLOE added RASCI principles added

Appendix 1- Quality Assurance Framework Quality Assurance Process South Yorkshire and Bassetlaw is committed to improving the quality of care for our patients and therefore assessing, measuring and benchmarking quality is a key focus. We recognise the need to strengthen and standardise our quality assurance processes across the cluster by identifying and sharing good practice. We recognise that quality is everyone s business and therefore we intend to develop our quality assurance processes in partnership with other commissioners, the LA, providers, clinicians, service users and carers. Our Pledge We will take positive steps to ensure that we protect patient safety. We will ensure services that are commissioned are evidence based, outcome focussed and aimed at reducing clinical variation. We will monitor and improve the experience of patients accessing our services. QUALITY ASSURANCE FRAMEWORK The quality assurance framework describes our approach to monitoring and assuring quality in all our commissioned services and it specifically applies to all commissioned NHS and Independent Providers. The three domains of quality: patient safety, clinical effectiveness and patient experience will be monitored through routine internal contractual processes and clinical governance structures and external sources such as CQC, Monitor, peer reviews, national surveys etc. Providers are required to have their own quality monitoring processes in place and through the duty of candour and the contractual relationship with commissioners they have to provide information and assurance to commissioners and engage in system wide approaches to improving quality. There is a process for escalation in relation to Quality Assurance Stage 1 Routine Quality Assurance Monitoring Stage 2 Local Enhanced Quality Assurance Stage 3 Regional Enhanced Quality Assurance

Stage 1) Routine Quality Assurance Monitoring Routine Monitoring includes the following: Quality Metrics Patient Safety Indicators include: monitoring of HCAI, safeguarding vulnerable children and adults, patient safety incidents, never events, complaints, mortality rates, and workforce numbers, skills and training. Clinical Effectiveness Indicators include: The implementation of the National Institute of Clinical Excellence guidance, delivery of CQUINS, key performance indicator monitoring, learning from audit and peer reviews and using benchmarking resources such as the Hospital Guide to improve clinical outcomes. Patient Experience Indicators include: Patient reported outcomes measures, patient survey results, respecting privacy and dignity, eliminating mixed sex accommodation monitoring, complaints monitoring, CQC inspection results, patient advisory and liaison service, health watch etc. Routine Quality Assurance Meetings Commissioners and providers will be involved in a number of meetings where quality should be the key priority and focus of those meetings. For example monthly quality review meetings are a contractual requirement and this gives opportunities for quality monitoring and assurance to be gained. It is important that lead clinicians are involved in these meetings to enable a full and comprehensive discussion around quality. Other meetings include focussed meetings around specific areas such as District Infection Control meetings, Root Cause Analysis, Local Intelligence Network, Clinical Networks, Safeguarding Board meetings Emergency Planning, Case management reviews etc. Stage 2 Local Enhanced Quality Assurance Enhanced assurance includes Enhanced Quality Assurance Meetings Commissioners should work closely with providers in ensuring processes are transparent in how we gain quality assurance. This may involve being invited to join provider governance and patient safety meetings. Clinician to Clinician meetings, Commissioning joining PEAT inspection visits and patient safety walk rounds. The duty of candour placed on all providers should support this process as they will be required to be open and transparent. Enhanced Local Targeted Quality Assurance Visits SY&B patients will be able to access safe care, which is evidence based, personalised and responsive. If commissioners are not gaining sufficient assurance that our pledge to patients is being met then we may want to take extra steps to understand where the assurance gaps are.

Commissioners would work closely with providers in undertaking a targeted quality assurance visit using an appreciative inquiry approach. This should be done within the SY&B policy framework to ensure that the approach follows a structured and purposeful methodology. Local Quality Review Meeting with Commissioners and regulators Where there are quality concerns identified or the level of assurance is insufficient a Local Quality Review meeting is held with commissioners and regulators to share intelligence and determine if the actions undertaken or proposed by the provider give the appropriate level of assurance. Local Quality Review Meeting with Commissioners and regulators and providers If the Quality Review Meeting does not gain assurance the next stage is a Quality Review Meetings held with commissioners, regulators and providers where further actions and monitoring are considered Quality Assurance visit using appreciate enquiry methodology Stage 3 Regional Enhanced Quality Assurance Regional Rapid Response Review (using Keogh methodology) chaired by regional Medical Director or an NHS England Chief Nurse Regional Risk Summit (using Keogh methodology) Key features of the Risk Summit model are as follows: any statutory organisation local, regional or national, including providers themselves who has a serious concern about the quality of care in a provider organisation can trigger a Risk Summit. The Risk Summit should normally be convened within 24/48 hours of the request; it would consider the RRR report 4

S Y & B Clinical Commissioning Groups / NHS England Quality Assurance and Escalation Process for NHS Providers NHS Hospital and Community Providers Local Assurance Patient Safety Serious Incidents/ Never Events Safeguarding reviews HCAI rates Staffing Levels Staff Training Effectiveness NICE guidance HSMR/SHMI Local Audits Peer Reviews CQUINS schemes Readmission rates Experience Complaints PROMS Local Patient Surveys Local Healthwatch data NHS Choices Patient Opinion 1:1 Commission / Provider meetings Contract Quality Review Meeting Safeguarding Board Meetings CD Local Intelligence Network Area Prescribing Committee Clinician to Clinician Meetings Commissioner attendance at Provider Governance meetings Board to Board meetings Service levels visits Executive/CO/Clinician meetings Full Site Quality Review Visit Quality Surveillance Group Regional Risk Summit Routine Quality Reporting Evidence Monitoring Routine Quality Assurance Meetings Enhanced Quality Assurance Measures Regional Enhanced Quality Assurance External Assurance BODIES CQC Registration / Inspection CQC Intelligent Monitoring Monitor Public Health England (Local Authority) PLACE Visits Overview and Scrutiny Professional bodies DATA Health and Social Care Information Centre NHS England Quality Dashboard National Reporting and Learning System (Safety Incidents) Dr Foster Central Alert system. NICE NCPOD reports National Audit (NCAPOP) National Patient Survey National Staff Survey National Peer Reviews Quality Review Process Enhanced Quality Assurance Quality Assurance Meetings Routine Reporting Evidence Monitoring

Quality Assurance Framework Independent Providers Local Assurance Incident reporting Safeguarding incidents SCR/IMR HCAI Complaints Low Level Concerns Referrals Individual case management review Visiting community health teams Care Management Reviews Contract Monitoring Meetings Infection Control Committee Local Intelligence Network Quality Improvement Framework Programme Routine Assurance Visits Quality Assurance Visit Quality Review Meetings Regional Risk Summit Routine Quality Reporting Evidence Monitoring Routine Quality Assurance Meetings Enhanced Quality Assurance Measures Regional Enhanced Quality Assurance External Assurance CQC Registration / Inspection CQC Intelligent Monitoring Monitor Public Health England (Local Authority) PLACE Visits Overview and Scrutiny Professional bodies CHC Team Local Authority Monitoring Professional Bodies Healthwatch Quality Assurance Visit Enhanced Quality Assurance Measures Quality Assurance Meetings Quality Reporting Evidence Monitoring

Appendix 2 a) Risk Assessment Table 1 Consequence score (C) Choose the most appropriate domain for the identified risk from the left hand side of the table. Then work along the columns in same row to assess the severity of the risk on the scale of 1 to 5 to determine the consequence score, which is the number given at the top of the column. Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Extreme Patient and Staff Safety Quality Minimal injury requiring no / minimal intervention or treatment. No time off work Peripheral element of treatment or service suboptimal Informal complaint/ inquiry Minor injury or illness, requiring minor intervention Requiring time off work for >3 days Overall treatment or service suboptimal Formal complaint Local resolution Single failure to meet internal standards Minor Moderate injury requiring professional intervention Requiring time off work for 4-14 days. RIDDOR reportable incident An event which impacts on a small number of patients Treatment or service has significantly reduced effectiveness Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major injury leading to long-term incapacity / disability Requiring time off work for >14 days Mismanageme nt of patient care with longterm effects Noncompliance with national standards with significant risk to patients if unresolved Multiple complaints / independent review Low performance rating Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients Unacceptable level or quality of treatment / service Gross failure of patient safety if findings not acted on Inquest / ombudsman inquiry Gross failure to meet

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Extreme Human Resources / Organisation al Development Statutory Duty / Inspections Short-term low staffing level that temporarily reduces service quality (< 1 day) No or minimal impact or breech of guidance/ statutory duty implications for patient safety if unresolved Reduced performance rating if unresolved Low staffing level that reduces the service quality Breech of statutory legislation Reduced performance rating if unresolved Major patient safety implications if findings are not acted on Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training Single breech in statutory duty Challenging external recommendati ons / improvement notice Critical report Uncertain delivery of key objective/servi ce due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating national standards Non-delivery of key objective/servi ce due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Critical report Severely critical report

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Extreme Adverse Publicity / Reputation Business Objectives Finance Service / Business Interruption Rumours Potential for public concern Insignificant cost increase / schedule slippage Small loss Risk of claim remote Loss/interrupti on of >1 hour Local media coverage short-term reduction in public confidence Elements of public expectation not being met <5 per cent over project budget Schedule slippage Loss of 0.1 0.25 per cent of budget Claim less than 10,000 Loss/interrupti on of >8 hours Local media coverage long-term reduction in public confidence 5 10 per cent over project budget Schedule slippage Loss of 0.25 0.5 per cent of budget Claim(s) between 10,000 and 100,000 Loss/interrupti on of >1 day National media coverage with <3 days service well below reasonable public expectation Noncompliance with national 10 25 per cent over project budget Schedule slippage Key objectives not met Uncertain delivery of key objective/loss of 0.5 1.0 per cent of budget Claim(s) between 100,000 and 1 million Purchasers failing to pay on time Loss/interrupti on of >1 week National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence Incident leading >25 per cent over project budget Schedule slippage Key objectives not met Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) > 1 million Permanent loss of service or facility

Consequence score (severity levels) and examples of descriptors 1 2 3 4 5 Domains Negligible Minor Moderate Major Extreme Impact on Environment Minimal or no impact on the environment Minor impact on environment Moderate impact on environment Major impact on environment Extreme impact on environment

Table 2 Likelihood score (L) What is the likelihood of the consequence occurring? The frequency-based score is appropriate in most circumstances and is easier to identify. It should be used whenever it is possible to identify a frequency. Likelihood score 1 2 3 4 5 Descriptor Rare Unlikely Possible Likely Frequency How often might it / does it happen Probability Percentage likelihood of occurrence This will probably never happen/recur Do not expect it to happen/recur but it is possible it may do so Might happen or recur occasionally Will probably happen/recur but it is not a persisting issue Almost certain Will undoubtedly happen / recur, possibly frequently 0-5% 6-20% 21-50% 51-80% 81-100%

Consequence Table 3 Risk scoring = consequence x likelihood ( C x L ) Calculate the risk score by multiplying the consequence score by the likelihood score. Risk Matrix (1) Negligible (2) Minor (3) Moderate (4) Major (5) Extreme (1) Rare (2) Unlikely Likelihood (3) Possible (4) Likely (5) Almost certain 1 2 3 4 5 2 4 6 8 10 3 6 9 12 15 4 8 12 16 20 5 10 15 20 25 1-5 Low 6-11 Medium 12-15 High 16-20 Very High 25 Extreme The risk tolerance/appetite under which risks can be tolerated is a score of 11 or below where the assessment has been undertaken following the implementation of controls and assurances.

c) Risk Profile Sample Risk Profile December 2014 This sample Risk Profile identifies 8 domains that further work is required to provide assurance that the risks are being managed effectively and any gaps in assurance or controls are being addressed, Domain Uncontrolled Current Timescale Risk Risk Stroke Services 20 15 6 Months Increasing HSMR Standard ratio 20 20 3 Months Fractured NOF 12 9 Continue with routine monitoring Significant changes in Executive Team Increasing incidences of CDIff over past 3 months 16 12 6 Months 20 20 3 Months Safeguarding 16 12 6 Months Persistent none compliance with NICE TA 12 12 6 Months Privacy and Dignity 12 9 Continue with routine monitoring Patient Experience 12 9 Continue with routine monitoring Reducing rate of incident reporting to NRLS 16 12 6 Months Pressure Ulcers 12 12 6 Months

VTE 12 9 Continue with routine monitoring NB Risk Tolerance is a score of 11 or below 1-5 Low 6-11 Medium 12-15 High 16-20 Very High 25 Extreme

d) Risk Threshold Matrix Risk Threshold Matrix The risk tolerance/appetite under which risks can be tolerated is a score of 11 or below where the assessment has been undertaken following the implementation of controls and assurances. Risks scored at 12 or above must be treated. Risks scored at 16 or above must be notified to the Board through the Assurance Framework or via exception reporting. 1-5 Low No Commissioner action. Continue with routine monitoring 6-11 Medium No Commissioner action. Continue with routine monitoring Commissioners will closely monitor the Provider action plan. Persistent risks which remain at this score for over 6 months will be subject to a Commissioner Appreciative 12-15 High Enquiry. Where 6 or more areas of risk are scored as High at any one time, a Commissioner Appreciative Enquiry will be considered based on clinical judgement. The timescale for completion of a proposed Commissioner Appreciative Enquiry will be a maximum three months subject to Board approval The Trust will be given 3 months to mitigate the risk. If the risk score is not reduced to at least High after a 16-20 Very High period of 3 months then it will be subject to a Commissioner Appreciative Enquiry. The timescale for completion of a proposed Commissioner Appreciative Enquiry will be a maximum one month subject to Board approval 25 Extreme Immediate Commissioner Appreciative Enquiry. The timescale for completion of a proposed Commissioner Appreciative Enquiry will be one week and may be undertaken following approval of the Chief Executive (or nominated deputy) with the Board being informed as soon as practicable. Clinical judgement regarding specific risks may override thresholds

Appendix 3- Toolkit Appendix 3a Quality Dashboards to go in here

Appendix 3b Visit Preparation Data and Document Review In advance of any proposed visit a detailed data and document review should be undertaken to form an initial judgement of the Trust/Provider. This should take the form of dashboard or balance scorecard sheet and take account of the qualitative and quantitative data. This will help with the generation of a list of questions / issues to be discussed with the organisation being visited. More importantly it will help form the rationale and scope of the appreciative enquiry. The attached template provides a generic data / document list and should be tailored to fit the specific area being reviewed. It is not exhaustive and more detailed reports from a variety of departments will support this summary, e.g. detailed dashboard on patient safety. In addition to completing the template, it is helpful to provide a summary overview of emerging issues from the review.

Overview of emerging issues Good Practice Example: Overview of emerging issues from the data. There is evidence that the Trust and other stakeholders have identified areas of concern. These may be summarised as: A&E and emergency care pathway performance (quantified) and impact on patient care / experience (less well quantified although most recent inpatient survey does appear to reflect the same areas) Training and supervision Robust governance systems for reporting, identifying necessary actions and following up complaints, SIs etc (within clear timescales)? Most of these issues have been identified as needing action for at least a year. It is not clear (from the documents and information available in advance of the visit) what actions have been taken to address either the specific issues or any underlying issues. High level questions: Is there awareness at Board level of what the key issues are? What do the Board think is being done to tackle them? What do the Board think the blocks are? Is there Board level leadership? How progress is reviewed and actions changed if necessary? What is the view of other staff (clinical in particular)? How would the Trust describe their approach to governance issues what are the mechanisms in place?

High level questions Is there awareness at Board level of what the key issues are relating to safety, experience and quality? This should reflect Board discussions held and evidence on the Trust/Provider risk register? What do the Board think is being done to tackle them? What do the Board think the blocks to progress are and what evidence is there of Board engagement. How progress reviewed and actions are changed if necessary? What is the view of other staff (clinical in particular)? How would the Trust describe their approach to governance issues what are the mechanisms in place? Also explore - Clinical Quality Review meetings with commissioners systematic, type of issues covered, follow up? Explore how Quality & Safety services have improved and impact on patient care/outcomes?

Quality and safety Governance Theme Data / Documentation Preliminary Judgement (based on) Follow up questions Notes and actions from previous 6 months of Clinical Quality Review meetings Board Reports from previous 6 months Clinical Governance (or equivalent) reports from previous 6 months Local Clinical Quality Review dashboard (this may already include some of the items identified separately below) Outcomes of National Audit Programmes as appropriate (e.g. MINAP, Sentinel) Programmes of work arising from the QRP to reduce harm and improve quality Analysis of SIs, incidents and actions taken Mechanisms for reporting identifying action and follow up? Senior level ownership? What analysis does the Trust do of all incidents, what measures are in place to ensure reporting, how does the Trust identify and follow up any trends?

Workforce Theme Data / Documentation Preliminary Judgement (based on) Follow up questions Peer review reports (national e.g. Cancer or local) Hospital Standardised Mortality Rates and analysis Analysis of staff to patient ratios, skill mix, vacancy and sickness levels, use of temporary and agency staff What are they? How does the Trust use information on HSMRs and other indicators systematically to investigate and assure itself of quality of patient care? What are vacancy and sickness levels in key areas? Use of temporary and agency staff? Impact on patient care?

Patient experience Theme Data / Documentation Preliminary Judgement (based on) Follow up questions Staff survey results Response rate? What does most recent survey show? How does the Trust follow up the results of the staff survey? Discuss with key staff in terms of what they think the underlying issues are? Impact on patient care? Workforce Deanery Reports and Surveys (e.g. PMETB survey, Foundation Review Visits) Patient Experience Survey Results (National and Local) Analysis of complaints and actions taken What issues identified and how have they been followed up? Has the Trust used the patient survey results (and other local information on patient experience, including complaints) to review and improve services?

Operation al Performa nce Regulator view / action Theme Data / Documentation Preliminary Judgement (based on) Follow up questions CQC Registration CQC Annual Health Check (Core Standards element in particular) What / where is the challenge in terms of assurance of compliance with core standards? CQC Service Reviews How does the Trust systematically review and act on areas of concern / recommendations from external reviews? CQC Hygiene Code Inspections Observation of environment on visit day? Discuss what systems / changes made as a result of inspection? Audit Commission / Monitor / other reports Performance against operational standards and targets (including trends) Performance year to date against Tier 1 vital signs and existing commitments reviewed. What does this mean for patient Discuss any underlying issues, how do the Trust identify and make contingency plans to deal with capacity issues that may delay patient care in key service areas?

Local Stakeholder engagement and perspective Theme Data / Documentation Preliminary Judgement (based on) Follow up questions experience? NHS Performance Framework outcome (where available) Performance across all domains? Health Overview and Scrutiny Committee papers Notes etc of Patient / User Forums Media analysis Are patients and other stakeholders involved in dealing with areas of concern? How is Trust tackling and then demonstrating improvements / changes to public (via media if appropriate)?

Appendix 3c Lines of Enquiry for Chief Executive Please Note: For those questions where an issue is raised, please ask the follow on question: What are you doing about the problem? Theme Hypothesis Question Evidence Strategic Strategic Strategic Strategic There is clarity in the organisation of Strategic Direction in relation to Clinical Services There is clarity in the organisation of Strategic Direction in relation to Clinical Services There is clarity in the organisation of Strategic Direction in relation to Clinical Services Nurse and Medical Directors demonstrate competence in the delivery of their Board Roles specifically in relation to quality, patient safety and experience. Does the Trust have a Strategy on Clinical Services? If Yes: How is this being taken forward? If No: How are you managing without a Strategy? Do you have confidence in your Nurse/Medical Director to lead on quality, patient safety and experience? What are their functions relating to Quality & Safety?

Theme Hypothesis Question Evidence Strategic Nurse and Medical Directors demonstrate competence in the delivery of their Board Roles specifically in relation to quality, patient safety and experience. If Yes: Are they working collaboratively on this agenda? Strategic Patient Safety Patient Safety Staffing Nurse and Medical Directors demonstrate competence in the delivery of their Board Roles specifically in relation to quality, patient safety and experience. Patient Quality & Safety indicators are presented to the Board on a regular basis Patient Quality & Safety indicators are presented to the Board on a regular basis Staffing establishments are reviewed and altered to provide safe and effective care. If no: what action are you taking? How is the Board briefed on quality, safety and patient experience? What are your current clinical risks and how are you mitigating against them? How are you confident that clinical staffing levels in the Trust ensure safe and adequate provision?

Theme Hypothesis Question Evidence Responsibility Responsibility Responsibility COMMENTS Board considers external reports to ensure that they benchmark themselves against risk and mitigate as appropriate Board considers external reports to ensure that they benchmark themselves against risk and mitigate as appropriate Board considers external reports to ensure that they benchmark themselves against risk and mitigate as appropriate Comments Have you assessed the Trust's position against the findings/recommendations set in the HCC report on Mid Staffordshire Hospital? If Yes: What was the outcome of the assessment? If No: Are you proposing to complete an assessment? What do you see as the biggest challenges in your Trust?

Appendix 3d Lines of Enquiry for Medical Director Please Note: For those questions where an issue is raised, please ask the follow on questions: What are you doing about the problem? Theme Hypothesis Question Evidence Strategic Strategic Strategic Strategic There is clarity on the Strategic Direction of the Trust There is clarity on the Strategic Direction of the Trust There is clarity on the Strategic Direction of the Trust There is clarity on the Strategic Direction of the Trust Does the Board have a clinical strategy in which quality is the organising principle? If Yes: Obtain a copy and for an explanation of how it was - developed? - how it is being delivered? If No: ask what action is being taken to develop a strategy and how they lead clinical services currently in the absence of a formal strategy? What value set does the organisation have in relation to patient safety, quality of care and experience and are the Nurse Director and Medical Director working collaboratively to ensure these

Theme Hypothesis Question Evidence values are met? What is being done to ensure all Clinicians and Clinical teams are contributing to harm reduction and Quality improvement in the Trust? Strategic There is clarity on the Strategic Direction of the Trust Are the roles and responsibilities of the Nursing and Medical Directors clearly understood by the Board in relation to the quality agenda? Strategic There is clarity on the Strategic Direction of the Trust Do the Nursing and Medical Director have any difficulty engaging the Board? Examples of issues taken to the Board? Responsibility It is unclear who in the organisation is responsible Can you tell me who has overall responsibility for the quality & patient safety agenda is in your trust? Clinical Standards Report goes to the Board on a regular basis Do you report clinical indicators of care to the Board? e.g. HIAs Clinical Standards Report goes to the Board on a regular basis IF YES: What do you report? Clinical Standards Report goes to the Board on a regular basis How was this decided?

Theme Hypothesis Question Evidence Clinical Standards Report goes to the Board on a regular basis Where is this on the Board Agenda? Is there meaningful debate, discussion and decision making? Clinical Standards Report goes to the Board on a regular basis Does your clinical staff attend the Board, for example HCAI agenda? Matron Reporting? Patient Experience Patient Experience Strategy approved by the board Who takes the Board Lead for Patient Experience Patient Experience Patient Experience Strategy approved by the board What input did you and clinical colleagues have to the development of the Patient Experience Strategy? Patient Experience Patient Experience Strategy approved by the board What reports go to the Board in relation to Patient Experience and how often? Patient Experience Patient Experience Strategy approved by the board What level of debate and discussion occurs in relation to Patient Experience and where is this on the agenda? Patient Experience Patient Experience Strategy approved by the board How do you become aware/involved if there are complex complaints relating to clinical care and ensure that systems are put in place to learn from these? Patient Safety Patient Safety indicators are presented to the Board on a regular basis How do you ensure that key high level indicators are discussed and actions

Theme Hypothesis Question Evidence Patient Safety Patient Safety Patient Safety indicators are presented to the Board on a regular basis Patient Safety indicators are presented to the Board on a regular basis taken where trends are identified? Is there debate and discussion about SMR and actions planned where risks are highlighted above acceptable norms? How do you ensure that policy is in place to minimize the risk and maintain standards in relation to HCAI agenda? Patient Safety Patient Safety Patient Safety Patient Safety indicators are presented to the Board on a regular basis Patient Safety indicators are presented to the Board on a regular basis Patient Safety indicators are presented to the Board on a regular basis How do you ensure that staff have the equipment they need to deliver care appropriately and is there a system in place for training? What learning is taken and how are you further developing culture of reflection and lifelong learning? How do you ensure ward to board feedback on quality, safety and patient experience? Facilities Patient Environment is fit for purpose Do you have a programme to ensure maintenance of the ward/department environments?

Theme Hypothesis Question Evidence Facilities Patient Environment is fit for purpose What processes do you have in place to monitor the environment and assure yourself and the Board that standards are acceptable Staffing Staffing establishments are reviewed and altered to provide safe and effective care Has the Trust undertaken a review of staffing which was reported to the Board Staffing The Board are assured in relation to the quality of pre and post graduate education Do you gather and use information from QA reports relating to the provision of pre and post graduate education? COMMENTS Comments What do you see as the biggest challenges in relation to quality, patient safety and experience and what are you doing about them?

Appendix 3e Lines of Enquiry for Director of Nursing Please Note: For those questions where an issue is raised, please ask the follow on question: What are you going to do about the problem? Theme Hypothesis Question Evidence Strategic There is clarity on the Strategic Direction of the Trust Does the Board have a clinical strategy? Strategic Strategic Strategic There is clarity on the Strategic Direction of the Trust There is clarity on the Strategic Direction of the Trust There is clarity on the Strategic Direction of the Trust If Yes: Obtain a copy and for an explanation of how it was - developed? - how it is being delivered? If No: ask what action is being taken to develop a strategy and how they lead clinical services currently in the absence of a formal strategy? What value set does the organisation have in relation to patient safety, quality of care and experience and are the Nurse Director and Medical Director working collaboratively

Theme Hypothesis Question Evidence to ensure these values are met? Strategic There is clarity on the Strategic Direction of the Trust Are the roles and responsibilities of the Nursing and Medical Directors clearly understood by the Board in relation to the quality agenda? Strategic There is clarity on the Strategic Direction of the Trust Do the Nursing and Medical Director have any difficulty engaging the Board? Examples of issues taken to the Board? Responsibility It is unclear who in the organisation is responsible Can you tell me who has overall responsibility for the quality & patient safety agenda is in your trust? Clinical Standards Report goes to the Board on a regular basis Do you report clinical indicators of care to the Board? e.g. HIA Clinical Standards Report goes to the Board on a regular basis IF YES: What do you report?

Theme Hypothesis Question Evidence Clinical Standards Report goes to the Board on a regular basis How was this decided? Clinical Standards Report goes to the Board on a regular basis Where is this on the Board Agenda? Is there meaningful debate, discussion and decision making? Clinical Standards Report goes to the Board on a regular basis Do your clinical staff attend the Board, for example HCAI agenda? Matron Reporting? Patient Experience Patient Experience Strategy approved by the Board Who takes the Board Lead for Patient Experience Patient Experience Patient Experience Strategy What input did you have to the development of the Patient Experience Strategy?

Theme Hypothesis Question Evidence approved by the Board Patient Experience Patient Experience Strategy approved by the Board What reports go to the Board in relation to Patient Experience and how often? Patient Experience Patient Experience Strategy approved by the Board What level of debate and discussion occurs in relation to Patient Experience and where is this on the agenda? Patient Experience Patient Experience Strategy approved by the Board How do you become aware/involved if there are complex complaints relating to clinical care and ensure that systems are put in place to learn from these? Patient Safety Patient Safety indicators are presented to the Board on a regular basis How do you ensure that key high level indicators are discussed and actions taken where trends are identified?

Theme Hypothesis Question Evidence Patient Safety Patient Safety indicators are presented to the Board on a regular basis Is the debate and discussion about SMR and actions planned where risks are highlighted above acceptable norms? Patient Safety Patient Safety indicators are presented to the Board on a regular basis How do you ensure that policy is in place to minimise risk and maintain standards in relation to HCAI agenda? Patient Safety Patient Safety indicators are presented to the Board on a regular basis How do you ensure that staff have the equipment they need to deliver care appropriately and is there a system in place for training? Patient Safety Patient Safety indicators are presented to the Board on a regular basis How do you use soft intelligence relating to quality, safety and patient experience? Patient Safety Patient Safety indicators are presented to the Board on a How do you ensure ward to board feedback on quality, safety and patient experience?

Theme Hypothesis Question Evidence regular basis Facilities Facilities Staffing Patient Environment is fit for purpose Patient Environment is fit for purpose Staffing establishments are reviewed and altered to provide safe and effective care. Do you have a programme to ensure maintenance of the ward/department environments? What processes do you have in place to monitor the environment and assure yourself and the Board that standards are acceptable? Has the Trust participated in the recent Audit Commission Acute Ward Staffing review, or undertaken an alternative review which was reported to the Board? Staffing Staffing establishments are reviewed and altered to provide safe and effective care. IF YES: What did the benchmarks show? Staffing Staffing establishments are reviewed and altered to provide safe and effective care. What actions did you take? Did you take the results to the Board and where there any decisions made regarding investment requirements?

Theme Hypothesis Question Evidence Staffing Staffing establishments are reviewed and altered to provide safe and effective care. Alternatively: Have you undertaken and establishment review? Staffing Staffing establishments are reviewed and altered to provide safe and effective care. IF YES: When and how often do you do this? What tool do you use? Staffing Staffing establishments are reviewed and altered to provide safe and effective care. What was the outcome? Was investment required and approved by the Board? Staffing Staffing establishments are reviewed and altered to provide safe and effective care. How did the establishment review link to the annual business planning process (Service developments/reconfigurations planned)/ workforce & OD plan or contingencies for activity fluctuations?

Theme Hypothesis Question Evidence Staffing The Board are assured in relation to the quality of pre and post graduate education Do you gather and use information from QA reports relating to the provision of pre and post graduate education? COMMENTS Comments What do you see as the biggest challenges in relation to quality, patient safety and experience and what are you doing about them?

Appendix 3f Assurance Visits Checklist for Packs 1 VISIT SCHEDULE Plan for the day 2 SITE MAP, ADDRESS AND CONTACT DETAILS 3 LETTER TO CHIEF EXECUTIVE 4 BRIEFING SUMMARY 5 QUALITY INSPECTION TOOL 6 RISK SUMMIT SUMMARY 7 PATIENT SURVEY SUMMARY 8 STAFF SURVEY SUMMARY 9 SUMMARY REPORT OF NON MEDICAL QA 10 REVISIT FOUNDATION PROGRAMME REVIEW 11 WORKFORCE BRIEF 12 PERFORMANCE BRIEF 13 CQC INSPECTION HISTORY 14 CQC COMPLIANCE HISTORY 15 CQC RISK PROFILE 16 DOCUMENTS HELD BY COMMSIONERS RE SI FOLLOW UP and CONCERNS RE FT

Appendix 3g Template Letter to be inserted Insert Logo Our Ref: xxxx Insert Date XXXX Chief Executive XXX Dear xxxx Re: Commissioner Visit to XXXXXX Hospital NHS Trust Further to the recent conversations, I am writing to confirm arrangements for the Commissioner led visit to the trust on insert date. The background to the visit is the flagging of continued high HSMRs at the Trust or could be routine baseline intelligence gathering to triangulate evidence regarding Quality & Safety of Services. You have briefed us thoroughly on the work you are doing to improve both mortality rates and patient experience, but we felt it was important that we should arrange to see this first hand. The visit will seek to undertake a rapid assessment of the trust s overall position on the provision and governance of clinical services on the emergency care pathway, including an assessment of patient safety and experience. The visit will focus on: Leadership and governance arrangements within the Trust on quality and safety issues Rapid review of the aforementioned clinical areas which will include: a. visiting the A&E and emergency admission wards b. meeting a cross-section of clinical staff to see and hear first-hand about the provision of patient services c. meeting a cross-section of patients and carers in a focus group setting or similar to assess their experience of these services d. assessment of clinical staffing levels in the clinical areas visited

Any issues/concerns raised through a number of different sources available to NHS England/CCG such as national reporting from regulators, SI reporting and actions taken, performance against key clinical indicators such as HCAIs Any other matters that may arise from the visit. We would propose that the visiting team includes the following representation: The Director of Nursing, the Director of Performance and the Medical Director An A&E consultant or acute physician from another Trust in Yorkshire & the Humber Members of the Nursing team Clinical representatives from the CCG We will aim to agree with you the timescales for the visit and the programme in the next few days. XXXXX (note: point of contact required for coordination from commissioner and at Trust) will share with you the timetable template we have used in other visits and arrange the logistics of the visit with your office. We will also agree with you any information we would want you to forward to us before the visit (NB we will try to keep the information request to a reasonable level). If in the meantime if you feel you need any further clarification please do not hesitate to contact me directly. Yours sincerely Insert Name and Designation

Appendix 3h Timetable for NHS XXXXX Visit to XXXXX on Day/Month 2010 Time Team Trust Venue 08.00-09.00 Pre- meeting for Commissioning team 09.00-10.00 Medical Director/Director of Nursing/ Director of Performance Meeting xxx (CEO) 09.00 12.00 Senior Nurse CCG/ Clinical Team Members xxxxxxx (Director of Nursing) and xxxxx (General Manager for xxxxx Division) e.g. Escort through urgent care & critical care pathways 10.00-11.30 Medical Director/Director of Nursing Meeting with Staff and Staff side reps: (See separate attendance list)

12.00 13.00 Commissioner team lunch and reflection 13.00-14.00 CCG Nurse Director and Senior Nurse Meeting Matrons/Senior Nurses: (See separate attendance list) CCG Medical Director and GP Meeting with Senior Medics: (See separate attendance list) Time Team Trust Venue 13.00-17.00 CCG Nurse Director/ Clinical Team Members Visits to clinical areas escort (General Manager for Medical Division) and matron (when available) if required 14.30-16.00 Medical Director/Director of Nursing/ Director of xxxxxxx (Medical Director)

Performance xxxxx (Director Nursing) Senior Nurse CCG/ Patient Engagement Lead Patients and carers groups: (See separate attendance list ) 16.00-17.00 Medical Director/Director of Nursing/ Director of Performance Random visit to clinical areas: escorts - Matrons 17.00 19.30 Commissioner team reflection 19.30 Director will speak to CEO re emerging issues

Appendix 3i Observational Visit Checklist Areas to be observed Tick 1 Environment Fit for purpose Tidiness Cleanliness Ambience how it feels Sign posting/ directions What works well/ what needs attention? 2 Staffing Welcoming attitudes and behaviours ID Badges worn Right number on duty Someone in charge Ability to describe purpose and function of the area issues and concerns / positive aspects 3 Patients Look clean and well cared for Privacy and dignity maintained at all times Same sex accommodation available i.e. same sex toilets and bathrooms, same sex bays Safety maintained

Food and nutrition needs met NB: If there is an opportunity to speak to patients and ask their views about the service from a patient experience perspective then the team should do this

Appendix 3j Observational Visits initial Feedback Form Feedback by: Date: Trust Wide Overall Impression General Comments: Good Practice:

Immediate Risks (Hot issues for urgent action now): Issues / Concerns (to be addressed in the next 3 months): Further Consideration (2-way Feedback / Expectations when Report Ready / Next Steps / Timescales: Appendix 3k Tool for Enquiry Visits

Document control Version 6 Date Status December 2014 Final Adapted from SSPCT governance review tool Patient Experience Review Tool Questions are colour coded: White - for Matrons Amber - for Matrons and Clinical Staff Green - for Clinical Staff Name of clinical area/ward Date

Name of person(s) undertaking assessment Completion In each section, consider whether as a clinical area response is compliant for each statement, and put a tick in the appropriate box by the side of each statement. Based on the responses given, a calculation will be made using the traffic light system to give an indication of the mechanisms that are in place to promote a high standard in the quality of care provided (Red immediate development work required; Amber a little development work required; Green compliant with the standard) Each section to be scored individually, which will give some indication where further development work may need to be targeted. Colour Score indicator Score interpretation Red More than 5 No responses immediate development work required Amber 3 to 5 No responses a little development work required Green 2 or less No responses compliant with the standard

1. Quality Standard Staffing Staffing Levels are at a level that enables the clinical team to deliver safe and effective patient care No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views Observation 1 Review 6 off duties from clinical areas (prospective and retrospective) If available scrutiny from electronic rostering system 2 Guidelines for duty rotas including annual leave, study leave are in place and followed. The guideline should include 23% uplift to meet agenda for change criteria 3 Bank and Agency process in place that facilitates ability to meet minimum staffing levels 4 Skill Mix standard for each specialty Training of non-registered staff - Competencies and sign off - New starters process - Clinical supervision/preceptorship

5 Turnover / sickness levels 6 What type of nursing model is implemented eg: Team Nursing Nurse in charge 7 Process in place to induct Bank/Agency Staff 8 Is the right number of staff on duty today? If No: What have you done about this 9 Are there regular visits by the Matron to the Ward/Area 10 Is there a Site Management system in place and do staff understand and use it to get support 13 Whistle blowing policy in place and staff aware of how to raise concerns

2. Quality Standard Clinical Standards Patients and Carers experience safe and effective clinical care, sensitive to their individual needs and preferences, that promotes high quality care for the patient No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views Observation 1 There is adequate signage/maps/directions in the clinical area/ward to support effective communication to patients, relatives and carers 2 Staff introduce themselves to patients relatives and carers 3 All staff wear an ID badge when on duty 4 Next of kin or principle carer is identified, agreed with the patient and the impact of care is assessed 5 Patients, relatives and carers know who to contact first if they have any questions regarding care 6 There is evidence of essence of care/ or alternative

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views Observation audits and action plans to implement change as appropriate 7 There is evidence of high impact interventions for HCAI being implemented NB: Ask patients if staff wash hands 8 The ward/ department has implemented the principles of releasing time to care and displays a dashboard of information 9 There is evidence of care plans, fluid balance charts, infusion pump charts and MEWs scoring system in place 10 Any information given to the patient is fully explained and understood

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views Observation 11 Information regarding the PALS service is given to patients, relatives and or carers 12 Planned care is agreed and recorded with patients (and or relatives/carers) prior to treatment or care 13 Where appropriate, explicit or expressed consent is sought from the patient prior to treatment or care

3. Quality Standard Patient Experience The clinical area/ ward collects and acts upon feedback from Patients and Carers/Families No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views 1 Does the ward get feedback in relation the annual patients survey and is there a local action plan that is reported on 2 Patients and or relatives/carers views are sought, listened to and acted upon from: e.g Dr Foster Patient Tracker Local Surveys Discussions and Interviews Safety walkabouts Via Releasing Time to Care Programme 3 Is there evidence of thank you cards on the wards 4 The ward staff manages patient complaints at a local

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views level? 5 Information regarding the PALS service is given to patients, relatives and or carers 6 There is information readily available for patients, relatives and or carers on how to make a complaint about the quality of care that is provided if needed 7 Do any of the ward staff participate in a patient experience group e.g. Support Groups for the specialty or trust wide groups 8 Staff are aware of policies and procedures regarding the safeguarding of vulnerable adults and children and know how to access them

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views 9 Staff have attended mandatory training for the protection of vulnerable adults and children 10 Patient privacy is maintained by the use of curtains and screens 11 Permission is obtained before entering any private area, such as behind screen curtains, bathrooms and cubicles 12 Patients wear clothing that maintains modesty & dignity (such as their own clothes or hospital clothing) 13 Dignity & modesty is maintained for those patients moving between different care environments 14 Patients are protected from unwanted public view for example using curtains, screens. Walls. Clothes and

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views covers 15 Patients are called by their preferred name, and this is documented 16 Patient call systems are answered in a timely manner 17 There is a quiet or private space available for patients to use, and patients are made aware of is availability 18 Precautions are taken to prevent information being shared inappropriately for example telephone conversations being overheard, computer screens being viewed and white boards being read

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views 19 Procedures are in place for sending or receiving patient information for example hand-over procedures, consultant or teaching rounds, admission procedures, telephone calls, or breaking bad news 20 Same sex facilities are provided, and there is access to segregated or age specific toilet and washing facilities 21 Staff are aware of their role in protecting patients privacy & dignity 22 Staff are aware of individual patient cultural & religious beliefs and how it may change delivery of care 23 Patients look clean and cared for and are dressed in appropriate attire.

No. Criteria to be assessed Evidenced by Comments Observat ion Document ation Staff view s Patient/car er/ relative views 24 Bed spaces are clean and tidy with items within easy reach of patients e.g. drinks/meals etc 25 Bathrooms and toilets including commodes are clean and tidy

4. Quality Standard Patient Safety Staff are responsible for ensuring patients safety is maintained No. Criteria Evidenced by Comments Observat ion Document ation Staff view s Patient/care r/ relative views 1 The medicine trolley(s) and individual patient drug lockers/drug cupboard are locked and are attached securely to a wall when not in use 2 All resuscitation equipment is clean, in date, easily accessible and a daily signed checking schedule is up to date 3 Equipment used for moving and handling patients is adequate, accessible, clean and maintained in good working order 4 All patients wear a clear and accurate identity band which comply with the Trusts Patient ID policy 5 There is a register of all equipment that is used in the clinical area/ward, which included serial numbers

No. Criteria Evidenced by Comments Observat ion Document ation Staff view s Patient/care r/ relative views 6 There is a maintenance record in the clinical area/ward of when all equipment was last checked or serviced 7 For all equipment used in the clinical area/ward there is a maintained list of all staff trained in it use 8 If staff feel they need more equipment there is a process to access it 9 Staff know how to report an incident and have knowledge of the Trust procedure on incident reporting 10 Staff receive feedback on incidents and actions that are required to prevent repetition 11 Staff understand what is meant by the term Serious untoward incident (SUI) and are able to differentiate it from the general term incident

No. Criteria Evidenced by Comments Observat ion Document ation Staff view s Patient/care r/ relative views 12 Staff are trained/ participate in Root Cause Analysis 13 Staff know how to access on-call system for any work issues out of hours and escalation plan 14 There is a clear record of all staff who have attended annual mandatory training (such as manual handling, resuscitation and fire) 15 Staff are aware of Trust safety policies such as Health & safety, violence & aggression, and lone working 16 Where appropriate, access to the clinical area/ward is strictly controlled 17 Agency & bank staff are subject to authentication and have their ID checked & validated

No. Criteria Evidenced by Comments Observat ion Document ation Staff view s Patient/care r/ relative views 18 Agency & bank staff are subject to local induction programme 19 Patients are assessed on admission for their risk of falling using a validated assessment tool. 20 Falls assessments are repeated during the care episode if there has been a change in the patients treatment or condition 21 Staff know what & how to record when a patient who has sustained a fall during their stay in hospital 22 Staff know the specific circumstances for when bed rails should be used on a patients bed

5. Quality Standard Facilities The care environment meets the needs of the service No. Criteria Evidenced by Comments Observat ion Documenta tion Staff view s Patient/care r/ relative views 1 The entrance to the care environment is obvious, sign posted clearly, safe, welcoming, easily reached and entered 2 How it feels the environment feels pleasant, calm, secure, safe and reassuring 3 Furnishings (chairs, wall coverings, floors, carpets, doors etc) are all in good repair and have no stains or marks 4 The area is the appropriate temperature and where possible, has natural daylight and where appropriate lighting can be controlled by the patient

No. Criteria Evidenced by Comments Observat ion Documenta tion Staff view s Patient/care r/ relative views 5 The area is free from inappropriate clutter (such as in exits, corridors, bathrooms, shower areas etc) 6 Linen and laundry segregation, storage and disposal are well managed and appropriate 7 Regular routines for cleaning and managing waste are in place that meet national standards 8 Telephones, calls, televisions, music, visitors and admissions are managed effectively to minimise disruption 9 There is signage on the clinical area/ward to notify patients, relatives and carers of facilities such as toilets, bathrooms, fire exits and directions to other services

No. Criteria Evidenced by Comments Observat ion Documenta tion Staff view s Patient/care r/ relative views 10 There is an environmental risk assessment (safety check) of the patient s personal; space that includes such as removal of obstructions to observations, sighting of hand gels, obstructions and clutter around the bed, and obstructions to prevent access to means of suicide etc 11 The patient s plan of care reflects their safety needs and documents that they have been given the opportunity to ask questions 12 Cleaning Schedules are available and visible

Key Lines of Enquiry for consideration within a Mental Health setting Evidenced by Comments Documentation Staff views Patient/carer/ relative views Care and Welfare Issues Health records - are they up to date, signed and dated Care plans to be reviewed to ensure care plans are relevant to individual needs Do care plans identify needs, aims and interventions linked to outcomes Do care plans include physical needs of individual patients where appropriate Are care plans accurate and have they been updated How is care planning supported by MDT process

Evidenced by Comments How are patients and families involved in the planning and evaluation of care Documentation Staff Views Patient/carer/ relative views Do care plans contain individual risk assessment to support the delivery of care Is care delivered in line with the care plan Does the patient s plan of care reflect their safety needs and documents that they have been given the opportunity to ask questions Mental Health Act - Are patients detained in line with the Act is there documentary evidence to support this and is it up to date Are staff familiar with the Mental Health code of practice Does section 17 leave take place on the ward if so what is the process and is this documented in the patients records

Evidenced by Comments How are records of seclusion made and stored Documentation Staff Views Patient/carer/ relative views For families how does the hospital and staff communicate with you and how does that make you feel about your family member Are Staff are aware of their role in protecting patients privacy & dignity can they describe this Are individual patient risk assessments undertaken and care planned to address these risks, are these interventions evaluated What activities are available to patients are they appropriate and varied How are patients nutritional needs addressed Is there in place a process for monitoring the quality of the records and how is this shared What are the observational systems in place for Level 1, 2 and 3

Evidenced by Comments How is line of sight maintained for patients in segregation or seclusion Documentation Staff Views Patient/carer/ relative views Safeguarding Do patients feel safe on the ward Do staff know how to make a referral to the safeguarding team How are issues addressed from safeguarding How do safeguarding concerns get referred to CQC Are there safeguarding procedures available on the ward

Evidenced by Comments Observe interactions between patient's and staff Documentation Staff Views Patient/carer/ relative views Can staff articulate the role of the safeguarding lead for the hospital How are patients belongings including their money looked after Staffing Is the ward fully staffed in line with the funded establishment Is there any vacancies Is the skill mix appropriate

Evidenced by Comments Are agency staff used Documentation Staff Views Patient/carer/ relative views Have there been difficulties in recruiting staff What does the organisation deem to be mandatory training How many staff have been trained in Safeguarding, BLS, Restraint, Medicines management How is Training of non-registered staff identified and delivered How are staff assessed as competent and what is the process for sign off and on-going assessment What is the induction process for new starters How do staff receive clinical supervision

Evidenced by Comments Are there examples of learning from incidents and complaints on the ward Documentation Staff Views Patient/carer/ relative views Incident Reporting Do staff know what incidents to report Do staff know how to report incidents Who investigates the incident How is learning shared and changes in practice monitored Medicines Management

Evidenced by Comments Documentation Staff Views Patient/carer/ relative views Are medicines stored safely How does patients medicines get reviewed and now often does this happen Have care plans been updated in line with the medication regime Do Medication Administration charts demonstrate that patients are receiving the right medication at the right time and in the right format Where medications are omitted is this documented along with the rational for omission What process is in place for administering medications in a psychiatric emergency e.g. rapid tranquilisation Where this has process has been used is the documentation clear and robust in relation to the decision making process and the type of medication given and evaluations of its use

Evidenced by Comments what is the process for monitoring patients on high dose antipsychotics Documentation Staff Views Patient/carer/ relative views For a patient on high dose psychotics review the monitoring system Environment How does the ward feel does the environment feels pleasant, calm, secure, safe and reassuring Are Furnishings (chairs, wall coverings, floors, carpets, doors etc.) are all in good repair and have no stains or marks Are there any ligature risk, have these been identified on the ward as part of the routine environmental audits Is the environment safe for the client group

Evidenced by Comments Is there a robust methodology for ensuring the safety of the environment Documentation Staff Views Patient/carer/ relative views Is the environment clean Is there is a maintenance record in the clinical area/ward of when all equipment was last checked or serviced Is there an evacuation plan in place is there available specialist equipment for patients with specific needs Quality Assurance

Evidenced by Comments How do staff know what the quality of the service they deliver is what changes have occurred as a result of audits that had been undertaken What type of audits are included in the ward plan Documentation Staff Views Patient/carer/ relative views How often are audits undertaken what changes have occurred as a result of audits that had been undertaken How is the outcome monitored and changes made What are the arrangements for the management of risk How does the ward/hospital benchmark itself against national reports e.g. Francis Is there a system of peer review in place

Evidenced by Comments How does the Senior Team gain assurance as to the quality of care being delivered Documentation Staff Views Patient/carer/ relative views How are clinical policies developed introduced and monitored Patient Experience What's the process for making a concern or complaint How is that reviewed and investigated How is the learning shared and embedded into practice How does the ward collect the views of patients and their families

Evidenced by Comments How are patients involved in decisions about themselves Documentation Staff Views Patient/carer/ relative views How are patients involved in decisions about the ward and its activities Senior Management How does the senior management team know what the quality of care is on the wards Can the senior team describe their approach to governance issues what are the mechanisms in place? How is quality measured and monitored within the hospital Can the team describe the key issues relating to safety, patient experience and clinical effectiveness

Evidenced by Comments How are organisational risks identified and managed Documentation Staff Views Patient/carer/ relative views Is there a business Continuity plan in place

Appendix 3l Detailed Feedback Form to be used in conjunction with Toolkit Feedback by: Date: Area Visited: General Comments: Good Practice:

Immediate Risks (Hot issues for urgent action now): Issues / Concerns (to be addressed in the next 3 months): Further Consideration (2-way Feedback / Expectations when Report Ready / Next Steps / Timescales:

Appendix 3m Immediate Feedback on Site Visit with CEO at end of day Feedback by: Date: Trust Wide Overall Impression Thank you for accommodating team, car parking, lunch, refreshments etc General Comments: Good Practice: Immediate Risks (Hot issues for urgent action now):

Issues / Concerns (to be addressed in the next 3 months): Further Consideration (2-way Feedback / Expectations when Report Ready / Next Steps / Timescales: Comments to note including deadline dates agreed when report will be sent to Trust

Appendix 4 Confidentiality Agreement «Return_Re cord_numb Name Directio n Reason Comment Disclosure of information to provide healthcare. Non healthcare but is a medical purpose as defined in Unrelated to healthcare or other medical purpose Who is sharing? From To What is shared? How is it shared? (Indicate all that apply. Information must only be shared by secure means) E-mail Post (paper and Fax In person Other (Please Comments Frequency Comments Signed (To be signed by managers responsible for each Department/Service) Name. Dept/Org Signed Date

Name. Dept/Org Signed Date

Appendix 5 Equality Impact Assessment (For: policies, services & strategies) Please refer to the Equality Impact Assessment Guidelines when completing this template. Step 1: About your piece of work 1. Directorate / Business Unit: Nursing 2. Policy / Strategy / Service to be assessed: Commissioning for Quality Assurance and Improvement using an Appreciative Enquiry Approach 3. Lead Officer: Margaret Kitching 4. Equality Impact Assessment Person / Team: Julie Finch 5. Date of Assessment: December 2014 Review Date: 6. The main purpose and outcomes of policy/strategy / service to be assessed 7. Groups who the piece of work should benefit or apply to, for example: - Service users - Staff December 2014 This policy will benefit patient care in terms of ensuring high standards of care and potential risks associated with inadequate care will be reduced All commissioners Service Users Staff Provider Organisations

- Other internal or external stakeholder CQC, Monitor (Will the piece of work be delivered in partnership with another agency?) 8. Groups who the piece of work should benefit or apply to, for example: - Service users - Staff - Other internal or external stakeholder (Will the piece of work be delivered in This policy will benefit patient care in terms of ensuring high standards of care and potential risks associated with inadequate care will be reduced All commissioners Service Users Staff Provider Organisations CQC, Monitor partnership with another agency?) 9. Any associated strategies, guidelines, NHS West Midlands Appreciative Enquiry Tool Kit frameworks Step 2: Gathering Information 1. Who should be served by the policy / strategy / piece of work? Patients and service users will benefit by this implementation of this policy. The belief that strengthening quality assurances processes within commissioning will support provider organisations who deliver health care to continually make quality

improvements and benefit the quality of care that patients receive. 2. What relevant information do you have about the people who this piece of work is aimed at? (Baseline information is given in the guidance notes, please refer to these and then add further information relevant to your area of work). Refer to guidance notes for further demographic information. Race Gender (including transgender) Disability Age Faith Information (research / data) Information regarding the protected characteristic profile of: Barnsley Doncaster Rotherham Sheffield Bassetlaw Is published on each CCG website Known or potential inequalities Potential language barriers Potential accommodation issues relating to transgender patients. Providers must follow the requirement of the Equality Act 2010 and Equality and Human Rights Commission guidelines Potential language and communication barriers for people with learning disabilities Barriers to accessing to services without reasonable adjustments: e.g. estate adjustments, staff awareness & skills Patients in transition ages 16-18 may be more vulnerable Issues relating to dignity and nutrition disproportionately affect older service users People from different faiths may have specific nutritional / accommodation / other requirements. Particular attention needs to be paid to end of life service users with respect to different religious

requirements. Sexual Orientation Same sex partner carers sometimes experience barriers through staff lack of understanding in terms of information sharing Human Rights Do you have enough information about the different groups to inform an equality impact assessment? Yes/ No If not, this area should be addressed in your action plan. The Policy will affect everyone with no discrimination, is applicable to everyone. 3. Do you have monitoring data or consultation findings specific to your area of work? If yes list the sources of evidence here & go to Step 3, if No list the actions required to get more data. This Policy is aimed at ensuring full engagement with all clinicians in order to ensure that clinicians are empowered to drive the changes in a structured way where there is an agreed requirement for clinicians to take part requiring additional funding. 4. What consultation activity has taken place / will be taking place on this piece of work and the equality impact assessment? All members of quality leads policy groups have reviewed and consulted on this document.

Step 3: Assessing Impact 1. What does your monitoring data on your service users tell you? Are any groups under or over represented compared to what you would expect to see from the baseline data in Step 2. What are the potential access issues or barriers for people in each of the equality groups? Race See 2.2. above Gender (including transgender) Disability Age Faith Sexual Orientation Human Rights 2. Based on the evidence gathered have you identified any potential differential impact for any of the equality groups? This policy is a change in the way we engage clinicians and will take time before we can say with confidence that we are fully engaging with clinicians and that this is embedded in the culture of our staff. Positive Negative Race Gender (including transgender) Disability

Age Faith Sexual Orientation Human Rights Is the differential impact as a result of indirect or direct discrimination? Yes / No. (Please refer to the glossary in the guidelines for explanation of these terms, if necessary). If the differential impact is a result of indirect discrimination, is this objectively justifiable or proportionate in meeting a legitimate aim? If yes, provide details here: Step 4: Promoting Equality 1. What has been done to promote equality in this piece of work? This includes any measures you ve put in place to: Improve the accessibility of your service Improve the quality of outcomes for people from different groups Make your service/policy/strategy more inclusive Ensure staff are trained appropriately Promote community cohesion or good relationships between different groups of people. (Think about physical access, communications needs, staff awareness, partnership working)

Race Gender (including transgender) Disability Age Faith The Patient Experience Quality Standard includes assessment criteria relating to staff awareness of individual patient, cultural & religious beliefs (22) An additional criterion is recommended relating to staff knowing how to access interpretation services (23) Sexual Orientation Human Rights 2. What further actions are required? 3. Have any changes been made to this piece of work as a result of doing the Equality Impact Assessment? 4. How have you consulted on this piece of work? As point 4 in Step 2 above. As point 4 in Step 2 above. 5. How will the outcomes from this EIA be managed and reviewed?

Appendix 6 Principles for managing quality in specialised commissioning including the RASCI template

NHS England INFORMATION READER BOX Directorate Medical Operations Patients and Information Nursing Policy Commissioning Development Finance Human Resources Publications Gateway Reference: 02001 Document Purpose Document Name Author Publication Date Target Audience Additional Circulation List Description Guidance Principles for managing quality in specialised commissioning including RASCI template NHS England 18 August 2014 Directors of Nursing, NHS England Regional Directors, NHS England Area Directors #VALUE! Guidance document outlining the standard process for managing quality in specialised commissioning, including the RASCI process (Responsible, Accountable, Supporting, Consulted and Informed), template. Cross Reference Superseded Docs (if applicable) Action Required Timing / Deadlines (if applicable) Contact Details for further information 0 0 Best practice By 00 January 1900 Stacey McCann Nursing Directorate Quarry House Quarry Hill, Leeds LS2 7PD 07768 866530 Document Status Email: stacey.mccann1@nhs.net This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet

Contents Background and challenges.. 4 Agreed model.5 Terminology.6 Responsibilities...6 RASCI template..7 RASCI definitions 7 Appendix 1 Key principles for managing quality in specialised services.8 Appendix 2 Example RASCI template..9

Background From the 1st April 2013, NHS England took on the statutory responsibility for commissioning specialised services. NHS England is a single national commissioner that discharges much of its specialised commissioning responsibility through ten of its Area Teams. Commissioners have a shared responsibility for ensuring there is timely reporting of serious incidents by the providers they commission services from and for quality assuring the robustness of the serious incident investigation, learning and action plan implementation undertaken by their providers. Until this time there has not been a common operating procedure for assigning Area Team responsibilities for performing relevant quality functions in relation to NHS Englandcommissioned specialised services. Challenges One of the challenges in assuring quality within specialised commissioning is the number of Area Teams that may be involved with a specialised services patient or provider: A patient; will reside in the geographical location of one area team known as the Originating Area Team (any one of the 27 area teams could be the originating area team); will be treated by a provider that is geographically based in an Area Team that is known as the Geographical Host Area Team which may be different to the Originating Area Team, (could be within the geographic boundary of one of the 17 non specialised Area Teams or the 10 Specialised Commissioning Area Teams where that area team is NOT the Contracting Area Team); will be treated by a provider who is broadly the responsibility of the specialised commissioning Area Team within whose functional boundary the provider sits. This Area Team is called the Functional Host Area Team (can only be one of the 10 specialised commissioning area teams); and may be distinct again from the Geographical Host Area Team and the Originating Area Team; and will be treated by a provider who is contracted by a specialised commissioning Area Team that may be further afield again (particularly prominent in independent sector mental health where there may be one provider with multiple sites) This Area Team is known as the Contracting Area Team, (can only be one of the ten specialised commissioning Area Teams)

For example, a person is referred to Huntercombe Hospital in East Yorkshire; - they live in Stratford upon Avon (Arden, Hereford & Worcestershire Area Team) the Originating Area Team; - the Geographical Host Area Team is North Yorkshire & Humber Area Team (the area team where the unit is); - the Functional Host Area Team is South Yorkshire & Bassetlaw Area Team (the specialised commissioning Area Team covering that patch); and - the national contract is held by Birmingham, Black Country & Solihull Area Team as the Contracting Area Team. The ten Directors of Nursing from the Specialised Commissioning Area Teams have agreed a way forward towards greater standardisation and production of a single operating model for assigning Area Team responsibilities. A set of principles were developed and approved at the Specialised Commissioning Oversight Group in June 2014. Agreed model The Geographical Host Area Team is responsible for performing the commissioning functions in relation to the quality of NHS England commissioned services within their geographical boundary including assuring the appropriate responses to serious incidents and safeguarding incidents by those providers.