POLICY DOCUMENT Burton Hospitals NHS Foundation Trust MANAGEMENT OF EXTERNAL AGENCY VISITS, INSPECTIONS, ACCREDITATION AND RESULTING RECOMMENDATIONS Approved by: Trust Executive Committee On: 30 January 2018 Review Date: November 2020 Corporate / Directorate Corporate Clinical / Non Clinical Department Responsible for Review: Distribution: Essential Reading for: Information for: Non Clinical Governance Executive Directors, Clinical Directors, Divisional Directors, Divisional Nurse Directors, Clinical Leads, Heads of Department All staff Policy Number: Version Number: 57 7 Signature: Date: Chief Executive 30 January 2018 External Agency Visits, Inspections & Accreditation / Version 7 / December 2017
Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Management of External Agency Visits, Inspections, Accreditation and resulting Recommendations Original Issue Date: August 2006 Date of Last Review: November 2017 Reason for amendment: Review Responsibility: Director of Governance Stored: Trust Intranet Site Linked Trust Policies: Key words: External visits / visitors / inspections E & D Impact Assessed EIA 189 Responsible Committee / Group None Consulted Chief Executive Executive and Divisional Directors Clinical Directors Divisional Nurse Directors Heads of Department Clinical Leads External Agency Visits, Inspections & Accreditation / Version 7 / December 2017
POLICY INDEX SHEET REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 5 Review November 2014 6 Review and update November 2017 7 Review and update December 2017 Minor updates External Agency Visits, Inspections & Accreditation / Version 7 / December 2017
Management of External Agency Visits, Inspections, Accreditation and resulting Recommendations CONTENTS Paragraph Number Subject Page Number 1 Background 1 2 Policy Objective 1 3 Scope of Policy 1 4 Definitions 1 5 Process for maintaining a schedule of external agency visits 6 Duties 2-3 7 Developing Action Plans to implement recommendations made following external visits 8 Recording of identified Risks. 4 9 Policy monitoring and effectiveness 4 2 4 Appendix 1 Procedure for unannounced visits 5-6 External Agency Visits, Inspections & Accreditation / Version 7 / December 2017
Burton Hospitals NHS Foundation Trust MANAGEMENT OF EXTERNAL AGENCY VISITS, INSPECTIONS, ACCREDITATION AND RESULTING RECOMMENDATIONS 1. BACKGROUND The purpose of this Policy is to outline the Trust approach to preparing for, and responding to, the requirements and recommendations of external agency assessments, inspections and accreditations. This process provides the Board with assurance that all of these are effectively managed and the necessary actions implemented across the Trust. 2. POLICY OBJECTIVE The purpose of this Policy is to provide a framework for the management of external agency visits, inspections and accreditations including the supporting processes for: Nominating an individual to coordinate and report on reviews by external agencies Maintaining a schedule of assessment and accreditation review dates Developing, maintaining, implementing and monitoring action plans Recording identified risks on the risk register. 3. SCOPE OF POLICY This Policy will apply to all external agency visits, inspections and accreditations in which the Trust participates. It will also include H M Coroner Future Death Reports. 4. DEFINITIONS External agency an authoritive body which has been given a role by the NHS Executive in regulating the corporate and professional activities of all NHS Trusts. Accreditation relates to audit and review activities of both internal and external bodies, who provide Assurance that the services being delivered by the Trust are fit for purpose and achieving the desired outcomes as laid down by the Trust s strategy and policies. Future Death Reports (Previously Rule 43) this rule provides that where the evidence at an Inquest gives rise to a concern that circumstances creating a risk of other deaths will occur or will continue to exist in the future, and in the Coroner s opinion, action should be taken to prevent the occurrence or continuation of such External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 1
circumstances, or to eliminate or reduce the risk of death created by such circumstances, the Coroner may report the circumstances to a person who may have power to take such action. 5. PROCESS FOR MAINTAINING A SCHEDULE OF EXTERNAL AGENCY VISITS 5.1 All external agency visits will be managed centrally through the Chief Executive s Office where a schedule of external visits, inspections or accreditation / review dates will be maintained to ensure visits, inspections and accreditations do not overlap. Notification of any unannounced visit will also be managed by the Chief Executives Office. The procedure for managing unannounced visits can be found in Appendix 1. 5.2 All requests for visits originating outside of this office should be forwarded, together with any supporting documentation, directly to the Chief Executive. 6. DUTIES 6.1 Board of Directors The Board functions as the main corporate decision making body and considers the key strategic and managerial issues connected with the Trust s statutory and other functions. The Board will require assurance that all external agency visits, inspections and accreditations are appropriately managed, and that recommendations and actions arising from these are dealt with in a timely and robust fashion and in accordance with this Policy. 6.2 Chief Executive 6.2.1 Appointing a nominated lead The Chief Executive will ensure that a schedule of review dates is maintained for all external agency visits / inspections / accreditations and will nominate a suitable individual (Nominated Executive / Clinical Lead) to coordinate the visit, report to the Board of Directors and develop action plans on external reviews, visits and accreditations. Copies of all supporting documentation will be forwarded to the nominated Executive / Clinical Lead. At the same time, a copy will be sent to the Director of Governance for logging. 6.3 Nominated Executive / Clinical Lead 6.3.1 The Nominated Executive / Clinical Lead for coordinating and reporting will: Identify a nominated person within the Division to take responsibility for liaising with the review agency and managing all supporting arrangements External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 2
Ensure that all relevant staff are aware of the visit / inspection / accreditation review Ensure that the report is presented to the Board of Directors or appropriate Board Committee Respond to the review findings, including the development of an action plan Provide a quarterly progress report on progress against the action plan to the Trust Executive Committee and / or appropriate Board Committee Ensure that copies of all reports are forwarded to the Director of Governance for logging Ensure that all risks identified by the external agency are formally assessed and included on the risk register. 6.4 Nominated Divisional Lead 6.4.1 The nominated Divisional lead is responsible for ensuring that all operational arrangements relating to the visit / inspection / accreditation review are actioned promptly and efficiently and will: Liaise with the review agency and manage the organisational arrangements for the visit / inspection / accreditation review Ensure that all staff involved in the visit are provided with information on the content and format of the visit and are aware of their role and responsibilities Collate any evidence required in support of the visit / inspection / accreditation review Provide the first point of contact for any queries / concerns Provide regular updates to the nominated Executive / Clinical lead. 6.5 Director of Governance 6.5.1 The Director of Governance will ensure that all external reviews / visits and resulting reports are mapped appropriately. 6.6 Head of Legal Services 6.6.1 The Head of Legal Services is responsible for recording details of all Future Death Reports received by the Trust and liaising with the appropriate Clinical Director / Divisional Director to ensure that an appropriate response is sent to the Coroner, within the 56 day timescale, addressing the issues raised. 6.6.2 All Future Death Report enquiries will be reported to the Board of Directors, or appropriate Board Committee, by the Director of Governance on a case by case basis. In addition, updates of all Future Death Report letters will be given to the CCG. External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 3
6.6.3 The Head of Legal Services will ensure that any risks identified as a result of a Future Death Report are highlighted to the Medical Director / Chief Nurse to ensure it is entered onto the appropriate risk register. 7. DEVELOPING ACTION PLANS TO IMPLEMENT RECOMMENDATIONS MADE FOLLOWING EXTERNAL REVIEWS 7.1 The Nominated Executive / Clinical Lead will review the external visit feedback and report to the Board of Directors, or designated Board Committee. Action plans will be developed to address the recommendations, giving timeframes. The action plan will be approved and monitored by the Board of Directors, or designated Board Committee. 8. RECORDING OF IDENTIFIED RISKS 8.1 The Nominated Executive / Clinical Lead will review the external visit feedback and identify any principle risks which may threaten the achievement of the Trust s objectives. These will be entered onto the appropriate risk register. 9. MONITORING AND EFFECTIVENESS 9.1 The reports arising from external reviews, visits and accreditations provide a valuable source of assurance for the Board of Directors and will be mapped as part of the Board Assurance Framework against the Trust s objectives and principal risks. The effectiveness of this Policy will be measured by: Ensuring that action plans are developed and delivered and address the issues arising from all external reviews, visits and accreditations. These will be monitored by the Board of Directors or designated Board Committee Independent audit of recommendation progress and evidence of change in practice. 9.2 Additionally, the Director of Governance will monitor the effectiveness of this Policy by providing an annual review to the Quality Committee detailing the visits undertaken, nominated Executive / Clinical Leads and results of any completed external assessment and actions taken. External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 4
Appendix A STANDARD OPERATING PROCEDURE FOR MANAGING NOTIFICATION OF UNANNOUNCED EXTERNAL AGENCY VISITS 1. Introduction 1.1. This document seeks to provide effective co-ordination for the notification of unannounced external agency visits, inspections and accreditations. A flow diagram can be found at Appendix 1 of this procedure. 2. Notification of the Visit 2.1. In-hours: All notifications of unannounced visits should come through the Chief Executive s Office. The person taking the call in the office needs to:- Obtain as much information as possible including but not limited to:- o Names of person / people attending o Name of organisation / agency they are attending from o Date and time of intended visit o Specific areas for the visit o Reason for the visit Communicate in person or by telephone (not email) all the above information to the Chief Executive / Deputy Chief Executive who will nominate a Named Lead for the visit Communicate in person or by telephone (not email) all the above information to:- o The identified nominated Named Lead o Chief Nurse o Chief Operating Officer o Director of Governance o Divisional Director for the area concerned 2.2. Out of hours: All notifications of unannounced visits should be directed through switchboard. Switchboard will obtain as much information as possible including but not limited to:- o Names of person / people attending o Name of organisation / agency they are attending from o Date and time of intended visit o Specific areas for the visit o Reason for the visit External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 5
Switchboard will then communicate in person or by telephone (not email) all the above information to the On Call Executive who will nominate a Named Lead for the visit taking into consideration the capacity arrangements at the time of the visit Switchboard will also communicate in person or by telephone (not email) all the above information to :- 3. Facilitating the Visit o The identified nominated Named Lead o Chief Nurse o Chief Operating Officer o Director of Governance o Divisional Director for the area concerned 3.1. The person that has taken the call will be responsible for providing initial support to the Named Lead if required in terms of a prolonged visit, any of the following might apply:- 4. Post visit o Access to staff, buildings, records, etc o Orientation site visit, maps, plans, telephone numbers etc o Refreshments o Office space, phones etc o Feedback Sessions 4.1. The Named Lead will ensure that feedback is given to the Chief Executive and relevant Directors in a timely and appropriate manner. 5. Examples of Potential Visitors from External Agencies 5.1. These are examples of the type of organisations/agencies who may wish to undertaken unannounced visits to the Trust:- Care Quality Commission Health & Safety Executive Health Scrutiny Committee NHSI Clinical Commissioning Groups External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 6
STANDARD OPERATING PROCEDURE FOR MANAGING NOTIFICATION OF UNANNOUNCED EXTERNAL AGENCY VISITS IN HOURS Appendix 1 Notify Chief Executive s Office of any unannounced visit CEO / Deputy CEO will nominate a named lead (depending on reason for visit) Named Lead will coordinate visit Named Lead will ensure timely, appropriate feedback is given to CEO and relevant Directors OUT OF HOURS Notify switchboard of any unannounced visit On Call Executive will nominate a Named Lead (depending on reason for visit) Named Lead will coordinate visit Named Lead will ensure timely, appropriate feed back is given to CEO and relevant Directors External Agency Visits, Inspections & Accreditation / Version 7 / December 2017 7