THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS

GOVERNORS’ VISITS – TRAINING AND PROTOCOL

  1. INTRODUCTION

Governors will recall the debate in early 2013 stemming from the Francis Inquiry report and regarding the appropriate conduct of Governors’ visits to wards and departments and the agreement reached on a protocol for such visits. It was also agreed that such visits were not intended to be “mock inspections” but were intended to offer Governors an opportunity to learn about the “shop floor” working of the Trust at first hand and offer an informal mechanism for patients and staff to give feedback on any aspect of care or the environment.

In the wake of the recent conclusion of the independent Lampard Review, it is now timely to revisit policy and procedure in this arena to ensure that the Trust can display best practice in both the protection of its patients and staff and in facilitating a core activity for its Governors.

  1. GOVERNORS’ VISITS PROTOCOL

The protocol is attached at Annex 1 as an aide memoire for all Governors who may wish to undertake visits to wards and departments.

  1. TRAINING FOR GOVERNORS

It was agreed in 2013 that any Governor wishing to conduct visits would receive specific training, based upon a combination of elements from the Trust’s staff induction programme and some bespoke components, to include inter alia Infection Prevention & Control, Safeguarding, Privacy & Dignity and Confidentiality. It may be that there are some Governors who were elected this year who have not yet received this training. Those who wish to do so should make themselves known to the Trust Secretary. It is also good practice to renew this training every three years and hence longer-serving Governors are encouraged to undertake this.

  1. RECOMMENDATION

To receive the briefing and note the requirement for specific training before undertaking visits to wards and departments.

Steven Reed

Trust Secretary

12th November 2015

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS

PROTOCOL FORWARD AND DEPARTMENT VISITS BY GOVERNORS

  1. AIM

To assess and monitor the quality of patient experience provided to individuals attending any of the Newcastle Hospitals by regular visits to individual wards and departments,primarily by members of the QPE group of Governors (other Governors may conduct or join visits, subject to compliance with the requirements set out here).

  1. HOW THIS IS TO BE ACHIEVED

Governors will carry out these visits on a friendly and informal basis as a“critical friend” (i.e.not as a 'formal inspection'), to consider the patient and staff experiences in the area. To achieve this, governors will be allocated to specific wards / departments so as to become well known by the staff there,enabling them to talk freely about any concerns or issues which they might have, knowing that anything learnt during visits will be kept anonymous and with the primary purpose of enabling improvements to be made in the overall patient and staff experience where required.

  1. REQUIREMENTS

Governors wishing to undertake such visitsshould comply with the following:

i) Have undergone the relevant Employment checks, including Disclosure and Barring Servicecheck before undertaking any visits.

ii) Have attended an Induction Programme on various aspects of ward visiting and ward etiquette, including Infection Prevention & Control and Safequarding, to ensure Trust Policies are adhered to and Governors understand how these apply during a visit.

iii)Ensure that they maintainPatient/Staff Confidentiality, and that they respectPrivacy and Dignity.

iv) Ensure thatthe smooth running of the ward/department is not affected by their presence.

v)Check with Nursing and Patient Services Director's Office (Helen Lamont's PA on 0191 223 1512)prior to a planned visit that there are no other formal visits or auditsarranged for the same time. This will prevent wasted journeys for the governor involved and help to minimise disruption to wards/departments.

vi)Wards/Departments may be informed in advance of the name of the Governor who will visit them but not when.

vii) Any Governor (whether or not a member of the Quality of Patient Experience group) is welcome to join these visits, providedthey have undertaken the required training.

  1. CONDUCT OF VISITS

i)Governors must wear and display their Trust Photo ID badge when attending for any visit.

ii)On arrival they must make their presence known to the Nurse in Charge of the Ward. This is to check that their visit will not interfere with any other activities taking place.

iii)Dress and behaviour should be appropriate to the hospital environment. Guidance may be found in the Governors’ Code of Conduct and the Trust Dress and Appearance Policy.

iv)The Governor should check with the Nurse in charge if there are any patients who should not be visited, e.g. for reasons of infection control.

v) An important part of any visit is to observe what is going on and to note any areas of concern if it affects the care of patients. If the Governor perceives a problem the attention of the Nursein charge should be drawn to this problem.

vi)Governors will be aware of the need for safeguarding of vulnerable patients and of themselves. The Governor should only visit a patient in a single cubicle when accompanied and should not draw the curtains around a bed when visiting a patient in a bay.

vii)With the above exceptions Governorsare free to talk with any patients or relatives, provided this is with their agreement. They should introduce themselves to patients / carers and explain the purpose of their visits. These discussions should be used to obtain views about the patient's experiences and on any other matters they may wish to raise. The confidentiality of any information learnt should be respected and only non-identifiable information should be included in any report.

viii)The Governor is free to talk to any member of staff who is agreeable, provided this does not interfere with the conduct of their duties - again they should introduce themselves and explain the purpose of their visit.

ix)When talking to members of staff the Governor should respect the confidentiality of anything told to them. Information should only be divulged to other staff with that individual’s permission. Where necessary and appropriate (and if requested by the member of staff), information may be divulged on an anonymous basis.

x)Following the visit a report should be written detailing the findings and observations. If there are facts which require checking (to avoid any error or misunderstanding of what has been observed) this should be done by contacting the Ward Sister / Charge Nursebefore submitting the report. The final report should be forwarded to the Chairman of the QPE group for onward transmission as agreed. If there are any aspects of the report which should not be forwarded this must be clearly identified for the attention of the Chairman. Please refer to the flowchart (attached) for the detailed process.

13thMarch 2013

Revised November 2015