SCOTTISH PRISON SERVICE
HEALTH CARE STANDARDS
Foreword and Introduction
Foreword
It is our aim to provide health care to the prisoner population of the Scottish Prison Service that is equivalent to that available in the wider community setting and in a manner that is consistent with the standards set by national health professional and advisory bodies, and the The Prisons and Young Offenders Institutions (Scotland) Rules 2006. To achieve this, we have developed and revised health care standards against which our health care services will be measured.
These standards were developed internally and were derived from known best practice in the delivery of healthcare to patients with health conditions in the categories of mental health, addictions and primary care.
We aim to test these standards annually through a process of self-audit, completed by health care management in each local establishment, which is then reported to HQ, with corrective action plans developed to close any gaps in compliance. Health and Care Directorate staff based at SPS headquarters will also conduct a selective secondary assurance process.
This folder has been produced to support the self-audit process described above and to provide all staff with an explanation of the purpose and benefit of the health care standards tool.
It is our intention to keep these standards under regular review and a group has been established to achieve this.
Dr Andrew Fraser
Director of Health and Care
Introduction
These Health Care Standards were developed by a sub-group of the SPS Prison Nurses Forum. The Group reviewed the existing health care standards and developed these further to reflect changing needs in healthcare delivery and up to date healthcare practice. The Standards will be subject to regular review and revision ensuring that the standards reflect the changing needs of our patient population and healthcare and service developments.
This is a working folder divided into sections and contains each of the 13 standards, an evidence template to guide Establishments to the practice, information and documentation which is likely to be required to demonstrate compliance, and the documentation to be used during the auditing process, which are attached as appendices in this folder.
Health Care Standards Review Group
The Review Group is made up by the Health Care Managers from across the SPS and representatives from Health and Care Directorate. In addition to the initial work to develop the standards, the Group will have an ongoing remit to review and revise standards.
In brief the group will meet twice yearly to:
· Review each standard to determine its continued legitimacy;
· Recommend changes to reflect the changing healthcare needs of the prison population and in line with modern healthcare practice in NHS and the wider community;
· Inform and advise the Health and Care Directorate on compliance;
The Nursing Services Manager, on behalf of the group will:
· Produce an Annual Report on healthcare standards compliance for SPS
· Analyse audit reports and action plans prepared by individual establishments;
This Group welcomes and encourages feedback from every member of staff involved in the day-to-day delivery of health care services within our Establishments, and your views and opinions are valued.
If you wish to comment or suggest improvements to the Standards or highlight any issue that you consider has a positive or negative impact on compliance with these Standards, please channel this through the Establishment Health Care Manager/ Clinical Manager in Charge, or direct to the Nursing Services Manager at Headquarters. This will ensure that the Review Group has the opportunity to consider these views at the next planned Review Meeting.
Purpose of Health Care Standards.
The Standards provide four key groups with information on the standards of care that should be available to the prisoner population and enables measurement against predetermined statements to assess compliance. It also incorporates a process to identify gaps in compliance and plan to ensure necessary improvements can be effected within identified timescales.
The four key groups for whom this information is essential are:
1. Governors; provides evidence of measurable outcomes on the delivery of healthcare across all establishments and allows delivery within their own establishment to be benchmarked with the service overall,
2. Healthcare staff; who are given guidance on the expectations the organisation has of them in respect of the standard of care they are required to deliver
3. Prisoners; who are given a framework that demonstrates the level of service they can expect to receive,
4. External partners and stakeholders; who are provided with a guide to the level of care delivered to our patient population
Assurance Process
The Audit mechanism has been designed as a self-assessment process conducted annually by the healthcare managers in each local Establishment. This section details the process and gives an explanation of how it should be applied. Reference is made to the documentation to be used during the audit process, which is included in the final section of this folder.
1. A Baseline Audit and Evidence Template
The baseline audit and evidence template allows for each Standard to be measured against clearly defined statements. The evidence template is a useful guide as to the information or documentation that is likely to be required for the Establishment to demonstrate that it meets compliance with the Standard.
2. Corrective Action Plans
After the local audit has been completed, the Health Care Manager/Clinical Manager in Charge is required to develop a correctional action plan to address any identified gaps in compliance.
All actions identified will be categorised in terms of the level of risk the shortfall presents to the Establishment. Where the shortfall is deemed to be significant, action should be taken immediately to resolve the issue. A demonstrable improvement should be evidenced within four weeks of the audit being completed. Shortfalls presenting lower risk may be resolved over a longer time period, but must be specified in the corrective action plan.
3. Corrective Action Plans Progress Report
To ensure actions are actually put in place to overcome the shortfall from the standard, a progress report will be completed and agreed with the GIC before being submitted to the Nursing Services Manager. This information will be used in part to inform the secondary assurance process.
4. Performance Summary
The performance summary is a process to quickly identify compliance through a simple scoring mechanism against the clearly defined Standard statements.
Yearly Reporting Cycle
Quarter 1 (April to June)
In the first quarter a full self-audit of all standards is to be completed by each Establishment. The Health Care Manager/Clinical Manager in Charge will be responsible for completion. The GIC will be asked to sign off the self-audit and draft corrective action plan and submit to Prisons Directorate. Prisons Directorate will consult with the Health and Care Directorate on the Establishment self-audits. Health and Care Directorate will report to Prisons Directorate an overview of the self-audits highlighting Healthcare Standard compliance and provide a view of the priorities to achieve compliance for non-compliant areas against the draft action plans.
Quarters 2 (July to September) and 3 (October to December)
In the second quarter Prisons Directorate will feed back to Establishments its review of Healthcare Standards and agree detailed corrective action plans for non-compliant areas. Health and Care Directorate will commence its secondary assurance process. There will be scope within the secondary assurance phase to address themes or standards that arise from the self-audit process.
In the second and third quarters, Health and Care Directorate will undertake establishment visits to monitor recovery plans and overall compliance; and complete its secondary assurance programme. The Risk Management Audit Committee will wish to see the process largely complete for its January meeting.
Quarter 4 (January to March)
In the fourth quarter the Health and Care Directorate will submit an annual report with recommendations on Health Care Standards for the following year to Prisons and Partnership and Commissioning Directorates.
The Health Care Standards Review Group will continue to monitor implementation of the new Health Care Standards portfolio and framework throughout the reporting year. It will appraise the adequacy of the standards audit, validity of audit methods, making general and specific comment and will meet formally in February to review and revise the Health Care Standards.
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