JOINT HEALTH SCRUTINY COMMITTEE – 12 APRIL 2006
ITEM -9 Watford and Three Rivers PCT
ACTION PLAN: Standards For Better Health – Trust Declarations 2005 – 2006
Standard / C1a Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents.Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / The Board was insufficiently assured that that the numbers of delayed transfer of care patients was acceptable. / Mary Jamal / There is now a system of weekly (DTC) meetings across all Intermediate Care Services to monitor and move patients through the system as a multidisciplinary approach which includes Adult Care Services.
Clear lines of accountability, roles and responsibilities have been developed with Service Leads.
Working with WHHT discharge team to develop predictive forecasting to demonstrate where capacity and demand is within primary care intermediate care services.
Actions Planned or Taken / The Discharge Planning Team work to ensure that all patients who are suitable are transferred to appropriate intermediate care settings. This work has resulted in a reduction from 24/5 patients/week having delayed transfers of care to 9 per week. This work has resulted in a significant reduction in Category C delays
The Team will continue to work to maintain, and improve where possible, delayed transfers of care.
Achieved by 31.03.06
Standard / C3 Healthcare organisations protect patients by following National Institute for Clinical Excellence (NICE) interventional procedures guidance.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 1/04/2005
Draft Declaration / Responsible (inc a Director) / Final Declaration
Description of the Issue / The Interventional Procedures NICE Guidance was discussed in Dec 03 & Feb 04 at Clinical Governance committee meetings. Then referred to Herts-wide Public Health group. The PCT does not have a written policy related to new interventional procedures. HSC2003/011 relates more to acute hospital trusts. In the event of a new procedure, either NICE supported or not, the Clinical
Effectiveness Committee would provide the process through which agreement was reached with all relevant parties and approve and ratify all new interventions undertaken by the PCT. The committee(s), appropriate to the interventional procedure is in question, would consider requests from clinical
professionals. Decisions made would be communicated to the appropriate
clinical professionals through the communication cascade system, and
attendance at the committees. The PCT has never had an instance where NICE guidance does not exist, but would follow best practice in the event of an instance. The PCT achieved CNST Level 1a in September 2004. / Toni Leggate
Sheila Borkett-Jones
Ginny Snaith
Joe Kearney / Following further discussion in the Joint Clinical Effectiveness Committee (10.01.06) the PCT is now assured that Core Standard C3 has been met since 01.04.05 as the previous decision, concerning the PCT need for a written policy in addition to the HSC2003/011 being unnecessary, has been upheld
Actions Planned or Taken / To discuss the need for a policy or procedure at Clinical Effectiveness
Committee including a designated committee that must be notified of requests from, clinical professionals wishing to undertake a new interventional procedure. To check if the Herts-wide Public Health group has discussed the need of PCTs.
Achieved since 01.04.05
Standard / C4a Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA).
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / The Trust induction programme is currently being reviewed and will include infection control training for all staff, there will then be additional input for clinical staff. Local induction (clinical staff) does include infection control. / Tracey Cooper Julie Juliff
Louise Podmore
Ginny Snaith / The new induction programme will be launched in 2006. This will include mandatory training on infection control for all staff. In the meantime a programme of training has started for currently employed non-clinical staff. All currently available training for clinical staff will continue.
Actions Planned or Taken / A planned review awayday in November 2005 re Induction programme will include Infection Control, which will be included in the new Induction Programme from Jan 06. At that time there will be a review of the last 6 mths inductees to ensure they have completed all aspects of the new programme.
Standard / C4b Healthcare organisations keep patients, staff Insufficient assurance and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / 1. The Herts Equipment Service run training on the medical equipment that is loaned out. All training open to non permanent staff. However there is insufficient evidence that all non-permanent staff receive training for all
medical equipment used by the Trust.
2. There is no PCT-wide Medical Devices group. Requirements are discussed within the relevant service, with Clinical Effectiveness Committee when appropriate and the Medical Equipment Loans, who provide the equipment. / 1. Julie Juliff
Tracey Cooper
Ginny Snaith
2. Toni Leggate
Sheila Borkett-Jones
Ginny Snaith / 1. Equipment training is included in the list of mandatory training – the new programme of mandatory training days will come into effecting 2006 and will include medical devices training.
2. Discussed at CEC 21.02.06. It was decided that at this point in time there is no need for a Medical Devices Group for the PCT. The current arrangements with HPT regarding Medical Devices are undergoing review and the HPT are negotiating a new SLA (with expert providers) to provide advice, support and guidance in the purchase, maintenance, and replacement of medical equipment is expected to be in place for the period April 2006 to March 2009. The PCT will be able to sub-contract to this service.
Actions Planned or Taken / 1. The training team to assess this situation, review current training availability with service leads and ensure that all staff can, and do, receive appropriate training prior to using medical equipment.
2. To discuss the need for a Medical Devices Group at the Clinical
Effectiveness Committee. If required a subgroup will be formed.
Standard / C4d Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / 1. The PCT does not comply with CNST 7.1.6. the Medicines Policy is being written, to be adopted by the relevant Committee.
2. There is insufficient evidence that the PCT ensures that unlicensed medicines activity complies with current guidance.
3. There is insufficient evidence that staff have access to accredited information sources about medicines. / Rasila Shah
Sandra Briant
Joe Kearney / 1.The revised Medicines Policy to CEC April 2006
2. The SLA for the Pharmacy services for West Herts Hospital NHS Trust (WHHT), including a combined WHHT, Herts PCTs and Herts Partnership Trust unlicensed medicines policy, has not progressed as far as was expected in year. Potential changes to service configuration has caused some delay. Should these changes be approved then a full pharmacy review will be undertaken.
3. The Non-medical Practitioner Prescribing Policy will formalise the processes already in place, which include staff continued professional development. In line with this policy the Trust will ensure that prescribers have access to education and training as appropriate to maintain their competencies as laid down by the National Prescribing Authority.
Actions Planned or Taken /
- To finalise the Medicines Policy, to have it ratified and adopted & implemented across the PCT.
- To finalise the SLA for the Pharmacy services for West Herts Hospital NHS Trust (WHHT) and to have a combined WHHT, Herts PCTs and Herts Partnership Trust unlicensed medicines policy.
- To set up systems and a programme to ensure that staff receive timely information and have access to accredited information sources about medicines.
- 1. Will be achieved for 2006-7 declaration.
3. Achieved.
Standard / C4e Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 01/08/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / The PCT has a SLA for Waste Management with the HPT. The Competent Person is the designated lead, the Health & Safety Manager. All waste from Trust premises are collected and destroyed. Registration with the Environment Agency for the safe disposal of Hazardous Waste was actioned July 05. The PCT ensures that it complies with Health and Safety Executive (HSE) guidance, Safe disposal of clinical waste (ISBN 0 7176 24927) & no deficiencies were identified at the HSE inspection March 05. Waste management issues would be
reported through the Adverse Incident Policy and passed to the Board as
appropriate. Arrangements for waste management are reviewed as part of the SLA for Waste Management with HPT. The PCT passed CNST Level 1a in September 04. Waste is not treated on site at any PCT Unit. Treatment is off site. Contract managed by HPT through their SLA. All Units were registered for the Hazardous Waste Regulations in July 05 (DAC) August (W3R). The
treatment of waste at Trust premises is subject to periodic risk assessments. Any incidents should be reported under the Trust Adverse Incident policy. The responsible person who completes and signs the transfer or special consignment
note has had training in legislative requirements associated with the documents. / Bob Aldous Ginny Snaith / Registration with the Environment Agency for the safe disposal of Hazardous Waste was actioned July 2005
Actions Planned or Taken / Registration with the Environment Agency for the safe disposal of Hazardous Waste was actioned July 2005 /
Completed July 2005
Standard / C5a Healthcare organisations ensure that they conform to National Institute for Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care.Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 21/02/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / There is a newly established mechanism for monitoring implementation of NICE guidance. Processes have recently been developed to ensure there are
Implementation plans, which set out clearly defined responsibilities, timelines, actions and the resources required to achieve broad compliance with the guidelines, recommendations. The previous adhoc system will now be robust.
Project groups set up when required. / Vaughan Tayler
Joe Kearney / System established and procedure agreed by CEC February 2006.
Actions Planned or Taken / To establish a robust system to ensure the PCT conforms to NICE technology appraisals, when appropriate, or provides an acceptable rationale for non
compliance. Undertake a programme to 'catch up' with NICE guidance published before current system. / Achieved 21.02.2006
Standard / C5d Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 30/09/2005
Draft Declaration / Responsible / Final Declaration
Description of the Issue / The PCT did not have a policy/strategy for prioritising and conducting clinical
audits. This has been developed, will be agreed and implemented. / Toni Leggate
Ginny Snaith / Clinical Audit Facilitator employed August 2005. Developed a Clinical Audit Strategy and Audit Plan. Agreed strategy and plan through Clinical Effectiveness Committee on 6.09.05. Implement throughout PCT. Strategy and Plan reviewed by the Clinical Effectiveness Committee in Feb 2006
Actions Planned or Taken / Developed a Clinical Audit Strategy and Audit Plan. Agreed strategy and plan through Clinical Effectiveness Committee on 6.09.05. Implement throughout PCT – this has been ongoing since April as part of a continuous cycle. / Achieved September 2005
Standard / C7b Healthcare organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / There is no Counter Fraud Policy but, through the Service Level Agreement
with PSU for the Counter Fraud Service, the PCT ensures that sufficient proactive work is undertaken to detect fraud and corruption. The Director of Integrated Governance is the lead for Counter Fraud issues. In addition the Medicine Management lead work closely with Pharmacists, the Payroll department audits claims, staff claim exact mileage, which is scrutinised by
Service Leads/ line managers. The PCT follows the Counter Fraud and Security Management Service guidelines and have appointed a nominated lead. In addition, the Herts Partnership Trust training course, Relating to People, has been approved as covering the Counter Fraud and Security Management Service Conflict Resolution training. This training is compulsory for Dacorum PCT staff. The Director of integrated Governance is the identified a senior member of staff who is responsible for leading and co-ordinating the work of the local
counter fraud service. The PCT Audit Committee considers Fraud and
Corruption through the internal audit plan reporting process. / Bob Aldous
Ginny Snaith / During the process to prepare the draft policy it was discovered that the PCT had previously adopted the DoH 2002 document. This policy has been updated regarding the PCT Whistle-blowing contact and has been issued for comment.
Ratified bythe Audit Committee in March 06.
To be disseminated & implemented from April 06.
Actions Planned or Taken / Develop a counter fraud policy and disseminate throughout the organisation. / Achieved.
Standard / C7e Healthcare organisations challenge discrimination, promote equality and respect
human rights.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / The PCT complies with current legislation and has submitted the 3 year Race Equality plan to the DoH. The PCT has a Race Equality Scheme. The Board approved the Race Equality Strategy in June 2005. This now includes the Race Equality Scheme There are action plans for Race Equality and the Disability
Discrimination Act, which are regularly updated and reviewed by the Equality Steering Group. The PCT Chair leads on human rights, discrimination and promotion of equality and sits on the Equality Steering Group. Progress in delivering the race equality scheme, and all aspects of equality & diversity, are reported to the PEC & Board and through an annual report. / Ginny Snaith / The Dacorum reviewed Race Equality Scheme has been published on the PCT website.
Actions Planned or Taken / Publish the three yearly review of the race equality scheme. /
Achieved by 31.03.06
Standard / C20a. Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisationStart Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 30/01/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / 1. The PCT has carried out initial environmental risk assessments in 2004 of all sites. However action plans were not produced. There is a rolling schedule of annual Safety and Security Audits in progress.
2. No mandatory use of ID cards.
3. Very limited security re access to some premises. / Bob Aldous
Ginny Snaith / 1.Subsequent to the Draft Declaration it was realised that the reports on the initial environmental risk assessments in 2004 included action plans which are audited annually.
2.Following the Draft Declaration it was realised that Section 2.9 in the Staff Handbook states ”You will be issued with a personalised identity badge, which you must wear at all times when on duty…” The handbooks were distributed to existing staff from summer 2005. All new recruits are provided with the handbook at induction. There is no need for a separate policy.
3. The PCTs trained Local Security Management Specialist can conduct crime reduction surveys in line with the home office guidance “passport to crime reduction” to indicate improvements in security that can be implemented at specific sites. A programme has been started which gives precedence to ‘at risk’ sites.
Actions Planned or Taken / 1. Plan to undertake environmental risk assessments of all PCT premises with Action Plans produced – Dec 2005
2. To discuss and if appropriate produce and implement a policy on ID for all staff.
3. To consider mechanisms to improve security regarding 'open' access to PCT premises. / 1. Already in place by April 2005
2. In place April 2005
3. Achieved by 31.03.06
Standard / C22b Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by ensuring that the local Director of Public Health’s annual report informs their policies and practices.
Start Date of Non-Compliance or Insufficient Assurance / 01/04/2005
End Date of Non-Compliance or Insufficient Assurance (planned or actual) / 31/03/2006
Draft Declaration / Responsible / Final Declaration
Description of the Issue / While the PCT can, in specific areas, demonstrate improvements in health e.g. teenage pregnancy, there is insufficient evidence to show that the PCT takes steps to ensure that service level agreements (SLAs) with provider organisations reflect the conclusions and recommendations of the APHR. / Trudi Southam / The SLAs have Schedule E Quality Standards which will have been informed by the APHR.
Actions Planned or Taken / To ensure that the conclusions and recommendations of the APHR are reflected in service level agreements (SLAs) with all provider organisations for 2006 onwards. /
Achieved by 31.03.06
Updated 16.03.06