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Provider registration
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* Please confirm the name of
your organisation 1. Enter all or part of your organisation name and
click search. 2. In the retrieved list, click select next to your
organisation name. 3. Click the continue button
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Heart of
England NHS Foundation Trust - RR1
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Application and declaration of compliance for registration
as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk.
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance. These are available on our website at
www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. If you need more space to answer any questions
on this form, please complete the extra information text box at the end of
the section 2.
While considering your application the Care Quality
Commission is entitled to ask for further information and may arrange a
site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
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Title
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Applicant's First Name
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Last Name
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Mark
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Goldman
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Who is the
applicant?
This declaration must be signed by the applicant or by an
individual duly authorised to sign on behalf of the organisation.
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* []
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by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
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Section 1 - Service Provider details
What is the service provider?
This is the legal entity or person(s) applying to register
to provide the regulated activities. If you are an organisation it is the
name of the company or trust.
Details of the service provider, including email address
and main website (if applicable) will appear in the register that we are
legally required to keep and make available to the public. The email
address we require in this section is the general email address of the
organisation, for example queries@nhstrust.org.uk. This should not be a
personal email address unless it is this persons role to answer/redirect
general queries from members of the public
1.0 Details of the Applicant
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* Name of Service Provider
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Heart of
England NHS Foundation Trust
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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Business wide Email (if
applicable)
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Website
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www.heartofengland.nhs.uk
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* Main Business Telephone
(including extension)
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0121 424 2000
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Business Fax
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0121 424 2200
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Note: This address will be printed on the registration
certificate and published on the internet as the provider details
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* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
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[] Treatment
of disease, disorder or injury
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[] Surgical
procedures
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[]
Diagnostic and screening procedures
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[] Maternity
and midwifery services
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[]
Termination of pregnancies
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[] Services
in slimming clinics
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[] Family
planning services
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Treatment of disease, disorder or
injury
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Surgical procedures
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Diagnostic and screening procedures
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Maternity and midwifery services
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Termination of pregnancies
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Services in slimming clinics
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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01214240329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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1.1 Details of the nominated individual
What is a Nominated Individual?
Each organisation applying for registration must nominate
an individual to act as main point of contact for the CQC. They must be a
director, manager or secretary of the organisation with responsibility for
supervising the management of the regulated activity. It may be that you
will want to appoint one nominated individual to cover one, several or all
the regulated activities you provide. However, you must consider the need
for that individual to fulfil the responsibility of supervising the
management of the regulated activity.
The address of the nominated individual/s is their
business address and contact telephone number. We also need the nominated
individuals business email address for contact purposes
Regulated Activity: Family planning services
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* Job title in Organisation
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Chief
Executive
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Nominated individual
business email address
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Mark.Goldman@heartofengland.nhs.uk
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* Nominated Individual
Business telephone (including extension)
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0121 424 0329
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Nominated Individual Business
mobile
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Nominated Individual Business
fax
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Section 2 - Other Information
What are the Invoice and financial contact details needed
for?
There are no fees for registration with the Commission as
you are already registered with us under the Health Care Associated
Infections Regulations. However there will be annual fees, and we need to
know who and where to send invoice and financial information. Please
provide us with contact details of the appropriate person within the trust
to contact about this and the invoice address.
2.0 Invoice and financial contact details
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* Contact First name
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Adrian
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* Job title in Organisation
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Director of
Finance
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* Address line 1
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Heartlands
Hospital
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Address line 2
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Bordesley
Green East
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* Business Wide Email
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Adrian.Stokes@heartofengland.nhs.uk
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* Business telephone
(including extension)
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0121 424 0814
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Section 2.1 - Statement of Purpose
All service providers (please see question 1.0 for
definition of service provider) including NHS Trusts, are required by law
to have a Statement of Purpose for each of the regulated activities they
are registered for.
The aim of the Statement of Purpose is to provide
information about:
- what you want to achieve in carrying out your regulated
activity.
- the services you provide for the purpose of carrying out
your regulated activity, and the locations from which you provide them.
This information should be to a level of detail that enables us to have a
good understanding about the specific nature of your services. For example,
if you are registered for 'surgical procedures' your statement of purpose
should define exactly what type of surgery this is, such as cardiac or
neurosurgery, and whether this is for children as well as adults.
The Statement of Purpose must include the information set
out in Schedule 3 of The Health and Social Care Act 2008 (Miscellaneous
Provisions) Regulations 2010. We will require you to send us your Statement
of Purpose once you are registered with us, or during our assessment of
your application, if we need further clarity about the types of services
you provide. You must notify us if you make any changes to your Statement
of Purpose
Section 2.2 - Information about Nominated Individuals
You are required by law either to supply this information
(if the Commission requests it) or to have it available for us to see if we
so wish. We are not asking you to submit this information now, but only to
confirm that you have it available and that it is satisfactory. We may ask
to see it in the future.
An enhanced Criminal Records Bureau check (Including
information relevant to
vulnerable children or adults) must be available. In order
to be considered as
satisfactory information this CRB must be less than one
year old.
Evidence of proof of identity could be either a copy of
your birth certificate or passport.
Evidence of satisfactory conduct in relation to previous
employment could be
satisfactory references.
Documentary evidence of relevant qualifications could be
certificates or other suitable
evidence of your relevant professional qualifications.
A full employment history together with satisfactory
written explanation for gaps in
employment could be provided by a Curriculum Vitae.
*Please confirm that you have the
following information available for the Nominated Individual/s applying for
registration and that such full and satisfactory information is available
if required by CQC.
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* Enhanced CRB ( including information
relevant to Vulnerable adults or children)
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* Proof of identity including a recent
photograph
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* Satisfactory evidence of conduct in
relevant previous employment where such employment was concerned with the
provision of services relating to a) health or social care; and/or b)
children or vulnerable adults
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* where a person has previously worked
in a position whose duties involved work with vulnerable adults or
children, verification so far as is reasonably practical of the reason
why the position ended
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* Documentary evidence of any relevant
qualification
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* A full employment history together
with a satisfactory written explanation of any gaps in employment
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* Satisfactory information about any
physical or mental conditions which are relevant to the person's ability
to carry on, manage or work for the purposes of, the regulated activity
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* 2.3 Respecting and
involving people who use services *How do you ensure the views and
experiences of people who use services are listened to and acted upon
when running your service/s? - How have the views and experiences of
people who use services, their carers and representatives influenced your
service priorities and plans?(Max 2000 characters)
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In recent years Urology,
Critical Care and Vascular surgery have presented to patient groups their
plans for significant changes in service. Patient and carer views,
experiences, questions, queries and concerns were taken into
consideration before plans were finalised. More recently the pre-event
with key stakeholders around maternity services at Solihull Hospital
further demonstrates the Trust's commitment to genuine engagement with
the public. Senior managers and clinicians are regularly invited to
attend local committee forums where they have the opportunity to speak
with and present plans to local residents as well as taking on board
views and experiences from those present. In addition, HEFT has a
membership database of 100,000 local residents who are invited to attend
topical seminars, give their views and opinions on new services and
developments. Together with this, an established network of user groups provides
service leads with the opportunity to ask patients and carers for input.
For example, the Disability Advisory Group (DAG) works closely with the
Trust to assess compliance with DDA regulations including assessing
obstacles to access and enabling the organisation to make reasonable
adjustments to overcome these physical barriers in a timely manner. DAG
was also influential in the implementation of disability awareness
training which was successfully delivered to clinical teams. The Ethnic
Minority Advisory Group has influenced the recruitment of a Muslim chef
and the building of a brand new multi-faith centre at Heartlands
Hospital. This group has now developed to include emerging immigrant
communities and ensure their views are incorporated as part of the
Trust's service priorities and plans. The Good Hope Patient/Carer
Advisory Group has received presentations from many service leads. Their
comments have helped influence projects such as the new uniform policy.
Our Consultative Council is an over arching independently led Trust user
group.
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* - How have their views and
experiences influenced how you deliver the services (across the range of
regulated activities applying to register?)(Max 2000 characters)
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The efficient operational
structure at HEFT supports the implementation of service-specific
feedback exercises with patients. Over 50 of these have been completed in
just the last 12 months and the process involves the Patient & Public
Engagement (PPE) team recommending a methodology specific to the make up
of the patient population. One example is Cystic Fibrosis. Here, the
patient group is young, technically aware but often isolated for extended
periods following admission. The PPE team, in conjunction with clinical
colleagues, designed an electronic patient diary which over 25 patient
completed during the study period. Feedback received from these patients
including feelings of isolation and loneliness has since led to the
purchase of laptops enabling patients in respiratory to stay connected
and entertained during their stay. Self completion surveys designed
specifically for other respiratory patients has also helped the Trust
pull together a comprehensive feedback report on views and experiences of
services whilst enabling the Respiratory Medicine Directorate to act
quickly and appropriately. The ward is now displaying 'You said, we did .
. .' style posters in clinical areas as part of an extended trial before
the PPE team plans further displays in other parts of the organisation.
Currently the PPE team is also conducting speciality specific studies in
Cardiology, Colorectal surgery, Acute Medicine and a new Outpatient
clinic located in a local community Boots clinic. This Outpatient clinic
is being compared with the current in-house service to influence the
provision of services moving forward.
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* - What is the provider
doing to increase the influence people have on planning or delivery of
the services?(Max 2000 characters)
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As an example, the Good Hope
User Group has spent the last 6 - 12 months meeting senior
representatives from the Trust in order to gain a better understanding of
the current delivery and plans around services. Most recently the group
was involved in the introduction of new staff uniforms; having a direct
influence on the design and style of these garments. Positive feedback
means plans are now underway to set up new user group representation for
all 3 main hospital sites. Whilst the format of the Solihull User Group
will be similar to Good Hope the diversity of the Heartlands community
means the user group will initially comprise a series of timely visits to
community groups to talk about hospital services and obtain patient and
public feedback which it is believed will provide enriching feedback
relevant to specific communities. It will also help capture the views of
those who may not usually volunteer their views. Attendees from the
community will also be asked whether they would like to be part of a more
permanent Heartlands user group at this initial meeting stage. The Trust
has a history of visiting community locations to obtain public feedback
and the new user group structure will allow a formal mechanism to feed
through the Consultative Healthcare Council and into the Trust's
Committee Structure. In the last 12 months a visit to the local Asian
Elders Association highlighted a perception in the community that the
workforce was not representative of the local community and that people
in the community were unsure how to obtain employment with the
organisation. As a direct result, the Trust's Human Resources team
visited the centre to obtain views of how this could be improved and the
Association was given information about the twice weekly 'Job Shop' . This
is a drop in service where members of the public are assisted with
completing electronic application forms thus enabling association members
to take word of this service out to their community.
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* 2.4 Equality, diversity and
human rights*How do you ensure people's equality, diversity and human
rights are actively promoted in your services? - How do you ensure that
the promotion of equality, diversity and human rights influence your
service priorities and plans?(Max 2000 characters)
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The Equality and Diversity
agenda is lead through the Equality and Diversity Department. This team
undertakes the planning and implementation of it's work through various
Trust structures. There are a range of strategies and action plans aimed
at influencing services provided to patients as well as the priorities
for the Trust, all of which are outlined in legislative and Department of
Health directives. The governance for the Equality and Diversity function
is delivered mainly through the Diversity Steering Group; which
undertakes corporate and operational level functions, to ensure the
agenda is communicated and implemented with all levels of staff across
the Trust. The Equality and Diversity agenda and priorities are also
addressed through other strategic and operational committee structures in
the Trust e.g. Governance and Risk Committee, Equality in Employment
Group, Nursing and Midwifery Standards/Quality Sub-group, the Governors
Consultative Council and Trust user/service advisory groups.
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* - How does the promotion of
equality, diversity and human rights influence how you deliver services
across the range of regulated activities you are applying to
register?(Max 2000 characters)
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The promotion of Equality and
Diversity and Human Rights is currently influenced through the mechanisms
described above; as well as the Terms of Reference and the activities
undertaken by the Diversity Steering Group; HEFT Diversity Staff Network
and the E&D Champions. These include external/internal drivers e.g.
Equality legislation, code of practice, NHS directives; in areas such
as:- Disability, Race, Gender, Age, Sexual Orientation, Religion/Belief,
Human Rights; as well as local priorities in relation to NSF requirements
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* - What are you doing to
increase the influence of equality, diversity and human rights issues on
the planning and delivery of the services?(Max 2000 characters)
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The Equality and Diversity
Department has developed and continues to deliver Equality and Diversity
training e.g. Trust Corporate Induction, local induction programmes and
Equality Impact Assessment Training. This aims to influence equal access
for all, in the planning, development and delivery of services for
patients and staff. This is supported by additional training which has
been commissioned, developed, delivered and evaluated to ensure that
staff have the knowledge, skills and competencies to address issues
related to patient care and meeting their individual needs, in areas such
as:- Disability, Race, Gender, Age, Sexual Orientation, Religion/Belief,
Human Rights. The training includes:- Human Rights, Disability Equality
and Customised E&D sessions [which include Cultural Awareness,
Managing Diversity, Caring for the Muslim Patient. The training outlined
above enables staff to plan, develop and deliver services which meet the
needs of all patients and deals with important issues such as risk
management, informed consent and vulnerable adults / children. The
E&D Department has driven the collation, publication and use of
Equality data to influence further development, planning and
reconfiguration of services in order to meet the individual needs of patients.
All E&D training registration forms are submitted to HCDU [Healthcare
Careers Development Unit]. The three main areas of training [Equality
Impact Assessment, Disability Equality and Human Rights]
dates/times/venues are posted on the E&D webpage and also include
synopsis of this training. Evidence is also submitted, when required, to
the Trust's "Sharepoint", for the purpose of internal/external
audits. In addition; this information is posted regularly on the Daily
Communications Bulletin e-mail.
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2.5 Extra Information Please
complete this box if there is any additional information you wish to give
us relating to this application: (Max 2000 characters)
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Further information relating to
stakeholder engagement: Representatives from the Trust's volunteer
service also attended to give information and successfully recruited
several volunteers this way. Other routine feedback mechanisms in place
include sending out 200 patient surveys at random to recently discharged
patients. The questions are based on the national inpatient survey which
provides the Trust with a regular means of monitoring the organisations'
performance against the national survey. The recently launched
non-clinical 'Back-to-the Floor' program is an innovative way of
capturing feedback from the bedside and delivering this straight to
service leads and the Trust Board. Over 50 Non clinical manager have been
successfully recruited to the program and each is assigned a ward on
which they conduct 15 patient surveys each month on electronic
touch-screen devices. The data is 'real time' thus enabling the
organisation to monitor itself using relevant data, as opposed to
national surveys which tend to be produced months in arrears and is not
specific to particular wards.
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Location section
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Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Ashfurlong
Medical Centre
|
|
* Address line 1
|
233 Tamworth
Rd
|
|
* Town/city
|
Sutton
Coldfield
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Ashfurlong Medical Centre
NHS site code: RR103
Address line 1: 233 Tamworth Rd
Address line 2:
Town/city: Sutton Coldfield
County: West Midlands
Postcode: B75 6DX
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both children
and adults, with responsible officers and timescales identified for
completion. These action plans and future compliance will be monitored
via the respective Safeguarding Committees - both of which are chaired by
the Chief Nurse. It is anticipated that the two action plans will be
merged in the near future - to streamline the actions and ensure greater
consistency across the whole safeguarding agenda. To support this, the
Trust is also developing options for a combined Safeguarding Unit. A
Senior Nurse for Safeguarding Adults has recently been appointed to lead
this agenda and the Trust will shortly be advertising nationally for a
Nurse Consultant in Safeguarding Children. Both of these posts are new
and reflect further investment in the Safeguarding Agenda by the Board.
The Lead Officers for Safeguarding Children and Adults together with the
Executive Lead (Chief Nurse) sit on the Trust's Governance & Risk
Committee where they report on safeguarding issues and compliance. The
Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys.This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Diagnostic and screening procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non compliance you are required to
complete an action plan telling us what measures you will take to be
compliant with the Registration Regulations for each regulated activity.
The Guidance about Compliance describes what compliance with the
Regulations looks like and you should use the guidance to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse, please
explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Birmingham
Chest Clinic
|
|
* Address line 1
|
151 Great
Charles Street
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 1950
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
[]
Diagnostic and screening procedures
|
|
[] Family
planning services
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of service
that best describes the service you provide (this should reflect those
you identify in your statement of purpose). You can choose more than one
service type. For example you may provide a care home and a domiciliary
care agency, or if you are an acute hospital you may also provide a
supporting diagnostic imaging service. For each of the service types that
you choose, please state the regulated activities you provide at that
location.
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Birmingham Chest Clinic
NHS site code: RR130
Address line 1: 151 Great Charles Street
Address line 2: Queensway
Town/city: Birmingham
County: West Midlands
Postcode: B3 3HX
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Diagnostic and screening procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Diagnostic and screening procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Family planning services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Family planning services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Castle Vale
Renal Unit
|
|
* Address line 1
|
Unit 8-11
|
|
Address line 2
|
Castle Vale
Industrial Estate
|
|
* Town/city
|
Sutton
Coldfield
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Castle Vale Renal Unit
NHS site code: RR131
Address line 1: Unit 8-11
Address line 2: Castle Vale Industrial Estate
Town/city: Sutton Coldfield
County: West Midlands
Postcode: B76 1AL
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Good Hope
Hospital
|
|
* Address line 1
|
Rectory Road
|
|
* Town/city
|
Sutton
Coldfield
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
[] Surgical
procedures
|
|
[]
Diagnostic and screening procedures
|
|
[] Maternity
and midwifery services
|
|
[]
Termination of pregnancies
|
|
[] Family
planning services
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
[] Acute
Services
|
|
[] Community
healthcare service
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Good Hope Hospital
NHS site code: RQ305
Address line 1: Rectory Road
Address line 2:
Town/city: Sutton Coldfield
County: West Midlands
Postcode: B75 7RR
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Surgical procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Surgical procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Diagnostic and screening procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Diagnostic and screening procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Maternity and midwifery services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Maternity and midwifery services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Termination of pregnancies
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Termination or pregnancies
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 10: Assessing and monitoring the quality of
service provision, please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive training
programme and revised Level 1, 2 and 3 programmes are currently being
rolled out across the Trust to all staff. The new Regulation, relating to
safeguarding in general - both children and adults, and the additional
detailed outcomes for this Regulation, have required the Trust to further
review its processes and outcomes across both the children's and adults
safeguarding agendas, and some gaps have been identified in the areas
relating to Safeguarding Adults: o Policies and processes - the Safeguarding
Adults policies will need to be updated to reflect new guidance -
particularly in relation to the Mental Health Act and Deprivation of
Liberties (DOLS). o Monitoring systems need to be developed and
implemented to ensure that we are actively monitoring, reviewing,
improving and learning lessons from our safeguarding processes in order
to ensure that quality and safe outcomes are being delivered for our
staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Family planning services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Family planning services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 10: Assessing and monitoring the quality of
service provision, please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Heartlands
Hospital
|
|
* Address line 1
|
Bordesley
Green East
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
[] Surgical
procedures
|
|
[]
Diagnostic and screening procedures
|
|
[] Maternity
and midwifery services
|
|
[]
Termination of pregnancies
|
|
[] Services
in slimming clinics
|
|
[] Family
planning services
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
[] Acute
Services
|
|
[] Community
healthcare service
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Heartlands Hospital
NHS site code: RR101
Address line 1: Bordesley Green East
Address line 2:
Town/city: Birmingham
County: West Midlands
Postcode: B9 5SS
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 10: Assessing and monitoring the quality of
service provision, please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys . This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Surgical procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Surgical procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Diagnostic and screening procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Diagnostic and screening procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Maternity and midwifery services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Maternity and midwifery services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Termination of pregnancies
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Termination or pregnancies
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together with
the Executive Lead (Chief Nurse) sit on the Trust's Governance & Risk
Committee where they report on safeguarding issues and compliance. The
Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Services in slimming clinics
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Services in slimming clinics
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Family planning services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Family planning services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Runcorn Road
Dialysis Unit
|
|
* Address line 1
|
36 Runcorn
Road
|
|
Address line 2
|
Balsall Heath
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Runcorn Road Dialysis Unit
NHS site code: RR1XX
Address line 1: 36 Runcorn Road
Address line 2: Balsall Heath
Town/city: Birmingham
County: West Midlands
Postcode: B12 8RQ
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Location section
|
Application and declaration of
compliance for registration as a health and adult social care provider.
Applications under section 11 of the Health and Social
Care Act 2008
This application and declaration of compliance form is for
registration with the Care Quality Commission. Registration entitles you to
provide applicable regulated activities associated with health and social
care. The complete list of The Health and Social Care Act 2008 (Regulated
Activities) Regulations 2009 can be found on our website at www.cqc.org.uk
It is an offence under section 10 of the Health and Social
Care Act 2008 to carry out a regulated activity without registering with
the Care Quality Commission. You could be prosecuted, and it could lead to
your application being refused.
You should only use this form if you are an NHS provider
currently registered for Health Care Associated Infection with the
Commission. It is not for use by healthcare providers who are registering
for the first time.
When completing the form you should also refer to the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009 and
the guidance about compliance.
These are available on our website at www.cqc.org.uk
You must complete every field that is mandatory (marked
with an asterisk), other fields are optional but if you have this
information available please provide it. We will reject an incomplete
application and return it. The
Care Quality Commission is entitled to ask for more information while considering
your application or during a site visit.
Please ensure that your completed application and
declaration form does not contain any confidential personal information
about patients or staff.
Statement on Data Protection Act 1998
The information you have provided in this form and any
other information you submit in support of your application will be used by
the Commission for the purposes of processing your application for
registration, including fact verification, and matters connected with the
Commission's statutory functions. The Commission may also share your
information with third parties for the purposes of regulatory activity, law
enforcement or any other purpose permitted by law.
The Commission will publish information on the Commissions
website www.cqc.org.uk to enable the public to find and compare care
services in their local area. The Commission may also be required to
disclose your information pursuant to a request under access to information
legislation, such as the Freedom of Information Act 2000.
Your information will be stored
securely and held for the periods set out in the Commission's retention and
disposal schedule.
|
Title
|
Applicant's First Name
|
Last Name
|
|
|
Mark
|
Goldman
|
|
* []
|
by clicking on this checkbox,
you indicate your agreement that the information provided will be used as
stated. If you do not agree then please contact the National Contact
Centre on 03000 616161
|
Section 3 - Regulated Activities and Locations
Please detail which regulated activities you undertake in
your location for each service type.
What is a location?
A location is the place where regulated activities are
provided and where a type of service is carried on. For example, a location
could be each hospital run by the same NHS trust or each care home run by
the same organisation. A location can cover an area - but it is the 'main
address' from which the regulated activity is carried on, or carried on
from (such as a hospital or domiciliary agency branch) that we expect to
see in applications for registration. The term location is important
because providers declare compliance against each regulated activity at
each location.
|
* Name of location
|
Solihull
Hospital
|
|
* Address line 1
|
Lode Lane
|
|
* Business Wide Email
|
catherine.williams@heartofengland.nhs.uk
|
|
Website
|
www.heartofengland.nhs.uk
|
|
* Business telephone
(including extension)
|
0121 424 2000
|
Please select as many of the following options as provided
by your location.
|
* Regulated Activities What is a
Regulated Activity? Regulations set out the activities that trigger the
need for you to register. The regulated activities are described in the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2009.
If any of these activities are carried out, the providers of those
activities must register with the Care Quality Commission.
|
|
[] Treatment
of disease, disorder or injury
|
|
[] Surgical
procedures
|
|
[]
Diagnostic and screening procedures
|
|
[] Maternity
and midwifery services
|
|
[]
Termination of pregnancies
|
|
[] Family
planning services
|
|
* Service Type What is a service type?
This section sets out the range of service type listings available and
replicates the service types in the guidance about compliance. See the
Guidance about Compliance for the full list. Please choose the types of
service that best describes the service you provide (this should reflect
those you identify in your statement of purpose). You can choose more
than one service type. For example you may provide a care home and a
domiciliary care agency, or if you are an acute hospital you may also
provide a supporting diagnostic imaging service. For each of the service
types that you choose, please state the regulated activities you provide
at that location.
|
|
[] Acute
Services
|
|
[] Community
healthcare service
|
|
* Service User Band(Which people do
you provide services to) What is a service user band? Describe the needs
of the people who use your service. For example do you offer a service
for people with mental health needs, dementia, older people, children
(under the age of 18 years old) or people with learning or physical
disability? You will need to ensure that these needs are the same as
those listed in your statement of purpose.
|
Section 4 Declaration of compliance
Please complete this section for each location in which
you carry out regulated activities and continue in the free text box at the
end of the declaration if necessary. Please refer to the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2009 for the legal
requirements
The guidance about compliance for providers illustrates
how each of the regulations may be reliably met. Providers may decide on
alternative approaches but should be prepared to justify and evidence to
the Care Quality Commission how the chosen approach is equally or more
effective in ensuring the regulations are met.
This form is asking you to declare whether you are fully
compliant or non compliant with the Registration Regulations relevant to
the regulated activities you provide. A provider who will be compliant with
the registration regulations will meet the outcomes for people who use
services as set out in the guidance about compliance. A provider who is
non-compliant has not met elements of the registration regulations as
described by the outcome statements in the guidance about compliance.
Evidence to support the declaration must be available on request. You must
complete a declaration of compliance for each location in which you wish to
carry out regulated activities.
For each of the regulations where you identify you are non
compliant you will need to tell us:
- The ways in which you are non compliant
- What you will do to become compliant
- When you will become compliant
- How you will sustain your level of compliance
4.0 Locations and Regulated
activities
Name of location: Solihull Hospital
NHS site code: RR109
Address line 1: Lode Lane
Address line 2:
Town/city: Solihull
County: West Midlands
Postcode: B91 2JL
The service provider will be compliant on registration, or
at the timescale specified in the action plan, and will continue to be
compliant with the registration regulations for each regulated activity
undertaken at the location. The service provider will notify the commission
of any changes in the status of their compliance.
Regulated Activity: Treatment of disease, disorder or
injury
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Treatment of disease, disorder or injury
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the
implementation of the policies to measure the quality and effectiveness
of outcomes for patients and carers. We are currently identifying good
practice with regards to a Restraint Policy and associated training. This
will result in the development and implementation of a new Restraint
Policy for the Trust - which will be fully supported by a comprehensive
training package for relevant staff. The revised Level 1 training
programme for children's safeguarding is currently being rolled out
across the Trust and in parallel the Level 2 and 3 training is being
developed, ready for rollout. Safeguarding Adults training is currently
being reviewed and in the medium term it is anticipated that the training
will be delivered as a single session on Safeguarding - covering both
Children, Young People and Adults, as part of the Trust mandatory
training programme. The Trust has appointed an experienced facilitator in
Safeguarding Children and Young People to drive forward this agenda. Work
is now underway to identify the most appropriate way of setting up a
'flagging' system - to alert all healthcare professionals in the Trust to
potential safeguarding issues - including DNAs. The nursing team are
working closely with another Trust where this system is already
implemented - particularly to address governance issues relating to the
implementation of such a system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment demonstrated
that there was no systematic and trust-wide approach for the continuous
review and maintenance of nursing staffing levels. Furthermore, this
assessment identified that many areas do not meet recommended levels as
defined by Hurst but that there are also areas of over establishment
across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Surgical procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Surgical procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Diagnostic and screening procedures
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Diagnostic and screening procedures
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Maternity and midwifery services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Maternity and midwifery services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Termination of pregnancies
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Termination or pregnancies
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals.
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill.
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation.
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
Regulated Activity: Family planning services
|
|
Compliant
|
Non Compliant
|
|
Regulation 9: Care and welfare
of service users
|
O
|
O
|
|
Regulation 10: Assessing and
monitoring the quality of service provision
|
O
|
O
|
|
Regulation 11: Safeguarding
service users from abuse
|
O
|
O
|
|
Regulation 12: Cleanliness and
infection control
|
O
|
O
|
|
Regulation 13: Management of
medicines
|
O
|
O
|
|
Regulation 14: Meeting
nutritional needs
|
O
|
O
|
|
Regulation 15: Safety and
suitability of premises
|
O
|
O
|
|
Regulation 16: Safety,
availability and suitability of equipment
|
O
|
O
|
|
Regulation 17: Respecting and
involving service users
|
O
|
O
|
|
Regulation 18: Consent to care
and treatment
|
O
|
O
|
|
Regulation 19: Complaints
|
O
|
O
|
|
Regulation 20: Records
|
O
|
O
|
|
Regulation 21: Requirements
relating to workers
|
O
|
O
|
|
Regulation 22: Staffing
|
O
|
O
|
|
Regulation 23: Supporting
workers
|
O
|
O
|
|
Regulation 24: Cooperating with
other providers
|
O
|
O
|
Family planning services
Section 4 Declaration of compliance
What is a
declaration of compliance?
Where you have declared non
compliance you are required to complete an action plan telling us what
measures you will take to be compliant with the Registration Regulations
for each regulated activity. The Guidance about Compliance describes what
compliance with the Regulations looks like and you should use the guidance
to help you.
|
You have declared you are not
compliant with Regulation 11: Safeguarding service users from abuse,
please explain (max 2000 characters)
|
In October 2009, the Trust
declared non-compliance against Core Standard CO2 'Safeguarding Children
and Young People. This was as a result of an internal review of child
safeguarding arrangements in July 2009 which revealed some gaps in our
existing processes. Following the outcome of that review, an action plan
was put in place by the Trust to address the perceived deficiencies.
Significant progress has been made against the initial plan and most
initiatives are due for completion at the end of March 2010. Specific
attention has been given to the implementation of a comprehensive
training programme and revised Level 1, 2 and 3 programmes are currently
being rolled out across the Trust to all staff. The new Regulation,
relating to safeguarding in general - both children and adults, and the
additional detailed outcomes for this Regulation, have required the Trust
to further review its processes and outcomes across both the children's
and adults safeguarding agendas, and some gaps have been identified in
the areas relating to Safeguarding Adults: o Policies and processes - the
Safeguarding Adults policies will need to be updated to reflect new
guidance - particularly in relation to the Mental Health Act and
Deprivation of Liberties (DOLS). o Monitoring systems need to be
developed and implemented to ensure that we are actively monitoring,
reviewing, improving and learning lessons from our safeguarding processes
in order to ensure that quality and safe outcomes are being delivered for
our staff and patients. o Training - although significant work has been
undertaken in the provision of training, we need to ensure that uptake of
this training is increased and there is a complete rollout of the Level 1
training as well as ensuring that appropriate Level 2 and 3 training
programmes are implemented for both adults and children. o Restraint - a
gap has been identified in the requirement for a more robust Restraint
Policy with associated procedures and training.
|
|
What will you do to become
compliant (Max 2000 characters)
|
Both the Safeguarding Adults
and Safeguarding Children's policies are currently being re-written and
should be ratified by the end of March 2010. Both policies will reflect
new legislation and guidance. The Safeguarding procedures will be
supported by an audit programme which will be developed to monitor the implementation
of the policies to measure the quality and effectiveness of outcomes for
patients and carers. We are currently identifying good practice with
regards to a Restraint Policy and associated training. This will result
in the development and implementation of a new Restraint Policy for the
Trust - which will be fully supported by a comprehensive training package
for relevant staff. The revised Level 1 training programme for children's
safeguarding is currently being rolled out across the Trust and in
parallel the Level 2 and 3 training is being developed, ready for
rollout. Safeguarding Adults training is currently being reviewed and in
the medium term it is anticipated that the training will be delivered as
a single session on Safeguarding - covering both Children, Young People
and Adults, as part of the Trust mandatory training programme. The Trust
has appointed an experienced facilitator in Safeguarding Children and
Young People to drive forward this agenda. Work is now underway to
identify the most appropriate way of setting up a 'flagging' system - to
alert all healthcare professionals in the Trust to potential safeguarding
issues - including DNAs. The nursing team are working closely with
another Trust where this system is already implemented - particularly to
address governance issues relating to the implementation of such a
system.
|
|
When will you do this by?
|
30-09-2010
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
Section 2 above summarises the
high level actions that we have identified to address the perceived gaps
in our current arrangements. There are detailed action plans for both
children and adults, with responsible officers and timescales identified
for completion. These action plans and future compliance will be
monitored via the respective Safeguarding Committees - both of which are
chaired by the Chief Nurse. It is anticipated that the two action plans
will be merged in the near future - to streamline the actions and ensure
greater consistency across the whole safeguarding agenda. To support
this, the Trust is also developing options for a combined Safeguarding
Unit. A Senior Nurse for Safeguarding Adults has recently been appointed
to lead this agenda and the Trust will shortly be advertising nationally
for a Nurse Consultant in Safeguarding Children. Both of these posts are
new and reflect further investment in the Safeguarding Agenda by the
Board. The Lead Officers for Safeguarding Children and Adults together
with the Executive Lead (Chief Nurse) sit on the Trust's Governance &
Risk Committee where they report on safeguarding issues and compliance.
The Trust is an active participant in the Local Safeguarding Boards (both
Adults and Children) and provides evidence of compliance and audit of
practice as and when required.
|
|
You have declared you are not
compliant with Regulation 22: Staffing, please explain (max 2000
characters)
|
The Trust believes that it is
not fully compliant with this outcome. The Trust Chief Nurse commissioned
a Nurse establishment review in June 2009 on all wards across all sites
with the exception of the assessment units and critical care. Prior to
this, the Trust had not had a structured, systematic, trust-wide
approach. These areas along with Maternity, Women's and Children's
Services will be included in phase 2 of the review which will be
undertaken in Spring 2010. The Trust used the 'Hurst model' 2002, which
utilises a 'Nurse per occupied bed' formula approach. This model used
data from 308 hospital wards in the UK. This initial risk assessment
demonstrated that there was no systematic and trust-wide approach for the
continuous review and maintenance of nursing staffing levels.
Furthermore, this assessment identified that many areas do not meet
recommended levels as defined by Hurst but that there are also areas of
over establishment across our 3 hospitals
|
|
What will you do to become
compliant (Max 2000 characters)
|
A further risk assessment has
been conducted of those wards rated red and those green to explore
potential re-distribution of resource. This work is in progress. The
Nursing and HR teams are also working closely to maintain effective swift
recruitment of Nurses and temporary staffing utilisation. An initial
local risk assessment for utilisation of non ward based nurses has been
undertaken and resource redistributed to base wards. Risk assessment is
undertaken when flex capacity is opened to determine safe staffing. The
Group Head Nurses are now working with the Finance and HR teams to
determine the setting of 'Hours per Patient' per day model that is
integral to the E-Rostering system that has a planned roll out start date
of February 2010. A plan of regular review utilising an agreed tool will
be developed. The Chief Nurse is a member of the National Energising for
Excellence project which involves a model of using a patient activity
tool developed by an Acute Trust in Sheffield and our quality metrics. Further
work is now well underway reviewing all non ward based Nursing roles,
there is potential for redistribution of some existing nursing resource
from this initiative. During 2010/11, the nursing directorate will
develop a systematic approach to the continuous review of nurse
establishment across all parts of the organisation. This will result in a
quarterly report to monitor staff levels with quality of care and patient
experience. This will be reported to the Trust's Nursing and Midwifery
Board and to Trust Board
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
A plan of regular review
utilising an agreed tool will be developed. The Chief Nurse is a member
of the National Energising for Excellence project which involves a model
of using patient activity tool developed by an Acute Trust in Sheffield
and our quality metrics. It is envisaged that the ward performance
monitoring schedule that is in development will include establishment
data on a quarterly basis. In addition, the Trust Board monitors monthly
KPIs relating to staffing including staff in post against establishment,
sickness rates, vacancies and recruitment time to hire and temporary
staffing fill
|
|
You have declared you are not
compliant with Regulation 23: Supporting workers, please explain (max
2000 characters)
|
The Trust believes that it is
not fully compliant with this outcome due to a low reported take up of
appraisals for staff in the 2008 and 2009 staff surveys. This is also
reflected in a number of concerns in the Trusts QRP - staff survey
results from 2008 flagged up a number of issues about the take up and
quality of appraisals and development planning. The Trust has already
recognised that the take up and quality of appraisals is a key challenge.
A new appraisal scheme was agreed and rolled out during 2009, early take
up (as evidenced by our local staff survey results) has shown minor
improvement. We believe that a major operational restructure that took
place over summer through to November will have impacted on appraisal
rates. The Trust does not currently have a central recording system for
appraisals and therefore has to rely on the survey outcomes to give an
indication of take up rates.
|
|
What will you do to become
compliant (Max 2000 characters)
|
The Trust Executive Directors
will consider the appraisal roll out plan for 2010 in February. In order
to improve compliance this year, key recommendations are: o Continued
full Executive commitment to drive appraisal roll out. o Further
communication and information sessions will be offered across the Trust.
o Improvements to documentation based on evaluation and feedback to
ensure system is user friendly. o A corporate timeline to conduct
appraisals, starting April with the Executive team and completion by
September. o A move to link incremental pay progression under Agenda for
Change to outcomes from appraisal. This will require consultation and
system changes and is planned for 2011/12. o Continuation of training for
appraisers and appraisees. o Close monitoring of appraisal take up
utilising an ICT system and pulse surveys of appraisees. Number of
appraisals completed will be included in the Board People KPI pack. In
addition to this, the Trust currently has a dedicated project team and
medical lead looking at appraisal for doctors in preparation for
revalidation
|
|
When will you do this by?
|
31-03-2011
|
|
How will you make sure that
you continue to be compliant? (Max 2000 characters)
|
From April 2010 onwards,
measures to ensure on going compliance will include: o An annual timeline
for completion of appraisals o Regular reporting to Trust Board and
Executives as a KPI
|
|
|
Declaration
|
Section 5 Provider Application
declaration
This declaration must be signed by the applicant or by an
individual duly authorised to sign on behalf of the organisation.
Before signing this declaration, you are advised to check
that the regulated activities you have identified in Section 1 - Service Provider,
correspond to those you have identified for each location in Section 3 -
Regulated Activities and Locations
I hereby declare that the information detailed in this
application is true and accurate.
I understand that Section 37 of the Health and Social Care
Act 2008 makes it an offence to knowingly make a statement which is false
or misleading in a material respect in this application, or in any of the
documents submitted with this application. I understand that to knowingly
make a false declaration could render me liable to prosecution and could
lead to the refusal of this application.
I understand that non-compliance with the relevant
legislation could lead to conditions being imposed on my registration. It
may also lead to the refusal of my application or cancellation of
registration if I do not comply once registered.
I have kept a copy for my records of all the documentation
submitted for my application.
In making this application for registration with the Care
Quality Commission, I agree to comply with the Health and Social Care Act
2008 and associated regulations.
From the date I send you this application and until you
make a decision about it, I will let you know about any changes to the
information I have supplied.
I confirm that I am aware of and will comply with the
legislation and associated regulations. I will meet the outcomes in the
Guidance about Compliance and understand that you may take this into
account in decisions relating to my registration.
|
* I agree that the information
contained in this form may be used as conditions of registration
|
|
* Has the Trust Board or equivalent
discussed and agreed the content of the application and declaration (To
view a printable version of the form contents, please click here)
|
|
* []
|
Signed: (In signing the
application form you are declaring that the information contained within
it is true and accurate. Knowingly making a false declaration could
render you liable to prosecution and lead to the refusal of the
application.)
|
|
O
Baroness
|
|
O
Cllr.
|
|
O Dame
|
|
O Dr.
|
|
O Lady
|
|
O Lord
|
|
O Miss
|
|
O Mr.
|
|
O Mrs.
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O Ms.
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O
Professor
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O
Reverend
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O
Rt.Hon.
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O Sir
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O
Sister
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* Job title in Organisation
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