Healthcare Commission Annual Health Check 2006/07 Presentation to Neighbourhood Services & Children & Young People Scrutiny Committees 3 rd April 2007

Assessment framework 2006/07

Standards for Better Health 2006/07 Compliance with all 24 core standards ‘Shadow’ progress with developmental standards -D1 Patient safety -D2a Clinical & cost effectiveness

Annual Health Check 2005/06 How safe & clean is the organisation? How long will I wait? How good is the care I receive? Will I be treated with dignity & respect? Does the organisation help me to stay healthy? How well is it managed? arecommission.org

Annual Health Check 2005/06 Excellent - Use of resources based on Monitor’s risk rating, dependent on achievement of the financial element of the Trust’s Annual Plan Good - Quality of care based on; -Core standards -New targets -Existing targets -Improvement reviews

Quality of services To be excellent for quality of services, a trust must achieve the highest scores for core standards (fully met), existing national targets (fully met) and new national targets (excellent).

Self assessment process Core standards Review, update & validate evidence for all core standards Compliance with C5a, C10a, C13b Measures in place to meet the Code of Practice for Prevention & Control of Health Care Associated Infections (Hygiene Code) Developmental standards D1 Patient safety D2a Clinical & cost effectiveness (stroke, cancer, heart disease)

Insufficient assurance C5a NICE appraisals & guidance compliant from 10 th February 2006 Clinical Policy Group reviews guidance, identifies appropriate lead clinician who assesses compliance with guidance & develops & monitors an action plan if necessary

Insufficient assurance C13b Appropriate consent Audit of compliance with Trust consent policy carried out & reported to Board of Directors. System to reinforce & monitor training established.

Part year compliance C10a Employment checks compliant from 14 th March 2006 Postgraduate Institute of Medicine & Dentistry (PIMD) could not give assurance that appropriate Criminal Records Bureau Checks (CRB) had been carried out on trainees (Feb 2006) Internal scrutiny showed Trust compliant from 14 th March 2006

Core standards assessment Evidence of compliance to Board of Directors for C5a, C10a & C13b Executive Director leads review & validate evidence, assess risk of non compliance using; -criteria for assessment -prompts -inspection guides -risk matrix

Developmental standards assessment Executive Directors review & assess level of progress using; 7 steps safety assessment Developmental standards toolkit -criteria for assessment -comparative data -sources of data Priorities for improvement Developmental standards action plan

Declaration process Review & quality assurance of evidence Internal audit of selected standards Third party verbatim comments; OSCs, PPIF, Board of Governors, SHA Board of Directors sign off 30 th April -General statement of compliance -Measures in place to meet Hygiene Code -Core standards compliance -Developmental standards progress Submit electronic declaration midday 1 st May Publish declaration & share with 3 rd parties by 18 th May