Standards for Better Health – update for Overview & Scrutiny Committee Jacqui Evans Clinical Governance Manager 22 February 2006

2 HCC standards for better health interim (draft) declaration

3 Draft declaration Thank you for your comments Also received favourable comments from the PPI Forum and the SHA Action planning based upon comments in the declaration We have not been chosen for an inspection by the HCC

4 Draft declaration – not met Decontamination (C4c) – Units have centralised during 4/5 February – Further building of office space – Fully operational before end of March 2006 – External validation booked for April 2006 Should be fully compliant by 31 March 2006

5 Draft declaration – insufficient compliance Patient safety notices (C1b) Child protection (C2) Infection control (C4a) Medical devices (C4b) NICE compliance (C5a) Records management (C9) Dignity and respect (C13a) Consent (C13b) Confidentiality (C13c) Patient information (C16) Environment/H&S (C20a) Privacy and confidentiality (C20b) Cleanliness (C21)

6 Interim action plan Leads for each item of insufficient / non compliance Action over last few months to implement action plan Progress reported to Trust Board Assurance Committee Progress reported to SHA Good progress on all items

7 Specific issues Cleanliness (C21) – insufficient assurance Infection control (C4a) – insufficient compliance Discharge arrangements (C6)

8 Specific issues - cleanliness No specific external validation New contract in 2005 Scheduled ‘technical’ audits by contractors Scheduled ‘managerial’ audits by dedicated monitoring officers Comparison of results discussed at penalty group meeting Complaints decreased to 2-3 per month Pre-PEAT assessment (30/1 & 3/2) led by nurses and inc patient representative PEAT (environment rather than cleanliness)

9 Specific issues – infection control Trust Infection Control Committee with DIPC Reporting to the Board (outcomes & actions) IC annual programme (inc. Winning Ways) Range of policies approved by DIPC Care bundles (Saving Lives, 2005) Audits – handwashing, environmental, commodes Range of education opportunities – induction, link programme, doctors Serious outbreaks - C. Difficile (Jan 06) Surveillance (weekly) on C. Diff, MRSA, VRE MRSA (national target) – hand hygiene & IV lines

10 Specific issues – discharge arrangements Range of multi-agency meetings – Discharge facilitators group – Quadrant strategy meetings – Countywide delayed transfer meetings Discharge Policy (Feb 05) – multi-agency Expanded team of discharge co-ordinators Current focus on planning & discharge dates Programme of audits Integrated care pathways - Single assessment process (eSAP) rollout continues

11 Summary Good progress in all areas of insufficient or non compliance End of year position improved Greater understanding of the Standards by the organisation