1. 1 Replaced star rating system Published annually in October Two elements –Quality of services –Use of Resources Annual health check

2. 2 Use of resources Five components 2005/6-2006/7 –Financial Standing weak/weak –Financial management weak/fair –Financial reporting fair/fair –Internal Control fair/good –Value for Money weak/fair Moderated by External Auditors

3. 3 Quality of services Three elements –Core standards –National targets –Compliance with Hygiene Code

4. 4 Core standards Seven domains Safety Clinical & Cost Effectiveness Governance Patient Focus Accessible & responsible care Care environment & amenities Public health 24 standards 49 components

5. 5 Process Declaration Comment from external bodies Healthcare Commission checking process

6. 6 Trust process Assurance Compliance Unit Performance Assessment Framework Ongoing review Audit Committee

7. 7 Next Steps 14 April 2008Begin submitting declarations 30 April 2008 Final date for submission 16 May 2008Publish declaration October 2008Results published

8. 8 Standard 4a 2006/7 Patient safety is enhanced by the use of health care processes, working practices and systemic activities that prevent or reduce the risk of harm to patients. Health care organisations keep patients, staff and visitors safe by having systems to ensure that the risk of health care acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year-on-year reductions in MRSA 2007/8 The risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleansliness, achieving year on year reductions in MRSA. The healthcare organisation has systems to ensure the risk of healthcare associated infection in accordance with The Health Act 2006 Code of Practice for the Prevention and control of Health Care Associated Infections (DOH 2006) To note: the measurement of the MRSA target is undertaken through the ‘national targets’ component of the annual health check’

9. 9 Excerpt from compliance framework Initiatives in HCAI in SATH in 07/08 Enhancing Senior Management and Trust Board Involvement - Infection control committee now chaired by Chief Executive, monthly reports on HCAI to Trust Board, weekly meetings on HCAI attended by senior staff Strengthening the Infection Control Team by creation of a new ICN post, additional secretarial support and increasing the DIPC time by 2 PAs Implementation of weekly Hand Hygiene audits in all clinical areas using NPSA tool. Using scores as key performance indicator. Alcoholic hand gel available at all bed spaces and signage for hand hygiene being upgraded Implementation of Saving Lives audit programme and use of scores as key performance indicator

10. 10 continued Opening of a cohort ward at PRH to increase isolation capacity particularly for MRSA and C difficile Extension of MRSA screening to include renal dialysis patients, all emergency medical and surgical admissions and elective surgery at PRH (to be extended to RSH when more staff in place in microbiology and cohort isolation facilities ready at RSH) Introduction of Root Cause Analysis for all cases of MRSA bacteraemia with development and monitoring of action plans to address any issues uncovered Introduction of Root Cause Analysis for all deaths in SATH where C difficile is identified as the main or a contributory cause of death Review of the antibiotic policy and introduction of a short antibiotic policy to reduce use of broad spectrum antibiotics which predispose to C difficile or other resistant organisms

11. 11 continued Creation of two new antibiotic pharmacist posts to assist in the audit and control of antibiotic prescribing Review of uniform policy and introduction of “bare below the elbows” policy for all staff including medical staff With RJAH, purchase and installation of a “ Smartcycler” analyser which will allow rapid detection of MRSA by molecular methods Review of central and peripheral lines policies Introduction of Care Plans for patients with MRSA or C difficile infections We have recently launched phase 3 of the CleanYourHands campaign

12. 12 continued Restriction of ward stock of antibiotics to reduce overprescribing Medical Director and consultant microbiologists wrote to all medical staff about restricting use of antibiotics to reduce C difficile infection Introduction of 7 day testing for C difficile Enhancing cleaning through the recruitment of a rapid response team and introduction of chlorine based cleaning products “Deep Clean” programme including comprehensive refurbishment planned on both sites

13. 13 continued 2.3Ongoing Work in Infection Control Education – all staff receive education in Infection Control at induction and Mandatory update Training including medical staff Policy Review - Key Infection Control Policies recently reviewed in line with National guidance including Hand hygiene, Cleaning & Disinfection, Isolation, Gastro-intestinal infections, Clostridium Difficile, Colour Coding for cleaning materials & equipment

14. 14 continued Regular PEAT inspections involving Modern Matrons Continuing Audit programme – including this year compliance with MRSA and C difficile policy and validation of hand hygiene and High Impact Intervention audits by ward staff Routine surveillance – including alert organism surveillance, mandatory surveillance for MRSA bacteraemia, C difficile, VRE bacteraemia and orthopaedic infections

15. 15 PPI Forum response The Trust has introduced Cohort (Infection) Wards at both hospitals. New information boards including infection control information targeting patients and visitors have been placed in key areas. Cleaners’ duties are laid down and discussed regularly to ensure sufficient time is available to achieve the targets. Members of the Forum attended Hand Washing Roadshows for staff at both hospitals. A Forum member was invited to attend an Infection Control training session for the staff.The Forum is still concerned that the Trust has to count MRSA bacteraemia cases which prove positive within 48 hours of admittance. Some of these cases in this Trust have been transferred from another NHS site and this could result in the double counting of cases. Also, the demand to reduce by a fixed percentage applying to all hospitals appears unreasonable. It is easy for a Trust with a high rate of infection to reduce 10% year on year, much more difficult for a Trust starting from a low rate. This appears to penalise the Trusts who were performing well initially

16. 16 Decision Recommend declare compliant against Standard 4a

17. 17 PPI Forum response Standard 4e. The prevention, segregating, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, public and the environment The Patient and Public Involvement Forum still have a member as part of the Patient Environment Action Team. The Forum Member reports that this is a very valuable experience with excellent two way working. The comments made by the Member have been acted upon

18. 18 PPI Forum response Standard 7a Healthcare organisations apply the principles of sound clinical and corporate governance The Forum has an Observer on the Shrewsbury and Telford Hospital Trust Board and reports that the Corporate Risk Register is reported upon regularly at Trust Board meetings

19. 19 PPI Forum response Standard 13 a Staff treat patients, their relatives and carers with dignity and respect The Forum has 2 members on the Trust’s Community Engagement Forum which covers many aspects of the patient’s experience with the Trust. The Forum has set up an Older Persons Working Group which looks at privacy, dignity, respect, attitude, etc. This Group considers there are times when patients deserve more privacy and respect

20. 20 Standard 13a Healthcare Commission will use: NHS staff survey questions on awareness training Healthcare Commission A&E survey questions on dignity and respect Healthcare Commission adult inpatient survey questions on dignity and respect Healthcare Commission young persons patient survey questions on dignity and respect DH Estates and facilities: PEAT – privacy and dignity; staff Calls to Healthcare Commission helpline – coded as abuse to vulnerable adults/attitude and behaviour Healthcare Commission complaints data

21. 21 Trust Evidence Patients/Carers are involved in Induction A Carers Policy is in place July 04 and its revision will be one of the workstreams of the Trust’s Community Engagement Group. Diversity & Equality Policy July 05 Healthcare Commission young persons patient survey – privacy, respect and dignity – score 90% - top 20% of Trusts Healthcare Commission outpatients survey – privacy, respect and dignity – score 93% middle 60% of Trusts Healthcare Commission adult inpatients survey – privacy, respect and dignity score 88% -middle 60% of Trusts Healthcare Commission A&E patients survey – privacy, respect and dignity – score 87% - middle 60% of Trusts Essence of Care sub-groups have been established to look at key elements eg Privacy and Dignity and include Patient Public Involvement Forum Members and Carers NB there was no staff survey question on awareness training PEAT – Good/excellent

22. 22 PPI Forum response Standard C 13b Appropriate consent is obtained when required, for all contact with patients and for the use of confidential patient information The Forum has checked leaflets for the Trust to ensure clarity and ease of comprehension

23. 23 PPI Forum response C14a Healthcare organisations have systems in place to ensures patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services The Trust provided information on the Complaints system to the Community Engagement Forum. This appeared to be very robust.

24. 24 PPI Forum response C15a Healthcare organisations have systems in place to ensure that patients are provided with choice and that it is prepared safely and provides a balanced diet The Infection Control Working Group of the Forum has inspected the kitchens at the hospitals and was impressed by the standard of cleanliness. Talking to patients and staff the choice and quality of the food seems very good

25. 25 PPI Forum response C15a Patients’ individual nutritional, personal and clinical dietary requirements are met, including where necessary help with feeding and access to food 24 hours per day The Forum still has concerns about the protection of meal times from interruptions. Senior members of staff need to ensure that food is consumed and if not why not.

26. 26 Standard 15a Healthcare Commission will use: Healthcare Commission young persons patient survey questions on food rating/access to food and drink DH Estates and Facilities: PEAT – food scores DH Estates and Facilities: ERIC – access to food/meals not eaten Healthcare Commission performance indicator in better hospital food Healthcare Commission complaints data (hotel services – food) Audit Commission: Acute Hospital Portfolio – catering review (2001)

27. 27 Standard 15a Trust Evidence / Assurances PEAT Inspections/Assessments –Excellent/Good Patient Menu Group Food Audit Reports The Food Safety Policy revised December 2007 Food Safety Audits and Inspections by Food Safety Officer and Environmental Officer Training Records (Induction, Statutory and Catering) HACCP – Hazard Analysis Critical Control Points Healthcare Commission young persons patient survey questions on food rating scored 61% (top band) and /access to food and drink 81% (middle concentrates on the significant hazards to food safety. Pre-requisites (Good Catering Practices) for HACCP will be incorporated into the Trust Food Safety Policy

28. 28 Standard 15a The implementation of HACCP is now being developed and implemented at RSH to ensure commonality of standards over both sites. A review of HACCP at PRH will also be undertaken. Implementation- ongoing The Patient Menu Group is addressing the issue of ensuring all standard recipes have been analysed in terms of their nutritional composition.In particular a priority area is that of the high protein high calorie menu for vulnerable patients. Another area which is highlighted is the provision of altered texture menus, and the implementation of national descriptors. The latter is being addressed through Speech and Language Therapy in collaboration with Dietetics. Food safety management system in place – Current HACCP procedures and services are currently under review to explore single site production of patient food

29. 29 PPI Forum response Standard 16 Information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after-care. All aspects of communication with patients are brought to the Community Engagement Forum for information and approval. The Forum has been asked to check leaflets during the year.

30. 30 PPI Forum response Standard17 The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services Forum members were involved in discussing the content of Patient Questionnaires looking at Service Delivery.

31. 31 PPI Forum response C21 Healthcare services are provided in environment which promote effective care and optimise health outcomes by being well-designed and well maintained with cleansliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises The Patient and Public Involvement Forum undertakes regular inspections of both Critical Care and general areas on both the Royal Shrewsbury and Princess Royal Hospital sites. On subsequent inspections almost all the areas of concern to the Forum have been rectified. Where there are still problems, many are in the pipeline to be corrected. Standards of cleanliness are, in general, very impressive.

32. 32 PPI Forum response As a final comment, the Trust has become involved in the Productive Ward Scheme and the Forum considers this displays an innovative attitude to improving the patient experience. Our congratulations to the Trust on taking this action; it will be interesting to observe the results of implementing the Scheme

33. 33 T&W OSC response Core Standard C23 Health care organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the National Service Frameworks and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections.

34. 34 T&W OSC response The PCT has recently approved plans within its 2008-09 budget which will help to address some of the required actions within the NSF. The Stroke Standards are contained within the National Service Framework for Services for Older People – they are Standard 5 within that NSF. The general approach of the NSF covers prevention; immediate care; early & continuing rehabilitation; and long-term support.

35. 35 T&W OSC Actions required were:- That every health system should, in partnership with other agencies and where appropriate: review current arrangements, in primary care and elsewhere to identify those at greatest risk of stroke, and to intervene actively to reduce those risks; and to agree local priorities to improve the rates of identification and effective intervention in stroke review current arrangements, in primary care and elsewhere, for TIA and to agree and implement a local protocol for the rapid referral of patients with TIA who may be at risk of stroke review current hospital services for stroke using the clinical audit methodology developed by the Royal College of Physicians on the basis of this, agree local priorities for action required to establish an integrated stroke service, which is regularly audited with a continuing cycle of improvement

36. 36 T&W OSC response Specifically By April 2004 PCTs will have ensured that: every general practice, using protocols agrees with local specialist services, can identify and treat patients identified as being at risk of a stroke because of high blood pressure, atrial fibrillation or other risk factors every general practice is using a protocol agreed with local specialist services for the rapid referral and management of those with TIA every general practice can identify people who have had a stroke and are treating them according to protocols agreed with local specialist services every general practice has established clinical audit systems for stroke All general hospitals, which care for people with stroke, to have a specialised stroke service as described in the stroke service model.

37. 37 T&W OSC response Although Telford & Wrekin PCT has developed a stroke strategy, we fall well short of these requirements – most particularly the requirement that all patients suffering a stroke should be treated in a specialist stroke service – it is very much hit and miss as far as local patients are concerned. We note the publication of the new national Stroke Strategy which will help in focussing attention on this area and acknowledge that Telford & Wrekin PCT has recently approved plans within its 2008-09 budget which will help to address some of the required actions within the NSF.

38. 38 Standard 23 HCC evidence Healthcare Commission PIs in completeness of ethnic coding in workforce datasets HES – invalid or blank records; ethnicity coding NHS plan database – developing future LDP processes NHS workforce census Ethnic group hospital activity monitoring (e.g. proportional admissions by ethnic group) Healthcare Commission complaints (health and healthcare outcomes, actions to build population or community-based healthcare services) Department of Health – PSA targets (health of the population) Improving Working Lives – evidence of support in place to manage a healthy balance between work and outside commitments (flexible working and healthy workplace standards – practice plus)

39. 39 Standard 23 Narrative on current position by lead NSF updates to Board & Clinical Governance Executive The Trust is not only working for improvements within the community but is also ensuring staff and patients have access to the benefits via the no smoking policy, dietary advice and facility improvement. Smoking policy reviewed in January 2008. IWL Practice Plus achieved Ethnicity coding good for workforce and patients NICE guidance disseminated across Local Health Authority

40. 40 Compliance with Hygiene Code The Shrewsbury and Telford Hospital NHS Trust recognises that the Health Act 2006 introduced a statutory duty on NHS organisations from October 1st 2006 to observe the provisions of the Code of Practice on Healthcare Associated Infections. As a result the Board has reviewed its arrangements and is assured that it has suitable systems and arrangements in place to ensure that the Code is being observed at this trust. Specifically the Board can confirm that the Trust : –Has a designated Director of Infection Prevention and Control, –Has designated lead managers responsible for cleaning and decontamination –Receives routine reports on infection control and associated issues –Takes ever appropriate action to ensure patients, staff and visitors are protected against the risks of Healthcare Associated Infections

41. 41 General Compliance statement Reasonable assurance has been provided to the Trust Board that there has been no lapses in fully meeting the core standards during the period 01 April 07 to 31 March 08.

42. 42 General Compliance Statement The Trust relies on external and internal sources of assurance/evidence that are updated on an ongoing basis. This includes national surveys, CNST, internal and external audit, PEAT assessments. The Trust also received substantial assurance following an internal audit review in relation to its risk management processes. This means that the Board is receiving consistent information across the full range of the Trust's activities. There is evidence of high level debate and probing by Executive and Non-Executive Directors of the performance information received. Clear responsibilities and accountabilities have been laid out to enable the Trust to make its declaration. Clear action plans exist where there are lapses in control or gaps in assurance, and progress against these plans is monitored.

43. 43 General compliance statement The Declaration is also supported by an internal audit assessment that was undertaken in order to provide assurance regarding the process that the Trust has adopted in order to make its final declaration in respect of compliance with the Standards for Better Health. The report concluded that the Trust has integrated Standards for Better Health within its performance management and assurance/risk management frameworks. The report concluded that the Trust has a reasonable process to support the preparation of its declaration.

44. 44 Next steps Declare compliance with Hygiene Code General compliance statement Compliance with core standards Submit Declaration and stakeholder comments to HCC by 30 April Publish on internet Bring final paper to May Board for information