Urgent Health UK Barndoc Healthcare Ltd. (Barndoc)

Transcription

1 Internal Audit, Counter Fraud and Consultancy Services Urgent Health UK Barndoc Healthcare Ltd. (Barndoc) Final Internal Audit Report: Francis Report Report Reference: UHUK03/14-Barndoc Published: November 2013 Distribution List (for Action) Sonia Cabezas, Head of Governance Chris Curtis, Head of Performance Alan Levett, Acting Chief Executive Officer Additional Copies (Final Report - for Information) n/a ASSURANCE OPINION RATING Assurance Opinion Overall Assurance Opinion n/a Green

2 EXECUTIVE SUMMARY AUDIT BACKGROUND, SCOPE AND OBJECTIVES As part of the 2013/14 audit plan it has been agreed by the Board of Urgent Health UK and, hence, its members to conduct a review of the members response to the Francis Report and to assess whether the members can effectively demonstrate compliance against the relevant recommendations made. The Francis Report tells a story of appalling suffering of many patients within a culture of secrecy and defensiveness. Although the public inquiry was focused on one organisation, it highlights a whole system failure. A system which should have had checks and balances in place, and working, to ensure that patients were treated with dignity, and suffered no harm. The 1,782 page report has 290 recommendations which cut across and have major implications for all levels of the health service across England. The recommendations are focussed on the following themes: emphasis on and commitment to common values throughout the system by all within it; readily accessible fundamental standards and means of compliance; no tolerance of non compliance and the rigorous policing of fundamental standards; openness, transparency and candour in all the system s business; strong leadership in nursing and other professional values; strong support for leadership roles; a level playing field for accountability; and information accessible and useable by all allowing effective comparison of performance by individuals, services and organisation. From the 290 recommendations raised in the Francis Report we identified the 42 recommendations which affect or have a potential effect on out of hours services and are measurable. See Appendix B for a summary of each of the 290 recommendations, highlighting those covered and not covered by this review. The comments highlighted in this report are intended to be pointers for further discussion. The results of this assessment should be read in conjunction with the Berwick Report 1. As such, no recommendations have been made at this time. OVERALL CONCLUSION AUDIT ASSURANCE OPINION It is the view of Internal Audit that the overall assurance opinion is Green as recorded in the table on the face of this report and in accordance with the opinion definitions at Appendix A of this report. Our opinion is based on our high level review which has focussed upon the processes in place and discussion with management rather than detailed testing of all areas. GREEN AMBER RED Overall from the recommendations assessed the organisation meets the requirement the Francis recommendations, however, there may be minor improvements needed. The organisation meets some, but not all of the recommendation requirements, but has operational systems/processes to address the area. The organisation does not meet the requirement of the Francis recommendations. Area Under Review Overall Page No Putting Patients First Green 6 Fundamental Standards of Behaviour Green 6 Responsibility for, and Effectiveness of, Regulating Healthcare Amber 8 Enhancement of the Role of Supporting Agencies Green 9 Effective Complaint Handling Green 9 Openness, Transparency and Candour Amber 14 Nursing 2 Amber 16 Leadership Amber 18 Information Green 18 Coroners and Inquests Green 20 With the exception of reviewing the executive summary of the Francis Report, the organisation has not undertaken any specific action in response to it or the recommendations it makes. 1 Professor Don Berwick, an international expert in patient safety, was asked by the Prime Minister to carry out the review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals. The report was published on the 6 th August Although the Francis Report is specific to the role of nurses, we have looked at all clinicians in relation to the recommendations made. Final Report UHUK05/14-Barndoc Francis Report 2 of 35

3 EXECUTIVE SUMMARY Our key findings of the ten areas were as follows: Putting Patients First The Clinical Commissioning Groups (CCGs - Enfield, Barnet and Haringey) who commission services from the organisation have requested that Barndoc provide them with a follow up report to the recommendations of the Francis Report during October Barndoc have stated that this review will form part of the report to the commissioners. Fundamental Standards of Behaviour Incidents can be reported through the Incident Investigation and Reporting and Raising Concerns at Work policies. Awareness of these processes is highlighted during the organisation s induction programme which incorporates an Essential Reading package. In addition, all policies are available on the extranet. The organisation is in the process of developing a service level agreement with the contracted GPs which clearly sets out their conduct when working for Barndoc. This is due to be sent out to staff by the end of October The organisation did not report any Serious Incidents Requiring Investigation (SIRI) during 2012/13, however in quarter one of 2013/14, there was one incident which was the failure of the N3 connection provided by Enfield CCG. Whilst this was not directly their fault, it was reported and appropriate contingency plans were put into operation which ensured the organisation could continue to operate. Responsibility for, and Effectiveness of, Regulating Healthcare Currently there is no Code of Conduct in place for Board members, however it was stated that each member operates under their own professional Code of Conduct such as the GMC. There is a draft agreement which sets out the expectations of Board members however, this has yet to be ratified. With the exception of Information Governance training, there is no specific training package delivered to Board members. In the past the Board members had been provided with Risk Management training however, this lapsed a year ago. The organisation is currently in the process of contacting all members of staff, including Board members to ensure that they have completed their Essential Reading package. Enhancement of the Role of Supporting Agencies The organisation is a member of Urgent Health UK and as such, participates in an annual audit plan. Our risk management findings from 2012/13 were as follows: Processes relating to the management of risk are well established within the organisation. This includes procedures in place for the identification, assessment, recording, monitoring and reporting of risks, arising from both internal and external activities. Risks are identified through different channels and assessments are completed with the responsible director or senior manager. Datix is used for the recording of all risks, which provides the organisation with the facility to capture information effectively and extract information in a variety of formats. The above review highlighted three recommendations and as of 26 th September 2013, two of the three recommendations had been completed. The provision of risk management training to Board members is still to be delivered. Effective Complaint Handling Service users have a variety of methods available to them should they wish to make a complaint. The organisation s website directs complainants to contact them via the telephone, post or by . Outputs of the complaints and patient experience process are not shared via the organisation s website, however an overview of complaints, concerns and incidents are provided to the Clinical Governance Committee and Board. Total figures relating to the number of complaints, concerns and incidents are included in the organisation s annual report. Complainants are informed of how they can gain access to advocacy service through the organisation s patient information leaflet and website. Monthly reports are provided to the commissioners which provide an overview of all complaints and incidents. The organisation has in place a Communications Policy which details how communications, both internally and externally, must be sensitive to the situation and fit for purpose. Final Report UHUK05/14-Barndoc Francis Report 3 of 35

4 EXECUTIVE SUMMARY Openness, Transparency and Candour Improvements could be made with regards to some of the organisation s policies and procedures. The organisation does not have a Being Open policy and a number of its key policies do not incorporate the ten principles on being open. The organisation does not publish its performance data on its website and has no plans to do so. The Head of Corporate Services confirmed that no concerns had been reported under the Reporting Concerns at Work policy in recent times, however did inform us of an historical issue (six years ago) in which a member of staff was investigated by an external body in relation to a data protection breach. As a result of this investigation, guidance was issued to all staff in relation to their access to patient records, we were informed there has been no such issues since. Nursing The organisation recently wound down its nursing provision due to the implementation of the 111 service, however still has some nurses on its nurse bank. There is no a Lead Nurse in the organisation however, the clinical responsibilities are covered by the Deputy Medical Director. We were informed that the Deputy Medical Director is active in the local health community. Each clinician has to go through an audit process in which their performance is benchmarked against the organisational average. In house appraisals occur on an annual basis and for 2012/13 clinician compliance was 60-70%. There is the Fit and Proper Persons process which is a standard process which the law requires with regards to the appointment of Board members, and can also be used in disciplinary proceedings however, this has not been required. Information The Chief Executive has been designated the organisation s SIRO and the Medical Director is the designated Caldicott Guardian. Both have received appropriate training. The organisation does not have a Pseudonymisation and Anonymisation policy, however, the general principles are covered in the Confidentiality and the Information Security policies. Each clinician is provided with statistical feedback on a quarterly basis. This incorporates multiple strands of information including incident and complaint data, call handling times and prescribing habits. These information strands are collated and each clinical member of staff is reviewed against the organisational average. Information is shared with the Clinical Governance Committee which has a rolling agenda to discuss clinical issues. This information would not necessarily be shared with any external agency, unless there was a clinical or other need to do so. There has been no specific audits on data quality, however the organisation completes data cleansing exercises on items such as special patient notes and reviews the quality of data as part of the audit process and during any investigations. There is no defined process in place for the organisation to promote positive behaviour outside the one-to-one s and appraisal process. Leadership As previously noted, there is no specific code of conduct in place for Board members. Each member is, however governed by their own professional code of conduct such as the GMC. The Board level job descriptions do not include the qualities generally considered necessary for a good and effective leader. The member of staff in charge of patient safety is the Medical Director. Coroners and Inquests Coroner s reports come into the organisation through the Medical Director. All reports are dealt with promptly and are compiled in a standard Barndoc format. The Head of Governance stated that they have a good relationship with the coroner. OPINION RATING It is the view of Internal Audit that the overall assurance opinion is Green as recorded in the table on the face of this report and in accordance with the opinion Final Report UHUK05/14-Barndoc Francis Report 4 of 35

5 definitions at Appendix A of this report. Our opinion is based on our high level review which has focussed upon the processes in place and discussion with management rather than detailed testing of all areas. Internal Audit would like to acknowledge the help and assistance given by Barndoc s staff during the course of this review. EXECUTIVE SUMMARY Robert Loader, Deputy Director of Audit REPORT DATA Date Work Undertaken: September 2013 Date of Issue of Draft Report: 11 th October 2013 Date of Return of Draft Report: 21 st November 2013 Date of Approval of Final Report: 21 st November 2013 Lead Auditor: John Harle Client Lead Manager(s): Sonia Cabezas, Head of Governance Chris Curtis, Head of Performance Client Lead Director: Alan Levett, Acting Chief Executive Governance/ Regulatory Link: Final Report UHUK05/14-Barndoc Francis Report 5 of 35

6 DETAILED FINDINGS Recommendation Question/Evidence Needed Our Assessment 1-2 All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work. Confirm what action has taken as a result of the Francis Report? There has been no formal action taken as a result of the Francis Report. Each such organisation should announce at the earliest practicable time its decision on the extent to which it accepts the recommendations and what it intends to do to implement those accepted, and thereafter, on a regular basis but not less than once a year, publish in a report information regarding its progress in relation to its planned actions. Look for action plans, meeting minutes etc. The organisation s Clinical Commissioning Groups (CCGs - Barnett, Enfield and Haringey) have stated that during October 2013, they would like a follow up report on the recommendations of the Francis Report. n/a Putting Patients First Recommendation Question/Evidence Needed Our Assessment 8 Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are commissioned to provide services. What response have your commissioners requested to the Francis Report? Fundamental Standards of Behaviour Recommendation Question/Evidence Needed Our Assessment 11 Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional disagreements about procedures must be required to take the necessary corrective action, working with their medical or nursing director or line manager within the trust, with external support where necessary. Professional bodies should work on devising evidence-based standard procedures for as many interventions and pathways as possible What processes are in place to deal with professional concerns, both in terms of reporting and addressing them? Is this formally documented (Whistleblowing/GP Handbook/Code of Conduct), how is this shared with staff members? As noted above, the organisation s commissioners have requested a follow up report on the recommendations in October Clinical Quality Review Group standing items/action plan August 2013 The organisation use the information streams such as general incident report/trend analysis, patient feedback reports and clinical audit scores which may highlight potential issues with professional conduct. This would be managed through a performance management route. The organisation is in the process of developing a service level agreement with the contracted GP s which clearly sets out how they are to conduct themselves when working for Barndoc. This is due to be sent out to staff by the end of October There is a Raising Concerns at Work policy in place. The policy was approved on 30 th May 2013 and is due for review by June It includes the following sections: Final Report UHUK05/14-Barndoc Francis Report 6 of 35

7 DETAILED FINDINGS introduction states that the policy was written in light of the public interest disclosure act 1998; principles; implementation of the raising concerns at work policy; the policy; where to go for advice; how to raise a concern; confidentiality and anonymity; what happens once a concern is raised; and public interest disclosure. 12 Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting. Confirm if there is an incident reporting policy/process in place? Note the level of incidents reported during Q1 2013/14. Test the feedback process on a random sample of five incidents. All policies are available to staff via the extranet and all staff are required to complete an Essential Reading package when they begin work with the organisation, which includes the Raising Concerns at Work and the Incident Reporting and Investigation policies. Raising Concerns at Work policy Performance Management policy Incident Reporting and Investigation policy Audit policy GP SLA (in draft form) Essential Reading package There is an Incident Reporting and Investigation policy in place. The policy was ratified on the 25 th September 2013 and is due for review on 25 th September The policy grades incidents as level 1 to 3: 1. Incident that can be managed locally and does not have a serious ongoing consequence. 2. Incident that can still be managed locally, however the nature of the incident may have the consequence in terms of potential to cause a serious adverse outcome of injury or interruption to service that require on-going treatment. 3. Incident that would lead to serious injury, service disruption or serious criminal activity. Level three incidents are classed as Serious Incidents (SI). The policy states how all incidents should be managed, incidents are reported electronically through the Datix system which each desktop PC is linked to or by the use of a hard copy form which is then sent to the Head of Governance. Final Report UHUK05/14-Barndoc Francis Report 7 of 35

8 DETAILED FINDINGS There were a total of 24 incidents recorded in Quarter one of 2013/14. A random sample of five of these incidents was reviewed on Datix and we can confirm that the process is being adhered to and appropriate feedback is being provided to staff who reported the incident. Incident Reporting and Investigation policy Quarter 1 Datix report Responsibility for, and Effectiveness of, Regulating Healthcare Recommendation Question/Evidence Needed Our Assessment 79 There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a requirement to comply with a prescribed code of conduct for directors. Does the organisation have a code of conduct document in place relating to Board members? If yes, obtain a copy is it up to date? Currently, there is no specific code of conduct governing Board members however, there is a draft agreement which sets out expectations of Board members. This has yet to be ratified. Each Board member operates under their own code of conduct such as the ACCA, GMC, HPC and/or NMC. 84 Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a post, licensed bodies should be obliged by the terms of their licence to report the matter to Monitor, the Care Quality Commission and the NHS Trust Development Authority. 86 A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors. (although aimed at FTs, this is appropriate to all organisations) Have any Board members been terminated in the last three years? If so, what action was taken? Is there a defined process in place? What training is provided for Board members? Is this documented, who monitors attendance/completion? Ask for evidence of completion? n/a No Board members have been terminated during the last three years. We were informed that if there were a concern, it would be handled via the organisation s Disciplinary policy. Disciplinary policy Risk Management training has been done in the past, however this has since lapsed. All Board members have to do information governance training via the online Connecting for Health package, this has to be completed annually which is currently up to date. The organisation outsource their HR function, as such they have identified that they have gaps in the training records. The organisation is in the process of writing to all staff members, including Board members, to ensure that staff have completed the Essential Reading package. No further training is currently planned. Final Report UHUK05/14-Barndoc Francis Report 8 of 35

9 DETAILED FINDINGS Essential Reading package Enhancement of the Role of Supporting Agencies Recommendation Question/Evidence Needed Our Assessment 91 The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards at least as rigorous as those required by the NHS Litigation Authority. Covered by the overall review and annual audit plan in place over the last three years. Link to 2012/13 Annual Report Results Risk Management and overall. Effective Complaint Handling Recommendation Question/Evidence Needed Our Assessment 109 Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust. Note the different methods by which patients can provide feedback/register a complaint is this actively promoted (complaints leaflet, website etc)? The organisation is a member of Urgent Health UK and as such, participates in an annual audit plan. Our risk management findings from 2012/13 were as follows: Processes relating to the management of risk are well established within the organisation. This includes procedures in place for the identification, assessment, recording, monitoring and reporting of risks, arising from both internal and external activities. Risks are identified through different channels and assessments are completed with the responsible director or senior manager. Datix is used for the recording of all risks, which provides the organisation with the facility to capture information effectively and extract information in a variety of formats. The above review highlighted three recommendations, as of 26 th September 2013, two of the three outstanding recommendations had been completed. An update was requested with regards to the outstanding recommendation and it was stated that training in risk management had still not been provided to the Board however it was planned to do so. The organisation has not however, given a timescale for this to be achieved. UHUK/07/13 Barndoc risk management Final Report Patients can provide feedback via the organisation s website. This can consist of complaints, compliments or concerns and the website includes a postal address, telephone and address. Patients are also provided with patient leaflets which are available at treatment centres and they are also carried in the doctor s bags. Patients are also invited to complete a patient experience survey, either at Final Report UHUK05/14-Barndoc Francis Report 9 of 35

10 DETAILED FINDINGS (link to recommendation 111) the end of their consultation at a treatment centre or through the monthly postal survey that is sent to a random sample of patients. 110 Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the outcome of the complaint, but the duties of the system to respond to complaints should be regarded as entirely separate from the considerations of litigation. 111 Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation. 112 Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated a desire to have the matter dealt with as such. Note whether any actual or intended litigation has occurred during 2012/13. Confirm whether there are any processes in place to deal with this event, should it occur. Is this promoted on the website, through patient experience surveys, within treatment centres? Select a random sample of five negative comments received via the PES and note how they have been dealt with. From the latest set of surveys results ask for the raw data where available. Look for staff/premises related concerns. The patient forum has been set up in which any responder to surveys, complainants and general public can join which has the aim of improving the service by involving patients. Compliments, Comments and Complaints policy Staff guidance documents on managing feedback Organisation s website Patient information leaflet No actual or intended litigation occurred during 2012/13. In the event of litigation, the organisation would be contacted by the relevant organisation, such as the GMC. The organisation request that their GPs must inform them if there is an outstanding investigation. Where there are serious concerns, a GP would not be able to work for the organisation whilst an investigation was on going. n/a As per recommendation 109, outputs of complaints and patient experience surveys are not shared on the organisation s website however, patient compliments are. Outputs from complaints, incidents, compliments and patient experience are included in the organisation s annual report. Organisation s website 2012/13 Annual Report Discussions were held with the Head of Governance indicated that patient experience surveys come under the agenda of the Clinical Governance Committee and quarterly reports are provided. The patient experience survey is anonymised and therefore the organisation cannot respond back to the individual. The organisation found that making the process anonymised improved their response rate. They do advise patients how they could receive detailed feedback, should they choose this option, there were, however, no example of this at the time of the review. Final Report UHUK05/14-Barndoc Francis Report 10 of 35

11 DETAILED FINDINGS Any negative points are highlighted for learning, dependant on what it is and any positive points are to highlighted to staff and on the organisation s website. 113 The recommendations and standards suggested in the Patients Association s peer review 3 into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS. 114 Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation. Who is the Complaints Manager? Does the organisation review its complaints handling process? How is the learning from complaints shared across the organisation? (obtain examples) Does the organisation ask for feedback from complainants on how their complaint was handled? Is there an SI process/policy in place? Is this separate to their incident Organisation s website Patient experience survey information on Survey Monkey The Head of Governance is the complaints manager and the Chief Executive signs off the complaints. The complaints handling process is reviewed annually or when required dependant on the legislation, this review consists of looking at the policies and procedures and some analysis of the raw data to ascertain if any trends are apparent. Learning is usually shared in the organisation through a change in policy or procedure, a direct memo from the Medical Director or learning bulletins to all staff. Complainants are not currently asked for feedback on the complaints process however, the complainants are informed that they could request a meeting with Barndoc and they are provided with the details of the Ombudsman. Complaints policy Template closure complaints letter Example of two memos to staff regarding complaints issues Comments as per recommendation 12. The SI process is covered under the Incident Reporting and Investigation policy. Barndoc defines 25 events that could be described as SI s or Never Events 3 The Patients Association - Staffordshire Complaints Project 1. Making the complaints process as positive as possible for individuals, by employing Patient Champions to play a lead role in complaints handling. They will be senior figures recruited from outside the trust ideally from the local community to encourage transparency and independence and reduce the current inequalities. Led by a senior nurse, they will deliver a Complaint Support Service that will provide complainants with a clear judgement as to whether their complaint was handled appropriately or not. 2. Improving the independence, rigour and validity of complaints investigation through regular sample reviews of complaints handling peer review panels consisting of magistrates, clinicians, community members and complaints managers will convene every quarter to review a sample of complaints and how they were handled by the Trust. 3. Ensuring that learning from complaints is harnessed and used to improve future care. It will do this by working with Pilgrim Projects to help some complainants record patient voices reflective digital stories of patient care that will be a key factor in helping the trust understand the ways in which it did not get things right, using narrative as well as data to bring the issues to life. These will be developed into presentations with supporting material to highlight key issues and will be used in teaching seminars for doctors and nurses. 4. Assessing the quality of the complaints handling process at the Trust by introducing a complaints survey this will be given to all patients/carers who make a complaint. The results will be benchmarked against other hospitals who have agreed to be part of a benchmarking group for this project. Final Report UHUK05/14-Barndoc Francis Report 11 of 35

12 DETAILED FINDINGS reporting process/policy? What does the organisation class as an SI? Note how many SI's were reported during 2012/13 note whether they ve been handled appropriately look to see if actions have been taken? (link to recommendation 112) in an out of hours primary care setting. In addition to this it defines level three incidents which require an enquiry led investigation external to the organisation including: serious harm or death to a patient; very serious criminal activity by staff; exceptional public interest; and require the implementation of the business continuity plan. 115 Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: a complaint amounts to an allegation of a serious untoward incident; subject matter involving clinically related issues is not capable of resolution without an expert clinical opinion; a complaint raises substantive issues of professional misconduct or the performance of senior managers; and a complaint involves issues about the nature and extent of the services commissioned. 116 Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those Identify whether any of the four criteria have occurred during 2012/13 and if so what the organisations response was. Identify if there is a process in place to address this recommendation. Is it documented in the There were no SIs recorded in 2012/13, however in quarter one of 2013/14 there was one SI which was in relation to the failure of the N3 connection provided by Enfield CCG. This was beyond the control of Barndoc and contingency plans were put into operation which enabled the organisation to continue to provide an effective service. Logs of this incident were reviewed on the Datix system. At the monthly commissioning meeting the organisation have been requested to disclose any SI s and all three commissioners are provided with quarterly incident summaries. Incident reporting and investigation policy Annual report 2012/13 None during 2012/13. n/a The Comments, Compliments and Complaints policy states that if a complainant is not satisfied by the final response to their complaint, they will be offered a meeting with the Chief Executive of any other officer from senior management to discuss any unresolved issues at the resolution Final Report UHUK05/14-Barndoc Francis Report 12 of 35

13 DETAILED FINDINGS forms of support. 118 Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust s response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible, the summary should be shared confidentially with the Commissioner and the Care Quality Commission. 120 Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to do so. 122 Large-scale failures of clinical service are likely to have in common a need for: provision of prompt advice, counselling and support to very distressed and anxious members of the public; swift identification of persons of independence, authority and expertise to lead investigations and reviews; complaints policy? How are complainants made aware of this process? Confirm whether any such meetings have occurred during 2012/13. Confirm if this occurs? Confirm the frequency and level of detail reported to the organisation s commissioners. Obtain the last report as evidence. Confirm whether the organisation has a communications policy. meeting. A complainant may attend or choose not to attend a resolution meeting and refer their complaint for independent review. The patient information leaflet gives the appropriate details of the advocacy services are available to complainants, including links to the ICAS service. Meetings with complainants do occur and during 2012/13 two meetings took place. Comments, Compliments and Complaints policy Patient information leaflet No specific complaints information is recorded on the organisation s website. However, complaints summaries are reported to the Board and Board documents (open meeting minutes) are available to the public upon request. Complaints summaries are disclosed to the commissioners regardless of the outcome. Organisation s website Commissioners receive monthly reports of complaints, reports contain anonymised summaries of the complaint and the action taken. adherence to timescales; summary of the complaint; outcome of complaint; and any further actions required. June, July and August 2013 Commissioners reports Clinical Governance reports June, July and August 2013 The organisation have a Communications policy and it defines the following principles of communications: strategic; corporate; and responsive. The document sets out how both internal and external communications should be set out and in all cases states that we will aim to be sensitive Final Report UHUK05/14-Barndoc Francis Report 13 of 35

14 DETAILED FINDINGS a procedure for the recruitment of clinical and other experts to review cases; a communications strategy to inform and reassure the public of the processes being adopted; and clear lines of responsibility and accountability for the setting up and oversight of such reviews. both in content and vocabulary to the needs and views of various individuals and groups with regards to age, disability, gender sexual orientation, religion and race. We will also be sensitive to such groups as the newly bereaved, newly diagnosed etc Communications policy Such events are of sufficient rarity and importance, and requiring of coordination of the activities of multiple organisations, that the primary responsibility should reside in the National Quality Board. Openness, Transparency and Candour Recommendation Question/Evidence Needed Our Assessment 173 Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful. 175 Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative). 176 Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission. 177 Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission. 179 Gagging clauses or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care. Confirm whether the organisation has a being open policy. Is it up to date? (link to recommendation 173) What data is available to patients on the website? Is it up to date? Confirm if the organisation have ever added gagging clauses or non disparagement clauses to any policy/contract. There is no specific Being Open policy however, openness is referred to in the bulk of the organisation s policies and openness is also referred to in contracts and SLAs with the GPs and general staff. Barndoc management state that they ensure that they are transparent to all appropriate bodies. n/a No requirement to make statements to the commissioners other than the NQR results. n/a No data is available with the exception of general information on the organisation s website Organisation s website No gagging orders have been put in place. n/a Final Report UHUK05/14-Barndoc Francis Report 14 of 35

15 DETAILED FINDINGS 180 Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency. 181 A statutory obligation should be imposed to observe a duty of candour: on healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may request; and on registered medical practitioners and registered nurses and other registered professionals who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare provider by which they are employed has caused death or serious injury to the patient to report their belief or suspicion to their employer as soon as is reasonably practicable. Review five policies to see if they incorporate the 10 principles of Being Open: 1. acknowledgement; 2. truthfulness, timeliness and clarity of communication; 3. apology; 4. recognising patient and carer expectations; 5. professional support; 6. risk management and systems improvement; 7. multidisciplinary responsibility; 8. clinical governance; 9. confidentiality; and 10. continuity of care. Does the organisation have a whistleblowing policy in place? If so, has it ever been used? Note if the relevant parties (patient, professional bodies, CQC, NPSA etc.) have been informed? The NHS standard contract for 2013/14 requires in such event that the patient is notified and that the notification be accompanied by the offer of a written notification and must be recorded for audit processes. Is this requirement incorporated within the whistleblowing policy? Complaints: Incidents: Risk Management: Clinical Audit: Training Strategy: This policy incorporate the ten principles, and states that: This policy ensures that the system for managing comments and complaints complies with legislative requirements and are dealt with in line with the Local Authority Social Services and NHS Complaints (England) Regulations 2009 and incorporates the Care Quality Commission Essential Standards for Quality and Safety registration requirements (under Outcomes 1- Respecting and involving people who use services, Outcome 16- Assessing and monitoring the quality of service provision and Outcome 17- Complaints) Does not meet the ten principles. Does not meet the ten principles. Does not meet the ten principles. Does not meet the ten principles. The organisation has a Raising Concerns at Work policy. Head of Corporate Services was not aware of any use of the Raising Concerns at Work policy since an issue in This issue related to a data protection. Appropriate investigations were completed by an external body including the Police and guidance was issued to staff in relation to the accessing of patient data. The policy does not incorporate the NHS standard contract for 2013/14 requirement that in such event that the patient is notified and that notification be accompanied the offer of a written notification and must be recorded for audit purposes. Raising Concerns at Work policy Final Report UHUK05/14-Barndoc Francis Report 15 of 35

16 DETAILED FINDINGS The provision of information in compliance with this requirement should not of itself be evidence or an admission of any civil or criminal liability, but noncompliance with the statutory duty should entitle the patient to a remedy. Nursing (all clinicians) Please note whether the organisation uses nurses or not. Recommendation Question/Evidence Needed Our Assessment 185 There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: selection of recruits to the profession who evidence the: o possession of the appropriate values, attitudes and behaviours; o ability and motivation to enable them to put the welfare of others above their own interests; o drive to maintain, develop and improve their own standards and abilities; o intellectual achievements to enable them to acquire through training the necessary technical skills; training and experience in delivery of compassionate care; leadership which constantly reinforces values and standards of compassionate care; involvement in, and responsibility for, the planning and delivery of compassionate care; constant support and incentivisation which values nurses and the work they do through: o recognition of achievement; o regular, comprehensive feedback on performance and concerns; and o encouraging them to report concerns and to give priority to patient well-being. What is the recruitment, interview and selection process? Is there any emphasis on the values, attitudes and behaviours towards the wellbeing of patients and their basic care needs? Is there a process in place? How does the organisation promote positive behaviour? What training programmes/opportunities are in place are these actively promoted and encouraged. The process has been documented in the Recruitment policy which states: Whilst Barndoc Healthcare is not part of the NHS we provide services to Primary Care Trusts and will thus recruit in accordance with the NHS Employment Check Standards introduced in March 2008 and emended in June 2009, July 2010, October 2012, January 2011, May 2011 and September All clinical staff are required to have an interview with the Medical Director and are required to produce evidence of their certificates, qualifications and professional registration They are also given an overview of the role and how the care of the patients are the organisation priority. This is then followed up by induction and the Essential Reading package. Training is actively encouraged and every year the organisation publishes a timetable of mandatory and optional training sessions available. The attainment of additional professional qualifications is also encouraged. All clinical staff are subject to a clinical audit process and feedback is given quarterly against the organisation s average. The staff also have annual appraisals and 1:2:1 s. There is no defined process in place for the organisation to promote positive behaviour other than through the clinical audit process. Essential Reading package Recruitment policy Final Report UHUK05/14-Barndoc Francis Report 16 of 35

17 DETAILED FINDINGS 193 Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They could be required to report to the Nursing and Midwifery Council on their performance on a regular basis. 194 As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice and its implementation. Alongside developmental requirements, this should contain documented evidence of recognised training undertaken, including wider relevant learning. It should also demonstrate commitment, compassion and caring for patients, evidenced by feedback from patients and families on the care provided by the nurse. This portfolio and each annual appraisal should be made available to the Nursing and Midwifery Council, if requested, as part of a nurse s revalidation process. At the end of each annual assessment, the appraisal and portfolio should be signed by the nurse as being an accurate and true reflection and be countersigned by their appraising manager as being such. 202 Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions must regularly review the adequacy of the arrangements in this regard. Is there an appraisal process in place? Note the current compliance %. Do they share the results with anyone? (link to recommendation 193) Is there a Director if Nursing role in place? Is there nursing representation on the committees/groups within the organisation? There is an annual appraisal process in place for all staff members. GPs also do this for OOH through Barndoc. The current compliance with the Barndoc appraisal process is 60-70% for the GPs, an exact figure could not be obtained at this time due to the updated HR system being implemented. The information is shared individually with the GPs, but not externally unless a serious issue was highlighted. Appraisal records The organisation recently wound down its nursing provision due to the implementation of the 111 service, however still has some nurses on its nurse bank. There is no Lead Nurse in the organisation however, the clinical responsibilities are covered by the Deputy Medical Director. We were informed that the Deputy Medical Director is active in the local health community. 203 A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession. Dependant on whether there is a Director of Nursing in post. If so, are they involved with their local/national healthcare Deputy Medical Director job description Not in place, however we were informed that the Deputy Medical Director sits on various Boards within the CCG s. Final Report UHUK05/14-Barndoc Francis Report 17 of 35

18 DETAILED FINDINGS community? n/a Leadership Recommendation Question/Evidence Needed Our Assessment 215 A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it. How is this enforced? How do you review Council level participation? (link to recommendation 79) No specific code of ethics, with the exception of the consultancy agreement and expectation document. The Board members are subject to their own professional bodies such as the GMC. The organisation is in the process of developing a code of conduct. 216 The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining the service to be delivered as a safe and effective service. 217 A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have. 218 Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a fair and proportionate procedure, with the effect of disqualifying them from holding such positions in future. Is this in place? Is there an individual on the Council assigned responsibility for patient safety? Is this in place? Obtain copies of job descriptions. Is there a process in place if it does? If so, has been applied over the last three years? Consultancy agreement Expectations document The assigned individual in charge of patient safety is the Medical Director. Medical Director Job Description This is not included in the job descriptions. Medical Director job description. Deputy Medical Director job description. Director of Finance job description. There is the Fit and Proper Persons process which is a standard process which the law requires. The Board is regulated by the Companies Act however, there is no set inhouse policy or procedure. n/a Information Recommendation Question/Evidence Needed Our Assessment 245 Each provider organisation should have a board level member with responsibility for information. Confirm who this is and what training they have undertaken. The Medical Director is the organisation s Caldicott Guardian and the Chief Executive Officer is the organisation s SIRO. Both have received appropriate training. Final Report UHUK05/14-Barndoc Francis Report 18 of 35