EXECUTIVE SUMMARY. NHS Constitution Champion in place Strategic Workforce Development Committee will monitor and review baseline assessment

Transcription

1 NHS Constitution Baseline Assessment (Draft) Northern Devon Healthcare NHS Trust Report to Trust Board Date Tuesday 6 April 2010 Agenda Number S2 Agenda Item NHS Constitution Baseline Assessment (Draft) Sponsor Maureen Bignell, Director of Personnel and Development Prepared by Maureen Bignell, Director of Personnel and Development Presented by Maureen Bignell, Director of Personnel and Development 1 Purpose and key issues EXECUTIVE SUMMARY The purpose of this paper is to inform the Board of the baseline assessment relating to staff rights, expectations and legal duties. Key issues include: Engagement and involvement with staff Staff have clear roles and responsibilities Staff have opportunities for personal development and access to appropriate training for their jobs to succeed Staff have opportunities to maintain health, well being and safety Staff have employment rights protected. 2 Supporting Information The NHS Constitution Baseline Assessment report is attached. 3 Controls and assurances NHS Constitution Champion in place Strategic Workforce Development Committee will monitor and review baseline assessment 4 Legal Implications Employment legislation provides rights of staff 5 Equality and Diversity Implications The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report in relation to promoting and respecting rights of staff 6 Patient, Public and Staff Involvement The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate. The Joint Negotiation and Consultative Committee were consulted on assessment and will be involved with the on-going development and review. Personnel and Development Directorate Page 1 of 37

2 NHS Constitution Baseline Assessment (Draft) Northern Devon Healthcare NHS Trust 7 Cost implications There are no cost implications. 8 Potential risk to the organisation Nil. 9 Board prompts Has the Board received the assurance it requires that the self assessment is a fair reflection of the position relating to staff rights and expectations? 10 Recommendations The Board is asked to APPROVE the report. 11 References Staff Survey 2009 NHS Constitution 12 Strategic Objectives The Trust s Strategic Objectives were reviewed by the Board in July Effective care Financial health Modern environments Exceptional workforce Integrated care Sustainable services 13 Principal Risks The Principal Risks have been identified through the Trust s risk management processes. They are updated as and when required. Financial planning & management Clinical records management X Strategic & business planning X Leadership & management X Workforce numbers Unsafe behaviour X Workforce skills External demands Procedural management Partnership arrangements Equipment & facilities arrangements Personnel and Development Directorate Page 2 of 37

3 South West Strategic Health Authority NHS Constitution Baseline Assessment (draft) Revised to include Staff rights, expectations and legal duties This baseline assessment toolkit is intended to help NHS South West organisations to: assess their position in relation to the 39 rights and pledges specific to working with patients and local communities; report on actions from NHS South West Conference held on 11 December 2009 assess the workforce information relating to the staff rights, pledges and expectation, taking into account the National NHS Health & Well-being Review The Booorman Report. The assessment will also enable the South West Strategic Health Authority to report to the Department of Health on regional progress. For each action (A), pledge (P) and right (R) a short minimum assurance statement has been included. You may wish to add other sources of assurance statements into these boxes. Please Red/Amber/Green rate your organisation against each of these statements to demonstrate level of. Where a right or pledge is only relevant to Primary Care Trusts this is reflected in the assurance statement. Primary Care Trusts If your organisation is not fully compliant with a particular assurance statement please indicate what actions you will take to reach, by what date and include a named lead Director responsible for the actions. You only need to Red/Amber/Green rate each action (A), pledge (P) and right (R) overall. Please also include any other sources of evidence you can identify. For the other rights and pledges your evidence should offer clear justification for each rating. When the completed assessment has been agreed by your Board it should be returned to Jo Perry, Deputy Director of Corporate Affairs, South West Strategic Health Authority by 26 February If you have any questions or require further guidance please contact Jo Perry on or jo.perry@southwest.nhs.uk Personnel and Development Directorate Page 3 of 37

4 Name of organisation PATIENT RIGHTS/PLEDGES 1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the NHS Constitution. The Primary Care Trust has a process in place to trigger referral to alternative providers if waiting times are exceeded. Quarterly National Reporting Systems to the SHA on Waiting Times. 2. You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. The Primary Care Trust has a process in place to ensure that NICE recommendations are implemented. Quarterly report to the SHA. 3. You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme. 4. The NHS commits to provide programmes as recommended by the UK Screening Committee The Primary Care Trust commissions a vaccination programme in line with the recommendations of the Joint Committee on Vaccination and Immunisation. The Primary Care Trust commissions a screening programme in line with the recommendations of the UK Screening Committee. Quarterly performance reports to the SHA on MMR and Flu vaccines and VSB10 (Immunisation). Monthly data to the Health Protection Agency on vaccines. Quarterly report to the SHA and VSA09 (Breast), VSA10 (Bowel), VSA15 (Cervical). 5. You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament. Fundamental NHS principle. Evidence not required but please confirm. 6. You have the right to access NHS services. You will not be refused access on unreasonable grounds. A formal policy for dealing with violent and abusive patients has been adopted. Personnel and Development Directorate Page 4 of 37

5 7. You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary. The Primary Care Trust has undertaken a Joint Strategic Needs Assessment as part of the development and implementation of its Local Strategic Plan. 8. You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner. The Primary Care Trust has a process in place to manage the commissioning of treatments from European Economic Area countries. 9. You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age. A single equalities scheme has been adopted, implemented and is monitored. 10. The NHS commits to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered. Communications and engagement plans include actions to ensure decision making is communicated and understood. 11. The NHS commits to make the transition as smooth as possible when you are referred between services, and to include you in relevant discussions. Patient pathways include processes to ensure effective transitions between services and organisations. 12. You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly Knowledge and Skills Frameworks for all staff are in place. Personnel and Development Directorate Page 5 of 37

6 approved or registered organisation that meets required levels of safety and quality. The PCT only commissions from providers who have full CQC registration. 13. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. Reporting to the SHA on: NPSA reporting system Annual Survey VSB 15 Reported against ambitions National Reporting Systems. There is a health-economy agreed plan for further measureable improvement against these domains. 14. The NHS commits to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice. Health services are provided in a clean and safe environment as reported to the Care Quality Commission and in accordance with the requirements of the Health and Safety Executive. Monthly reporting of HCA1 database to the Health Protection Agency VSA01 (MRSA) and VSA03 (CDiff). Personnel and Development Directorate Page 6 of 37

7 15. The NHS commits to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. Reports to the SHA on: NPSA Reporting System Annual Survey VSB 15 Reporting against ambitions National reporting system. There is a health-economy agreed plan for further measureable improvement against these domains. There is a clear programme for publicising progress against both existing quality improvement projections and plans for measureable quality improvement in the future. 16. You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you or your doctor feel would be right for you, they will explain that decision to you. A process to manage decisions concerning the provision of exceptional treatments is in place. A robust process is in place to make decisions on funding new medicines and other treatments. The PCT publishes clear information on the processes for local decision making, individual funding requests and the appeals process. Personnel and Development Directorate Page 7 of 37

8 17. You have the right to be treated with dignity and respect, in accordance with your human rights. A privacy, dignity and respect policy/statement has been adopted. VSB15 (Patient experience) and VSB16 (public confidence). 18. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests. A policy on obtaining informed consent has been adopted. Reports on mixed sex accommodation. 19. You have the right to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing. Procedures are in place to ensure that patients are able to make informed decisions about proposed treatments. Patient information is regularly reviewed and updated. 20. You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure. A records management policy has been adopted. The policy includes specific actions to ensure that confidential information is kept secure. Reports to the SHA on completion of the Information Governance Toolkit. 21. You have the right of access to your own health records. These will always be used to manage your treatment in your best interests. Procedures are in place to provide access to health records on request. A process to manage complaints relating to access to health records is in place. Personnel and Development Directorate Page 8 of 37

9 22. The NHS commits to share with you any letters sent between clinicians about your care. Procedures are in place to ensure that clinician s letters are shared with patients. 23. You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons. There is a clear procedure in place for the public to register with the GP of their choice. VSA06 (GP Access). 24. You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply. Patient information on how to register with a GP includes this provision. 25. You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs. The Primary Care Trust has arrangements in place to: ensure that patients who need an elective referral are offered a choice of any clinically appropriate provider; National Choice Survey. Monthly Choose and Book information for 18 weeks reported to the SHA. ensure that where a patient has not been offered that choice, and notifies the Primary Care Trust that they have not been offered that choice, that patient may choose any clinically appropriate secondary care provider. 26. The NHS commits to inform you about the healthcare services available to you, locally and nationally. The Primary Care Trust communication plan includes actions to provide up to date information on healthcare services. Personnel and Development Directorate Page 9 of 37

10 27. The NHS commits to offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available. The communications plan includes actions to ensure decision making is communicated and understood. 28. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this. Procedures are in place to ensure that patients are routinely involved in discussions and decisions about their healthcare. 29. You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services. Communications, engagement and stakeholder relations plans include actions to ensure appropriate and proportionate involvement of patients and the public in service planning, development or change. 30. The NHS commits to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services. 31. The NHS commits to work in partnership with you, your family, carers and representatives. Communications, engagement and stakeholder relations plans include the provision of clear and accessible information on planning and delivery of NHS services. Working in partnership with families, carers and representatives is part of the engagement plan. 32. You have the right to have any complaint you make about NHS services dealt with efficiently and to have it properly investigated. A complaints policy has been adopted. 33. You have the right to know the outcome of any investigation into your The complaints policy includes procedures to ensure the Personnel and Development Directorate Page 10 of 37

11 complaint. communication of the outcomes of complaints investigations. 34. You have the right to take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS. The complaints policy, complaints literature and letters to complainants provide information on how to take complaints to the Health Services Ombudsman. 35. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body. This is a legal right and as such does not require an assurance statement. Rating not required 36. You have the right to compensation where you have been harmed by negligent treatment. 37. The NHS commits to ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment. A procedure for managing compensation payments is in place. The complaints policy includes access to support and reassurance of the impact of a complaint on future treatments. Complaints handling is monitored. 38. The NHS commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. A clear process to provide timely information, feedback and apologies is in place. This is monitored and reported as part of the formal process for receiving and acting on lessons arising from complaints, claims or PALS. 39. The NHS commits to ensure that the organisation learns lessons from complaints and claims and uses these A formal process to receive and act on lessons arising from complaints, claims or PALS is in Personnel and Development Directorate Page 11 of 37

12 to improve NHS services. place. This process links directly to the Board. Personnel and Development Directorate Page 12 of 37

13 ACTIONS FROM SOUTH WEST NHS CONSTITUTION CONFERENCE & STAFF RIGHTS/EXPECTATIONS AND LEGAL DUTIES Actions arising from NHS South West Constitution Conference held 11 December 2009 A1 NHS Boards must identify a Board level lead on the NHS Constitution Board Level Champion identified; Board Report Fully compliant NHS Board Champion is: Mrs Carolyn Mills Director of Nursing Name Job Title: Actions arising from NHS South West Constitution Conference held 11 December 2009 Not relevant A2 Primary Care Trusts need to identify an NHS Constitution Champion to promote the Constitution and to act as an advocate on behalf of the public A3 Primary Care Trusts need to work with NHS Providers and Third Sector organisations to ensure they have regard to the NHS Constitution in their activity for the NHS. A4 NHS organisations need to sign up to the NHS South West Communications Strategy [attached] NHS Constitution Champion identified; The organisation has a framework in place. The organisation has implemented a Communications and engagement plan based on NHS South West Communications Strategy. Board Report Board Compliance report. Board Compliance report. Organisational Communications strategy approved by board in 2008 Not relevant Fully compliant Primary Care Trust Champion is: Name Job Title: A5 Staff work with staff-side representatives to ensure with the Staff Pledges and Rights in the NHS Constitution The NHS Constitution forms part of regular agenda at Staff-side and Staff Engagement meetings Board Compliance Report; JNCC Engagement Meetings; Values and vision Fully compliant Personnel and Development Directorate Page 13 of 37

14 engagement events STAFF PLEDGES, RIGHTS, EXPECTATIONS & LEGAL DUTIES P1 Provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities. The organisation has an up-todate job description in place for all staff, which clearly outlines their roles and responsibilities; The organisation will introduce the NHS Constitution in future Job Descriptions/person specifications. Job descriptions are and continue to be evaluated under the Agenda for Change Terms and Conditions for Job Evaluation [except Medical and dental staff]; The organisation has promoted the NHS Constitution to all staff within the organisation. Board report confirming with the NHS Constitution for Staff rights and pledges. Confirmation of application of National Agenda for Change Job Evaluation, or equivalent Job Evaluation process for FTs. Banding process in place, consistency checking processes. Generic job descriptions for majority of posts. NHS Constitution is incorporated into the organisations Induction arrangements; NHS constitution is incorporated into OD plan Partially compliant Maureen Bignell Director of Personnel and Develom Board report for April 2010 Induction processes to be developed further to incorporate NHS constitution April 2010 NHS staff rights and NHS values to be incorporated into recruitment literature and promoted on job website and intranet April 2010 Joint work to be undertaken with staff reps and wider staff to finalise staff charter NHS Constitution is promoted on Trust Intranet; May 2010 The organisation has a Staff Charter, outlining staff rights, pledges and responsibilities. The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on: Guidance to managers to support discussions during appraisal process to ensure that staff have a understanding where there roles makes a difference to patients Personnel and Development Directorate Page 14 of 37

15 KP3: % of staff feeling valued by work colleagues KP4: % of staff agreeing that they have an interesting job KP7 % of staff working in a well-structured team environment Using e-rostering and workforce reports analayse working hours of staff P2 Provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed. The organisation has in place for all staff a personal development pan, supported by an individual KSF outline [for Agenda for Change staff]; The organisation has in place a mechanism which defines the relevant mandatory and developmental training required for specific roles; The personal development plan clearly outlines appropriate development training to support the employee; The organisation has in place appropriate training providers [internal /external] and training prospectus to satisfy individual and job requirements. Board report on CARE QUALITY COMMISSION standards and with staff receiving appraisal and personal development plans. Evidence of an Organisational Training Plan based on PDPs. Evidence of an organisational Training programme and/prospectus. Staff attitude survey results demonstrate Trust is in highest 20% in: Number of staff appraised, having PDPs and having support from immediate managers The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on: KF13 - % of staff appraised in last 12 months KF15 - % appraised with PDPs in place KF16 support from immediate managers Partially compliant Guidance to managers to facilitate a discussion on what opportunities are available to develop potential. P3 Provide support and opportunities for The organisation has arrangements in place either by Internal Occupational Health service Partially compliant Health and Well-being to be Personnel and Development Directorate Page 15 of 37

16 staff to maintain their health, wellbeing and safety. internal or external agreements to provide Occupational Health and Wellbeing arrangements for staff; The organisation has in place an action plan to deal with the recommendations from the Boorman Report. Health and safety training reports Board Report responding to the Boorman Report, including an action plan to develop Health and Wellbeing of staff; Board level champion for Health and Wellbeing; developed further into the occupational health service October 2010 Analysis on causes of workrelated stress and action plan to be developed Violence and aggression action plan Health and well-being promoted on Intranet and success in iniatives Staff attitude survey results demonstrate Trust is in highest 20% in: KP17 - % receiving H & S training in last 12 months KP27 - % experiencing harassment, bullying or abuse from staff in last months KF28 Perceptions of effective action from employer towards violence and aggression KF30 - % feeling pressure in last 3 months to attend work when feeling unwell. P4 Provide the opportunity for all staff to Engage in decisions that affect them and the services they provide. The organisation has a staff engagement strategy in place. The organisation engages with staff through appropriate Trades Union machinery ie Joint Staff Committee. Recognition Agreement with Trades Unions and Professional Organisations. Joint Staff Committee Facilities agreement. Partially compliant Staff engagement involvement strategy to be reviewed Partnership working Personnel and Development Directorate Page 16 of 37

17 The organisation has in place arrangements to engage with staff who are non-representatives of TU/Professional organisations. Joint Staff Committee Terms of Reference.Consultation Working party minutes of management of change meetings Staff attitude survey results demonstrate Trust is in highest 20% in: KF33 - % of staff able to contribute towards impreovements at work KF38 - % having equality and diversity training in last 12 months arrangements to be reviewed Guidance to managers to facilitate a discussion with employee to ensure staff understand their role and where it fits in. Analyse areas in the Trust where staff are reporting poor communication between senior management and staff and develop an action plan R1 The NHS has a good record of fair employment and respecting the rights of staff. All Staff have a Contract of Employment based on National Terms and Conditions, and reflecting the rights of staff. Staff Charter incorporating the rights of staff and the NHS constitution. Contracts of Employment based on National Terms and Conditions. Partially compliant Staff charter to be finalised in consultation with staff side May 2010 R2 Rights embodied in general employment and discrimination law. The organisation has in place arrangements to support Equality and Diversity and Equal Opportunities. Audit reports Equal Opportunities Policy; Bullying and Harassment Policy; Fully compliant The organisation has a framework of policies and procedures in place to comply with employment and discrimination legislation. Violence and Aggression Policy; Grievance and Appeals Policy; Involvement/Engagement Policy; Health and Safety Policy; Flexible Working Policy; Personnel and Development Directorate Page 17 of 37

18 Whistle blowing policy. Staff Charter, setting out the responsibilities and expectations of staff. Board report satisfying with the NHS Constitution Staff rights and pledges. High level of staff trained in Equality and Diversity. Board reports including extensive information on equality data and action plan Training Plan OD Plan Arrangements to train all managers in key policies and procedures. Staff Survey results; Care Quality Commission evidence; Human Resources/Workforce Board Reports; E1. Expectations and legal duties of Staff: The Constitution also includes expectations that reflect how staff should play their part in ensuring the success of the NHS and delivering high-quality care. The organisation has a framework which sets out the expectations of and makes clear the legal duties placed on staff. Care Quality Commission evidence; Human Resources/Workforce Board reports. JNCC minutes Discussion and promotion at Staff Engagement meetings; Staff Newsletters; Staff Induction Programme; Partially compliant Build on JNCC discussions with staff reps to develop a final staff charter and engage staff across the organisation through listening events May-June 2010 Expectations: The highest quality of patient care is delivered by staff who are ambitious in their expectations of themselves Promotion through the organisations intranet; Staff promotion material; Personnel and Development Directorate Page 18 of 37

19 and their colleagues, and strive to achieve beyond what is legally required of them. Staff signed up to the NHS Code of Conduct; Legal duties: Accept professional accountability; Take reasonable care of health and safety at work; Act in accordance with the express and implied terms of the employment contract; Not to discriminate against patients or staff; Protect confidentiality; Be honest and truthful. Staff Statement of Confidentiality ; Staff comply with Professional Codes of Conduct /Professional Regulatory Body registration. JNCC minutes (Feb 2010) Personnel and Development Directorate Page 19 of 37

20 Personnel and Development Directorate Page 20 of 37

21 South West Strategic Health Authority NHS Constitution Baseline Assessment (draft) Revised to include Staff rights, expectations and legal duties This baseline assessment toolkit is intended to help NHS South West organisations to: assess their position in relation to the 39 rights and pledges specific to working with patients and local communities; report on actions from NHS South West Conference held on 11 December 2009 assess the workforce information relating to the staff rights, pledges and expectation, taking into account the National NHS Health & Well-being Review The Booorman Report. The assessment will also enable the South West Strategic Health Authority to report to the Department of Health on regional progress. For each action (A), pledge (P) and right (R) a short minimum assurance statement has been included. You may wish to add other sources of assurance statements into these boxes. Please Red/Amber/Green rate your organisation against each of these statements to demonstrate level of. Where a right or pledge is only relevant to Primary Care Trusts this is reflected in the assurance statement. Primary Care Trusts If your organisation is not fully compliant with a particular assurance statement please indicate what actions you will take to reach, by what date and include a named lead Director responsible for the actions. You only need to Red/Amber/Green rate each action (A), pledge (P) and right (R) overall. Please also include any other sources of evidence you can identify. For the other rights and pledges your evidence should offer clear justification for each rating. When the completed assessment has been agreed by your Board it should be returned to Jo Perry, Deputy Director of Corporate Affairs, South West Strategic Health Authority by 26 February Personnel and Development Directorate Page 21 of 37

22 If you have any questions or require further guidance please contact Jo Perry on or Name of organisation PATIENT RIGHTS/PLEDGES 1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the NHS Constitution. The Primary Care Trust has a process in place to trigger referral to alternative providers if waiting times are exceeded. Quarterly National Reporting Systems to the SHA on Waiting Times. 2. You have the right to drugs and treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you. The Primary Care Trust has a process in place to ensure that NICE recommendations are implemented. Quarterly report to the SHA. 3. You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme. 4. The NHS commits to provide programmes as recommended by the UK Screening Committee The Primary Care Trust commissions a vaccination programme in line with the recommendations of the Joint Committee on Vaccination and Immunisation. The Primary Care Trust commissions a screening programme in line with the recommendations of the UK Screening Committee. Quarterly performance reports to the SHA on MMR and Flu vaccines and VSB10 (Immunisation). Monthly data to the Health Protection Agency on vaccines. Quarterly report to the SHA and VSA09 (Breast), VSA10 (Bowel), VSA15 (Cervical). 5. You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned Fundamental NHS principle. Evidence not required but please confirm. Personnel and Development Directorate Page 22 of 37

23 by Parliament. 6. You have the right to access NHS services. You will not be refused access on unreasonable grounds. A formal policy for dealing with violent and abusive patients has been adopted. 7. You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary. The Primary Care Trust has undertaken a Joint Strategic Needs Assessment as part of the development and implementation of its Local Strategic Plan. 8. You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner. The Primary Care Trust has a process in place to manage the commissioning of treatments from European Economic Area countries. 9. You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age. A single equalities scheme has been adopted, implemented and is monitored. 10. The NHS commits to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered. Communications and engagement plans include actions to ensure decision making is communicated and understood. 11. The NHS commits to make the transition as smooth as possible when you are referred between services, and to include you in relevant Patient pathways include processes to ensure effective transitions between services and organisations. Personnel and Development Directorate Page 23 of 37

24 discussions. 12. You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality. Knowledge and Skills Frameworks for all staff are in place. The PCT only commissions from providers who have full CQC registration. 13. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. Reporting to the SHA on: NPSA reporting system Annual Survey VSB 15 Reported against ambitions National Reporting Systems. There is a health-economy agreed plan for further measureable improvement against these domains. 14. The NHS commits to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice. Health services are provided in a clean and safe environment as reported to the Care Quality Commission and in accordance with the requirements of the Health and Safety Executive. Monthly reporting of HCA1 database to the Health Protection Agency VSA01 (MRSA) and VSA03 (CDiff). Personnel and Development Directorate Page 24 of 37

25 15. The NHS commits to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments. A measureable improvement can be shown against the five NHS South West domain of quality, which are: Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. Reports to the SHA on: NPSA Reporting System Annual Survey VSB 15 Reporting against ambitions National reporting system. There is a health-economy agreed plan for further measureable improvement against these domains. There is a clear programme for publicising progress against both existing quality improvement projections and plans for measureable quality improvement in the future. 16. You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you or your doctor feel would be right for A process to manage decisions concerning the provision of exceptional treatments is in place. A robust process is in place to make decisions on funding new Personnel and Development Directorate Page 25 of 37

26 you, they will explain that decision to you. medicines and other treatments. The PCT publishes clear information on the processes for local decision making, individual funding requests and the appeals process. 17. You have the right to be treated with dignity and respect, in accordance with your human rights. A privacy, dignity and respect policy/statement has been adopted. VSB15 (Patient experience) and VSB16 (public confidence). 18. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests. A policy on obtaining informed consent has been adopted. Reports on mixed sex accommodation. 19. You have the right to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing. Procedures are in place to ensure that patients are able to make informed decisions about proposed treatments. Patient information is regularly reviewed and updated. 20. You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure. A records management policy has been adopted. The policy includes specific actions to ensure that confidential information is kept secure. Reports to the SHA on completion of the Information Governance Toolkit. 21. You have the right of access to your own health records. These will Procedures are in place to provide access to health records Personnel and Development Directorate Page 26 of 37

27 always be used to manage your treatment in your best interests. on request. A process to manage complaints relating to access to health records is in place. 22. The NHS commits to share with you any letters sent between clinicians about your care. Procedures are in place to ensure that clinician s letters are shared with patients. 23. You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons. There is a clear procedure in place for the public to register with the GP of their choice. VSA06 (GP Access). 24. You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply. Patient information on how to register with a GP includes this provision. 25. You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs. The Primary Care Trust has arrangements in place to: ensure that patients who need an elective referral are offered a choice of any clinically appropriate provider; National Choice Survey. Monthly Choose and Book information for 18 weeks reported to the SHA. ensure that where a patient has not been offered that choice, and notifies the Primary Care Trust that they have not been offered that choice, that patient may choose any clinically appropriate secondary care provider. Personnel and Development Directorate Page 27 of 37

28 26. The NHS commits to inform you about the healthcare services available to you, locally and nationally. The Primary Care Trust communication plan includes actions to provide up to date information on healthcare services. 27. The NHS commits to offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available. The communications plan includes actions to ensure decision making is communicated and understood. 28. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this. Procedures are in place to ensure that patients are routinely involved in discussions and decisions about their healthcare. 29. You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services. Communications, engagement and stakeholder relations plans include actions to ensure appropriate and proportionate involvement of patients and the public in service planning, development or change. 30. The NHS commits to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services. 31. The NHS commits to work in partnership with you, your family, carers and representatives. Communications, engagement and stakeholder relations plans include the provision of clear and accessible information on planning and delivery of NHS services. Working in partnership with families, carers and representatives is part of the engagement plan. 32. You have the right to have any complaint you make about NHS services dealt with efficiently and to A complaints policy has been adopted. Personnel and Development Directorate Page 28 of 37

29 have it properly investigated. 33. You have the right to know the outcome of any investigation into your complaint. The complaints policy includes procedures to ensure the communication of the outcomes of complaints investigations. 34. You have the right to take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS. The complaints policy, complaints literature and letters to complainants provide information on how to take complaints to the Health Services Ombudsman. 35. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body. This is a legal right and as such does not require an assurance statement. Rating not required 36. You have the right to compensation where you have been harmed by negligent treatment. 37. The NHS commits to ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment. A procedure for managing compensation payments is in place. The complaints policy includes access to support and reassurance of the impact of a complaint on future treatments. Complaints handling is monitored. 38. The NHS commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively. A clear process to provide timely information, feedback and apologies is in place. This is monitored and reported as part of the formal process for receiving and acting on lessons arising from complaints, claims or PALS. Personnel and Development Directorate Page 29 of 37

30 39. The NHS commits to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services. A formal process to receive and act on lessons arising from complaints, claims or PALS is in place. This process links directly to the Board. Personnel and Development Directorate Page 30 of 37

31 ACTIONS FROM SOUTH WEST NHS CONSTITUTION CONFERENCE & STAFF RIGHTS/EXPECTATIONS AND LEGAL DUTIES Actions arising from NHS South West Constitution Conference held 11 December 2009 A1 NHS Boards must identify a Board level lead on the NHS Constitution Board Level Champion identified; Board Report Fully compliant NHS Board Champion is: Mrs Carolyn Mills Director of Nursing Name Job Title: Actions arising from NHS South West Constitution Conference held 11 December 2009 Not relevant A2 Primary Care Trusts need to identify an NHS Constitution Champion to promote the Constitution and to act as an advocate on behalf of the public A3 Primary Care Trusts need to work with NHS Providers and Third Sector organisations to ensure they have regard to the NHS Constitution in their activity for the NHS. A4 NHS organisations need to sign up to the NHS South West Communications Strategy [attached] NHS Constitution Champion identified; The organisation has a framework in place. The organisation has implemented a Communications and engagement plan based on NHS South West Communications Strategy. Board Report Board Compliance report. Board Compliance report. Organisational Communications strategy approved by board in 2008 Not relevant Fully compliant Primary Care Trust Champion is: Name Job Title: A5 Staff work with staff-side representatives to ensure with the Staff Pledges and Rights in the NHS Constitution The NHS Constitution forms part of regular agenda at Staff-side and Staff Engagement meetings Board Compliance Report; JNCC Engagement Meetings; Values and vision Fully compliant Personnel and Development Directorate Page 31 of 37

32 engagement events STAFF PLEDGES, RIGHTS, EXPECTATIONS & LEGAL DUTIES P1 Provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities. The organisation has an up-todate job description in place for all staff, which clearly outlines their roles and responsibilities; The organisation will introduce the NHS Constitution in future Job Descriptions/person specifications. Job descriptions are and continue to be evaluated under the Agenda for Change Terms and Conditions for Job Evaluation [except Medical and dental staff]; The organisation has promoted the NHS Constitution to all staff within the organisation. Board report confirming with the NHS Constitution for Staff rights and pledges. Confirmation of application of National Agenda for Change Job Evaluation, or equivalent Job Evaluation process for FTs. Banding process in place, consistency checking processes. Generic job descriptions for majority of posts. NHS Constitution is incorporated into the organisations Induction arrangements; NHS constitution is incorporated into OD plan Partially compliant Maureen Bignell Director of Personnel and Develom Board report for April 2010 Induction processes to be developed further to incorporate NHS constitution April 2010 NHS staff rights and NHS values to be incorporated into recruitment literature and promoted on job website and intranet April 2010 Joint work to be undertaken with staff reps and wider staff to finalise staff charter NHS Constitution is promoted on Trust Intranet; May 2010 The organisation has a Staff Charter, outlining staff rights, pledges and responsibilities. The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on: Guidance to managers to support discussions during appraisal process to ensure that staff have a understanding where there roles makes a difference to patients Personnel and Development Directorate Page 32 of 37

33 KP3: % of staff feeling valued by work colleagues KP4: % of staff agreeing that they have an interesting job KP7 % of staff working in a well-structured team environment Using e-rostering and workforce reports analayse working hours of staff P2 Provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed. The organisation has in place for all staff a personal development pan, supported by an individual KSF outline [for Agenda for Change staff]; The organisation has in place a mechanism which defines the relevant mandatory and developmental training required for specific roles; The personal development plan clearly outlines appropriate development training to support the employee; The organisation has in place appropriate training providers [internal /external] and training prospectus to satisfy individual and job requirements. Board report on CARE QUALITY COMMISSION standards and with staff receiving appraisal and personal development plans. Evidence of an Organisational Training Plan based on PDPs. Evidence of an organisational Training programme and/prospectus. Staff attitude survey results demonstrate Trust is in highest 20% in: Number of staff appraised, having PDPs and having support from immediate managers The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on: KF13 - % of staff appraised in last 12 months KF15 - % appraised with PDPs in place KF16 support from immediate managers Partially compliant Guidance to managers to facilitate a discussion on what opportunities are available to develop potential. P3 Provide support and opportunities for The organisation has arrangements in place either by Internal Occupational Health service Partially compliant Health and Well-being to be Personnel and Development Directorate Page 33 of 37