Attachment 4. Report to. Board of Directors. Date 28 March Title. Care Quality Commission (CQC) Inspection Improvement Plan. Sponsoring Director

Save this PDF as:
Size: px
Start display at page:

Download "Attachment 4. Report to. Board of Directors. Date 28 March 2014. Title. Care Quality Commission (CQC) Inspection Improvement Plan. Sponsoring Director"

Transcription

1 Attachment 4 Report to Board of Directors Date 28 March 2014 Title Sponsoring Director Author Previously considered by Executive Summary Care Quality Commission (CQC) Inspection Improvement Plan Medical Director and Director of Nursing, Quality and Patient Experience Anna Hills, Associate Director of Governance, Safety and Compliance N/A This report provides the Board of Directors with an update on progress towards implementing the improvement plan following the recent CQC inspection. The Board of Directors is asked to approve this report and to confirm that: 1. Suitable controls to prevent the risks to achievement of strategic objectives 1 and 2 materialising are in place or there are gaps in controls; 2. There is assurance that these controls are operating effectively or there are gaps in assurance; 3. Actions to address the gaps in controls and assurance should be identified and monitored by the Safety and Quality Governance Committee; 4. The Board Assurance Framework should be updated from the discussions as above. Related Trust objective 2013/14 Legal implications/ regulatory requirement Report for: 1. CQC standards X 2. Patient experience X 3. Values and behaviours framework 4. Staff performance framework 5. Partnership/community working for joined up services 6. Improved management structure 7. Financial performance Monitor, Care Quality Commission, HSE. Approval CQC improvement plan Anna Hills, Associate Director of Governance, Safety and Compliance March 2014 REP/BOD/AH1803/V1 Page 1 of 2

2 Introduction The Care Quality Commission undertook a routine unannounced inspection of the James Paget Hospital on 27 th and 28 th November In February 2014 the Board received and approved the improvement action plan in response to this inspection. Detailed findings, plan and progress report Regulation 13 HSCA 2008 (Regulated Activities) Regulations (CQC Outcome 9)Management of Medicines Moderate Concern All actions are progressing. A new action has been added, which is to undertake an assessment of improvement on March 31 st using our external review processes. Regulation 20 HSCA 2008 (Regulated Activities) Regulations (CQC Outcome 21) Records- Minor Concern Three of the four actions have been completed. The outstanding action is the completion of the plan to improve the quality and completeness of medical records. This is owned by the Medical Director who has implemented further measures to improve engagement of Consultants with this requirement. The Director of Nursing, Quality and Patient Experience is the lead for the recovery plan and each action is owned by an Executive or Assistant Director. The actionees are staff with responsibility for undertaking each action. Progress is monitored weekly by the Executive Team, with the CQC Monitoring Group, meeting fortnightly, to manage progress. Recommendation The Board of Directors is asked to approve this report and to confirm that: 1. Suitable controls to prevent the risks to achievement of strategic objectives 1 and 2 materialising are in place or there are gaps in controls; 2. There is assurance that these controls are operating effectively or there are gaps in assurance; 3. Actions to address the gaps in controls and assurance should be identified and monitored by the new Safety and Quality Governance Committee; 4. The BAF should be updated from the discussions as above CQC improvement plan Anna Hills, Associate Director of Governance, Safety and Compliance March 2014 REP/BOD/AH1803/V1 2

3 ACTION PLAN FOLLOWING CQC Inspection Dec 2013 Dated: 18/03/2014 Version: 1.0 Aim: The aim of this action plan is to ensure delivery of the improvement actions identified as a result of a CQC Inspection in November Content: This action plan captures all of the actions agreed by management as detailed within the final report and includes responsibilities and timescales for delivery. Responsibility for delivery: The Executive Director and Non-Executive Director leads for Medicine and Nursing are responsible for the delivery of this action plan. Monitoring: Delivery of this action plan will be monitored by the Trust s CQC Monitoring Group. Key for RAGBW rating of Actions: (W)hite = Not yet started (G)reen = Completed (A)mber = In progress (R)ed = Due but not complete (B)lue = Ongoing monitoring to be assured of continued achievement ID Action Required Responsibility Timescale RAG Comments 1 Outcome 9 Medicines Management- Director of Nursing, Quality and Patient Experience 1a 1b 1c 1d Improve compliance to standards of medicines management by providing pharmacy support to wards. Develop and execute a risk based plan Improve the safety and quality of the patient experience by ensuring all clinical staff demonstrate concordance with policies and codes of practice. Staff to be made aware of the report and reminded of the requirement to adhere at all times by letter and meeting Take immediate action to ensure that prescribing and administration practice is in accordance with standards and SOPs by issuing written guidance regarding PRN prescriptions. Review the Board/Ward round processes to confirm that MDTs are proactively progressing discharge plans. Pharmacist Pharmacist/ Deputy Director of Nursing, Safety Director of Nursing/ Medical Director Safety/ Deputy Director of Nursing Action on track. Pharmacist has provided a risk based plan for developing the pharmacy service. Pharmacy work has been rebalanced and wards 1, 2, ACU, EADU, SSMU, ICU, 6, 12, 15 and 17 are receiving a daily service. The available resources are flexed whenever contingencies are required to cover shortfalls Action Completed. Directors of Medicine and Nursing each held clinical summit meetings with their senior staff and reminded them of their respective duties Action Completed. The Pharmacist has initiated regular newsletter called OWL (Organisation Wide Learning) which includes this guidance as the first item Action Completed. Spot check shows the Board Round/Ward Round process is inconsistent. This matter to be resolved by divisions. 18/03/2014 pg. 1

4 ID Action Required Responsibility Timescale RAG Comments 1e 1f 1g 1h 1i 1j Reduce discharge delays attributable to provision of TTO medicines. Audit the ward and pharmacy processes, act on findings. Improve the patient experience by providing timely information about medicines during admission and at discharge. Improve the patient experience by providing staff with information about the referral process. Improve medicines security by making sure all combination locks which protect medicines are changed on a six monthly basis Improve the safety of PRN prescriptions by issuing guidance to prescribers. Establish forward audit plan of Standards for Medicines Management. 1k New Action Divisions to communicate a clear message through Lead Nurses and Matrons/ Ward Managers that nurses and members of the MDT must ensure that the process of providing patients with TTO s must be prioritised within their daily work plan. Pharmacist/ Director of Quality and Safety Pharmacist/ Director of Quality and Safety Pharmacist/ Director of Quality and Safety Pharmacist Audit method agreed Audit to take place during March. Revised deadline April 11 th Decision made to introduce a credit card style information measure which will be given to every patient. New implementation date Action on track. Posters to advertise the service have been designed for staff and a poster for patients is to be produced for general display Action complete. Plan in place to change every six months. Medical Director Action complete Pharmacist has issued the guidance within a Medicines OWL. Pharmacist 2 Outcome 21 Records- Director of Nursing, Quality and Patient Experience 2a 2b 2c Improve the completeness and quality of medical record keeping by reinforcing the framework for Formative Ward Rounds. Improve the completeness of nursing and MDT records by reinforcing the share your care process. Improve the completeness of the healthcare record by ensuring that wound photographs are filed in the patient documentation so that they are accessible to all members of Divisional Managers Deputy Director of Nursing Deputy Director of Nursing Action on track Pharmacist has developed 3 audit tools and training for pharmacists has started Revised deadline agreed at meeting on for all Consultants except Obs and Gynae who will complete to a different timescale Action complete. Implementation of SYC has been reinforced at meetings and 1:1 s with Matrons and Ward Managers Action complete. 18/03/2014 pg. 2

5 ID Action Required Responsibility Timescale RAG Comments 2d the healthcare team. Review how we present audit results to make it more impactful and easier for staff to identify areas needing improvement. Compliance Manager Action complete. Reports are sent with a reminder to the recipient that the detail must be shared with the team. 3 Outcome 2 Consent- Director of Nursing, Quality and Patient Experience- the provider may wish to note 3a 3b Improve the completeness of the consent process by ensuring that patients are provided with information with which to give their informed consent. Letter has been sent to all Consultant Surgeons to remind them of the requirement to provide information as part of the consent process. Improve the adequacy of the consent process by ensuring that staff taking consent act in accordance with best practice guidance with regards to mental capacity. Review training and address any gaps The CQC Monitoring Group agreed further actions as follows: Re-audit to be conducted to test effectiveness of this action. i Review the Consent Policy DD Elective Compliance Manager has agreed to support the DD Elective by undertaking a stakeholder consultation and reviewing the underpinning legislation in case it has changed since the policy was last published. ii Urgently review and implement Form 4. DDN Copping DDM/Elective iii Send controlled stationary communication to surgeons re information leaflets MD The review of Form 4 is complete. Now need to move to implementation stage. iv v Review the Mandatory Training uptake for Consent for medical staff Plan and deliver a training session which will address gaps in iv To be identified once scale of task is confirmed. This action cannot be started until we know the scope of the issue at iv. 18/03/2014 pg. 3

6 ID Action Required Responsibility Timescale RAG Comments V1 3c Design and implement a Competency Questionnaire to demonstrate learning. Improve the completeness of DNAR forms so that there is clear evidence of patient/carer involvement as appropriate to the mental capacity of the patient. Will complement action iv This action cannot be started until we know the scope of the issue at iv A flow chart has been designed to guide staff in the decision making process. Nursing and medical staff have been made aware that their practice must improve and the impact of this needs some further discussion. DQS leading on this matter. 3d New action Update Resuscitation Policy to reflect changes in DNAR decision making policies and guidance. Senior Resuscitation Officer st version to be completed by 21/03/14 and final version to be presented to Resuscitation committee on Outcome 16 Assess and monitor the quality of services 4a Check that the actions in this plan have had the required impact and that our services are compliant to the required standards. Director of Nursing, Quality and Patient Experience The next external review/corporate audits will focus specifically on these outcomes and will provide us with an evidence base of impact. This is due to take place March 31 st /03/2014 pg. 4

Mental Health. Bulletin. Introduction. Physical healthcare. September 2015

Mental Health. Bulletin. Introduction. Physical healthcare. September 2015 Mental Health September 2015 Bulletin Introduction Welcome to the second edition of the Mental Health Bulletin. In this issue we again look at some of the themes from recent inspections, as well as share

More information

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW.

Review of compliance. Redcar and Cleveland PCT Redcar Primary Care Hospital. North East. Region: West Dyke Road Redcar TS10 4NW. Review of compliance Redcar and Cleveland PCT Redcar Primary Care Hospital Region: Location address: Type of service: Regulated activities provided: Type of review: Date of site visit (where applicable):

More information

Document Details Title. Early Warning Score Protocol for Community Hospitals and Prisons to detect the Deteriorating Patient

Document Details Title. Early Warning Score Protocol for Community Hospitals and Prisons to detect the Deteriorating Patient Document Details Title Early warning Score Protocol for community Hospitals and Prisons to Detect the Deteriorating Patient Trust Ref No 1558-29748 Local Ref (optional) Main points the document This protocol

More information

Head of Internal Audit:

Head of Internal Audit: Head of Internal : Opinion on the effectiveness of the system of Internal Control at Northern Devon Healthcare NHS Trust for the year ended 31 March 2010 Roles and responsibilities The whole Board of Directors

More information

Policy for Care Quality Commission Essential standards of quality and safety self assessment and assurance process

Policy for Care Quality Commission Essential standards of quality and safety self assessment and assurance process Policy No: RM76 Version: 1.1 Name of Policy: Essential standards of quality and safety self assessment and assurance process Effective From: 25/04/2013 Date Ratified 15/03/2013 Ratified Patient, Quality,

More information

Summerfield Medical Limited

Summerfield Medical Limited Summerfield Medical Limited Summerfield Nursing Unit Inspection report 58 Whittington Road Cheltenham GL51 6BL Tel: 01242 259260 Website: www.summerfieldnursing.co.uk Date of inspection visit: 1 and 2

More information

R&D Administration Manager. Research and Development. Research and Development

R&D Administration Manager. Research and Development. Research and Development Document Title: Document Number: Patient Recruitment SOP031 Staff involved in development: Job titles only Document author/owner: Directorate: Department: For use by: RM&G Manager, R&D Administration Manager,

More information

REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 2015

REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 2015 Enc L REPORT TO THE TRUST BOARD OF DIRECTORS MEETING HELD IN PUBLIC ON 24 FEBRUARY 21 INTEGRATED GOVERNANCE REPORT Trust objectives supported by this paper To provide healthcare of the highest standard

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Lindsay House 110-116 Lindsay Avenue, Abington, Northampton,

More information

CONTROLLED DOCUMENT. Number: Version Number: 4. On: 25 July 2013 Review Date: June 2016 Distribution: Essential Reading for: Information for:

CONTROLLED DOCUMENT. Number: Version Number: 4. On: 25 July 2013 Review Date: June 2016 Distribution: Essential Reading for: Information for: CONTROLLED DOCUMENT Risk Management Strategy and Policy CATEGORY: CLASSIFICATION: PURPOSE: Controlled Number: Document Version Number: 4 Controlled Sponsor: Controlled Lead: Approved By: Document Document

More information

Medicines reconciliation on admission and discharge from hospital policy April 2013. WHSCT medicines reconciliation policy 1

Medicines reconciliation on admission and discharge from hospital policy April 2013. WHSCT medicines reconciliation policy 1 Medicines reconciliation on admission and discharge from hospital policy April 2013 WHSCT medicines reconciliation policy 1 Policy Title Policy Reference Number Medicines reconciliation on admission and

More information

Data Quality Rating BAF Ref Impact on BAF Risk Rating

Data Quality Rating BAF Ref Impact on BAF Risk Rating Board of Directors (Public) Item 6.4 Subject: Annual Review of Complaints Process Date of meeting: 28 th April, 2015 Prepared by: Lisa Gurrell Patient and family support Manager Presented by: Sue Pemberton

More information

Poole Hospital NHS Foundation Trust Report template

Poole Hospital NHS Foundation Trust Report template Report template Audit and Governance Committee Meeting Date of meeting: 11/11/2015 Chairman: Jean Lang Deloitte Audit Plan 2015/2016 Internal Audit Progress Report Risk Register new reds and amber risks

More information

THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT

THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT THE UNIVERSITY OF MANCHESTER PARTICULARS OF APPOINTMENT FACULTY OF MEDICAL & HUMAN SCIENCES MANCHESTER PHARMACY SCHOOL CENTRE FOR PHARMACY POSTGRADUATE EDUCATION Lead Pharmacy Technician, Learning Development

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Royal Free Hospital Urgent Care Centre Royal Free Hospital,

More information

SAFER Patient Flow Bundle

SAFER Patient Flow Bundle SAFER Patient Flow Bundle The patient flow bundle is similar to a clinical care bundle. It is a combined set of simple rules for adult inpatient wards to improve patient flow and prevent unnecessary waiting

More information

Guidance document for EMIS Web EPS Release 2 deployment

Guidance document for EMIS Web EPS Release 2 deployment Guidance document for EMIS Web EPS Release 2 deployment Crown Copyright 2011 Contents Guidance document for EMIS Web EPS Release 2 deployment... 1 1 Introduction... 4 1.1 Background... 4 1.2 Purpose...

More information

Central Alert System (CAS) Policy and Procedure

Central Alert System (CAS) Policy and Procedure Central Alert System (CAS) Policy and Procedure POLICY NUMBER Risk, Health & Safety.068 POLICY VERSION RATIFYING COMMITTEE Professional Practice Forum Most Recent DATE RATIFIED 26 April 2015 DATE OF EQUALITY

More information

Delivering Local Health Care

Delivering Local Health Care Delivering Local Health Care Accelerating the pace of change Delivering Local Integrated Care Accelerating the Pace of Change WG 17711 Digital ISBN 978 1 0496 0 Crown copyright 2013 2 Contents Joint foreword

More information

North Middlesex University Hospital NHS Trust. Annual Audit Letter 2005/06. Report to the Directors of the Board

North Middlesex University Hospital NHS Trust. Annual Audit Letter 2005/06. Report to the Directors of the Board North Middlesex University Hospital NHS Trust Annual Audit Letter 2005/06 Report to the Directors of the Board 1 Introduction The Purpose of this Letter 1.1 The purpose of this Annual Audit Letter (letter)

More information

Clinical, Quality and Safety Report. Public Board Meeting

Clinical, Quality and Safety Report. Public Board Meeting Title: Report to: Clinical, Quality and Safety Report Trust Board Date: 27 January 2014 Security Classification: Public Board Meeting Purpose of Report: The purpose of the Clinical, Quality and Safety

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Sunrise Operations of Westbourne 16-18 Poole Road, Westbourne,

More information

Review of compliance. Florence Nightingale Hospitals Limited Capio Nightingale Hospital. London. Region: 11-19 Lisson Grove Marylebone London NW1 6SH

Review of compliance. Florence Nightingale Hospitals Limited Capio Nightingale Hospital. London. Region: 11-19 Lisson Grove Marylebone London NW1 6SH Review of compliance Florence Nightingale Hospitals Limited Capio Nightingale Hospital Region: Location address: Type of service: London 11-19 Lisson Grove Marylebone London NW1 6SH Diagnostic and/or screening

More information

Board of Directors 22 nd May 2015

Board of Directors 22 nd May 2015 AGENDA ITEM: Item 14 Board of Directors 22 nd May 2015 PRESENTED BY: PREPARED BY: Jan Bloomfield, Executive Director of Workforce and Communications Denise Needle, Deputy Director of workforce (Development)

More information

Minutes of the meeting of the Integrated Governance Committee (IGC) Held on the 19 January 2012 Trust Headquarters, Springfield University Hospital

Minutes of the meeting of the Integrated Governance Committee (IGC) Held on the 19 January 2012 Trust Headquarters, Springfield University Hospital Minutes of the meeting of the Integrated Governance Committee (IGC) Held on the 19 January 2012 Trust Headquarters, Springfield University Hospital Present: Professor R Horton Non-Executive Director (Chair)

More information

Assessment modules. Australian Government Australian Aged Care Quality Agency. www.aacqa.gov.au

Assessment modules. Australian Government Australian Aged Care Quality Agency. www.aacqa.gov.au Assessment modules Australian Government Australian Aged Care Quality Agency www.aacqa.gov.au Assessment module compilation October 2014 Australian Aged Care Quality Agency 2014 ISSN 2204 1796 (print)

More information

Job Description. Professionally accountable to the Medical Director with respect to Trust-wide Medicines Optimisation.

Job Description. Professionally accountable to the Medical Director with respect to Trust-wide Medicines Optimisation. Job Description JOB DETAILS Job Title: Chief of Pharmacy Band: 9 Hours: 37.5 Department / Ward: Directorate: Pharmacy Cross Site Central Clinical Services ORGANISATIONAL ARRANGEMENTS Operationally accountable

More information

GENERAL PRACTICE BASED PHARMACIST

GENERAL PRACTICE BASED PHARMACIST GENERAL PRACTICE BASED PHARMACIST JOB PURPOSE Provide expertise in clinical medicines review 1 and address public health and social needs of patients in GP practices Reduce inappropriate poly-pharmacy

More information

Acute services with overnight beds Rehabilitation services Date of Publication: October 2012

Acute services with overnight beds Rehabilitation services Date of Publication: October 2012 Review of compliance East Sussex Healthcare NHS Trust Irvine Unit Bexhill Hospital Region: Location address: Type of service: South East Holliers Hill Bexhill-on-Sea East Sussex TN40 2DZ Acute services

More information

Introduction 2. 1. The Role of Pharmacy Within a NHS Trust 3. 2. Pharmacy Staff 4. 3. Pharmacy Facilities 5. 4. Pharmacy and Resources 6

Introduction 2. 1. The Role of Pharmacy Within a NHS Trust 3. 2. Pharmacy Staff 4. 3. Pharmacy Facilities 5. 4. Pharmacy and Resources 6 Index Index Section Page Introduction 2 1. The Role of Pharmacy Within a NHS Trust 3 2. Pharmacy Staff 4 3. Pharmacy Facilities 5 4. Pharmacy and Resources 6 5. Prescription Charges 7 6. Communication

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Kumari Care Limited 5 Palace Yard Mews, Queen Square, Bath,

More information

MENTAL HEALTH AND LEARNING DISABILITY ANNOUNCED INSPECTION. Downe Acute Inpatient Unit. South Eastern Health and Social Care Trust

MENTAL HEALTH AND LEARNING DISABILITY ANNOUNCED INSPECTION. Downe Acute Inpatient Unit. South Eastern Health and Social Care Trust MENTAL HEALTH AND LEARNING DISABILITY ANNOUNCED INSPECTION Downe Acute Inpatient Unit South Eastern Health and Social Care Trust 9 and 10 May 2012 1 Table of Contents 1.0 Introduction... 3 2.0 Ward Profile...

More information

Board of Directors Meeting in Public: 15 May 2014

Board of Directors Meeting in Public: 15 May 2014 Item No: 15 Board of Directors Meeting in Public: 15 May 2014 Report Title: Talent Management Executive/NED Lead: Director of HR and OD Report author(s) Sarah Shirtcliff and Rachel Jackson Approval Discussion

More information

Hospital pharmacy technician role / service definition grid

Hospital pharmacy technician role / service definition grid Hospital pharmacy technician role / service definition grid To be a competent hospital pharmacy technician, you must be able to complete the required task to the defined standard and to do this on every

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. The Manor House Whitton Road, Alkborough, Nr Scunthorpe, DN15

More information

Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks

Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks Review of compliance Rotherham, Doncaster and South Humber NHS Foundation Trust Great Oaks Region: Location address: Type of service: Yorkshire & Humberside Ashby High Street Scunthorpe Lincolnshire DN16

More information

National Occupational Standards. Compliance

National Occupational Standards. Compliance National Occupational Standards Compliance NOTES ABOUT NATIONAL OCCUPATIONAL STANDARDS What are National Occupational Standards, and why should you use them? National Occupational Standards (NOS) are statements

More information

www.uhs.nhs.uk/commercial

www.uhs.nhs.uk/commercial Sue Ladds & Mark Pepperrell Chief Pharmacist & Deputy Chief Pharmacist University Hospital Southampton NHS Foundation Trust www.nhs.uhs.uk/commercial Medicines and Technology Medicines are the most common

More information

Version No: 2 Date: 27 July 2015. Data Quality Policy. Assistant Chief Executive. Planning & Performance. Data Quality Policy

Version No: 2 Date: 27 July 2015. Data Quality Policy. Assistant Chief Executive. Planning & Performance. Data Quality Policy Version No: 2 Date: 27 July 2015 Data Quality Policy Assistant Chief Executive Planning & Performance Data Quality Policy Contents 1. Summary Statement 2. Context 3. Purpose 4. Scope 5. Detail of the policy

More information

OPEN BOARD OF DIRECTORS 2 nd December 2015

OPEN BOARD OF DIRECTORS 2 nd December 2015 OPEN BOARD OF DIRECTORS 2 nd December 2015 Open BoD: 02.12.15 Item: 13 TITLE OF PAPER TO BE PRESENTED BY ACTION REQUIRED Nurse Revalidation Progress Report Clive Clarke, Deputy Chief Executive, on behalf

More information

Job Description Nurse Practitioner

Job Description Nurse Practitioner Job Description Nurse Practitioner The post holder is responsible for the delivery of general practice nursing to the whole practice population and specialised care to patients with HIV, their carers,

More information

Health Information and Quality Authority Regulation Directorate

Health Information and Quality Authority Regulation Directorate Health Information and Quality Authority Regulation Directorate Compliance Monitoring Inspection report Designated Centres under Health Act 2007, as amended Centre name: Centre ID: Kilbrew Recuperation

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Warrington Hospital Lovely Lane, Warrington, WA5 1QG Tel: 01925635911

More information

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST Appendix A PERFORMANCE MANAGEMENT FRAMEWORK Corporate Performance Document PATIENT EXPERIENCE CSF 1: Measure and exceed patient expectations, improving the

More information

Nursing & Midwifery Learning Disability Liaison Nurse Acute Services Band 7 subject to job evaluation. Trustwide

Nursing & Midwifery Learning Disability Liaison Nurse Acute Services Band 7 subject to job evaluation. Trustwide PLYMOUTH HOSPITALS NHS TRUST JOB DESCRIPTION Job Group: Job Title: Existing Grade: Directorate/Division: Unit: E.g., Department, Area, District Location: Reports to: Accountable to: Job Description last

More information

Summerfield Medical Limited

Summerfield Medical Limited Summerfield Medical Limited Summerfield Nursing Unit Inspection report 58 Whittington Road Cheltenham Gloucestershire GL51 6BL Tel: 01242259260 Website: www.summerfieldnursing.co.uk Date of inspection

More information

Advanced Nurse Practitioner JD October 2013 East Cheshire Hospice HK

Advanced Nurse Practitioner JD October 2013 East Cheshire Hospice HK EAST CHESHIRE HOSPICE (ECH) JOB DESCRIPTION JOB TITLE: DEPARTMENT: ADVANCED NURSE PRACTITIONER CLINICAL SERVICES PROFESSIONALLLY ACCOUNTABLE TO: HEAD OF CLINICAL & OPERATIONAL SERVICES BAND: 6 / 7 DEPENDENT

More information

JOB DESCRIPTION. Corporate Governance Manager. 45 hours per week. Director of Compliance & Governance. London with national responsibilities

JOB DESCRIPTION. Corporate Governance Manager. 45 hours per week. Director of Compliance & Governance. London with national responsibilities JOB DESCRIPTION POST: SALARY: HOURS: REPORTS TO: LOCATION: Corporate Governance Manager 40,000 per annum 45 hours per week Director of Compliance & Governance London with national responsibilities JOB

More information

APPENDICES TO APPEAR ONLINE. Appendix 1 Systematic review search strategies

APPENDICES TO APPEAR ONLINE. Appendix 1 Systematic review search strategies APPENDICES TO APPEAR ONLINE Appendix Systematic review search strategies Key: /=MeSH term; ti=title; ab=abstract; $=truncation; *=focus of search & substitution; exp=explode; adj=adjacent to MEDLINE SEARCH

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Vision MH - Cornerstone House Barnet Lane, Elstree, WD6 3QU

More information

ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS

ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS ROLES, RESPONSIBILITIES AND DELEGATION OF DUTIES IN CLINICAL TRIALS OF MEDICINAL PRODUCTS STANDARD OPERATING PROCEDURE NO SOP 09 DATE RATIFIED 4/7/13 NEXT REVIEW DATE 4/7/14 POLICY STATEMENT/KEY OBJECTIVES:

More information

Report for the Meeting of the Trust Board of Directors Held in Public. Date of Meeting: 17 December 2013

Report for the Meeting of the Trust Board of Directors Held in Public. Date of Meeting: 17 December 2013 Report for the Meeting of the Trust Board of Directors Held in Public Date of Meeting: 17 December Enclosure: 7a Title of Report Ward Nursing Team Assurance Report November Author Executive Lead Lesley

More information

NHS Constitution Patient & Public Quarter 4 report 2011/12

NHS Constitution Patient & Public Quarter 4 report 2011/12 NHS Constitution Patient & Public Quarter 4 report 2011/12 1 Executive Summary The NHS Constitution was first published on 21 st January 2009. One of the primary aims of the Constitution is to set out

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Amvale Medical Transport - Ambulance Station Unit 1D, Birkdale

More information

Professional Standards and Guidance for the Sale and Supply of Medicines

Professional Standards and Guidance for the Sale and Supply of Medicines Professional Standards and Guidance for the Sale and Supply of Medicines About this document The Code of Ethics sets out seven principles of ethical practice that you must follow as a pharmacist or pharmacy

More information

FINANCE, PERFORMANCE AND INFORMATION DIRECTORATE INTEGRATED PERFORMANCE MANAGEMENT FRAMEWORK

FINANCE, PERFORMANCE AND INFORMATION DIRECTORATE INTEGRATED PERFORMANCE MANAGEMENT FRAMEWORK 1. Introduction FINANCE, PERFORMANCE AND INFORMATION DIRECTORATE INTEGRATED PERFORMANCE MANAGEMENT FRAMEWORK Coventry and Warwickshire Partnership NHS Trust (the Trust) recognises that the Integrated Performance

More information

Level: 3 Credit value: 5 GLH: 28 Relationship to NOS:

Level: 3 Credit value: 5 GLH: 28 Relationship to NOS: Unit 341 Implement UAN: Level: 3 Credit value: 5 GLH: 28 Relationship to NOS: Assessment requirements specified by a sector or regulatory body: Aim: T/506/1929 Management & Leadership (2012) National Occupational

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Southdowns Private Healthcare 97 Havant Road, Emsworth, PO10

More information

Safety Improvement Plan. Phao Hewitson Head of Clinical Governance

Safety Improvement Plan. Phao Hewitson Head of Clinical Governance Meeting Trust Board Date 29 th January 2015 ENC No 8 Title of Paper Lead Director Author Sign up to Safety Safety Improvement Plan Amir Khan Medical Director Phao Hewitson Head of Clinical Governance PURPOSE

More information

This Report is provided for: Decision Endorsement Assurance Information

This Report is provided for: Decision Endorsement Assurance Information Agenda item 12 Enclosure PAPER G Report to: Author: Presented by: SUBJECT: Trust Board 24 November 2014 John McIlveen, Trust Secretary John McIlveen, Trust Secretary Well-Led Framework for Governance reviews

More information

Hazard Identification, Risk Assessment and Management Procedure. Documentation Control

Hazard Identification, Risk Assessment and Management Procedure. Documentation Control Hazard Identification, Risk Assessment and Management Procedure Reference: Date approved: Approving Body: Implementation Date: Version: 3 Documentation Control GG/CM/007 Trust Board Supersedes: Version

More information

General Guidance on the National Standards for Safer Better Healthcare

General Guidance on the National Standards for Safer Better Healthcare General Guidance on the National Standards for Safer Better Healthcare September 2012 About the Health Information and Quality Authority The (HIQA) is the independent Authority established to drive continuous

More information

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic.

NICE Pathways bring together all NICE guidance, quality standards and other NICE information on a specific topic. Safe staffing for nursing in adult inpatient wards in acute hospitals overview bring together all NICE guidance, quality standards and other NICE information on a specific topic. are interactive and designed

More information

www.monitor.gov.uk Well-led framework for governance reviews: guidance for NHS foundation trusts

www.monitor.gov.uk Well-led framework for governance reviews: guidance for NHS foundation trusts www.monitor.gov.uk Well-led framework for governance reviews: guidance for NHS foundation trusts About Monitor Monitor is the sector regulator for health services in England. Our job is to protect and

More information

Guide for for (?2015/?20. Updated. 15 edition) October 2015. www.gov.uk/monitor

Guide for for (?2015/?20. Updated. 15 edition) October 2015. www.gov.uk/monitor Guide for for applicants Applicants (?2015/?20 Updated 15 edition) October 2015 www.gov.uk/monitor About Monitor As the sector regulator for health services in England, our job is to make the health sector

More information

Standard 5. Patient Identification and Procedure Matching. Safety and Quality Improvement Guide

Standard 5. Patient Identification and Procedure Matching. Safety and Quality Improvement Guide Standard 5 Patient Identification and Procedure Matching Safety and Quality Improvement Guide 5 5 5October 5 2012 ISBN: Print: 978-1-921983-35-1 Electronic: 978-1-921983-36-8 Suggested citation: Australian

More information

Decision Support Tool for NHS Continuing Healthcare User Notes

Decision Support Tool for NHS Continuing Healthcare User Notes Decision Support Tool for NHS Continuing Healthcare User Notes July 2009 1 Decision Support Tool for NHS Continuing Healthcare We have developed the Decision Support Tool (DST) to support practitioners

More information

www.monitor.gov.uk The NHS Foundation Trust Code of Governance

www.monitor.gov.uk The NHS Foundation Trust Code of Governance www.monitor.gov.uk The NHS Foundation Trust Code of Governance About Monitor Monitor is the sector regulator for health services in England. Our job is to protect and promote the interests of patients

More information

Details about this location

Details about this location Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Prince George Duke of Kent Court Shepherds Green, Chislehurst,

More information

Review of compliance. Ashbourne Homes Limited Lakeside. South East. Region: Brambling Watermead Aylesbury Buckinghamshire HP19 3WH.

Review of compliance. Ashbourne Homes Limited Lakeside. South East. Region: Brambling Watermead Aylesbury Buckinghamshire HP19 3WH. Review of compliance Ashbourne Homes Limited Lakeside Region: Location address: Type of service: South East Brambling Watermead Aylesbury Buckinghamshire HP19 3WH Care home service with nursing Date of

More information

4 CM/11/14/04 Chief Executive s report to the Board

4 CM/11/14/04 Chief Executive s report to the Board Meeting PUBLIC BOARD MEETING Date 19 November 2014 Agenda item Paper Number Item title Sponsor Author 4 CM/11/14/04 Chief Executive s report to the Board Chief Executive Naomi Paterson PURPOSE OF PAPER:

More information

RECORD KEEPING IN HEALTHCARE RECORDS POLICY

RECORD KEEPING IN HEALTHCARE RECORDS POLICY RECORD KEEPING IN HEALTHCARE RECORDS POLICY Version 6.0 Key Points The Policy provides a framework for the quality of the clinical record facilitates high quality, safe patient care and that subsequently

More information

Winterbourne View Evidence for inspection for LD Audit 23/5/2007

Winterbourne View Evidence for inspection for LD Audit 23/5/2007 Extracts relating to staff training CQC IAT 2011 0096 Winterbourne View Evidence for inspection for LD Audit 23/5/2007 Handwritten inspection notes Evidence sheets Tour and general discussion [..] Training

More information

JOB DESCRIPTION. JOB TITLE: Lead Pharmacy Technician-Grade 4. The Portland Hospital for Women and Children

JOB DESCRIPTION. JOB TITLE: Lead Pharmacy Technician-Grade 4. The Portland Hospital for Women and Children JOB DESCRIPTION JOB TITLE: Lead Pharmacy Technician-Grade 4 CLINICAL UNIT: BASE: MANAGED BY: ACCOUNTABLE TO: Pharmacy The Portland Hospital for Women and Children Pharmacy Manager Pharmacy Manager HOSPITAL

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Harrow Health Limited 37 Love Lane, Pinner, Harrow, HA5 3EE

More information

QUALITY ASSURANCE COMMITTEE - 22 June 2015 -

QUALITY ASSURANCE COMMITTEE - 22 June 2015 - laint QUALITY ASSURANCE COMMITTEE - 22 June 2015 - QAC: 22.06.15 Item: TITLE OF PAPER Complaints Quarterly Report (01 January-31 March 2015) FROM Rosie McHugh Director of Organisation Development/Board

More information

Trust Board Meeting: Wednesday 14 May 2014 TB2014.53. Nursing and Midwifery - Safe staffing levels report for the month of March 2014

Trust Board Meeting: Wednesday 14 May 2014 TB2014.53. Nursing and Midwifery - Safe staffing levels report for the month of March 2014 Trust Board Meeting: Wednesday 14 May 2014 Title Nursing and Midwifery - Safe staffing levels report for the month of March 2014 Status For information History Trust Board Seminar 21 st October 2013 Trust

More information

East & South East England Specialist Pharmacy Services Medicines Use and Safety Division Community Health Services Transcribing

East & South East England Specialist Pharmacy Services Medicines Use and Safety Division Community Health Services Transcribing East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety Division Community Health ervices Transcribing Guidance to support the

More information

MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST PHARMACEUTICAL SERVICES JOB DESCRIPTION. 75% Top Band 4 2 nd year Pharmacy Department, Leighton Hospital

MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST PHARMACEUTICAL SERVICES JOB DESCRIPTION. 75% Top Band 4 2 nd year Pharmacy Department, Leighton Hospital MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST PHARMACEUTICAL SERVICES JOB DESCRIPTION POST: BAND: LOCATION: RESPONSIBLE TO: MANAGED BY: TRAINEE PHARMACY TECHNICIAN 70% Top Band 4 1 st year 75% Top Band 4

More information

Nursing Staff Levels Board Report 2014/2015 Month 3

Nursing Staff Levels Board Report 2014/2015 Month 3 Nursing Staff Levels Board Report 2014/2015 Month 3 Item Page Background 2 Monthly Summary 3 s 4-16 Background Introduction Following the publication of the Francis Report (2013) and the Berwick Report

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Borough of Poole - Civic Centre Borough of Poole, Civic Centre,

More information

Patient Centered Medical Home (PCMH): Communication and Care Coordination

Patient Centered Medical Home (PCMH): Communication and Care Coordination Patient Centered Medical Home (PCMH): Communication and Care Coordination Phillip Roemer, MD Assistant Professor of Medicine General Internal Medicine Feinberg School of Medicine Northwestern University

More information

Informatics: The future. An organisational summary

Informatics: The future. An organisational summary Informatics: The future An organisational summary DH INFORMATION READER BOX Policy HR/Workforce Management Planning/Performance Clinical Document Purpose Commissioner Development Provider Development Improvement

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Prestige Nursing - Newcastle First & Second Floors, 22 Athenaeum

More information

Request for feedback on the revised Code of Governance for NHS Foundation Trusts

Request for feedback on the revised Code of Governance for NHS Foundation Trusts Request for feedback on the revised Code of Governance for NHS Foundation Trusts Introduction 8 November 2013 One of Monitor s key objectives is to make sure that public providers are well led. To this

More information

Information Governance and Management Standards for the Health Identifiers Operator in Ireland

Information Governance and Management Standards for the Health Identifiers Operator in Ireland Information Governance and Management Standards for the Health Identifiers Operator in Ireland 30 July 2015 About the The (the Authority or HIQA) is the independent Authority established to drive high

More information

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS MEETING HELD ON 16 MAY 2012

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS MEETING HELD ON 16 MAY 2012 B SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS MEETING HELD ON 16 MAY 2012 Subject Supporting TEG Member Lead Author Status 1 Healthcare Governance

More information

Case Study: Chesterfield Royal Hospital NHS Foundation Trust The Importance of Good Governance

Case Study: Chesterfield Royal Hospital NHS Foundation Trust The Importance of Good Governance Case Study: Chesterfield Royal Hospital NHS Foundation Trust The Importance of Good Governance Summary In March 2008, Chesterfield Royal Hospital NHS Foundation Trust experienced increased numbers of new

More information

PM Governance. Executive Team ADCA ADCA

PM Governance. Executive Team ADCA ADCA Item 6.5a Action Plan against the Recommendations Made in the Review of Risk Management Arrangements by PM Governance, November 2014 Key: PM Governance Paul Moore, Risk Consultant ADCA Associate Director

More information

South West Medicines Management Training Scheme. Handbook

South West Medicines Management Training Scheme. Handbook South West Medicines Information and Training South West Medicines Management Training Scheme Handbook This medicines management training & assessment programme has been approved by a panel authorised

More information

A Guide to Corporate Governance for QFC Authorised Firms

A Guide to Corporate Governance for QFC Authorised Firms A Guide to Corporate Governance for QFC Authorised Firms January 2012 Disclaimer The goal of the Qatar Financial Centre Regulatory Authority ( Regulatory Authority ) in producing this document is to provide

More information

MINUTES OF A MEETING OF THE TAMESIDE HOSPITAL NHS FOUNDATION TRUST BOARD 28 April 2011

MINUTES OF A MEETING OF THE TAMESIDE HOSPITAL NHS FOUNDATION TRUST BOARD 28 April 2011 MINUTES OF A MEETING OF THE TAMESIDE HOSPITAL NHS FOUNDATION TRUST BOARD 28 April 2011 Present Mr T Presswood Mrs C Green Mr P Dylak Mr A Anderson Mr T Ward Miss K Brown Mrs D Bates Dr T Mahmood Mr A Griffiths

More information

Code of Ethics for Pharmacists and Pharmacy Technicians

Code of Ethics for Pharmacists and Pharmacy Technicians Code of Ethics for Pharmacists and Pharmacy Technicians About this document Registration as a pharmacist or pharmacy technician carries obligations as well as privileges. It requires you to: develop and

More information

Job Description. The post holder will be responsible for assessing care needs, and the planning, delivery and evaluation of individual care.

Job Description. The post holder will be responsible for assessing care needs, and the planning, delivery and evaluation of individual care. Job Description 1. Job Details Job title: Registered Nurse Current Job grade: Band 5 Reports to (Title): CMT: Department/Ward: Location/Site: Ward Leader Various All Departments & Wards All Sites 2. Job

More information

Subcutaneous Insulin Audit Tool

Subcutaneous Insulin Audit Tool Name of organisation Audit completed by Designation Date Recommendations 1. Is there promotion of insulin as a high risk medicine in your organisation? 2. Does your organisation promote use of the word

More information

The Use of Electronic signatures for Prescribing Chemotherapy and data entries on the Aria MedOncology system V3.0

The Use of Electronic signatures for Prescribing Chemotherapy and data entries on the Aria MedOncology system V3.0 The Use of Electronic signatures for Prescribing Chemotherapy and data entries on the Aria MedOncology system V3.0 January 2013 Table of Contents 1. Introduction... 3 2. Purpose of this Policy... 3 3.

More information

5.0 KNOWLEDGE, SKILLS AND EXPERIENCE REQUIRED

5.0 KNOWLEDGE, SKILLS AND EXPERIENCE REQUIRED Appendix 16 Example Job Description for a Homecare Pharmacy Technician 1.0 JOB DETAILS Job title: Pharmacy Technician Specialist, Homecare Medicines Management Reports to: Pharmacy Procurement Manager

More information

Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011. South West Acute Hospital Learning Disability (LD) review.

Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011. South West Acute Hospital Learning Disability (LD) review. Report to: Trust Board Agenda item: 10. Date of Meeting: 9 March 2011 Title of Report: Status: Board Sponsor: Author: Appendices South West Acute Hospital Learning Disability (LD) review. For information

More information

Key purpose Strategy Assurance Policy Performance

Key purpose Strategy Assurance Policy Performance Trust Board Meeting: Wednesday 11 March 2015 Title Quality Committee Chairman s Report Status History For Information This is a regular report to the Board Board Lead(s) Mr Geoffrey Salt, Committee Chairman

More information

Review of concerns and complaints handling within NHS Wales submission from the General Pharmaceutical Council

Review of concerns and complaints handling within NHS Wales submission from the General Pharmaceutical Council Review of concerns and complaints handling within NHS Wales submission from the General Pharmaceutical Council Executive summary 1. The General Pharmaceutical Council (GPhC) is the regulator for pharmacists,

More information