Report to Trust Board

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1 Report to Trust Board Date of Board Meeting: 25 th November 2009 Subject: Trust Board Lead: NHS Litigation Authority (NHSLA) Assessment Preparation Rosie Musson Head of and Partnerships Presented by: Rosie Musson Head of and Partnerships Aim of the report: This report provides the Board with Background/General Principles of NHSLA Project plan in preparation for March 2010 Current self Monitoring arrangements. Key points: Project plan is on target to ensure the Trust is adequately prepared for Level 1 in March 2010 Self indicates that currently standards are on target for full compliance by January 2010 Recommendation: 1. The Board receive the report for information and assurance 2. The Board note that the Department and the Committee are monitoring progress 3. The Board receive and update report in January 2010 Board action required (please tick) Information Approval Discussion Assurance Other (please state) Key Standard(s) for Better Health: Implications: Financial: HR/Personnel: Community/user: Equality & Diversity: 1

2 1. Introduction Dudley and Walsall Mental Health Partnership NHS Trust is a member of the NHS Litigation Authority (NHSLA) and is currently preparing for Level 1 in March Whilst the Trust has to achieve Level 1 first, from the onset DWMHPT is aspiring to Level 3 by 2012 and all work being undertaken will underpin this vision. By aspiring to level 3 DWMHPT demonstrates commitment to robust governance and risk management arrangements. This report provides Background/General Principles of NHSLA Project plan in preparation for March 2010 Current self Monitoring arrangements. 2. Background and General Principles The NHS Litigation Authority (NHSLA) is a Special Health Authority which was established in 1995 to administer the Clinical Negligence Scheme for Trusts (CNST) and thereby provide a means for Trusts to fund the cost of clinical negligence claims. Their role quickly expanded and in 1999, the Risk Pooling Schemes for Trusts (RPST) was established to fund the cost of legal liabilities to third parties and property losses. Membership of the schemes is voluntary and open to all NHS Trusts. Funding is on a pay-as-you-go non profit basis and the Trust will receive a discount on contributions when the Trust can demonstrate compliance. The promotion of good risk management, governance and assurance are integral components the NHSLA schemes. The NHSLA risk management standards are designed to address organisational, clinical and nonclinical/health and safety risks. The standards and process are designed to: provide a structured framework within which to focus effective risk management activities in order to deliver quality improvements in organisational governance, service user care, and safety of service users, staff, contractors, volunteers and visitors; increase awareness and encourage implementation of the national agenda for the NHS; encourage and support organisations in taking a proactive approach to improvement reflect risk exposure and empower organisations to determine how to manage their own risks contribute to embedding risk management into the organisation s culture; reduce the level of claims by reducing the number of adverse incidents and likelihood of recurrence assist in the management of adverse incidents and claims provide assurance to the organisation, other inspecting bodies and stakeholders, including service users 2

3 If the Trust complies with the standards, it will benefit from the investment in risk management by paying lower scheme contributions. General Principles Assessment against the standards is a mandatory requirement for scheme membership. The Trust may only be assessed against the standards once in any financial year. When the Trust has achieved level 1 or 2, the Trust may apply for at the next level the following financial year. However, in order to ensure that systems are embedded, the NHSLA advise to wait at least two years before being assessed at level 3. As previously stated the Trust will receive a discount subject to the level they have attained. The discounts are: Level 1 10% Level 2 20% Level 3 30% The progression through the standards follows the development (Level 1), implementation (Level 2), monitoring and review (Level 3) of policies and procedures. Each level contains five standards and within each standard there are ten criteria which are equally weighted. The five standards are: Competent & Capable Workforce 3. Safe Environment 4. Clinical Care 5. Learning from Experience The pass mark at each level is 40 out of 50 criteria with no fewer than seven criteria passed in one standard. Evidence in support of a criterion must be in place and effective at the time of the. Draft documentation, or planned or proposed systems that have not been implemented will not be admissible. 3. Project Plan - Timeline The timeline below details progress to date and actions still to be taken. The Trust is working towards all actions being complete by January 2010 ready for submission of evidence in February 2010 and the in March The integrated Committee is responsible for monitoring progress and receiving exception reports. 3

4 Key = GREEN demonstrates actions completed. JUNE 2009 JULY AUGUST SEPTEMBER OCTOBER Meeting with NHSLA Baseline to be assessor completed Leads to be identified Identify polices/docume nts to be developed/revie wed Self tool to be issued to identified leads for completion Leads to complete self tool and develop action plans Leads completed self tools and action plans to Organisational self tool and action plan to be completed Leads progress reports and revised action plans to NOVEMBER DECEMBER JANUARY 2010 FEBRUARY MARCH All polices to be completed All policies to be ratified Complete evidence template. Assessment for Level 1 Check all evidence Review and update organisational self Trust Board Update Evidence template Collate evidence Leads progress reports and revised action plans to Committee update Review organisational self Review all evidence. Identify gaps in evidence Trust Board Update Forward evidence to Assessor Develop action plan following Level 1 Way forward to achieve Level 2/3 4

5 4. November 2009 Self Assessment Summary N.B Each Standards contains 10 components. The pass mark at each level is 40 out of 50 criteria with no fewer than seven criteria passed in one standard. NHSLA Standard RED AMBER GREEN Target for full compliance Jan 2010 None Exceptions 2 Competent and 9 1 Jan 2010 None capable Workforce 3 Safe Environment 10 Jan 2010 None 4 Clinical Care 5 5 Jan 2010 None 5 Learning from Experience 4 6 Jan 2010 None RED AMBER GREEN Action to control risk is agreed but no action started Action to control the risk is adequately started Risk under control Self currently indicates that no standards are yet fully compliant, however these standards are on target to achieve full compliance by January Any exception reports and remedial action plans will be monitored by the governance department and the Committee. Recommendations The Board receive the report for information and assurance The Board note that the Department and the Committee are monitoring progress The Board receive and update report in January

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