NHSLA Risk Management Standards for NHS Trusts Providing Mental Health & Learning Disability Services 2011/12

NHSLA Risk Management Standards for NHS Trusts Providing Mental Health & Learning Disability Services 2011/12 Oxford Health NHS Foundation Trust Level 1 March 2012

Contents Page 1: Executive Summary 3 Assessment Outcome 3 Key findings 5 Overview of assessment outcome 6 2: Assessment Results 7 Standard 1: Governance 7 Standard 2: Competent & Capable Workforce 11 Standard 3: Safe Environment 14 Standard 4: Clinical Care 18 Standard 5: Learning from Experience 22 3: Appendix 24 Contacts 24 The comments and findings of the assessment recorded in this report reflect the opinions of the assessor(s) based on the evidence provided by the organisation in relation to the requirements contained in the relevant standards manual. They should not be read as approval or comment in any other context. Page 2 of 24

Executive Summary Assessment Outcome Reference number T 657 Organisation assessed Services assessed Oxford Health NHS Foundation Trust All services Date of last assessment 6 th and 7 th October 2010 Assessment date 27 th and 28 th March 2012 Date next assessment due 27 th March 2014 Standards assessed NHSLA Risk Management Standards for NHS Trusts Providing Mental Health & Learning Disability Services 2011/12 Level prior to assessment Level 0 Level applied for Level 1 Level achieved Level 1 Discount awarded 10% The organisation was assessed against five standards each containing ten criteria giving a total of 50 criteria. In order to gain compliance at Level 1 the organisation was required to pass at least 40 of these criteria, with a minimum of seven criteria being passed in each individual standard. The organisation scored as follows: Governance 10/10 Competent & Capable Workforce 9/10 Safe Environment 7/10 Clinical Care 8/10 Learning from Experience 10/10 OVERALL COMPLIANCE 44/50 Detailed scores can be found in the organisation s evidence template which is a separate document that records the evidence reviewed and the compliance awarded at the assessment. Page 3 of 24

An overview of the risk areas covered by the assessment is provided within this report. Those criteria highlighted in green indicate the areas of compliance during the assessment. Those criteria highlighted in orange indicate the areas of noncompliance and those criteria not reviewed are highlighted in yellow. Prior to formal assessment the organisation was encouraged to conduct a selfassessment. The organisation s self-assessment results are depicted below and plotted against the actual assessment results. Chart 1: Comparison of the organisation s self-assessment to actual assessment outcome The graph below shows the number of organisations that have achieved compliance at each of the NHSLA assessment levels. 40 37 Number of Organisations 35 30 25 20 15 10 5 0 0 20 Level 0 Level 1 Level 2 Level 3 Not Yet Assessed 0 2 Chart 2: NHSLA mental health & learning disability assessment levels as at 1 st April 2011 Page 4 of 24

Key findings The organisation is to be congratulated on achieving compliance against Level 1 of the NHSLA Risk Management Standards for Mental Health & Learning Disability Trusts 2011/12. The organisation has undergone significant restructuring since its last assessment which resulted in the organisation being awarded a Level 0 by the NHSLA and being deemed as not yet assessed. Throughout the assessment the organisation s proactive approach to the assessment process was evident and it is clear that staff have worked extremely hard to achieve compliance with the standards. The organisation presented a comprehensive and fully completed evidence template for the assessment. Throughout the assessment interviews provided further clarity on the documentation of approved systems at Level 1. It was noted that some of the processes in relation to document control which have recently been introduced to the organisation still require additional work to fully implement. For example some of the policies on the intranet did not contain a signature on the front of the policies as required by the organisation. Also on occasions draft was left within the footer of the documents. The assessor was assured that these were administrative errors and as such the organisation was not penalised. The organisation is however advised to revisit the current documentation control processes and ensure they are robust and overarching prior to any future assessments. As discussed the organisation is reminded that at a Level 1 assessment the assessors check that all the Level 1 requirements are present, not the validity of the information. It was identified that some of the documentation submitted did not explicitly describe the Level 1 requirements fully. In addition on occasions the organisation made reference to processes being undertaken regularly or as required. The use of these words within documentation may impact upon the organisation s ability to achieve higher levels of assessment as the assessors will be unable to establish what regularly or as required means. The organisation needs to ensure that it clearly describes in its approved documents the processes it expects staff to follow in particular situations; the descriptions should provide clear guidance on the details of the practice it expects, who is responsible and where documentation should be recorded. The organisation is therefore advised to ensure that all documents are revisited again to ensure they contain a comprehensive description of the minimum requirements assessed at a Level 2 assessment and also ensure that these are reflective of actual practice and are achievable. It is also recommended that the organisation review all the approved documents to ensure the Level 3 requirements are present. The organisation should ensure that every approved document contains a comprehensive description of the processes used to monitor compliance with the minimum requirement for all the criteria. This should include details of what monitoring systems will be utilised, who has responsibility for undertaking the monitoring and how often the monitoring will be undertaken. In addition where monitoring has identified deficiencies the organisation must be able to demonstrate that systems are in place to address any shortfalls. An example of a chart used to capture this level of information has been forwarded to the organisation to help develop the monitoring sections within the current documents. Page 5 of 24

Overview of assessment outcome Non-compliant Not reviewed Standard Criterion 1 2 3 4 5 Governance Competent & Capable Workforce Safe Environment Clinical Care Learning from Experience 1 Risk Management Strategy Corporate Induction Secure Environment Patient Information Clinical Audit 2 Policy on Procedural Documents Local Induction of Permanent Staff Slips, Trips & Falls (Staff & Others) Health Record-Keeping Standards Incident Reporting 3 Risk Management Committee(s) Local Induction of Temporary Staff Slips, Trips & Falls (Patients) Management of Patients with a Dual Diagnosis of Mental Health Problems & Substance Misuse Concerns/Complaints 4 Risk Awareness Training for Senior Management Clinical Supervision Moving & Handling Physical Assessment & Examination of Patients Claims 5 Risk Management Process Risk Management Training Inoculation Incidents Medicines Management Investigations 6 Risk Register Training Needs Analysis Absent Without Leave (AWOL) Observation of Patients Analysis 7 Responding to External Recommendations Specific to the Organisation Clinical Risk Assessment Harassment & Bullying Resuscitation Improvement 8 Health Records Management Hand Hygiene Training Violence & Aggression Rapid Tranquilisation Best Practice - NICE 9 Professional Clinical Registration Moving & Handling Training Supporting Staff Involved in an Incident, Complaint or Claim Transfer of Patients Best Practice - National Confidential Enquiries/Inquiries 10 Employment Checks Medicines Management Training Stress Discharge of Patients Being Open Page 6 of 24

Assessment Results Standard 1: Governance Overview Effective functioning of the board, managerial leadership and accountability, and the organisation s systems and working practices will ensure that quality assurance, quality improvement and service user safety are central to the activities of the healthcare organisation. Organisations should apply the principles of sound corporate governance. Board level responsibility for risk management should be clearly defined and there should be clear lines of individual accountability for managing risk throughout the organisation leading to the board. Organisations should undertake systematic risk assessment and risk management. Risk management should be fully embedded in the organisation s management processes. All relevant employees, whether permanent or temporary, should be registered with the appropriate professional body and have undergone the required employment checks prior to working within the organisation. A score of ten out of ten was awarded in this standard. Criterion 1.1.2 Policy on Procedural Documents documented process for developing organisation-wide procedural documents. b. an explanation of any terms used in documents developed c. consultation process d. ratification process The Policy & Procedure for the Development & Implementation of Procedural Documents (February 2012) was provided as evidence for this criterion. With regard to the section relating to an explanation of any terms used within the documents under development, as discussed, the organisation is advised to consider expanding this section. The current policy only directs the author to define the type of document used for example whether it is a policy or a procedural document. It does not identify that this section should also define specific terms used within the documentation being produced that may Page 7 of 24

Criterion require additional explanation. In relation to the consultation and ratification processes for the documents being developed, the organisation should consider strengthening these sections to make it explicit which groups should be consulted in relation to the documents and which committees should ultimately ratify which documents. As discussed this could be demonstrated in a table format to assist staff in understanding the consultation and ratification pathway. 1.1.3 Risk Management Committee(s) The organisation has approved documented terms of reference for the high level committee(s) with overarching responsibility for risk. 1.1.4 Risk Awareness Training for Senior Management documented process for delivering risk management awareness training for all board members and senior managers. The Integrated Governance Committee was identified as the board subcommittee with overarching responsibility for risk. The current terms of reference lists reports received and produced by the committee therefore compliance was awarded. It was noted however that the information in relation to how this occurs and the frequency of these reports was minimal. The organisation is advised to review and amend the current terms of reference to ensure they clearly identify the reporting arrangements into and out of the Integrated Governance Committee. This should include the frequency of reporting and how this will be achieved for example receipt of minutes, exception reporting or specific quarterly/annual reporting. a. process for ensuring that all board members and senior managers receive relevant risk management awareness training The Risk Management Policy (March 2012) was provided as evidence against this criterion. Within the current document the arrangements for delivering risk management training to all board members was clearly defined. However the definition and training arrangements for senior managers was not as explicit. Assurance was provided that this training is provided and therefore compliance was awarded. The organisation is however advised to revisit the above policy on receipt of this report to make the arrangements more explicit. Page 8 of 24

Criterion 1.1.8 Health Records Management associated with paper and electronic health records. 1.1.10 Employment Checks documented process for ensuring that all appropriate employment checks are undertaken for all staff (temporary and permanent). e. process for retrieving records f. process for retention, disposal and destruction of records The Integrated Information Governance Policy (January 2012) and The Integrated Information Governance Policy Procedure Guidance (November 2011) were provided as evidence against this criterion. The organisation is congratulated upon the work that has been undertaken to integrate a number of documents relating to health records into the two documents above. The organisation is however advised to review these documents again to address the issues identified below. Within the current documents the systems relating to retrieval of health records out of hours were not explicit. This process for retrieval of records including out of hours is an area reviewed at higher levels of assessment therefore the organisation is advised to revisit and update these sections upon receipt of this report. In addition the current sections which relate to the retention, disposal and destruction of records would benefit from additional information to explicitly identify how these systems operate rather than stipulate that systems are in place. e. process for monitoring/receiving assurance that checks are being carried out by all external agencies (e.g. NHS Professionals, recruitment agencies, etc.) used by the organisation in respect of all temporary staff The Recruitment and Selection Procedure (February 2012) was provided as evidence for this criterion. Within this document there is a section which relates to temporary staffing for which compliance was awarded. The organisation confirmed that it rarely employs temporary staff choosing instead to use substantive staff to do agency or bank work. As discussed however it is possible that non substantive staff may be required on occasion and the current document does not explicitly identify how employment checks (including registration verification checks) will be undertaken in these Page 9 of 24

Criterion circumstances. The organisation should revisit the policy and ensure it explicitly describes the processes the organisation uses to verify that employment checks have been completed for all temporary staff used. Page 10 of 24

Standard 2: Competent & Capable Workforce Overview The organisation has a responsibility to deliver a safe service to service users by ensuring all staff are appropriately skilled. To ensure that both temporary and permanent staff are adequately equipped to work in a healthcare environment and provide care to service users they must receive training and support, both on initial appointment and on an ongoing basis. By ensuring effective, ongoing training, supervision and support, the organisation is promoting the delivery of high quality focused care as well as facilitating staff safety and wellbeing. A score of nine out of ten was awarded in this standard. Key findings and recommendations Criterion 1.2.1 Corporate Induction documented process for ensuring the corporate induction arrangements for all new permanent staff. b. minimum content of corporate induction programme(s) The Induction Policy (March 2012) was provided as evidence against this criterion. The current document identifies that corporate induction can be anything from two days to five days dependent upon the role you are going to be employed as within the organisation. The organisation has specified who should receive what induction within the organisations training needs analysis (TNA). It is therefore advised to cross reference staff to the TNA within the above policy so they are aware of the corporate induction pathway they are expected to complete. 1.2.3 Local Induction of Temporary Staff documented process for ensuring the local induction arrangements for all temporary staff. The Induction Policy (March 2012) was provided as evidence for this criterion. Within the current document there was a section which covers the processes for ensuring temporary staff complete a local induction therefore compliance was awarded. However as with the employment checks identified within standard one the current system is primarily aimed at substantive staff who do additional work within the organisation as opposed to those being employed by external agencies. It is appreciated that employment of Page 11 of 24

Criterion 1.2.6 Training Needs Analysis The organisation has a documented training needs analysis to identify the risk management training requirements for all permanent staff. temporary staff from external agencies is discouraged nevertheless as this can occur local induction processes must be clearly identified. The organisation should review and update this policy to include local induction arrangements for all temporary staff as a minimum this should include a comprehensive description of: a. duties b. minimum content of local induction programme(s) c. process for checking that all temporary staff complete local induction d. process for following up those who fail to complete local induction e. process for monitoring compliance with all of the above The criterion was awarded compliance as the assessor was able to establish from the evidence provided that the TNA incorporated all the prerequisite areas of training required as well as who should attend the training and the frequency of update training required. It was however noted that there was an inconsistent approach in relation to how the organisation described training within a number of additional policies required for other criterion across the assessment process. In some cases the training was fully described within the document and others simply cross referenced to the TNA. With the passage of time there is the potential that the training within the policy documents and the TNA can become contradictory unless this is closely monitored. It is therefore imperative that the organisation ensures the TNA is fit for purpose and remains current and accurate. As discussed the organisation may choose to remove specific training requirements from the individual policies and instead cross reference to the TNA. In this way the organisation can amend and review training continually without the need to revisit individual polices to amend each training section. Page 12 of 24

Criterion 1.2.7 Clinical Risk Assessment documented process for ensuring that all staff who undertake assessments of patients are competent in relation to clinical risk assessment and the management of clinical risk. Non-compliant c. tools/processes authorised for use within the organisation The Clinical Risk Assessment and Management Policy (January 2010) was provided as evidence for this criterion. Within the current document it is clear that the organisation utilises a number of risk assessment tools as an adjunct to the CPA risk assessment processes. It was however unclear how the use of these tools are authorised for use within the organisation. The assessor was informed that these would be formally authorised through the Psychological and Social Care Committee. However nothing could be found within the current document to describe this therefore compliance was not awarded. The organisation is advised to review and revise the above policy to explicitly identify which risk assessment tools the organisation uses and how these are authorised for use within the organisation. Page 13 of 24

Standard 3: Safe Environment Overview It is essential to provide a safe and secure environment in order to facilitate high quality clinical care. The environment should be safe for staff, service users and their visitors in order to prevent accidents, injury and disease. Risk of violence, bullying, harassment, and stress should be managed and minimised and the workplace should be one in which both patient and staff safety is managed sensibly and effectively. A score of seven out of ten was awarded in this standard. Key findings and recommendations Criterion 1.3.1 Secure Environment associated with the physical security of premises and assets. 1.3.2 Slip, Trips & Falls (Staff & Others) associated with slips, trips and falls involving staff and others. Non-compliant b. arrangements (including timescales) for producing a lockdown risk profile for each organisational site or other specific building/area The Lockdown Policy (January 2012) was provided as evidence for this criterion. Within the current document there was nothing which identified that the organisation has reviewed the arrangements for undertaking a lockdown risk profile and the timescales for completing this process. A separate project plan was provided as evidence which had been to the Emergency Planning Committee. This did cover the elements above therefore compliance was awarded. The organisation is advised to ensure these project plans are referenced within the current lockdown policy. b. requirement to undertake appropriate risk assessments for the management of slips, trips and falls involving staff and others (including falls from height) The Slips, Trips and Falls Policy (December 2011) was provided as evidence against this criterion. Compliance was not awarded as the assessor was unable to establish what risk assessments would occur in relation to slips, trips and falls involving staff and others. The assessor was informed that Page 14 of 24

Criterion 1.3.4 Moving & Handling associated with moving and handling. 1.3.6 Absent Without Leave (AWOL) Non-compliant reactive risk assessments would be undertaken once an incident occurs as well as a series of proactive risk assessments on an annual basis. The assessor was unable to find anything to explicitly identify the requirements to undertake the annual risk assessments therefore compliance was not awarded. The organisation is advised to review and amend the above document to explicitly identify the processes for ensuring both reactive and annual proactive risk assessments are undertaken. c. arrangements for access to appropriate specialist advice d. requirement to undertake appropriate risk assessments for the moving and handling of patients and objects e. arrangements for ensuring that action is taken as a result of risk assessments The Manual Handling Operations Policy (December 2011) was provided as evidence for this criterion. The current policy does not contain any information in relation to the specific arrangements to appropriate specialist advice. The organisation indicated that it does have access to specialist advice via the Hearts Handling Service which provides a service twenty four hours seven days a week. This is not currently described within the policy. This should be addressed upon receipt of this report. In addition there is a risk assessment tool which should be completed for patients however the current tool does not indicate what should happen with the risk assessment, when and how often this should be updated. This should be reviewed upon receipt of this report to ensure the risk assessment processes for patients are clear and explicit. b. procedure used when a patient absents themselves from an inpatient setting c. procedure used when a patient fails to return from a period of leave of Page 15 of 24

Criterion associated with patients who are absent without leave (AWOL). 1.3.7 Harassment & Bullying associated with the harassment and/or bullying of staff. 1.3.8 Violence & Aggression associated with the prevention and management of violence and aggression. Non-compliant absence The Patients Who are Absent Without Leave or Missing from Hospital Policy (November 2011) was provided as evidence for this criterion. Within the appendices there is a significant amount practical information regarding what actions staff are expected to take. These appear as stand-alone documents and are not referenced within the main body of the policy. The potential is therefore that valuable information could get missed without a clear link being made. It is therefore recommended that reference within the policy to vital practical actions within the appendix is made more explicit. The Dignity at Work Policy (February 2012) was provided as evidence against this criterion. The training requirements identified within the TNA did not match those within the above policy therefore compliance was not awarded. The organisation is advised to review both documents to ensure they correlate for future assessments. b. requirement to undertake appropriate risk assessments for the prevention and management of violence and aggression The Prevention and Management of Violence & Aggression Policy (December 2011) was provided as evidence against this criterion. Reference is made to undertaking an annual risk assessment in line with the Health and Safety Policy. Within the Health and Safety Policy however there was nothing explicit in relation to the management of violence and aggression. It was accepted that this is included within the general workplace risk assessment. The organisation should consider ensuring the risk assessment in relation to violence and aggression is made more explicit within the above policy. The organisation may consider adding the tool to the appendix to provide additional guidance for staff. Page 16 of 24

Criterion 1.3.10 Stress associated with work-related stress. d. requirement to undertake appropriate risk assessments for the prevention and management of work-related stress The Workplace Stress Policy (January 2012) was provided as evidence for this criterion. Compliance was awarded as there was a section which related to the management of work related stress. However for the above minimum requirement it was difficult to establish how the organisation undertakes proactive risk assessments to manage and prevent work related stress. A number of excellent initiatives were seen which demonstrate that the organisation does in fact undertake a significant amount of proactive work in relation to the management of stress. The organisation should therefore ensure the policy is updated to reflect this work. The organisation should explicitly describe how it undertakes proactive risk assessments to identify any potential areas within the organisation where stress intervention measures may be required. Page 17 of 24

Standard 4: Clinical Care Overview The care provided within the NHS environment should be of the highest quality and practiced to the safest level. To support this, robust guidance should be in place for all clinical care processes. Some of the higher volume and higher risk processes have been selected for assessment by the NHSLA, namely: dual diagnosis of mental health problems and substance misuse, physical assessment and examination of service users, medicines management,, observation, resuscitation and rapid tranquilisation. To underpin these care processes, systematic approaches must be in place to ensure there is effective communication between staff, service users and others throughout the continuum of care planning including the transfer and discharge processes. It is important for service users to receive clear information in relation to the care and treatment that is provided for them and that high standards of record keeping are consistent across the organisation. A score of eight out of ten was awarded in this standard. Key findings and recommendations Criterion 1.4.3 Dual Diagnosis associated with the management of patients who present with a dual diagnosis of mental health problems and substance misuse. 1.4.4 Physical Assessment & Examination of Patients d. process to be followed where a difference of opinion between professionals is apparent The Dual Diagnosis Policy (March 2012) was provided as evidence against this criterion. The current policy has a section which identifies the escalation processes when there is a difference of opinion between healthcare professionals in relation to treatment or care. It was noted however that there was nothing in relation to documenting the discussion and outcome of the difference of opinion. This should be reviewed and amended upon receipt of this report. c. process for ensuring appropriate follow up of physical symptoms d. ongoing assessment of physical needs for all patients, including timeframes Page 18 of 24

Criterion associated with the physical assessment, examination and ongoing physical care of patients. 1.4.5 Medicines Management associated with medicines in all care environments. Not reviewed c. process for ensuring appropriate follow up of physical symptoms d. ongoing assessment of physical needs for all patients, including timeframes The Physical Assessment and Examination of Service Users Policy (June 2011) was provided as evidence against this criterion. The organisation has identified that a full physical examination will normally be undertaken with twenty four hours of admission, documented within RIO and results communicated to the nurse in charge. With regard to the follow up of physical symptoms the policy was less robust as it did not establish explicit processes to follow. It is appreciated that actions would in some cases be based upon an individual s needs. However as discussed for certain situations the follow up can be summarised to provide staff with clear guidance regarding the actions they should take. In addition with regard to the need for ongoing physical examinations the policy talks about regular reviews. The use of these words within documentation may impact upon the organisation s ability to achieve higher levels of assessment as the assessors will be unable to establish what regular means. The organisation may stipulate a specific timeframe for review or make this specific to the needs of the individual patient. If they are patient specific the organisation should ensure staff are directed to document a specific reassessment timeframe within the health record. A number of documents were submitted as evidence against this criterion. The assessor was informed that there remain a number of medicines management documents within the organisation and that these are in the process of being reconciled but that this is still very much a work in progress. Unfortunately on the day of assessment due to unforeseen circumstances no one was available from pharmacy to assist the assessor in locating the prerequisite evidence within the approved document. It was therefore agreed that for the purpose of this assessment this criterion would not be reviewed and that no score will be awarded. The organisation is advised to ensure Page 19 of 24

Criterion 1.4.7 Resuscitation associated with cardiopulmonary resuscitation. Non-compliant that this criterion is revisited at the informal visit next year to provide assurance that systems are in place and fully operational. b. early warning systems in place for the recognition of patients at risk of cardio-respiratory arrest c. post-resuscitation care e. process for ensuring the continual availability of resuscitation equipment f. organisation s expectations in relation to staff training, as identified in the training needs analysis The Resuscitation Policy (December 2011) was provided as evidence against this criterion. Within the current document the assessor could not find any specific information relating to the early warning systems the organisation uses or post- resuscitation care arrangements for patients. The assessor was directed to the training section of the policy which discusses the use of MEWS and mentions post resuscitation care. However there was nothing to identify what early warning tools are used, or any guidance to staff in relation to their use. In addition post resuscitations care arrangements are not explicitly described. With regard to the training within the policy it was noted that this does not match the training within the organisations TNA. The TNA identifies a number of mandatory training courses however the policy only covers BLS. As previously identified the training requirements need to be consistent across all documents for compliance to be awarded. The processes for ensuring the continual availability of equipment are covered within appendix two of the policy. This lists the equipment which should be available within each area. For non-mental health areas the checks of the equipment are undertaken weekly however for MHLD areas this frequency is daily. During discussion at the assessment it was felt that all areas were in fact subject to daily checks. If this is the case the policy should Page 20 of 24

Criterion 1.4.9 Transfer of Patients associated with the transfer of patients. 1.4.10 Discharge of Patients associated with the discharge of patients. be amended accordingly. c. transfer requirements which are specific to each patient group The Policy for the Transfer and Transition of Patients between Services and Providers (March 2012) was provided as evidence against this criterion. The organisation had identified transfer requirements for a number of scenarios for which compliance was awarded. During discussion at the assessment it was also identified that there was a potential to expand this section as it did not explicitly cover internal transfer situations. The organisation is advised to review the policy upon receipt of this report to explicitly include internal transfers. d. documentation to accompany the patient upon discharge The Discharge Policy (March 2012) was provided as evidence for this criterion. Within the document there is a discharge flow chart which depicts the process for discharge where there are simple or complex discharge requirements. In relation to documentation to accompany the patient this was mentioned throughout the policy therefore compliance was awarded. As discussed the organisation may wish to consider strengthening this by developing specific checklist to capture all discharge requirements including the provision of information. This would ensure a consistent approach to discharge is adopted across the organisation no matter what services are provided. Page 21 of 24

Standard 5: Learning from Experience Overview All organisations should have in place robust systems for the reporting, management and investigation of adverse events (incidents), ill health and hazards, including those that result in no harm, which will help to facilitate organisational learning. Organisations should apologise and explain what happened to service users who have been harmed as a result of their healthcare treatment. Concerns, complaints and claims, when examined in conjunction with all reported adverse events, root cause analyses and near misses, allow trends to be identified at both a local and strategic level and changes to be implemented. This can reduce the recurrence of incidents, claims and complaints. The sharing of lessons learned from one service to other areas of the organisation helps to ensure that any system failures discovered during investigations are addressed by the organisation as a whole and pockets of good practice are not isolated. Organisations should consider and implement appropriate external guidance to ensure the organisation is operating as safely as possible. A score of ten out of ten was awarded in this standard. Key findings and recommendations Criterion 1.5.5 Investigations documented process for investigating all incidents, complaints and claims. e. process for following up relevant action plans The Incident Reporting & Management Policy (February 2012) was provided as evidence for this criterion. With regard to the follow up of relevant action plans there appeared to be some discrepancy as page 49 refers to a six monthly review however on page 44 a three monthly review is identified. The organisation should review these processes upon receipt of this report to ensure a consistent approach is adopted across the organisation. A long discussion was had in relation to the appropriateness of having one overarching document to cover incidents, complaints and claims investigations. For the purpose of this assessment the processes can be described separately or within an overreaching policy. For higher level assessments where these processes will be tested it is essential that the descriptions are accurate and reflective of actual practices. The organisation Page 22 of 24

Criterion 1.5.9 Best Practice National Confidential Enquiries/Inquiries documented process for ensuring that agreed best practice, as defined in National Confidential Enquiries/Inquiries, is taken into account in the context of the clinical services provided by the organisation. 1.5.10 Being Open documented process for ensuring that all communication is open, honest and occurs as soon as possible following an incident, complaint or claim. is therefore advised to revisit this issue upon receipt of this report and decide upon the best format for the documentation. g. process for documenting any decision not to implement National Confidential Enquiry/Inquiry recommendations The Receipt, Distribution, Implementation and Review of National reports and Guidance Policy (March 2012) was provided as evidence against this criterion. In relation to the above minimum requirement the organisation has documented the process for not implementing National Confidential Enquiries/Inquiries which it deems are not relevant to the organisation. As discussed this should be expanded upon receipt of this report to include situations where the organisation actively chooses not to implement the recommendations. a. process for encouraging open communication between healthcare organisations, healthcare teams, staff, patients and/or their carers The Being Open Policy (March 2012) was provided as evidence against this criterion. With regard to the above minimum requirement the focus of the document is primarily around the communication processes in relation to being open with patients and their relatives. There was minimal information in relation to internal arrangements across the organisations healthcare teams and between other healthcare organisations. The organisation is advised to review and strengthen these aspects within the policy. Page 23 of 24

Appendix Contacts Assessment/Report enquiries This report was prepared by Det Norske Veritas on behalf of the NHS Litigation Authority. Any queries regarding this report should be directed to: General enquiries Address for correspondence: NHSLA general enquiries General enquiries Risk management enquiries Address for correspondence: Website Det Norske Veritas Highbank House Exchange Street Stockport Cheshire SK3 0ET nhsla@dnv.com The NHS Litigation Authority 151 Buckingham Palace Road Westminster London SW1W 9SZ generalenquiries@nhsla.com riskmanagement@nhsla.com www.nhsla.com Page 24 of 24