NHSLA Risk Management Standards for NHS Trusts Providing Community Services 2011/12

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1 NHSLA Risk Management Standards for NHS Trusts Providing Community Services 2011/12 Milton Keynes Primary Care Trust Provider of Community and Mental Health Services Level 1 May 2011

2 Contents Page 1: Executive Summary 3 Assessment Outcome 3 Key findings 6 Overview of assessment outcome 8 2: Assessment Results 9 Standard 1: Governance 9 Standard 2: Competent & Capable Workforce 12 Standard 3: Safe Environment 15 Standard 4: Clinical Care 16 Standard 5: Learning from Experience 18 3: Appendix 19 Contacts 19 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 19

3 Executive Summary Assessment Outcome Reference number Organisation assessed Services assessed P029 Milton Keynes Primary Care Trust All services excluding mental health and learning disabilities Date of last assessment 24 th January 2006 Assessment date 26 th May and 27 th May 2011 Date next assessment due 24 th May 2013 Standards assessed Level prior to assessment NHSLA Risk Management Standards for NHS Trusts Providing Community Services 2011/12 Not assessed 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 9/10 Compliant Competent & Capable Workforce 9/10 Compliant Safe Environment 10/10 Compliant Clinical Care 9/10 Compliant Learning from Experience 10/10 Compliant OVERALL COMPLIANCE 47/50 Compliant Page 3 of 19

4 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. 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. Level 1 Summary Chart Compliance / Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment Self-Assessment Assessment 0 Standard 1 Standard 2 Standard 3 Standard 4 Standard 5 TOTAL Compliant Non-Compliant Not Reviewed TOTAL 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. Page 4 of 19

5 Number of Organisations Level 0 Level 1 Level 2 Level 3 Not Yet Assessed 23 1 Chart 2: NHSLA acute assessment levels as at 3 rd June 2011 Page 5 of 19

6 Key findings Milton Keynes Primary Care Trust Provider of Community and Mental Health Services was successful in demonstrating compliance with the Level 1 requirements of the NHSLA Risk Management Standards for NHS Trusts Providing Community Services 2011/12. The organisation should note that any mental health & learning disability services provided were not included as part of this assessment. The organisation is advised to undertake a self-assessment of these services against the nine criteria highlighted within table 9.2 on page 31 of the NHSLA Risk Management Standards manual. The organisation had not been assessed since 2006 and made the decision to opt into the 2010/11 assessment cycle. However, the original assessment date arranged for March 2011 was postponed, as the organisation requested further time to clarify and complete preparations for the proposed integration with Milton Keynes Hospital NHS Foundation Trust. The date for the proposed integration is still to be determined. Therefore the organisation made the decision to be assessed at Level 1 prior to the proposed integration with Milton Keynes NHS Foundation Trust as part of the Transforming Community Services Programme. Overall preparation for this assessment was good. There was involvement from senior staff members at the assessment, which demonstrated the importance of risk management within the organisation. The evidence template was populated with the Level 1 approved documentation. However, the links to the documentation were not always accurate or clear. For future assessments the organisation is advised to prepare the evidence template and ensure hyperlinks correctly signpost the assessors to the relevant sections with in the evidence. This will assist in reducing any time lost that may affect the assessment of all the criteria. Further information and guidance is available on the NHS Litigation Authority (NHSLA) website. Available at: Many of the approved documents had undergone recent amendments and revisions that did not always fit with the remaining context of the documents and would suggest that the process for monitoring document and version control was not fully embedded within the organisation. The organisation is advised to ensure that all corporate governance processes are explicitly described to ensure what is required and expected is clear to all, for example that documents are cross referenced and where possible hyperlinked for clarity and ease of access and that documents comply with the standards as stated in the organisation s Policy for Procedural Documents, Version 3.1 (April 2010). The organisation is advised to refer to guidance within the NHSLA Risk Management Handbook (2011/12) which provides additional information to support and help organisations in developing their risk management systems and practices. Available at: A number of the approved documents reviewed as part of the assessment contained only minimal descriptions and details of the processes staff were required to follow to reduce the risk area identified. Several of the approved documents included many appendices that provided further detail of the processes that should be implemented. However, in general, these processes were not referenced or linked in the main body of the document or in related documents and some of the appendices were in draft format. Page 6 of 19

7 The organisation is advised to ensure that the details of the system for monitoring, who has responsibility for monitoring, how the process will be monitored, what the time frame is for monitoring and where there are identified deficiencies or gaps how shortfalls in performance will be addressed, is written in each of the approved documents. It was refreshing to see that the organisation had included how learning would take place within the monitoring statements. There were two pilot criteria at Level 1 during this financial year, which received a positive score in this assessment. The organisation was also able to demonstrate that ten randomly selected documents provided for the assessment were available on the intranet. There was also supporting paper evidence of the minutes of relevant meetings approving the selected documents, which was well prepared and presented. Additionally the organisation was given positive scores for two criteria that were deemed non-applicable to the services provided; Supervision of Medical Staff in Training and Transfusion of Blood and Blood Products. The organisation will need to decide what work to progress with in an action plan as it may be that some of the approved documents assessed become harmonised after the proposed integration with Milton Keynes NHS Foundation Trust later in When reviewing the approved documents the organisation is advised to ensure there are explicit descriptions of required processes to enable staff to execute what is expected of them, it is also these processes that will be assessed at higher levels via implementation and monitoring. Page 7 of 19

8 Overview of assessment outcome Compliant Non-compliant Not reviewed Standard Criterion Governance Competent & Capable Workforce Safe Environment Clinical Care Learning from Experience 1 Risk Management Strategy Corporate Induction Secure Environment Patient Information & Consent 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) Screening Procedures Concerns/Complaints 4 Risk Awareness Training for Senior Management Supervision of Medical Staff in Training Moving & Handling Diagnostic Testing Procedures Claims 5 Risk Management Process Risk Management Training Inoculation Incidents Medicines Management Investigations 6 Risk Register Training Needs Analysis Maintenance of Medical Devices & Equipment Transfusion Analysis 7 Responding to External Recommendations Specific to the Organisation Medical Devices Training Harassment & Bullying Resuscitation Improvement 8 Health Records Management Hand Hygiene Training Violence & Aggression Venous Thromboembolism 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 Consent Training Stress Discharge of Patients Being Open Page 8 of 19

9 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 patient 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 also 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 nine out of ten was awarded in this standard. Key findings and recommendations Criterion Health Records Management documented process for managing the risks associated with paper and electronic health records. Non-compliant Findings and recommendations c. process for tracking records, d. creating records e. retrieving records, f. retaining, disposing and destruction of records The Records Management Policy, Version 5 (May 2011) which was the approved document provided for this criterion stated that there must be a system for tracking, creating and retrieving health records. Following a Page 9 of 19

10 Criterion Findings and recommendations discussion it appeared that there were local written arrangements, but these were not all provided as evidence or cross referenced in the underpinning Records Management Policy, Version 5 (May 2011). The Records Management Policy, Version 5 (May 2011) did not describe the process for the retention, disposal and destruction of records it stated that this was the responsibility of service managers and local processes must be in place. There was no evidence of local processes presented and it appeared that an external company managed archiving and disposal of records Professional Clinical Registration documented process for ensuring that all clinical staff (temporary and permanent) are registered with the appropriate professional body. Compliant On this occasion compliance could not be awarded as the processes for tracking, creating and retrieving records and the processes for retention, disposal and destruction of records were not written in approved documents that were provided as evidence or cross referenced in the underpinning policy document. The organisation is advised to clearly, accurately and in detail describe the processes in place for tracking, creating and retrieving records and the process for the retention, disposal and destruction of paper and electronic health records within the underpinning documents. b. process for ensuring registration checks are made directly with the relevant professional body, in accordance with their recommendations, in respect of all permanent clinical staff both on initial appointment and ongoing thereafter c. process for monitoring/receiving assurance that registration 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 clinical staff The Validation of Professional Registration Policy & Procedure, Version 2 (May 2011) which was the approved document provided for this criterion described the process for checking professional registration requirements for new employees and for ongoing checks. Page 10 of 19

11 Criterion Findings and recommendations Employment Checks documented process for ensuring that all appropriate employment checks are undertaken for all staff (temporary and permanent). Compliant The organisation is advised to clearly differentiate and document the processes for all staff groups, in all locations and to accurately describe how the outcomes from such processes are recorded and monitored centrally. a. duties The Recruitment, Selection and Retention Policy, Version 1 (December 2010) was the approved document provided for this criterion. The organisation is advised to review and update the approved document to ensure that all documents cross referenced to in the main body of the document refer to updated and valid working documents. Where other organisations provide services to compliment the recruitment process these should be identified and their role in the process described in the approved document. Page 11 of 19

12 Standard 2: Competent & Capable Workforce Overview The organisation has a responsibility to deliver a safe service to patients 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 patients they must receive training and support, both on initial appointment and on an ongoing basis. By ensuring effective, ongoing training 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 Local Induction of Permanent Staff documented process for ensuring the local induction arrangements for all new permanent staff Local Induction of Temporary Staff documented process for ensuring the local induction arrangements for all temporary staff. Compliant Non-compliant Findings and recommendations d. process for following up those who fail to complete local induction The Induction Policy, Version 5 (March 2011) was the approved document provided for this criterion. Compliance was awarded on this occasion as the process for following up those staff who fail to complete induction appeared implicit within the approved document. However, the organisation is advised to clearly, accurately and in detail describe the process to be followed when local induction is not completed in accordance with the organisation s standard requirements and to accurately cross reference other policy/guidance information to ensure all staff are informed, aware and able to comply with the organisation s requirements within the stated timescales. e. process for checking that all temporary staff complete local induction f. process for following up those who fail to complete local induction The Induction Policy, Version 5 (March 2011) was the approved document Page 12 of 19

13 Criterion Findings and recommendations provided for this criterion. On this occasion compliance could not be awarded as the evidence for the two minimum requirements above did not comply with the description in the Induction Policy, Version 5 (March 2011). The approved document stated that the same process, including the timescales, was applied to local induction for all staff whether permanent or temporary and the assessors were verbally informed that this was an accurate reflection of local practice. However the approved document reflected timescales that would not be appropriate or relevant for temporary staff Supervision of Medical Staff in Training Consent Training documented process for managing the risks associated with consent training. Not reviewed Compliant The organisation is advised to review the current document and include processes and timescales relevant for all grades of temporary staff, in all locations. Community organisations are not assessed against the requirements for this criterion and therefore a positive score has been awarded for this criterion. b. process for identifying staff who are not capable of performing the procedure but are authorised to obtain consent for that procedure d. process for following up those who have obtained consent for a procedure without being authorised to do so The Policy & Guidelines for Consent to Examination or Treatment, Version 5 (March 2011) was the approved document provided for this criterion. Compliance was awarded on this occasion as the approved document clearly stated that service managers have delegated responsibility for identifying staff that are not capable of performing the procedure but are authorised to obtain consent for that procedure. However, the organisation is advised to ensure that the parameters of this role are defined and agreed with the clinical director or lead clinician for the service, that there is procedure specific training available and that the identified staff receive the same. This must be communicated to all Page 13 of 19

14 Criterion Findings and recommendations practitioners who may be in a position to delegate the process of obtaining consent. The organisation is advised to ensure that the process for following up those who have obtained consent for a procedure without authorisation includes a system for disseminating outcomes to appropriate and relevant staff as necessary. Page 14 of 19

15 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, patients 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 ten out of ten was awarded in this standard. Key findings and recommendations Criterion Findings and recommendations Slips, Trips & Falls (Staff & Others) documented process for managing the risks associated with slips, trips and falls involving staff and others. Compliant a. duties b. requirement to undertake appropriate risk assessments for the management of slips, trips and falls involving staff and others (including falls from height) The Health and Safety Policy, Version 2 (May 2011) was the approved document provided for this criterion. Compliance was awarded for this criterion; however, the organisation is advised to make sure that the approved document complies with the organisation s Policy for the Production, Approval, Implementation and Review of a Policy, Protocol, Procedure or Guideline, Version 3.1 (July 2010) and ensure compliance with corporate governance procedures. Page 15 of 19

16 Standard 4: Clinical Care Overview The care provided within a clinical 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 procedures. Some of the higher volume and higher risk processes have been selected for assessment by the NHSLA, namely: consent, transfusion, venous thromboembolism, medicines management and resuscitation. Care should be provided in such a way as to minimise the risk to patients of misidentification and treatment. It is particularly important to ensure patients have clear information when undergoing procedures and that accurate information is shared between all professionals in all care environments. To underpin these care processes, systematic approaches must be in place to ensure there is effective communication between staff, patients and others and that high standards of record keeping are consistent across the organisation. A score of nine out of ten was awarded in this standard. Key findings and recommendations Criterion Screening Procedures (pilot) documented process for developing local policies to manage the risks associated with screening procedures. Not reviewed Findings and recommendations This is a pilot criterion for 2011/12 and as such a positive score has been awarded. In order to test the validity of the criterion, organisations were encouraged to provide evidence for each of the minimum requirements. Whilst compliance has automatically been awarded; the evidence provided was not reviewed due to the lack of time available Diagnostic Testing Procedures (pilot) documented process for developing local policies to manage the risks associated with diagnostic testing procedures. Not reviewed This is a pilot criterion for 2011/12 and as such a positive score has been awarded. In order to test the validity of the criterion, organisations were encouraged to provide evidence for each of the minimum requirements. Whilst compliance has automatically been awarded; the evidence provided was not reviewed due to the lack of time available. Page 16 of 19

17 Criterion Medicines Management documented process for managing the risks associated with medicines in all care environments Transfusion documented process for managing the risks associated with the transfusion process Venous Thromboembolism documented process for managing the risks associated with the prevention and management of venous thromboembolism. Compliant Not reviewed Non-compliant Findings and recommendations b. process for ensuring the accuracy of all prescription charts The Care and Control of Medicines Policy, Version 5 (February 2011) was the approved document provided for this criterion. Compliance was awarded on this occasion as the approved document implied that the process for recording and archiving records or information given to the patient complied with the requirements of the Records Management Policy, Version 5 (May 2011). The organisation is advised to clearly, accurately and in detail, describe the process for documenting when information is given to patients or amendments to prescription charts are made. The organisation confirmed it does not provide a blood transfusion service, as such a positive score was awarded. e. process for monitoring compliance with all of the minimal requirements The Venous Thromboembolism Policy, Version 1 (May 2011) was the approved document provided for this criterion. On this occasion, compliance could not be awarded as the monitoring process described in the approved document did not monitor the minimum requirements of the criterion, as a result the effectiveness of the implementation of the minimum requirements would not be monitored. Page 17 of 19

18 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 patients who have been harmed as a result of their healthcare treatment. Concerns, complaints and claims, when examined in conjunction with all reported adverse events, 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. There were no further comments to add other than those relevant within the executive summary. Page 18 of 19

19 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: Det Norske Veritas Highbank House Exchange Street Stockport Cheshire SK3 0ET NHSLA general enquiries General enquiries Risk management enquiries Address for correspondence: The NHS Litigation Authority 151 Buckingham Palace Road Westminster London SW1W 9SZ Website Page 19 of 19

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