CONTROLS ASSURANCE STANDARDS REPORT OF COMPLIANCE

Transcription

1 CONTROLS ASSURANCE STANDARDS REPORT OF COMPLIANCE

2 CONTENTS 1. Introduction 3 2. Descriptors for compliance 5 3. Self Assessment Scores Summary of Scores Self Assessment Scores - All Standards 7 4. Conclusion 53 Appendix 1 - SHSCT Implementation Programme 2008/

3 1. Introduction The Departmental Circular HSS (PPM) 5/2003 formally introduced Controls Assurance Standards into the Health and Social Care system and advised Health and Social Care Organisations that they would be annually required to assess and report their levels of compliance with the standards in support of the organisation s Statement of Internal Control (SIC). For 2008/09, all HSC organisations were required to achieve substantive compliance in all 22 standards. Compliance with the core standards: Financial Management Governance Risk Management is regarded as fundamental in underpinning individual Statements of Internal Control and provide the basis for compliance with the remaining standards. In the three core standards together with the following three standards were subject to independent verification by internal audit: Records Management Infection Control Emergency Planning Internal Audit have reported the outcome of the verification reviews and report that on the evidence submitted the Trust achieved Substantive compliance i.e.% or more in these six standards The sixteen non-core standards are: Buildings, Land, Plant and Non-medical Equipment Food Hygiene Decontamination of Medical Devices Environmental Cleanliness Environmental Management Fire Safety Fleet and Transport Management Health and Safety Human Resources Information and Communications Technology Management of Purchasing and Supply Medical Devices and Equipment Management Medicines Management Research Governance Security Management 3

4 Waste Management. Section 3 of this report presents the summary of scores from self assessment against the 22 standards in 2008/09. The process of self-assessment, integral to the controls assurance process, provides an understanding of the risks to the organisation s business and the Trust process requires that action plans are in place to control and monitor these. Comparison with the Trust s assessment in 2007/08 demonstrates that improvements have been made in year. Action plans are already in place for all standards for 2009/10 and work continues to build on the progress made and continually develop the governance arrangements and sources of assurance of the effectiveness of controls in operation in the Trust to manage risk. 4

5 2. Descriptors for Compliance The levels of compliance and scoring for controls assurance standards as defined by the Department of Health Social Services and Public Safety are presented in Table 2. Level & Scoring Negligible 0 Minimal 1 29 Moderate Substantive - 99 Full 100 Descriptor No compliance anywhere in the organisation with any of the requirements set by the standard A low degree of organisation-wide compliance with the requirements set by the standard. Demonstrable evidence that a start has been made towards compliance in some or all parts of the organisation. Low percentage of compliance by professional people as part of the self-assessment process A moderate degree of organisation-wide compliance with the requirements set by the standard. Demonstrable evidence that work is ongoing across most parts of the organisation to achieve compliance, although some directorates or departments may be in the very early stages of compliance. Medium percentage of compliance by professional people as part of the self-assessment process. Substantive organisation-wide compliance with all requirements set by the standard. Demonstrable evidence that most parts of the organisation are meeting most of the requirements set by the standard. Only minor non-compliance issues requiring, in the main, minor action(s). High percentage of compliance by professional people as part of the self-assessment process. Full compliance across the whole organisation with all requirements set by the standard Table 1 - DHSSPS Levels of Compliance 5

6 3.0 Self Assessment Scores 3.1 Summaries of scores for 2008/09 compared with 2007/08 The Trust scores for 2008/09 are presented below in table 2. This demonstrates that substantive compliance has been achieved for all standards and provides an overview of the areas where improvements have been made in 2008/09. Standard Level of Compliance Required by DHSSPS Scores 2008/09 Scores 2007/08 Verified by Internal Audit in 2008/09 Buildings, Land, Plant and Substantive Non medical equipment Decontamination of Medical Substantive Devices Emergency Planning Substantive Environmental Cleanliness Substantive 85 Environmental Management Substantive Financial Management Substantive Fire Safety Substantive Fleet and Transport Substantive Management Food Hygiene Substantive Governance Substantive Health and Safety Substantive Human Resources Substantive 83 Infection Control Substantive Information and Substantive 74 Communication Technology Management of Purchasing Substantive and Supply Medical Devices and Equipment Management Substantive Medicines Management Substantive Records Management Substantive Risk Management Substantive Security Management Substantive 78 Waste Management Substantive Research Governance Substantive Table 2 6

7 3.2 Self Assessment Scores All Standards 2008/09 BUILDINGS, LAND, PLANT AND NON MEDICAL EQUIPMENT Criterion 1 Board level responsibility for buildings, land, plant and non-medical equipment is clearly defined and there are clear lines of accountability throughout the organisation, leading to the Board 100 Criterion 2 A suitably qualified professional has been designated to manage the estate 100 Criterion 3 Criterion 4 Criterion 5 The organisation has a Board-approved estate strategy for the management of its buildings, land, plant and non-medical equipment that meets the requirements of its business plan and service strategy All activity relating to buildings, land, plant and non-medical equipment is undertaken in accordance with the organisation s estate policy and procedures. An annual review is undertaken to assess the capacity and capability of the estate to meet the needs of the organisation and legislative requirements Criterion 6 The organisation s asset base is managed systematically, based on an agreed approach 80 Criterion 7 Criterion 8 All property management issues are evaluated, considered, and dealt with to achieve optimum, financial control and stakeholder satisfaction The risk management process contained within the Risk Management standard is applied to HPSS estates

8 BUILDINGS, LAND, PLANT AND NON MEDICAL EQUIPMENT Criterion 9 The organisation has access to up-to-date legislation and guidance relating to HPSS estates 100 Criterion 10 Criterion 11 Criterion 12 Staff receive training and instruction on the safe operating and maintenance of HPSS estates and facilities commensurate with their roles and responsibilities HPSS estates personnel have the skills and capability to undertake their responsibilities in accordance with the Health and Safety at Work (Northern Ireland) Order 1978 Key indicators capable of showing improvements in the management of HPSS estates and/or providing early warning of risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly Criterion 13 The organisation benchmarks itself against other organisations. Criterion 14 The system in place for managing HPSS estates, including risk management arrangements, is monitored and reviewed by management and the Board in order to make improvements to the system 55 Criterion 15 The system in place for managing HPSS estates, including risk management arrangements, is monitored and reviewed by management and the Board in order to make improvements to the system 75 Sub Total 1195 Total Weighting 1500 Average Score 80 8

9 Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion 5 Criterion 6 Criterion 7 Criterion 8 Criterion 9 DECONTAMINATION OF RE-USABLE MEDICAL DEVICES Board level responsibility for decontamination of re-usable medical devices is clearly defined and there are clear lines of accountability for decontamination matters throughout the organisation, leading to the Board There is comprehensive organisation-wide implemented policy and procedures for the Decontamination of Re-usable Medical Devices. Appropriately qualified key personnel are in place in accordance with legislative and best practice guidance for decontamination. Decontamination issues are considered prior to the acquisition of re-usable medical devices and decontamination equipment through a broad-based Medical Devices and Equipment group(s), established in accordance with NIAIC Device Bulletin DB 94(NI) include membership of staff responsible for decontamination and reprocessing. All surgical instrument sets are tracked through the decontamination process and can be traced to individual patients. All re-usable medical devices are handled, collected and delivered in a manner that reduces the risk of contamination to the product, patients, staff and any area of the healthcare facility. Decontamination, storage and preparation of endoscopes for use is undertaken in accordance with Device Bulletin DB(NI) 2002/05 and current legislative requirements. All other re-usable medical devices are decontaminated and stored in accordance with legislative and best practice requirements. Decontamination equipment is subject to validation, calibration, monitoring and maintenance by appropriately qualified persons

10 Criterion 10 Criterion 11 Criterion 12 DECONTAMINATION OF REUSABLE MEDICAL DEVICES Ethylene oxide sterilizers are operated and used in accordance with legislative and best practice requirements All medical devices, decontamination equipment and surfaces are appropriately dealt with after use on patients known to have or who are in a risk category for CJD All decontamination equipment that does not meet the requirements of current standards and test methods is upgraded or replaced as soon as practicable in accordance with a planned replacement programme. N/A 80 Criterion 13 Criterion 14 Criterion 15 Criterion 16 All medical devices that cannot be easily cleaned and/or those in poor condition, are identified and subject to a planned replacement programme with equipment that is easier to clean, or replaced by a single use alternative. Sterile Services Department facilities meet the standards and requirements for the segregation of controlled environments. All other locations in which the decontamination of re-usable medical devices (including flexible endoscopes) is carried out are dedicated for the purpose and appropriately designed, maintained and controlled. The risk management process contained within the Risk management standard is applied to all aspects of decontamination of re-usable medical devices Criterion 17 All staff involved in decontamination processes have access to up-to-date legislation and guidance

11 Criterion 18 Criterion19 Criterion 20 Criterion 21 DECONTAMINATION OF RE-USABLE MEDICAL DEVICES Education and training in appropriate aspects of decontamination practice is provided to relevant healthcare staff, including those working in a clinical environment. Key indicators capable of showing improvements in the safety and efficacy of the system in place for decontamination of re-usable medical devices and/or providing early warning of risk, are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for decontamination is monitored and reviewed by management and the Board in order to make improvements. The Board seeks independent assurance that an appropriate and effective system of managing decontamination issues is in place and that the necessary level of controls and monitoring are being implemented. 80 Sub Total 1735 Total Weighting 2000 Average Score 87 11

12 Criterion 1 Criterion 2 EMERGENCY PLANNING Board/Authority level responsibility for emergency planning is clearly defined and there are clear lines of accountability throughout the organisation leading to the Board and the Chief Executive Officer and the Fire Authority for Northern Ireland and the Chief Fire Officer. The Chief Officer/Chief Fire Officer has overall responsibility for emergency planning and has given authority to a Senior Officer to work on emergency planning and liaise with the emergency services and all appropriate organisations. There is a major incident plan for the organisation to respond to both internal and external emergency situations and inter service inter agency cooperation during the response Criterion 3 All feasible/realistic types of emergency situations are addressed in the service continuity plan(s) 75 Criterion 4 Appropriate internal and external stakeholders in the major incident plan are consulted and 84 collaborated with concerning their roles and responsibilities. Stakeholders comprise the HPSS, the emergency services, Primary Care, voluntary organisations and district councils and organisations providing agency staff for HPSS deployment Criterion 5 Emergency preparedness is validated through the exercising and testing of emergency plans. 75 Criterion 6 The major incident plan is regularly reviewed 75 Criterion 7 The organisation provides funding and resources to ensure that emergency planning responsibilities are met and that it is able to respond effectively to a major incident Criterion 8 The organisation has access to up to date guidance relating to emergency planning Criterion 9 All appropriate staff should receive emergency preparedness training that is commensurate with their role in the major incident plan 71 12

13 Criterion 10 Criterion 11 EMERGENCY PLANNING Key indicators capable of showing improvements in emergency preparedness and/or providing early warnings of risk are used at all levels of the organisation, including the board, and the efficiency and usefulness of the indicators is reviewed regularly The system in place for emergency planning and preparedness is monitored and reviewed by management and the Board/Authority in order to make improvements to the system. HSS Boards have a responsibility to monitor emergency planning preparedness of Trusts and Agencies. DHSSPS is responsible for monitoring emergency planning preparedness of HSS Boards, Trusts, Agencies and the NIFB. 50 Criterion 12 The Board/FANI seeks independent assurance that an appropriate and effective system of managing emergency planning is in place and that the necessary levels of controls and monitoring are being implemented Sub Total 878 Total Weighting 1200 Average Score 73 13

14 Criterion 1 ENVIRONMENTAL CLEANLINESS Trusts are able to demonstrate strong and clear leadership at the highest level of management that encourages a culture of cleanliness matters. Clear accountability arrangements for environmental cleanliness, linked to infection prevention and control, risk management and to corporate and clinical and social care governance are in place. 95 Criterion 2 A consistently high standard of environmental cleanliness is delivered in all Trust facilities. 95 Criterion 3 Criterion 4 Criterion 5 Criterion 6 Criterion 7 Criterion 8 Service user s views on environmental cleanliness standards are integrated into the planning, implementation and monitoring process The most appropriate cleaning methods and frequencies are applied to specific functional areas within health and social care facilities proportionate to the relative risks. Trust facilities and fixtures are maintained to an acceptable condition to enable the effective and safe cleaning of the service user environment and new facilities are designed to provide easier cleanability The risk management process contained within the risk management system standard is also applied to the management of improvement of Standards of Environmental Cleanliness. Staff recruitment, retention, education and development programmes are developed so that staff are recruited and trained to undertake their duties in ensuring that the necessary levels of environmental cleanliness standards are achieved Key indicators capable of showing improvements in the Standard of Environmental Cleanliness are used at all levels of the organisation, including the Board

15 ENVIRONMENTAL CLEANLINESS Criterion 9 The organisation participates in benchmarking its performance of Environmental Cleanliness 75 Criterion 10 Criterion 11 Criterion 12 Total Weighting Score The system in place for Standards of Environmental Cleanliness, including risk management arrangements, is monitored and reviewed by management and the Board in order to make improvements to the system The Standard of Environmental Cleanliness is assessed by appropriate internal monitoring and audit and reported to the Trust Board The organisation s board should seek independent assurance that an appropriate and effective system of managing Standards of Environmental Cleanliness is in place, that the necessary level of controls and monitoring are being implemented and that there is visible evidence that Standards have improved. Sub Total Average

16 ENVIRONMENTAL MANAGEMENT Criterion 1 Board level responsibility for environmental management is clearly defined and there are clear lines of 100 accountability throughout the organisation, leading to the board. Criterion 2 The organisation has an effective policy and whole life strategy for environmental management, which has been 80 endorsed by the board and adopted throughout the organisation. Criterion 3 A thorough environmental review has been carried out to establish significant environmental risks. 80 Criterion 4 There are agreed environmental targets and management objectives, which are fulfilled by an on going 65 programme. Criterion 5 The risk management process contained within the risk management standard is applied to the management of 75 environmental risk. Criterion 6 There is access to up-to-date information on environmental legislation and guidance to all within the organisation 100 who require the information. Criterion 7 Appropriate training relevant to the achievement of environmental policies, objectives and targets is provided to 60 all staff within the organisation. Criterion 8 Key indicators capable of showing improvements in environmental management and the management of associated risks are used at all levels of the organisation, including the board, and the efficacy and usefulness of the indicators is reviewed regularly. Criterion 9 The system in place for environmental management, including risk management arrangements, is monitored and 80 reviewed by management and the board in order to make improvements to the system. Criterion 10 The Board seeks independent assurance that an appropriate and effective system of managing environmental risks is in place and that the necessary level of controls and monitoring are being implemented. 77 Total Weighting Score Total Sub Average

17 FINANCIAL MANAGEMENT Criterion 1 Financial objectives for the organisations are clearly defined, approved by the Board, and conform to 95 Department of Health, Social Services and Public Safety requirements Criterion 2 The organisation s senior management has defined and documented its strategy for managing risks, including objectives for, and its commitment to, risk management. The risk management strategy is relevant to the organisation s strategic context and its goals, objectives and the nature of its business. Management ensures that the strategy is understood, implemented and maintained at all levels of the organisation. Criterion 3 There is an Audit Committee overseeing the financial aspects of governance. 100 Criterion 4 Standing Financial Instructions, based on the Departmental model and updated to reflect current requirements, have been formally adopted by the Board, and promulgated throughout the organisation. Criterion 5 Financial risk management processes exist throughout the organisation. Criterion 6 There is an effective and documented system of internal control for all financial management systems. 65 Criterion 7 There is an adequately resourced, trained and competent finance function. 85 Criterion 8 All employees, including managers and the Board, are provided with adequate information, instruction and training on financial management. Criterion 9 The Board reviews the effectiveness of its system of internal control for financial management at least annually. 95 Criterion 10 Criterion 11 The Board receives regular reports on financial performance and activity. It is made aware of significant risks and determines and takes appropriate action 98 The Head of Internal Audit provides an annual assurance to the committee on the effectiveness of organisation s financial arrangements based on this standard

18 FINANCIAL MANAGEMENT Criterion 12 The organisation can demonstrate that it has done its reasonable best to meet its key financial objectives. 95 Sub Total 1088 Total Weighting 1200 Average Score 91 18

19 Criterion 1 Criterion 2 FIRE SAFETY Board level responsibility for fire safety is clearly defined and there are clear lines of accountability for fire safety throughout the organisation, leading to the Board. There is a documented fire safety policy that has been approved by the Board and has been communicated across the organisation. 100 Criterion 3 Criterion 4 Fire safety roles and responsibilities are clearly defined for all situations where accommodation is shared with other organisations. An annual Certificate of Firecode Compliance is satisfactorily completed, signed by the Chief Executive, and returned to Health Estates, Estate Policy Directorate Criterion 5 Staff and safety representatives are properly consulted on fire safety matters 95 Criterion 6 Fire incidents are dealt with in accordance with the processes contained in the Risk management standard. Criterion 7 All applications for fire certification for premises designated by Order under the Fire Services (Northern Ireland) Order 1984 (as amended) have been made

20 FIRE SAFETY Criterion 8 All premises controlled by the Housing (Northern Ireland) Order 2003 are appropriately managed and have been notified to the northern Ireland Housing Executive. Criterion 9 Applications made for all new building work, relevant changes of use and material alterations are covered by the Building Regulations (NI) Criterion 10 The risk management process contained within the Risk management standard is applied to fire safety. 85 Criterion 11 Fire safety risk assessments have been completed for all occupied premises and are maintained up-to-date. 75 Criterion 12 The organisation s premises meet the minimum physical statutory requirements laid down in the Fire Precautions (Workplace) Regulations (Northern Ireland) 2001 and the health and Safety (Safety Signs and Signals) Regulations (Northern Ireland) Criterion 13 All occupied areas have suitable and up-to-date emergency procedures in case of fire. 75 Criterion 14 The organisation s physical fire safety infrastructure is maintained and tested in accordance with legislation, Approved Codes of Practice, British Standards, and/or manufacturer s guidelines. 80 The organisation has access to up-to-date fire safety legislation, Approved Codes of Practice, Firecode, British Criterion 15 Standards, and other guidance relating to fire safety

21 FIRE SAFETY Criterion 16 Criterion 17 Criterion 18 Criterion 19 All staff receive a level of fire safety training that is appropriate for their individual responsibilities in the event of a fire and a record is made of all training received. Key indicators capable of showing improvements in fire safety and/or providing early warning of risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for managing fire safety, including risk management arrangements, is monitored and reviewed by management and the Board in order to make improvements to the system. The Board should seek independent assurance that an appropriate and effective system of managing fire safety is in place and that the necessary level of controls and monitoring are being implemented Sub Total Total Weighting Average Score

22 Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion 5 Criterion 6 Criterion 7 Criterion 8 FLEET AND TRANSPORT MANAGEMENT Board level responsibility for fleet and transport management including the environmental aspects, safety of occupants, vehicles and equipment, is clearly defined and there are clear lines of accountability throughout the organisation, leading to the board. There is a fleet and transport management policy/strategy, developed with the involvement of all stakeholders, which is reviewed on an annual basis and endorsed by the board. The organisation has identified targets for reducing environmental pollution from transport in partnership with relevant stakeholders and has associated timescales for achievement. These targets are communicated throughout the organisation. The organisation has taken into consideration travel by contractors and suppliers in its review, and introduced measures for reducing environmental pollution from transport. The organisation develops and maintains on-site traffic routes, traffic management systems and the provision of signs to provide, so far as reasonably practical, pedestrians and vehicles to circulate in a safe manner. The organisation develops a fleet and transport profile which has taken into consideration its operational needs, topography, changing demography, available resources, environmental pollution, armonizationn and relevant legislative standards. Acceptance checks are carried out on all newly delivered vehicles and their equipment (see reference to Terminology, page 2). All vehicles are properly maintained and repaired and are regularly inspected to ensure compliance with legislation and external contracts are monitored and reviewed

23 Criterion 9 Criterion 10 Criterion 11 Criterion 12 Criterion 13 Criterion 14 Criterion 15 FLEET AND TRANSPORT MANAGEMENT The organisation ensures that staff and contractors are aware of the vehicle insurance details, insurance reporting requirements and personal requirements of the appropriate driving licence. The risk management process contained within the core risk management standard is applied to fleet and transport management. Appropriate levels of information, instruction and training are provided for all persons who are required to drive or maintain vehicles in the course of providing a service on behalf of the organisation. The organisation has access to up-to-date legislation and guidance relating to requirements and risks associated with fleet and transport management. Key indicators capable of showing improvements in reducing the risks associated with fleet and transport management are used at all levels of the organisation, including the board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for managing fleet and transport is monitored and reviewed by management and the board in order to make improvements to the system. The board seeks independent assurance that an appropriate and effective system of managing fleet and transport is in place and that the necessary level of controls and monitoring are being implemented Sub Total 1250 Total Weighting 1500 Average Score 83 23

24 Criterion 1 FOOD HYGIENE Board level responsibility for food hygiene and catering services is clearly defined and there is a clear line of accountability throughout the organisation leading to the Board. 85 Criterion 2 Food premises are registered with the local council. 100 Criterion 3 Criterion 4 Criterion 5 Criterion 6 Criterion 7 All food and ingredients used by suppliers, catering, wards and departments are sourced in accordance with a known standard purchasing specification, which is used by all suppliers, contractors & catering management, and are from accredited suppliers. All foods are stored in appropriate conditions and protected from contamination and deterioration, including protection against pests. All food preparation, processing, manufacturing, distribution and transportation, is carried out in hygienic conditions. All foods, including raw materials, ingredients, intermediate products and finished products, are received and kept at temperatures, which comply with the Food Safety (Temperature Control) Regulations (Northern Ireland) Food safety assessments are carried out with the aim of identifying the critical food safety steps within the business and taking appropriate control measures to reduce any associated risks Criterion 8 All food handlers maintain a high standard of personal hygiene

25 Criterion 9 Criterion 10 FOOD HYGIENE Food incidents and complaints are dealt with in accordance with Food Standards Agency and Local Council guidance and the general requirements contained in the Risk Management standard. All food handlers are given supervision, instruction and/or training in accordance with their level of work activity and responsibility Criterion 11 There is access to up-to-date legislation and guidance relating to food hygiene. Criterion 12 Criterion 13 Criterion 14 Key indicators capable of showing improvements in catering services and food hygiene, and the management of associated risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for food safety is monitored and reviewed by management and the Board in order to make improvements to the system. The Board seeks independent assurance that an appropriate and effective system of managing catering and food hygiene is in place and that the necessary level of controls and monitoring are being implemented Sub Total 1177 Total Weighting 1400 Average Score 84 25

26 GOVERNANCE Criterion 1 There are clear accountability arrangements in place throughout the organisation. 80 Criterion 2 The board identifies the needs of its stakeholders on an ongoing basis and determines a set of key 85 objectives and outcomes for meeting these needs, including how it meets its duty of quality. Criterion 3 The board ensures that there are proper processes in place to meet the organisation s objectives 85 and secure delivery of outcomes. Criterion 4 The organisation is capable of meeting its objectives and delivering appropriate outcomes. 85 Criterion 5 Criterion 6 Criterion 7 The organisation learns and improves its performance through continuous monitoring and review of the systems and processes in place for meeting its objectives and delivering appropriate outcomes. The board ensures there are proper and independent assurances given on the soundness and 80 effectiveness of the systems and processes in place for meeting its objectives and delivering appropriate outcomes The board can demonstrate that it is doing its reasonable best to achieve its objectives and outcomes, including maintenance of a sound and effective system of internal control. Sub Total Total Weighting 0 Average Score 84 26

27 Criterion 1 Criterion 2 Criterion 3 Criterion 4 HEALTH AND SAFETY Board level responsibility for health and safety is clearly defined and there are clear lines of accountability for health and safety matters throughout the organisation, leading to the Board. Where required, there is a health and safety committee, or equivalent, constituted and working according to the requirements laid down in HSS (Gen1) 4/2000 and Article 4(7) of the Health and Safety at Work (Northern Ireland) Order 1978, which facilitates consultation on all health and safety matters. The organisation has a health and safety policy that complies with the requirements of the health and Safety at Work (Northern Ireland) Order 1978, Health Services Advisory Committee guidance and HSS (Gen 1) 4/2000 Individual directorates/departments have health and safety procedures, which address their own specific health and safety concerns and are compatible with the organisation s overall policy Criterion 5 All staff are made aware of the organisation s health and safety policy and, where appropriate, any directorate/departmental policies. Criterion 6 Staff and safety representatives are properly consulted on health and safety matters. Criterion 7 Compliance with health and safety legislation is routinely monitored. Criterion 8 Health and safety incidents, including injuries, diseases and dangerous occurrences, are dealt with in accordance with the processes contained in the Risk Management standard 80 27

28 Criterion 9 Criterion 10 HEALTH AND SAFETY Where two or more employers share the workplace, there is demonstrable evidence of cooperation on and co-ordination of health and safety measures. Contractors are briefed on health and safety requirements and, where appropriate, contractual obligations are formally notified. 85 Criterion 11 Plans are in place to address all situations that pose serious or imminent danger Criterion 12 Criterion 13 Criterion 14 The effectiveness with which management of health and safety responsibilities has been carried out is systematically assessed within individual performance reviews. Manual handling operations that involve risk of injury are, where possible, avoided. Risk of injury relating to any remaining manual handling operations is reduced to the lowest level reasonably practicable. All risks to employees and to any other persons affected by the activity of the organisation are continuously and systematically assessed Criterion 15 The risk control measures identified during risk assessments are implemented in order of priority. 75 Criterion 16 All identified health and safety risks and the effectiveness of implemented risk treatments are monitored and reviewed on a continuous basis

29 Criterion 17 Criterion 18 Criterion 19 Criterion 20 HEALTH AND SAFETY The Board is informed of and, where necessary, consulted upon all significant health and safety risks and associated treatment plans on a continuous basis Other stakeholders are kept informed and, where appropriate, consulted on the management of health and safety risk. There are sufficient competent persons to provide health and safety assistance to the organisation. There is access to up-to-date information on health and safety legislation and guidance, including DHSSPSNI guidance, to all within the organisation who require the information Criterion 21 Criterion 22 Criterion 23 Criterion 24 Employees, including managers and the Board, are provided with adequate information, 75 instruction and training on health and safety matters. Key indicators capable of showing improvements in health and safety management and/or providing early warning of risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for health and safety management, including risk management arrangements, is monitored and reviewed by management and the Board in order to make improvements to the system. The Board seeks independent assurance that an appropriate and effective system of managing health and safety is in place and that the necessary level of controls and monitoring are being implemented. Sub Total 1875 Total Weighting 2400 Average Score 78 29

30 Criterion 1 HUMAN RESOURCES Board level accountability for human resources is clearly defined and there are clear lines of responsibility for human resource matters throughout the organisation, leading to the Board. 100 Criterion 2 A comprehensive regional workforce plan will be produced annually. HSS Organisations will be required to provide workforce data to input to the regional plan. The plan will support the DHSSPS Regional Strategy and Priorities for Action and local health economy. 88 Criterion 3 Criterion 4 Criterion 5 The organisation is working to achieve Stage 1 of the Investors in People Standard and / or working towards full Investors in People accreditation by April All staff are recruited and employed in accordance with relevant statutory employment legislation and mandatory requirements. 100 The organisation takes action to prevent and tackle all forms of harassment, in accordance with the requirements of HSS (Gen 1) 3/1999 and HSS (Gen 1) 4/ Criterion 6 Staff sickness rates are consistently recorded, monitored, reported and reviewed against the targets published by the Department. 89 Criterion 7 Workplace accidents are consistently recorded, monitored, reported and reviewed. 77 Criterion 8 Incidents of workplace violence against staff are consistently recorded, monitored, reported and reviewed in line with the current Zero Tolerance Policy. 93 Criterion 9 All staff have access to a confidential occupational health service

31 HUMAN RESOURCES Criterion 10 All staff have access to a confidential counselling service. 100 Criterion 11 The Working Time Directive for all staff groups is implemented and living and working conditions for all staff groups comply with current guidance. Criterion 12 There is a comprehensive induction programme in place for all staff, whether in permanent posts or on temporary, casual, flexible or rotational contracts. 100 Criterion 13 Staff are given the opportunity to be involved in planning and delivering services. 85 Criterion 14 A regular staff survey is undertaken to measure the quality of working life. 100 Criterion 15 The organisation provides both personal and professional learning and development opportunities that are accessible and open to all staff. 69 Criterion 16 The human resource function has access to up-to-date information on employment and related legislation and guidance. 100 Criterion 17 The system in place for human resources is monitored and reviewed by management and the Board in order to make improvements to the system. 83 Criterion 18 The Board seeks independent assurance that an appropriate and effective system of managing human resources is in place and that the necessary level of controls and monitoring are being implemented. 100 Sub-Total 1612 Total Weighting 1800 Average Score 31

32 Criterion 1 Criterion 2 INFECTION CONTROL Responsibility for infection prevention and control (IPC) is clearly defined and there are clear lines of accountability for IPC matters throughout the organisation. There is an IPC Committee that endorses all IPC policies, procedures, and guidance, provides advice and support on the implementation of policies, and monitors the progress of the annual IPC programme. 80 Criterion 3 There is an appropriately constituted and functioning IPC Team. 75 Criterion 4 Prevention and control of infection is considered as part of all service development activity. 85 Criterion 5 An organisation wide annual infection prevention and control programme with clearly defined objectives is produced by the IPC T 80 Criterion 6 Written policies, procedures and guidance for the prevention and control of infection are implemented and reflect relevant legislation and published professional guidance. 85 Criterion 7 There is an annual programme for the audit of infection prevention and control policies and procedures. 80 Criterion 8 Criterion 9 Criterion 10 Timely and effective specialist microbiological support is provided for the infection prevention and control service. Surveillance of infection is carried out using defined methods in accordance with agreed objectives and priorities, which have been specified in the annual infection prevention and control programme. 75 A comprehensive annual infection prevention and control report is produced by the IPCT and is presented to the Trust Board

33 Criterion 11 Criterion 12 INFECTION CONTROL The Infection Prevention and Control Committee and IPCT have access to up-to-date legislation and guidance relevant to infection prevention and control. 100 Education and training in the prevention and control of infection is provided to all health care staff, including those employed in support services. 75 Criterion 13 Key indicators capable of showing improvements in infection prevention and control and/or providing early warning of risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. 75 Criterion 14 The system in place for infection prevention and control is monitored and reviewed by management and the Board in order to make improvements to the system. 75 Criterion 15 The Trust Board seeks independent assurance that an appropriate and effective system of managing infection prevention and control is in place and that the necessary level of controls and monitoring are being implemented. Criterion 16 An organisation wide hand hygiene policy and mechanism to ensure effective implementation are in place. 80 Sub Total 1315 Total Weighting 1600 Average Score 82 33

34 Criterion 1 INFORMATION & COMMUNICATIONS TECHNOLOGY The Chief Executive of the organisation has overall responsibility for all aspects of ICT and there are clear lines of accountability throughout the organization leading to the Board. 95 Criterion 2 The Board takes responsibility for the organisation s ICT, including ICT projects, and the use, sharing and management of information. Criterion 3 An ICT Steering Group, or equivalent, oversees decisions and is accountable to the Board for all matters 80 in relation to ICT. Criterion 4 There is an ICT Manager, or equivalent, with appropriate skills and qualifications. 100 Criterion 5 There is a comprehensive ICT Policy that is agreed by the Board and links into the organisation s overall strategic plan. 95 Criterion 6 There is a local programme for the exploitation of ICT, designed to achieve the organisation s business objectives, which is reviewed regularly. Criterion 7 An agreed ICT procurement process is adhered to throughout the organisation Criterion 8 A recognized ICT project management methodology is used and adhered to throughout the organisation together with a consistent set of management and control processes. 75 Criterion 9 All care information, either electronic or paper-based, is validated as authentic. 50 Criterion 10 All data and information is protected through the application of robust security measures, to ensure its confidentiality, integrity and availability

35 Criterion 11 Criterion 12 INFORMATION AND COMMUNICATIONS TECHNOLOGY The organization has up to date and tested continuity plans for all critical infrastructure components and core services. The risk management process contained within the Risk Management standard is applied to all aspects of ICT. 45 Criterion 13 The organization has access to up-to-date legislation and guidance relating to information 100 management and technology. Criterion 14 The ICT function is staffed with appropriately skilled ICT specialists. 85 Criterion 15 Criterion 16 Criterion 17 Criterion 18 All ICT stakeholders are appropriately trained to perform their duties with the information technology that is provided to them. All ICT stakeholders are trained to manage the information that they produce and use within their role. Key indicators capable of showing improvements in the management of ICT and/or providing early warning of risk are used at all levels of the organization, including the board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for managing ICT, including risk management arrangements, is monitored and reviewed by the board and senior management in order to make improvements to the system

36 Criterion 19 INFORMATION AND COMMUNICATIONS TECHNOLOGY The Board seeks independent assurance that an appropriate and effective system of managing ICT is in place and that the necessary level of controls and monitoring are being implemented. Sub Total 1415 Total Weighting 10 Average Score 74 36

37 MANAGEMENT OF PURCHASING AND SUPPLY Criterion 1 Board level responsibility for purchasing and supply is clearly defined and there are clear lines of accountability throughout the organisation, leading to the Board. 85 Criterion 2 There is a Board approved procurement strategy in place that is reviewed at least annually 91 Criterion 3 Criterion 4 Criterion 5 Criterion 6 Criterion 7 Criterion 8 There is a Board approved Strategic Procurement Plan in place for delivering the procurement strategy. All expenditure on externally sourced works, equipment, goods, supplies, services and personnel is subject to best procurement practice. Clear and appropriately detailed specifications are used for all purchases, as defined in a documented purchasing procedures manual. The purchase of all products and services conforms to an appropriate method of procurement, as defined in a documented purchasing procedures manual. All potential suppliers are identified through the use of pre-determined criteria that ensure regularity and propriety. The organisation evaluates tenders and awards contracts through the use of pre-determined criteria that ensure the delivery of best value Criterion 9 All contracts for goods, works and services are managed and regularly monitored and reviewed. 37

38 Criterion 10 Criterion 11 Criterion 12 Criterion 13 Criterion 14 MANAGEMENT OF PURCHASING AND SUPPLY There is access to up-to-date legislation and guidance relevant to the management of purchasing and supply. Information, instruction and training on purchasing and supply are provided to employees commensurate with their roles and responsibilities Key indicators capable of showing improvements in management of purchasing and supply and/or providing early warning of risk are used at all levels of the organisation, including the Board, and the efficacy and usefulness of the indicators is reviewed regularly. The system in place for the management of purchasing and supply is monitored and reviewed by management and the Board in order to make improvements to the system. The Board should seek independent assurance that an appropriate and effective system of managing purchasing and supply is in place and that the necessary level of controls and monitoring are being implemented Sub Total 1122 Total Weighting 1400 Average Score 80 38

39 MANAGEMENT OF MEDICAL DEVICES Criterion 1 Board level responsibility for Medical Devices and Equipment management is clearly defined and 85 there are clear lines of accountability throughout the organisation leading to the Board. Criterion 2 There is a broad-based Medical Devices and Equipment group, established in accordance with NIAIC Device Bulletin DB 94(NI Criterion 3 There is a comprehensive organisation-wide implemented policy and procedure for the management 80 of Medical Devices and Equipment. Criterion 4 All Medical Devices and Equipment are selected and acquired in accordance with the Health Estates 75 (NIAIC) and National Audit Office recommendations Criterion 5 All Medical Device developments, modifications and trials are conducted in accordance with relevant 75 legislation and guidance Criterion 6 All professional users and end-users have access to manufacturer s instructions and all user organisations certify that users have received instructions on the safe use of Medical Devices or Equipment Criterion 7 Where Medical Device/Equipment manufacturers automatically send copies of revised instructions to a named recipient, these are appropriately dealt with Criterion 8 All instructions supplied by the user organisation are evaluated for their adequacy Criterion 9 Delivery and pre-use checks are carried out on all newly delivered Medical Devices/Equipment Criterion 10 All newly delivered Medical Devices and Equipment are properly stored after acceptance Criterion 11 Medical Devices designated for single-use are not reused under any circumstances 80 Criterion 12 Criterion 13 All prescribing decisions concerning Medical Devices and Equipment are made by staff with appropriate professional qualifications and suitable experience, backed by appropriate administrative and technical support All necessary information required to properly manage the user organisation s range of Medical Devices/Equipment is recorded on a suitable system 39

40 MANAGEMENT OF MEDICAL DEVICES Criterion 14 All Medical Devices/Equipment are properly maintained and repaired Criterion 15 The in-house Medical Device/Equipment maintenance department is externally accredited Criterion 16 All Medical devices/equipment returned for servicing and repair prior to reuse are properly decontaminated. Criterion 17 Medical Devices/Equipment are replaced in accordance with an agreed policy. Criterion 18 All loaned Medical Devices/Equipment are collected when no longer needed. Criterion 19 All adverse incidents involving Medical Devices and Equipment are reported in accordance with 80 NIAIC Medical Device/Equipment Alert (NI) 2005/01. MDEA (NI)2005/01 may be downloaded from the NIAIC web site at Criterion 20 A complete record of guidance issued by the NIAIC is maintained; warning notices are distributed to the appropriate people in the organisation; and recommendations contained in the notices are implemented. Criterion 21 The risk management process contained within the risk management system standard is applied to the management of Medical Devices and Equipment risk Criterion 22 Staff are made aware of and, where necessary, trained in adverse incident reporting and 75 investigation requirements for Medical Devices and Equipment. Criterion 23 All professional users are trained in the safe operation of Medical Devices and Equipment. Criterion 24 All technical supervisors are trained in the safe operation of Medical Devices and Equipment Criterion 25 All end-users are given appropriate training in the safe and effective use of Medical Devices and Equipment 40