Date: Meeting: Trust Board Public Meeting. 6 May Title of Paper: Operation Yewtree Action Plan. Key Issues: (Actions, Timescales, Costs etc.

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1 Meeting: Trust Board Public Meeting Date: 6 May 2015 Title of Paper: Operation Yewtree Action Plan Key Issues: (Actions, Timescales, Costs etc.) On 26 February 2015, Kate Lampard published her second report following investigations into the abuse of individuals by Jimmy Savile on NHS premises. The 'Lessons learnt' report looks into Jimmy Savile's role as both a volunteer and a fundraiser in the NHS; and how he abused his celebrity status to gain access, influence and control in a number of NHS settings over a period spanning across 50 years. The report is based on evidence gathered from the independent investigations, calls for evidence and information provided by staff and patients during visits to hospital sites across the country. It takes into consideration the arrangements and systems which have already been put in place which are targeted at strengthening patient care and safety; and reflects on areas of good practice and lessons learned in NHS trusts. The report makes 14 recommendations - 13 of which have been accepted in principle and 9 which directly apply to Humber NHS Foundation Trust. An action plan to address these recommendations is attached. A joint statement in response to the Jimmy Savile investigations was released by NHS England, NHS Trust Development Authority, the Care Quality Commission and Monitor: Kate Lampard s Lessons Learnt report makes recommendations for Trusts to improve their policies and practice including access, volunteering, safeguarding, complaints and governance. The report shows that there is a variety of practice across the country. Following the Secretary of State s statement, Monitor and the NHS Trust Development Authority will write to all Trusts to ask them to review their current practice against the recommendations and to develop an action plan in response. All Trusts will then need to report back on their proposed actions within three months. Monitor wrote to the Trust on 13 March 2015 asking us to respond by 5pm Monday, 15 June 2015 with an overview of any necessary actions that we have taken as a result of the recommendations in the report or, where these are in progress, the date by which they will be completed. The Trust has also commissioned an external investigator to investigate allegations made in relation to Savile when he visited De La Pole Hospital in the 1970s. The investigation is still ongoing and on completion a full report will be produced and communicated as appropriate. Links to Strategic Objectives: Provide services that are safe, person centred, delivered in appropriate environments and sensitive to the needs of the individual Through the use of evidence based practice, provide high quality services to establish a

2 reputation for exceptional standards of care Provide and develop services that are efficient, cost effective and responsive to the needs of the people who use them Risk Issues: (Financial, Clinical, Governance etc) If the recommendations within the report are not addressed we potentially risk putting patients and staff at a risk in the future. Recommendations: Members of the Trust Board are asked to: Approve the attached action plan and agree that it can be forwarded to Monitor. Author of Report: Elizabeth Thomas, Director of Human Resources

3 Operation Yew Tree High Level Action Plan to Address National Recommendations Recommendations High level actions Current Position Action to fill Gaps Who and When REC 1. All NHS hospital trusts should develop a policy for agreeing to and managing visits by celebrities, VIPs and other official visitors. The policy should apply to all such visits without exception. REC 2. All NHS trusts should review their voluntary services arrangements and ensure that they are fit for purpose; volunteers are properly recruited, selected and trained and are subject to appropriate management and supervision; and all voluntary services managers have development opportunities and are properly supported. To develop a Policy for agreeing and managing visits by celebrities, VIPs and other official visitors. Carry out a review of voluntary services arrangements. Ensure that volunteers are properly recruited, selected and trained. There is no policy in place. In June 2014 activities involving Voluntary Services were suspended, allowing the Trust to evaluate the service and carry out an audit in July/August This audit considered all activities. Volunteers are subject to the normal recruitment process carried out in the Trust, including DBS checks and references. Volunteers attend a tailored induction and training is identified and addressed as appropriate. Develop and implement a policy None identified due to recent work which has been completed. No gaps identified as HR recently took over the recruitment process for volunteers following the audit of the services. Review current practice in relation to shared buildings with other providers to ensure that policies and systems are robust in relation to patient areas. E Thomas 1 June 2015 T Cope 1 September 2015

4 REC 3. The Department of Health and NHS England should facilitate the establishment of a properly resourced forum for voluntary services managers in the NHS through which they can receive peer support and learning opportunities and disseminate best practice. N/A REC 4. All NHS trusts should ensure that their staff and volunteers undergo formal refresher training in safeguarding at the appropriate level at least every three years. Ensure staff and volunteers undergo formal refresher training in safeguarding at the appropriate level at least every three years. Tailored safeguarding training has been agreed by both safeguarding Boards for volunteers. Safeguarding training for staff is every 3 years. Review following the reaudit of voluntary services in J Williams Dec 2015

5 REC 5. All NHS hospital trusts should undertake regular reviews of their safeguarding resources, structures and processes (including their training programmes), and the behaviours and responsiveness of management and staff in relation to safeguarding issues - to ensure that their arrangements are robust and operate as effectively as possible. Undertake regular reviews of safeguarding resources, structures and processes (including training programmes), and the behaviours and responsiveness of management and staff in relation to safeguarding issues. A review of safeguarding has recently been undertaken in the Trust and safeguarding resources have been increased. Safeguarding issues are raised at the Trust s Organisational Risk Management Group on a weekly basis and actions put in place where required. A quarterly report on safeguarding is presented to the Trust Board. There are several safeguarding policies in place. As part of the CQC action plan the Trust reviewed needs of children within families with parents or carers with mental health illness. Review all safeguarding policies to ensure that they are up to date and that they address the recommendations within the Operation Yewtree report. Communicate the policies, including how to raise and report concerns to all staff. Director of Nursing, Quality and Patient Experience (in partnership with the two safeguarding Boards) March 2016

6 Training uptake for the MH Capacity Act is 88%, for safeguarding adults 75% safeguard children 80% Safeguarding training for staff is every 3 years. A tailored programme for volunteers has been agreed by both safeguarding Boards. The Trust s Whistle Blowing Policy is due its next review in April Bring forward the next review and address recommendations from operation Yewtree and Francis s report on Freedom to Speak. Director of Nursing, Quality and patient Experience and E Thomas September 2015 REC 6. The Home Office should amend relevant legislation and regulations so as to ensure that all hospital staff and volunteers undertaking work or volunteering that brings them into contact with patients or their visitors are subject to enhanced DBS and barring list checks. N/A

7 REC 7. All NHS hospital trusts should undertake DBS checks (including, where applicable, enhanced DBS and barring list checks) on their staff and volunteers every three years. The implementation of this recommendation should be supported by NHS Employers. Not accepted, instead the DoH will carry out a review of current practices, and use of the DBS Update Service. Undertake DBS checks (including, where applicable, enhanced DBS and barring list checks) on their staff and volunteers every three years. A running programme is in place to ensure that checks are carried out every 3 years. An audit should be undertaken to assess any gaps in this process, where staff or volunteers are overdue their 3 yearly check. E Thomas June 2015 REC 8. The Department of Health and NHS England should devise and put in place an action plan for raising and maintaining NHS employers awareness of their obligations to make referrals to the local authority designated officer (LADO) and to the Disclosure and Barring Service. N/A

8 REC 9. All NHS hospital trusts should devise a robust trustwide policy setting out how access by patients and visitors to the internet, to social networks and other social media activities such as blogs and Twitter is managed and where necessary restricted. Such policy should be widely publicised to staff, patients and visitors and should be regularly reviewed and updated as necessary. Develop a robust trustwide policy setting out how access by patients and visitors to the internet, to social networks and other social media activities such as blogs and Twitter is managed and where necessary restricted. Widely publicise to staff, visitors and patients. Regularly reviewed and update. We currently have an inconsistent approach with no formal policy in place to manage and review usage. IG Committee has recently commissioned a piece of work to develop a policy to allow safe access to the internet and social networks for patients in in-patient areas. This is as a result of new PLACE requirements for us to provide access when safe and appropriate to do so. The policy will also need to comply with Home Office regulations for forensic patients. J Williams September 2015 REC 10. All NHS hospital trusts should ensure that arrangements and processes for the recruitment, checking, general employment and training of contract and agency staff are consistent with their own internal HR processes and standards and are subject to monitoring and oversight by their own HR managers. Ensure that arrangements and processes for the recruitment, checking, general employment and training of contract and agency staff are consistent with internal HR processes/ standards and that they are subject to monitoring and oversight by HR managers. We have an agency clearance form in place which is sent to all Agencies to complete and submit regarding each prospective agency worker to provide assurance that all checks have been completed in line with our own procedures. Medical Staffing use a checklist to receive copies of all clearances from the agencies prior to the Locum starting. Enhance the process to ensure that the monitoring and oversight of the policy is undertaken by HR Managers. E Thomas June 2015

9 REC 11. NHS hospital trusts should review their recruitment, checking, training and general employment processes to ensure they operate in a consistent and robust manner across all departments and functions and that overall responsibility for these matters rests with a single executive director. Review recruitment, checking, training and general employment processes to ensure they operate in a consistent and robust manner across all departments and functions. The HR department is centralised and the policies and processes around recruitment, checking, training and general employment apply across the Trust. The Director of Human Resources is responsible. None identified REC 12. NHS hospital trusts and their associated NHS charities should consider the adequacy of their policies and procedures in relation to the assessment and management of the risks to their brand and reputation, including as a result of their associations with celebrities and major donors, and whether their risk registers adequately reflect such risks. Work with our associated NHS charities to consider the adequacy of our policies and procedures in relation to the assessment and management of the risks to our brand and reputation, including as a result of our associations with celebrities and major donors, and whether the risk registers adequately reflect such risks. No work in relation to this recommendation is currently in place. Charitable Funds Committee to consider the recommendation and identify actions. A Snarr June 2015

10 REC 13. Monitor, the Trust Development Authority, the Care Quality Commission and NHS England should exercise their powers to ensure that NHS hospital trusts,(and where applicable, N/A independent hospital and care organisations), comply with recommendations 1, 2, 4, 5, 7, 9, 10 and 11. REC 14. Monitor and the Trust Development Authority should exercise their powers to ensure that NHS hospital trusts comply with recommendation 12. N/A