NHSLA Risk Management Standards for NHS Trusts Providing Acute Services 2011/12 Milton Keynes Hospital NHS Foundation Trust Level 1 October 2011
Contents Page 1: Executive Summary 3 Assessment outcome 3 Key findings 5 Overview of assessment outcome 7 2: Assessment Results 8 Standard 1: Governance 8 Standard 2: Competent & Capable Workforce 11 Standard 3: Safe Environment 14 Standard 4: Clinical Care 15 Standard 5: Learning from Experience 20 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 Organisation assessed Services assessed T164 Milton Keynes Hospital NHS Foundation Trust All services Date of last assessment 27 th October 2009 Assessment date 18 th October and 19 th October 2011 Date next assessment due 17 th October 2013 Standards assessed NHSLA Risk Management Standards for NHS Trusts Providing Acute Services 2011/12 Level prior to assessment Level 1 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 8/10 Compliant Competent & Capable Workforce 10/10 Compliant Safe Environment 10/10 Compliant Clinical Care 8/10 Compliant Learning from Experience 7/10 Compliant OVERALL COMPLIANCE 43/50 Compliant 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 Page 3 of 24
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. 90 80 70 67 78 Number of Organisations 60 50 40 30 20 10 0 0 Level 0 Level 1 Level 2 Level 3 Not Yet Assessed 23 1 Chart 2: NHSLA acute assessment levels as at 1 st April 2011 Page 4 of 24
Key findings Milton Keynes Hospital NHS Foundation Trust achieved a score of 43 out of 50 and will be pleased to retain compliance at Level 1 against the NHSLA Risk Management Standards for NHS Trusts Providing Acute Services 2011/12. The body of this report makes some specific recommendations which the organisation should consider along with the following generic comments which are applicable to a range of the documents and evidence seen during the assessment. The evidence template was populated with the organisation s approved Level 1 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 within the evidence. This will assist in reducing any time lost that may affect the assessment of all the criteria. The organisation is advised to ensure that all corporate governance processes are explicitly described in the standards detailed in the organisation s Policy for Policies Version 3.2 (October 2011). This will ensure that staff are aware of, and can comply with, the organisation s requirements when developing and ratifying approved policies and guidance documents. The omission of standardised information in the overarching policy suggests that compliance with corporate governance processes may not be fully embedded across the organisation. As an example the duties section of many of the approved documents presented for review contained a mixture of individual and committee duties. The order in which these are referenced in the various documents is muddled and confusing. In addition the organisation is recommended to consider expanding the process for monitoring compliance within this document as detailed below. Where an approved regional policy has been adopted for local use; the organisation should consider and document the system and process to formally acknowledge acceptance and implementation of this policy locally. As an example the Unified Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Adult Policy, Version 9 (February 2010) has been developed and ratified by South Central Strategic Health Authority in consultation with organisations in the south central region. The organisation has adopted and is tailoring the policy to address specific local requirements. As part of this review, the organisation is advised to document the consultation and ratification process for accepting and informing further updates to address local requirements. In addition, the organisation should consider doublebadging the document to reflect that it is a working document within the strategic health authority region and Milton Keynes Hospital NHS Foundation Trust. Whilst assessing the Level 1 documents provided there was evidence that the document control processes used within the organisation did not appear to have been adhered to in all circumstances. Many of the approved documents had been recently amended and track changes were still evident within them. The organisation must ensure that the process for the development, consultation and final ratification of approved documentation includes a robust checking process to make sure that all received comments and suggested revisions once agreed, are removed from the Page 5 of 24
document before publishing. The organisation should note that converting word documents into PDF format does not automatically remove hidden content. A number of the approved documents assessed contained only minimal descriptions and details of the processes staff were required to follow. The organisation is advised to fully and clearly describe these processes to ensure that staff are able to follow them to manage and reduce risk in the area identified, and to assist the organisation in demonstrating implementation and monitoring at the higher levels of assessment. In addition the majority of documents did not include cross referencing or hyperlinks to additional information to support staff in decision making. Where proforma templates have been developed, the organisation is recommended to attach these as an appendix and provide a reference to them within the approved document. With regard to the sections of the approved documents which describe the process for monitoring compliance with all of the above, the organisation is reminded that this requirement is about the organisation describing how they will monitor compliance with their own processes. It is advisable to introduce a standardised approach to this for all documents and for this to be included and described within the Policy for Policies Version 3.2 (October 2011. As a minimum the approved document should be describing the process for monitoring compliance against all of the minimum requirements within the criterion as described within the NHSLA Risk Management Standards for NHS Trusts Providing Acute Services 2011/12. Additionally where the monitoring identifies deficiencies the organisation should describe how shortfalls in performance will be addressed and relevant changes implemented. This may be included within the individual approved documents as part of the monitoring process or within the terms of reference of the reviewing committee or group charged with the responsibility for the review of monitoring processes. Standardising the way in which the organisation describes the process for monitoring compliance with all of the minimum requirements will support the organisation in working towards compliance at Level 3. There were two pilot criteria at Level 1 during this financial year, which received a positive score in this assessment. Additionally the organisation was given a positive score for one criterion that was deemed compliant to the services provided: 2.4 Supervision of Medical Staff in Training. Page 6 of 24
Overview of assessment outcome Compliant Non-compliant Not reviewed 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 8 Responding to External Recommendations Specific to the Organisation Health Records Management Medical Devices Training Harassment & Bullying Resuscitation Improvement 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 7 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 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 eight out of ten was awarded in this standard. Criterion 1.1.2 Policy on Procedural Documents documented process for developing organisation-wide procedural documents. Non-compliant c. consultation process g. associated documents h. supporting references i. process for monitoring compliance with all of the above The Policy for Policies, Version 3.2 (October 2011) was the approved document reviewed in support of this criterion. Unfortunately all the comments and suggestions submitted as part of the revision of this document had not been removed before sharing. This suggests that the process for robust document control is not embedded in the organisation. As this is a key corporate governance document that sets the Page 8 of 24
Criterion 1.1.4 Risk Awareness Training for Senior Management documented process for delivering risk management awareness training for all board members and senior managers. Non-compliant standard for all other corporate governance processes, it is imperative that the organisation s requirements and local standards are clearly and accurately reflected in this document. This will ensure a consistent approach to corporate governance processes across the organisation. In addition, the proforma templates referred to in the main body of the document were not attached in the appendices as stated and many associated documents were not hyperlinked. The organisation is advised to reference and hyperlink all associated documents so that staff can easily access documents located elsewhere such as the local intranet. Furthermore, the organisation is advised to review the references to associated external documents. This policy was amended in October 2011 but unfortunately still contains a reference to the Healthcare Commission which is no longer a legal entity. Therefore, on this occasion, compliance could not be awarded. For further comments regarding the issues identified please review the key findings section on page 5 of this report. c. process for following up non-attendance Two documents were presented for review in support of this criterion: The Risk Management Policy, Version 2 (August 2011) and the Learning and Development Policy, Version 8 (October 2011). Compliance could not be awarded for this criterion as the process to follow up individual board members and senior managers who do not attend or receive relevant risk awareness training is not explicit. The Learning and Development Policy, Version 8 (October 2011) details a single process to follow up those individuals who do not attend risk awareness training that is applicable to all staff groups. Within this process, it is clear that individual non-attendance is escalated to managers and directors to action. However, the process to distinguish the requirements to follow up Page 9 of 24
Criterion 1.1.9 Professional Clinical Registration documented process for ensuring that all clinical staff (temporary and permanent) are registered with the appropriate professional body. Compliant those senior managers and board members who do not attend risk awareness training is not explicit. The organisation is advised to expand the process to specifically address the follow up of senior managers and board members who do not attend risk management training, d. process in place for following up those permanent clinical staff who fail to satisfy the validation of registration process Compliance was awarded for this criterion, however the organisation is advised to include within the Registration with Professional Regulatory Bodies Policy and Procedure, Version 4 (March 2011) all relevant professional regulators in addition to the General Medical Council. Page 10 of 24
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 ten 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. Compliant e. process for following up those who fail to attend corporate induction The Learning and Development Policy, Version 8 (October 2011) was the approved document reviewed in support of this criterion. Compliance was awarded for this criterion, however, the organisation is advised to note the following comment: The approved document states that responsibility for making sure permanent staff attend and complete corporate induction is delegated to managers. However the process to make sure that staff are booked to attend corporate induction within stated timescales is not explicit. Whilst responsibility for following up those individuals who do not complete induction is delegated to managers at a local level, there is no end point to the process. The organisation is advised to review the approved document and processes to ensure that all new permanent staff attend and complete corporate induction and the process for following up on non-attendance is developed to include a final end process. Page 11 of 24
Criterion 1.2.3 Local Induction of Temporary Staff documented process for ensuring the local induction arrangements for all temporary staff. 1.2.4 Supervision of Medical Staff in Training 1.2.10 Consent Training documented process for managing the risks Compliant Compliant Compliant For further comments regarding the issues identified please review the key findings section on page 5 of this report. b. minimum content of local induction programme(s) c. process for checking that all temporary staff complete local induction The Learning and Development Policy, Version 8 (October 2011) was the approved document reviewed in support of this criterion. Compliance was awarded for this criterion, however, the organisation is advised to note the following comment: The organisation has developed proforma checklists to ensure temporary staff complete local induction. The organisation is recommended to consider including an additional column so that checklists are completed with signatures against each area requiring completion during local induction. The timescales for completing local induction detailed in the approved document is the same for all staff, whether permanent or temporary. The organisation is advised to consider amending the timescales specified for temporary staff to make sure that all temporary staff comply with the process of completing the local induction checklist within realistic and restrictive timescales. a. For this criterion the assessment team take assurance from the organisation's compliance with the General Medical Council (GMC) requirements for supervision as determined by the evidence available to the GMC. The organisation was successful in meeting the Level 1 requirements and therefore compliance has been awarded. d. process for following up those who have obtained consent for a procedure without being authorised to do so This is a pilot minimum requirement for 2011/12 and as such a positive score Page 12 of 24
Criterion associated with consent training. has been awarded. In order to test the validity of the minimum requirement organisations were encouraged to provide evidence. Whilst compliance has automatically been awarded the organisation may wish to consider the following points. The Policy and Guidelines for Consent to Examination or Treatment, Version 7 (September 2011) does not clearly describe the process for following up those staff who obtain consent when they have not been authorised to do so. The organisation is advised to review its approved document to ensure that this includes a clear process that staff must follow to reduce the risk area identified. For further comments regarding the issues identified please review the key findings section on page 5 of this report. 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, 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 1.3.7 Harassment & Bullying documented process for managing the risks associated with the harassment and/or bullying of staff. Compliant c. process for raising concerns about harassment and/or bullying Compliance was awarded for this criterion, however, the organisation is advised to note the following comment: The organisation is advised to review the Dignity At Work Policy, Version 3 (August 2011) to include an additional sentence in the main body of the document to reflect the process for raising concerns about harassment and/or bullying when it is the line manager who is the alleged perpetrator. This will ensure consistency of the process within the document and the flowchart provided in Appendix C. Page 14 of 24
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 eight out of ten was awarded in this standard. Key findings and recommendations Criterion 1.4.1 Patient Information & Consent documented process for providing information to patients and managing risks associated with consent. Non-compliant e. archiving arrangements for information given to patients f. process for monitoring compliance with all of the above The Policy and Guidelines for Consent to Examination or Treatment, Version 7 (September 2011) was the approved document reviewed in support of this criterion. Compliance could not be awarded for this criterion because the process described relates solely to consent procedures and the ability to destroy patient identifiable information. The organisation did not provide any information on the process for archiving information that is given to patients Similarly the process for monitoring compliance only referred to consent information. The organisation should note that for this criterion organisations must demonstrate an approved documented process for managing risks associated with all methods of providing and archiving information for Page 15 of 24
Criterion 1.4.3 Screening Procedures documented process for developing local policies to manage the risks associated with screening procedures. 1.4.4 Diagnostic Testing Procedures documented process for developing local policies to manage the risks associated with diagnostic testing procedures. 1.4.5 Medicines Management documented process for managing the risks associated with medicines in all care environments. Compliant Compliant Non-compliant patients. For further comments regarding the issues identified please review the key findings section on page 5 of this report. 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 organisation did not provide any documentation for review. 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 organisation did not provide any documentation for review. b. process for ensuring the accuracy of all prescription charts The Medicines Management Policy, Version 5.2 (July 2011) was the approved document reviewed in support of this criterion. The approved document is very large and unwieldy with many attachments. The organisation is advised to consider whether it is practical to have so much information in one document and whether staff can access key information as required in a practical and timely manner. The content in the document should provide detailed but succinct information for staff with clear signposting for ease of finding. In this way, the organisation can be assured that staff are able to comply with the standards set in local policies and guidelines to mitigate against the risk areas identified. Staff representatives verbally explained the process by which pharmacists Page 16 of 24
Criterion reconcile the accuracy of prescription charts. The process is not clearly described in the approved document, although reference is made to the Medicines Reconciliation Policy in the main body of the document. The Medicines Reconciliation Policy was not presented for review. Appendix J within the approved document is an example of a template document for recording daily ward communications between pharmacists and ward staff. Although there is a space on the template to add the bleep number of the attending pharmacist; the organisation is advised to include a space on this template so that the signature of the attending pharmacist can also be added to the document. In this way, clear and irrefutable evidence of the attending pharmacist can be assured. e. procedure for the safe disposal of all drugs The approved document clearly describes the process for the disposal of controlled drugs. However, the process for the disposal of all other drugs is not clearly described in the approved document, although there are brief references to the disposal of patient s own medication. Staff representatives verbally explained that all drugs and medication must be returned to the pharmacy department for disposal and that there is a separate policy which details the processes for the disposal of all drugs. Unfortunately this policy was not referred to in the approved document presented for review and therefore the assessor could not be assured that the organisation has a robust process for the safe disposal of all drugs. The organisation must ensure that all associated documents are referenced and signposted appropriately within the overarching approved document. For further comments regarding the issues identified please review the key findings section on page 5 of this report. f. organisation s expectations in relation to staff training, as identified in the training needs analysis The approved document states Training will be given in accordance with the Trust s Risk Management Training Needs Analysis and uptake will be Page 17 of 24
Criterion 1.4.6 Transfusion documented process for managing the risks associated with the transfusion process. Compliant monitored by Pharmacy. The organisation s training needs analysis identifies those staff groups who are required to undertake generic medicines management training as part of the mandatory training programme. Staff representatives confirmed that the bespoke training that pharmacists must complete to maintain their competence is recorded locally in paper format. Staff from the learning and development department explained the process currently underway to expand the information recorded on the organisational training needs analysis, which will record additional mandatory training for pharmacy staff. However, the separate locally held paper based record for pharmacy staff training does not currently link into the centrally held record and so it is unclear how the organisation is assured that all pharmacy staff are up to date with training requirements and competent in their daily practice. Furthermore there is no mention of locally held training records within the approved document. The organisation is advised to review and update the approved document to record and accurately reflect the processes currently in practice and continue to review the underpinning policy documents as the processes for recording training centrally evolve. Therefore compliance could not be awarded. e. organisation s expectations in relation to staff training, as identified in the training needs analysis Compliance was awarded for this criterion; however, the organisation is advised to note the following comment: The organisation s training needs analysis (TNA) identifies blood transfusion as a mandatory training requirement. However, it is not clear from the TNA which staff are expected to attend and complete the training or how frequently attendance for this training is required. The organisation is advised to review and amend the TNA to reflect the training requirements for specific staff as described in the Blood Transfusion Policy For The Administration Of Page 18 of 24
Criterion Blood And Blood Products, Version 6 (April 2011). Page 19 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 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 seven out of ten was awarded in this standard. Key findings and recommendations Criterion 1.5.3 Concerns/Complaints documented process for listening, responding and improving when patients, their relatives and carers raise concerns/complaints. Compliant c. process for the handling of joint complaints between organisations e. process by which the organisation aims to improve as a result of concerns/complaints being raised Compliance was awarded for this criterion; however, the organisation is advised to note the following comment: The Complaints Policy, Version 4.1 (June 2011) contained only minimal descriptions and details of the processes staff were required to follow to reduce the risk area identified. The organisation must ensure that its approved document provides clear, detailed information and processes for staff in order for them to comply with organisational requirements. 1.5.4 Claims Compliant d. communication with relevant stakeholders Page 20 of 24
Criterion documented process for managing all claims in accordance with NHSLA requirements. 1.5.5 Investigations documented process for investigating all incidents, complaints and claims. Non-compliant Compliance was awarded for this criterion; however, the organisation is advised to note the following comment: The Litigation And Inquests Policy, Version 1 (October 2011) makes reference to communication with local stakeholders such as the Strategic Health Authority and Primary Care Trust. The organisation is advised to consider whether any other relevant local or national stakeholders may need to be included in the description of communication with all relevant stakeholders and if appropriate, amend the approved document accordingly. a. duties b. organisation s expectations in relation to staff training, as identified in the training needs analysis c. different levels of investigation appropriate to the severity of the event(s) Compliance could not be awarded for this criterion. The Incident Reporting Policy and Procedure, Version 7 (August 2011) was the approved document reviewed in support of this criterion. Staff representatives confirmed that the approved policy is the overarching policy for investigating all incidents, complaints and claims. Unfortunately the processes detailed in the approved document relate in the main to the investigation of incidents. Whilst a reference to the investigation of complaints and claims is implied, the distinct processes for investigating complaints and claims are muddled and not clearly described within the approved document. In addition the duties and training requirements described in the approved document do not clearly describe and differentiate the specific requirements for the investigation of complaints and claims. The organisation is strongly recommended to review the approved documentation for investigating incidents, complaints and claims to ensure that the processes for investigating all events are specific, clearly described and include the different levels of investigation required dependent on the event that has occurred. The organisation must ensure that all associated Page 21 of 24
Criterion 1.5.7 Improvement documented process for encouraging learning and promoting improvements in practice, based on individual and aggregated analysis of incidents, complaints and claims. 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. Non-compliant Non-compliant documents are referenced and signposted appropriately within the overarching approved document. For further comments regarding the issues identified please review the key findings section on page 5 of this report. d. process for implementing risk reduction measures The Procedure For The Systematic Analysis And Reporting Of Incidents, Near Misses, Complaints and Litigation, Version 1 (October 2011) was the approved document reviewed in support of this criterion. Unfortunately, compliance could not be awarded for this criterion as the process for implementing risk reduction measures was not explicitly described within the approved document. The organisation must ensure that the approved document clearly describes the processes being implemented to make sure they provide clarity for all staff. e. process for conducting an organisational gap analysis f. process for ensuring that recommendations are acted upon throughout the organisation g. process for documenting any decision not to implement National Confidential Enquiry/Inquiry recommendations The National Service Frameworks, National Confidential And Other High Level Enquiry Policy, Version 2.1 (May 2009) was the approved document reviewed in support of this criterion. Unfortunately, compliance could not be awarded for this criterion as the processes for conducting an organisational gap analysis, acting upon recommendations and documenting decisions with regard to National Confidential Enquiries/Inquiries was not clearly described within the approved Page 22 of 24
Criterion document. The organisation must ensure that the approved documents clearly describe the processes being implemented to make sure they to provide clarity for all staff. 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