General Statement of Compliance
The Board of Northern Devon Healthcare Trust have assurance that a full assessment of it’s compliance against the core standards for the period 1 April 2008 to 31 March 2009 has been completed and that we are compliant with all of the 44 Standards.
In the 6 Standards where a statement was submitted of being compliant by year end in the 2007/8 declaration, this was achieved and close monitoring showed no further lapse in any of these 6 Standards.
Where the Trust has received visits from the HCC and any reports received, actions have followed to make any areas highlighted by the commission more robust strengthening the Trust’s compliance in these areas.
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C1a |
Healthcare organisations protect patients through systems that identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information derived from the analysis of incidents |
Compliant |
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C1b |
Healthcare organisations protect patients through systems that ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales |
Compliant |
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C2 |
Healthcare organisations protect children by following national child protection guidelines within their own activities and in their dealings with other organisations |
Compliant |
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C3 |
Healthcare organisations protect patients by following National Institute for Health and Clinical Excellence (NICE) interventional procedures guidance |
Compliant |
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C4a |
Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the risk of healthcare acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in Methicillin-Resistant Staphylococcus Aureus (MRSA) |
Compliant |
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C4b |
Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all risks associated with the acquisition and use of medical devices are minimised |
Compliant |
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C4c |
Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed |
Compliant |
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C4d |
Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that medicines are handled safely and securely |
Compliant |
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C4e |
Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment |
Compliant |
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C5a |
Healthcare organisations ensure that they conform to National Institute for Health and Clinical Excellence (NICE) technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care |
Compliant |
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C5b |
Healthcare organisations ensure that clinical care and treatment are carried out under supervision and leadership |
Compliant |
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C5c |
Healthcare organisations ensure that clinicians continuously update skills and techniques relevant to their clinical work |
Compliant |
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C5d |
Healthcare organisations ensure that clinicians participate in regular clinical audit and reviews of clinical services |
Compliant |
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C6 |
Healthcare organisations cooperate with each other and social care organisations to ensure that patients’ individual needs are properly managed and met |
Compliant |
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C7a&c |
Healthcare organisations apply the principles of sound clinical and corporate governance. Healthcare organisations undertake systematic risk assessment and risk management |
Compliant |
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C7b |
Healthcare organisations actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources |
Compliant |
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C7e |
Healthcare organisations challenge discrimination, promote equality and respect human rights |
Compliant |
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C8a |
Healthcare organisations support their staff through having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services |
Compliant |
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C8b |
Healthcare organisations support their staff through organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups |
Compliant |
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C9 |
Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required |
Compliant |
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C10a |
Healthcare organisations undertake all appropriate employment checks and ensure that all employed or contracted professionally qualified staff are registered with the appropriate bodies |
Compliant |
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C10b |
Healthcare organisations require that all employed professionals abide by relevant published codes of professional practice |
Compliant |
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C11a |
Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare are appropriately recruited, trained and qualified for the work they undertake |
Compliant |
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C11b |
Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in mandatory training programmes |
Compliant |
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C11c |
Healthcare organisations ensure that staff concerned with all aspects of the provision of healthcare participate in further professional and occupational development commensurate with their work throughout their working lives |
Compliant |
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C12 |
Healthcare organisations which either lead or participate in research have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied |
Compliant |
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C13a |
Healthcare organisations have systems in place to ensure that staff treat patients, their relatives and carers with dignity and respect |
Compliant |
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C13b |
Healthcare organisations have systems in place to ensure that appropriate consent is obtained when required, for all contacts with patients and for the use of any confidential patient information |
Compliant |
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C13c |
Healthcare organisations have systems in place to ensure that staff treat patient information confidentially, except where authorised by legislation to the contrary |
Compliant |
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C14a |
Healthcare organisations have systems in place to ensure that patients, their relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services |
Compliant |
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C14b |
Healthcare organisations have systems in place to ensure that patients, their relatives and carers are not discriminated against when complaints are made |
Compliant |
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C14c |
Healthcare organisations have systems in place to ensure that patients, their relatives and carers are assured that organisations act appropriately on any concerns and, where appropriate, make changes to ensure improvements in service delivery |
Compliant |
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C15a |
Where food is provided, healthcare organisations have systems in place to ensure that patients are provided with a choice and that it is prepared safely and provides a balanced diet |
Compliant |
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C15b |
Where food is provided, healthcare organisations have systems in place to ensure that patients’ individual nutritional, personal and clinical dietary requirements are met, including any necessary help with feeding and access to food 24 hours a day |
Compliant |
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C16 |
Healthcare organisations make information available to patients and the public on their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care |
Compliant |
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C17 |
The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services |
Compliant |
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C18 |
Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably |
Compliant |
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C20a |
Healthcare services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation |
Compliant |
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C20b |
Healthcare services are provided in environments which promote effective care and optimise health outcomes by being supportive of patient privacy and confidentiality |
Compliant |
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C21 |
Healthcare services are provided in environments which promote effective care and optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises |
Compliant |
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C22a&C |
Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organisations and making an appropriate and effective contribution to local partnership arrangements including Local Strategic Partnerships and Crime an Disorder Reduction Partnerships. |
Compliant |
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C22b |
Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by ensuring that the local Director of Public Health’s annual report informs their policies and practices |
Compliant |
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C23 |
Healthcare organisations have systematic and managed disease prevention and health promotion programmes which meet the requirements of the national service frameworks (NSFs) and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections |
Compliant |
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C24 |
Healthcare organisations protect the public by having a planned, prepared and, where possible, practiced response to incidents and emergency situations, which could affect the provision of normal services |
Compliant
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Comments from the South West Strategic Health Authority
On the basis of the evidence available to the Strategic Health Authority, there is no reason to disagree with the assessment made by the NHS organisation in its declaration.
We are confident that the NHS Trust is working to ensure that where any lapses have occurred, action is being taken to address this across the whole NHS organisation.
Comments from Devon County Council Health & Adult Services Overview/ Scrutiny Committee
Introduction
1. The Devon County Council Health and Adults’ Services Overview/Scrutiny Committee (OSC) has determined that the commentary provided in relation to the Northern Devon Healthcare NHS Trust (NDH) will be restricted to the former Healthcare Commission’s Core Standards C14a, C16 and C22a for acute trusts.
2. All references in this commentary relate to the reporting period 1 April 2008 until
31 March 2009 and pertain only to the Trust’s relationship with the OSC.
Core Standard C14a
3. Core Standard C14a refers to suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services for patients, their relatives and carers.
4. Comprehensive information about the complaints procedure to assist anyone wishing to log a complaint with the NDH is available on the NDH website and outlined in the leaflet “Making a Complaint”. Complaints can be made direct or via the Patients Advice and Liaison Service (PALS) which be contacted via a local telephone number, a direct email link or by post.
5. PALS officers provide correspondents with a range of information and advice, which is intended to assist in determining the most appropriate course of action in relation to a concern. Should the correspondent wish to pursue a formal complaint, the PALS officer will assist by forwarding that complaint to the complaints officer. Alternatively, the correspondent can contact the complaints officer directly.
6. The Trust also provides an online feedback form for positive and negative comments. A hard copy of the form can be obtained in any of the wards and departments in any of the Trust’s hospitals and be returned on the ward or in the department or centrally at North Devon District Hospital. The Trust also provides this information in other languages and formats, such as audiotape or large print.
7. The OSC is convinced that NDH complies with Core Standard C14a and endeavours to ensure that patients, relatives and carers have suitable and accessible information about, and clear access to, procedures to register formal complaints and feedback on the quality of services.
Core Standard C16
8. Core Standard C16 refers to the Trust making information available to patients and the public on their services, providing patients with suitable and accessible information on the care and treatment they receive and, where appropriate, informing patients on what to expect during treatment, care and after-care.
9. NDH provides a well-developed and comprehensive website which details all of the services provided by the Trust. The site also provides a wealth of information, including very detailed information for patients and visitors under different subsections.
10. The Trust also produces a wide range of leaflets and printed documentation on the services it provides. Publications are usually equipped with a number of different contact options for further information, including telephone numbers, postal and email addresses as well as web links. The Trust also offers the translation of information into different languages and can provide information in other formats on request, such as large print and audio tape.
11. The Trust also provides a minicom line at North Devon District Hospital for deaf or hard of hearing patients as well as a confidential, 24-hour telephone relay service for people with communication difficulties, enabling them to type in what they want to say and have an operator conduct the conversation for them. Induction loops are available at North Devon District Hospital and at two community hospitals. Personal listening devices are available on wards and in all departments at both North Devon District Hospital and the community hospitals. The provision of British Sign Language and support for the transport to hospital can also be arranged.
12. The OSC is confident that NDH is compliant in its requirement under Standard C16, to provide accessible information, of good quality, to patients and the public on the Trust’s services.
Core Standards C22a
13. Core Standard C22a refers to the promotion, protection and demonstrable improvement of the health of the community served and reducing health inequalities by co-operating with local authorities and other organisations.
14. Although the direct contact between the NDH and the OSC was limited in the past year, the NDH regularly engaged and co-operated with the OSC, providing information and updates on service provision, challenges the Trust was facing as well as scheduled actions and anticipated improvements and outcomes.
15. The Trust’s working relationship with the OSC has been constructive, robust, positive and productive throughout the past year and the NDH has proven itself to be committed to partnership working with the OSC.
16. The OSC is therefore confident that NDH is compliant in its responsibilities under Core Standard C22a.
Comments from the Cornwall County Council Health and Adult Services Overview and Scrutiny Committee
NORTHERN DEVON HEALTHCARE TRUST
Governance
C7a
The Trust has nominated a lead officer as a consistent point of contact with the Council’s Health and Adult Social Care Overview and Scrutiny Committee. This officer liaises regularly with the Committee and wherever appropriate arranges for the Trust to be represented at meetings with the Committee and coordinates requests for information.
The Committee has had limited contact with the Trust during the last 12 months and welcomes the opportunity to increase dialogue on issues which impact upon patients living in North Cornwall.
Accessible and responsive care
C17
The Trust presented its Service Strategy to the Committee on 20 May 2008 and invited views.
Comments from the Devon Link
LINks and Hosts have been working with the Healthcare Commission to assess how LINks can most effectively contribute to this year’s Annual Health Check. The year has seen the transition from PPI forums to links and the Devon LINk has focused on establishing itself and building a robust governance structure during this time. Therefore, the Devon LINk does not intend to contribute commentaries to NHS Trusts this year. However, the Devon LINk has agreed to share the views and experiences of services that it has gathered from local communities informally with the Healthcare Commission. This information will also be passed to the appropriate NHS Trusts during April.
The Devon LINk is building positive relationships with statutory partners and, as part of this intends to continue to share this information on a quarterly basis.
