Anglesey Local Health Board

Three - year programme

2009 - 2012

DRIVINGIMPROVEMENTTHROUGHINDEPENDENT AND OBJECTIVE REVIEW

July 2009

Review of Progressagainst HealthcareStandards for Wales

1 April 2008 - 31 March 2009

Anglesey Local Health Board

Contents Page

Executive Summary iii

1. Introduction and Background 1

2. Findings 3

3. Conclusion and Next Steps 17

Annex 1: Anglesey Local Health Board Internal

Audit Report

19

Annex 2: Summary of Healthcare Standards for

Wales

29

Annex 3: Maturity Level Definitions 37

Annex 4: Areas for Improvement 39

i

Executive Summary In May 2005 the Welsh Assembly Government published Healthcare Standards

for Wales, setting out a common framework to support the NHS and partner

organisations in providing effective, timely and quality services across all

healthcare settings. The standards are focused on improving the experience of

patients and service users by placing them at the centre of the way in which

services are planned and delivered, thus providing a basis for continuous

improvement.

This is the third year in which Anglesey Local Health Board (LHB) has been

required to self-assess its progress against each of the 32 standards and to

submit its assessments to Healthcare Inspectorate Wales (HIW) for testing and

validation. Section 1 of this report provides full details of the assessment

process adopted and the methodology used to test and validate the LHB’s self-

assessment.

On 26 and 27 March 2009 a selection of primary medical care practices in the

Anglesey LHB were visited by HIW as part of this year’s validation process. We

undertook a validation of the LHB’s self-assessment and focused on 10 on the 32

standards that relate to dignity and respect, child protection and protection of

vulnerable adults. Information was gathered to assist the validation process

against the Healthcare Standards at the User Experience level from a number of

sources. The LHB provided information to support its self-assessment; child

protection questionnaires were sent to all practices by the LHB and responses

were returned to HIW; and previous thematic reviews by HIW looked at areas of

dignity, respect, commissioning and protection of vulnerable adults.

iii

Overall, Anglesey LHB performed was assessed as providing a standard of care

that is a maturity of Developing or above at the User Experience levels for all ten

standards.

We were concerned that policies for the protection of vulnerable adults (POVA)

were not available in all of the GP practices visited and that not all staff had

undertaken POVA training.

The LHB should continue to monitor, support and encourage GP practices to

ensure that all practice staff receive an enhanced check by the Criminal Records

Bureau.

iv

1. Introduction and Background 1.1 Each year since 2007 NHS healthcare organisations across Wales have been

required to self-assess against the Healthcare Standards for Wales published by the

Welsh Assembly Government in 2005 the way in which they provide and

commission services. Our reports from 2007 and 2008 can be accessed from our

website www.hiw.uk or by writing to:

Healthcare Inspectorate Wales

Bevan House

Caerphilly Business Park

Van Road

Caerphilly

CF83 3ED

1.2 The 32 Healthcare Standards set out a common framework to support

healthcare organisations to provide effective, timely and quality services. They are

designed to deliver improved levels of care and treatment to the citizens of Wales.

1.3 As the leading health inspectorate in Wales, Healthcare Inspectorate Wales

tests and validates the self-assessments submitted by each organisation. To do this

we adopt each year an approach that is relevant to the issues that we believe or

people tells us matter most to the public of Wales.

1.4 This year we have validated and tested healthcare organisations’ compliance

and performance against the Healthcare Standards by undertaking unannounced

visits to every Welsh NHS Trust and a sample of GP practices across Wales. As

part of these visits we focused on:

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Child protection – as the Baby Peter case has highlighted concerns in

England.

Protection of Vulnerable Adults - as our previous reviews have

highlighted this as an area where more work is needed.

Dignity and respect issues – as these are key to a patient’s and service

user’s experience and should matter to us all.

1.5 In drawing our conclusions on Anglesey LHB’s performance against the

Healthcare Standards we:

Reviewed in detail the LHB’s responses in respect of Standards 4, 5, 6,

7, 8, 9, 10, 12, 15 and 17.

Used the information gathered from our recent reviews of Child and

Adolescent Mental Health Services and Substance Misuse Services to

validate the LHB’s submission.

Draw on information gathered as part of all all-Wales exercise we have

undertaken to evaluate the adequacy of child protection arrangements

across primary care.

1.6 We have also worked closely with the Internal Auditors of Anglesey LHB and

have relied on their findings as part of our validation work. Their report can be found

at Annex 1.

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2. Findings 2.1 To enable us to assess how well Anglesey LHB is delivering against

requirements relating to child protection, protection of vulnerable adults and dignity

and respect we looked in detail at the following 10 Standards:

Standard 4: Environment of Care.

Standard 5: Maintenance and Cleanliness.

Standard 6: Information and Communication.

Standard 7: Patients’ and Service Users’ contribution to Care Planning.

Standard 8: Dignity, Respect, Consent and Confidentiality.

Standard 9: Nutrition.

Standard 10: Access to Healthcare.

Standard 12: Care and treatment meets the patients and service users

needs.

Standard 15: Feedback, Compliments and Complaints.

Standard 17: POVA (Protection of Vulnerable Adults) and POCA (Protection

of Child Act).

2.2 The full set of 32 Standards are at Annex 2 and the Maturity Level Definitions

in Annex 3.

2.3 Our evaluation of the 10 Standards above has enabled us to provide an

assessment of how Anglesey LHB ensures that:

The services commissioned by the LHB for the population it serves are

provided in suitable, clean environments.

Useful and appropriate information is provided to patients/service users.

Patients and service users are appropriately involved in their care

planning.

Consent to care or treatment is appropriately sought and properly

documented.

Patients and service users are treated with dignity and respect.

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Patient information is treated confidentially.

Care provided takes account of a patient’s or service user’s physical,

cultural and psychological needs and preferences.

Systems and procedures in place to protect children and vulnerable

adults.

The details of our findings are set out below.

Standard 4: Environment of Care

2.4 The LHB enables service users to express comments or concerns about

developments in primary care. For example, issues raised by users at an open day

about the development at Amlwch were reviewed at an LHB meeting.

2.5 The LHB also has processes that enable staff to contribute to new

developments. For example, through attendance at workshops, differing groups of

staff have been able to influence the LHB’s strategy for estates management and

developments arising from that.

2.6 The LHB’s procedure for handling significant events ensures that practices

disclose to the LHB details of incidents affecting safety. These are reviewed at

meetings of the Clinical Management Group and lessons learnt are subsequently

considered at meetings of practice managers.

2.7 The LHB’s procedure for reviewing complaints or concerns that service users

submit to it. Following formal review, lessons learnt and any changes implemented

as a result are drawn to the attention of practices. The Community Health Council

(CHC) undertakes inspections of practices and is represented on planning groups,

such as the Estates Steering Group, to ensure that the public’s comments and ideas

can be aired. However, the LHB stated that no issues directly relating to the

environment have been received.

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2.8 The LHB has produced health and safety folders for all primary care practices

which are updated annually in line with changes to legislation. Health and safety is a

standard topic for annual induction training for primary care staff, the relevant

session being provided by the author of the folder. Health and safety has also been

identified as a training need through annual appraisals and the subject has been

included in the LHB’s primary care training plan.

2.9 During our review practices, patients and services users felt there was a lack

of privacy in reception areas and that conversations could be overheard in the

waiting rooms. There were also concerns raised about unsatisfactory seating and a

general lack of facilities for children. At one practice we visited patients and service

users reported that the stairs were unsuitable for mothers with babies or elderly

people.

2.10 The LHB has assessed itself as Developing at the User Experience level

across this standard. We consider that, based on the evidence provided and

information received, this maturity level is justified.

Standard 5: Maintenance and Cleanliness

2.11 The Board has various ways of assuring itself that the healthcare environment

is well maintained. The Primary Care Estate Strategy, approved by the Board, sets

out the findings of a review undertaken of the current ‘fitness for purpose’ of primary

care premises across the county. Based on a combination of its findings and

community needs assessments, the strategy prioritises plans for upgrading,

rebuilding or redeveloping sites and links these to the level of investment required.

The board receives regular updates on progress.

2.12 LHB staff and primary care contractors are able to raise any concerns through

the Clinical Governance Strategy which provide an overarching framework for all

processes that need to be in place and to ensure conformity with the Welsh

Assembly Governments (WAG) policies and strategies. The strategy works with

partners to improve the delivery of primary, secondary and community care to

produce consistently better health outcomes. Staff can also report any incident,

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hazard or near miss that occurs in the workplace or whilst at work to the Clinical

Governance Team through the Incident, Hazard and Significant Event reporting

policy.

2.13 The LHB has developed a local implementation plan on healthcare

associated infections. Relevant initiatives are monitored through audits and

inspections of all GP practices; for example there were audits of the standard of

minor surgery treatment rooms and hand hygiene procedures. The aim of these is

to verify self assessments submitted by each practice under the Dermatology Local

Enhanced Service. The outcomes were presented to the Board by the Medical

Director in January 2009.




Standard 6: Information and Communication

2.15 The LHB assists communication with patients, service users and the public in

various ways, including:

• Public information documents produced by the LHB are reviewed by its

virtual reading panel to ensure accessibility, clarity and usefulness.

• Providing access to advisors who speak in Polish, Mandarin, French and

Korean.

• All information produced for the public complies with the LHB’s Welsh

Language Scheme. The LHB regularly reminds staff of the availability of

Welsh language resources.

• The LHB has been in discussion with the Project Officer for the Wales

Interpretation and Translation Service who has been gathering data to

clarify the differing needs of each NHS organisation for interpreters and

translators.

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• To ensure that relevant information is accessible to all, the LHB has

distributed to its primary care contractors a database of resources for

interpretation and translation.

2.16 During our review of GP practices there appeared to be little pattern to the

way posters and leaflets were displayed. Also, there were insufficient themed

leaflets or posters advising services users or patients how they could obtain suitable

information.

2.17 We saw no evidence of any information being provided in minority languages

or Braille, although the practices we visited were able to provide patients with large

print information. Loop systems for the people with a hearing impairment were

found only in some practices. There was no evidence of any requests for the use of

interpreters, despite the various initiatives referred to at paragraph 2.17. There was

evidence that in two practices family and/or friends were used to interpret for

patients. The LHB should highlight the need to use interpreters to maintain the

patient confidentiality and privacy.

2.18 The LHB has assessed itself as Practising at the User Experience level

across this standard. However, given the lack of evidence or information to support

this assessment, we consider that the maturity level of Developing is justified.

Area for Improvement

1. The LHB needs to ensure information is available in an appropriate range of minority languages for the local population. 2. Patients and service users with sensory impairments should have consistent access to information and communication processes across all healthcare settings. 3. Independent translators, rather than family members or friends, should be used for communication to do with an individual’s care or treatment.

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Standard 7: Service Users’ contribution to Care Planning

2.19 The LHB provided details of programmes and examples over the past 12

months of patients and service users working in partnership with staff to make

decisions about their care plans. For example, the Expert Patient Programme,

which is designed to equip patients and service users with the skills to manage their

long term condition themselves. There is also, the “Look After Me” programme

which offers support to carers.

2.20 Training and education provided by the LHB has raised practices’ awareness

of the Map of Medicine and has helped to facilitate for all practices easy access to

the Integrated Care Pathways for Chronic Conditions. Training is also provided for

specific conditions: for example, spirometry training was given to practice nurses,

advanced nurse practitioners and health care assistants.

2.21 The LHB is currently piloting the implementation of a tele-health system which

enables patients to monitor their own condition. Results are sent to the GP who

assesses the patient’s condition and identifies any changes or abnormalities.

Treatment can be reviewed and altered if required.




Standard 8: Dignity, Respect, Consent and Confidentiality

2.23 The LHB’s human resources (HR) policies and procedures are reviewed

regularly and amended if necessary. Staff have the opportunity to comment via the

Staff Forum prior to the adoption or revision of such policies. All staff have access to

all HR policies and there is also training available through the HR department.

2.24 All LHB staff have a confidentiality clause within their contracts of

employment and confidentiality regarding patient information and information sharing

is included in the Induction pack. Training is provided for all new LHB staff on

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significant event reporting. Staff are encouraged to report incidents such as

significant legal, media or other interest, which may result in loss of reputation or

assets at the LHB to the Clinical Governance Team using the Incident and Hazard

Reporting Policy. Breaches of confidentiality both within the LHB and by contractors

are reported to the LHB as significant events.

2.25 All GP practices were committed to participate in the National Public Health

Service’s (NPHS) Clinical Governance self-assessment tool, the deadline for

submission of assessments being April 2009. The LHB will receive an analysis from

the NPHS of the information submitted by practices and this will be used to inform

the LHB’s Quality Outcomes Framework (QOF) visits and Clinical Governance visits

to practices during 2009-10. The self assessment tool covers a number of areas,

including the policy on chaperones.

2.26 During our review we found that patients and service users in all practices felt

that they were treated with dignity and respect. Staff were generally aware of the

importance of obtaining informed consent to treatment and the majority understood

the concept of capacity and were aware of support that was available in relation to

this.


across this standard. We considered that based on the evidence provided and


Standard 9: Nutrition

2.28 Community Health Councils monitor the performance of NHS services during

their visits to services they discuss any issues that patients or relatives wish to raise

regarding the care being provided. In Anglesey, the CHC sends reports of its visits

to the LHB for information.

2.29 The LHB has invited a dietician to support care homes to provide a

nutritionally balanced diet to patients and service users and to advise how and

when, if required, supplements should be given.

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2.30 The LHB’s nurse reviewers visit care homes regularly and any problems with

eating or drinking are identified. The LHB also requires copies of menus from

nursing homes to verify that patients do receive a varied, well balanced diet.

2.31 It is mandatory for care home staff to attend a food hygiene course. Evidence

is required by the home to ensure that staff have attended relevant training. This

evidence is required for Care and Social Service Inspectorate Wales (CSSIW)

inspections to ensure training is attended and maintained. Food handlers have

received Chartered Institute of Environmental Health (CIEH) level 2 awards in

catering. The LHB has not received any complaints about the preparation, storage

and handling of food.



information received, this maturity is justified.

Standard 10: Access to Healthcare

2.33 The LHB promotes equality of opportunity for staff through a number of HR

policies, which have been agreed through the all Wales HR forum. Equality

awareness training for LHB staff is provided as part of corporate induction.

2.34 During the annual QOF visits to GP practices visits, equality issues are

discussed and the LHB monitors practices’ compliance with the requirements of the

General Medical Services (GMS) Contract that relate to equity and access to

services. Arrangements were made by the LHB for Equip Cymru to provide GP

practices with disability awareness training.

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2.35 The LHB prepared a guide which provides practical advice on making

information available to service users in ways that take into account differing

linguistic, communication, physical and cultural needs. Anglesey and Gwynedd

LHBs, in conjunction with the North West Wales Trust, have developed a database

of companies, individuals and groups who have specific expertise in translation and

interpretation. This is a valuable resource for primary care contractors. The LHB

continues to draw the attention of primary care contractors to available interpreting

and translation services.

2.36 LHB works in partnership with various stakeholders to determine and respond

to the health needs of its population and to understand and assess the effect on

meeting these of individuals’ age, gender, disability, ethnicity, race, religion or sexual

orientation.

2.37 The LHB has taken steps to educate patient and service users in the use of

antibiotics. An article informing patients and service users about the use of

antibiotics was published in the LHB’s newsletter. The main message of the article

was that antibiotics are not always the answer to viruses and that there are other

remedies that may help to ease patients’ symptoms. A bilingual English and Welsh

flyer, entitled ‘Antibiotics don’t work against viruses’ was produced, by the GP to

hand to patients who present with a viral infection. Ten thousand copies of the flyer

have been produced, and a supply has been sent to each GP surgery on Anglesey.

2.38 In order to reduce teenage or unwanted pregnancies, the LHB has approved

funding for an emergency contraception service in pharmacies on Anglesey. As a

result, pharmacists will be able to dispense the ‘morning after pill’ free of charge to

those who need it. To raise public awareness of this new service, information was

included in the LHB’s newsletter and a news article will be sent to local newspapers.

Schools, colleges, primary care contractors and youth clubs will also be informed

and asked to provide publicity.



information received, the maturity level is justified.

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Standard 12: Care and Treatment Meets the Service Users’ Needs

2.40 The LHB has mechanisms in place to consult patients and service users

regarding issues that are relevant in primary and secondary care. For example the

Clinical Management group monitor key trends in complaints and significant events.

Also, the Public and Patient Involvement (PPI) complaints monitoring group

scrutinize any complaints that are reported to the LHB and ensure the relevant

policies are adhered and make appropriate recommendations where necessary.

2.41 Anglesey LHB has taken a lead role in establishing a Targeted Outreach

Health Service for the Homeless and Vulnerable Groups. Once the initial needs for

such a service were assessed the LHB held a workshop with service users, carers

and providers from voluntary, statutory & independent sectors to identify needs,

gaps and barriers. Following on from this a Task & Finish Group of the existing

Homeless Forum has been established and has developed the service model which

is currently being finalised to be operational from April 2009.

2.42 The LHB is working with partners to develop integrated care pathways for the

following conditions:

• Chronic Obstructive Pulmonary Disease (COPD)

• Heart Failure

• Diabetes

• Schizophrenia




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Standard 15: Feedback, Compliments and Complaints

2.44 The LHB has established clear timescales for handling complaints in

accordance with the Welsh Assembly Government’s guidelines. The LHB publicises

its complaints procedure, including timescales, on its website. All complaints, formal

or informal, are directed initially to the LHB’s Complaints Manager. Informal

complaints are dealt with via the LHB’s Patient Support Services. Information on

how to access the LHB’s Patient Support Services is included on the LHB’s website.

The LHB’s quarterly and annual reports on the handling of complaints includes

information about performance in meeting the set timescales by the LHB itself,

primary care contractors and nursing homes on Anglesey.

2.45 Complaints which are considered to be closed are scrutinised by the LHB’s

Complaints Monitoring Group. Information about individual patients is anonymised

throughout. This process enables the LHB to identify any trends in complaints,

training needs for practices or whether any further action is required by the LHB. It is

also an opportunity to ensure that lessons are shared.

2.46 The LHB provides all primary care contractors with a copy of the Assembly

Government’s training resource in the form of a CD-ROM on Complaints Handling in

the NHS. This was produced because primary care staff were allowing insufficient

time to attend training courses. Complaints handling also forms part of the LHB’s

programme for inducting primary care staff.

2.47 The LHB ensures that patients and service users are made aware of the

advocacy services provided by the CHC when complaints are made either orally or

in writing.

2.48 Our recent audit of GP practices reported that the views of patients and

service users are sought each year through a patient survey. Examples were

provided of changes made as a result. For example practices continue to review

new telephone systems and equipment.

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Standard 17: POVA (Protection of Vulnerable Adults) and POCA (Protection of Children Act). 2.50 The Baby Peter case in England has raised many issues of concern and

points of learning for health and social care organisations. In November 2008 we

issued each LHB with questionnaires for completion by primary care contractors

(GP, Dental, Pharmacists, and Ophthalmologists) across Wales, which were

designed to document and test their child protection and safeguarding

arrangements.

2.51 The LHB has adopted the new All Wales Child Protection Procedures which

have been distributed to all primary care contractors’ main surgeries, branch

surgeries and child protection leads, as well as other key individuals within the LHB.

Incidents involving an adverse outcome, a complaint, or deficiency procedure are

reported and managed via the LHB’s incident and hazard reporting policy.

2.52 The LHB stated that child protection level 2 training is mandatory every three

years for all LHB staff, with GP child protection leads and key individuals trained

annually to child protection level 3. Training is monitored through the maintenance

of a database.

2.53 A questionnaire regarding child protection was issued to all Primary Care

practices in Wales. However these were not distributed to primary care practices in

Anglesey.

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2.54 All the LHB’s own staff dealing with children have received CRB checks and

the LHB monitors that CRB checks have been undertaken for all new employees of

practices during the annual Clinical Governance visits. However, the absence of

additional information sought from practices about their arrangements for child

protection means that we lack an important perspective in drawing conclusions

about the rigour of CRB checking.

2.55 Therefore the LHB should continue to monitor, support and encourage GP

practices to ensure that all practice staff receive an enhanced check by the Criminal

Records Bureau.

2.56 The LHB’s Nurse Director is vice chair of the Local Safeguarding Children’s

Board, which monitors compliance with child protection procedures and aims to

improve and co-ordinate inter-agency working. The nurse director also chairs the

serious case review panel and has led reviews over the past year into the

circumstances of the deaths of three children.

2.57 The LHB stated that social services take the lead in considering any reported

POVA cases. LHB staff can raise concerns either orally or by completing an incident

report form and sending it to the social services adult co-ordinator.

2.58 During our review of GP practices, we were told that POVA policies were not

available in all practices and not all staff had undertaken POVA training therefore did

not understand POVA and were not able to recognise a vulnerable adult.




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Area for improvement:

4. The LHB must ensure that all staff are trained in the protection of vulnerable adults. 5. Policies and procedures in relation to protection of vulnerable adults should be available and accessible for all members of primary care staff. 6. The LHB should continue to monitor, support and encourage GP practices to ensure that all practice staff receive an enhanced check by the Criminal Records Bureau.

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3. Conclusion and Next Steps 3.1 This year’s assessment has demonstrated that Anglesey LHB has been able

to maintain a consistent level across all of the 10 key standards. In the view of the

review team, all ten standards were assessed as providing a standard of care that is

a maturity of Developing or above at the User Experience levels.

3.2 The LHB will need to consider the areas that have been highlighted as

requiring further improvement by this assessment and those raised via its Internal

Auditors when developing their Healthcare Standards Improvement Plan. These

areas for improvement, highlighted by our assessment, are summarised in Annex 4.

3.3 As part of the NHS restructuring during 2009, Anglesey LHB will be dissolved

and a new Betsi Cadwaladr Health Board established. This will be constituted from

the North Wales NHS Trust, North West Wales NHS Trust, Wrexham LHB, Flintshire

LHB, Conway LHB, Denbighshire LHB, Isle of Anglesey LHB and Gwynedd LHB.

The development of a Healthcare Standards Improvement Plan should be a

consolidation of areas highlighted for improvement across all eight organisations.

3.4 The new LHB will be required to submit a Healthcare Standards Improvement

Plan, approved by its Board, to the North Wales Regional Office of Welsh Assembly

Government’s Department for Health and Social Services by the end of October

2009. This plan will be agreed by the Regional Office, which will monitor its

implementation as part of the performance management arrangements in place for

NHS Wales. It will be made available on North Wales LHB’s website.

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Annex 1

ANGLESEY LOCAL HEALTH BOARD

INTERNAL AUDIT REPORT

HEALTHCARE STANDARDS

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MIAA Audit and Assurance

Anglesey Local Health Board Healthcare Standards Review Internal Audit Report 2009-10

NHS Restricted

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CONDUCT OF THE REVIEW Client Liaison Report Distribution Name Title Distribution Eirian Lloyd Clinical Governance Manager PDF Medwyn Williams Medical Director PDF

Review Completion Action Planned Date Actual Date Fieldwork Start 28-Apr-2009 28-Apr-2009 Fieldwork Complete 13-May-2009 13-May-2009 Discussion Document to Client 13-May-2009 13-May-2009 Responses by Client 13-May-2009 13-May-2009 Final Report 13-May-2009 13-May-2009

Discussion Meeting held with Name Title Actual Date Eirian Lloyd Clinical Governance Manager 13-May-2009

Review Preparation Review prepared on behalf of MIAA by Name TitleSimon Davies Principal Auditor

Darrell Davies Audit Manager

Tim Crowley Director Acknowledgement MIAA would like to thank all staff for their co-operation and assistance in completing this review. Further Information This report has been prepared as commissioned by the organisation, and is for your sole use. If you have any queries regarding this review please contact the Audit Manager. To discuss any other issues then please contact the Director.

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CONTENTS AND REVIEW Introduction and Background In 2005 the the Welsh Assembly Government’s set out the common framework of healthcare standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings. They came into force on the 1st June 2005 and are set out to achieve a number of important objectives. They aim to:

• bring clarity and consistency on public expectation for high quality patient care across all healthcare settings;

• establish firm foundations for continuous improvement in the delivery of all NHS funded care; and

• provide a framework both for self-assessment by healthcare organisations and for external review and investigation by Healthcare Inspectorate Wales.

Anglesey Local Health Board submitted their first self assessment on line for 2006/07, the first year of the process, and produced an improvement plan to aim to provide continuous improvement for each standard, which were submitted to required timescales. This was subsequently reviewed by Health Inspectorate Wales, who through review of their self assessment and evidence attached considered a number of standards had been over scored in terms of their risk maturity. For the 2007/08 submission, it was evident that the process was beginning to embed within the organisation. The 2008/09 review will further focus on the development of the LHB in ensuring progress being made in its operation against the standards, and ensuring engagement of its Board within the process, whilst also following up exceptions raised in the previous review. There are 32 healthcare standards covering four domains – First Domain: The Patient Experience, Second Domain: Clinical Outcomes, Third Domain: Healthcare Governance and the Fourth Domain: Public Health. Each standard within the domain describes the values that the domain represents. These are designed to deliver the improved levels of care and treatment the people of Wales have a right reasonably to expect. These standards will be taken into account by those providing healthcare, irrespective of the setting. Objective and Scope The objectives of the review are:- 1. To ensure the LHB has a robust mechanism for the collection, review and submission of data for the Healthcare Standards in Wales. 2. To ensure for standards 14,16,27,28 that Self assessment outcomes are clearly linked to evidence. 3. Quality Control of the evidence collated and outcomes decided has been applied by the organisation prior to submission to the Healthcare Inspectorate Wales. 4. Comprehensive Improvement Plans have been developed following the submission. 5. The Board is sufficiently engaged in the Healthcare Standards in Wales’s process.

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6. Follow up 08/09 exceptions raised. The review has focussed on reviewing the process in place at the Local Health board, through discussion with nominated leads.

Opinion The overall level of assurance is limited to the scope and objective of the review as defined and is limited to the findings as at the time the review was conducted. The classification of assurance allocated is in accordance with the definitions provided in Appendix B, Table B.1. The assurance level for this review is:

Significant Assurance

Summary of Recommendation To aid management focus in respect of addressing findings and related recommendations, the classifications provided in Appendix B, Table B.2. have been applied. The table below summarises the prioritisation (detail provided in Appendix A) of recommendations in respect of this review.

Critical High Medium Low Total

0 0 0 0 0

Management action has been agreed to address the issues raised within this review. Summary of high/critical recommendations: Management Summary Anglesey Local Health Board has assigned lead, and Director responsibility to each of the Standards. The self assessment for 2008/09 was submitted on time, observing a timetable issued to respective staff. A training session on the requirements for the 2008/09 submission was provided by the Clinical Governance Manager to all relevant staff involved in the process. Quality Assurance processes have been implemented throughout the stages of submission, providing for review by the Clinical Governance Manager / Clinical Governance Officer, online review by non-officer board members of which evidence was observed from one board member, and a more formalised Quality Assurance by Lead Directors for standards which they were responsible. This formalised QA to provide a clear audit trail could have been improved by sign off and return of the form prior to submission. The self assessment was subject to formal sign off by the Chief Executive. A review was undertaken of standards 14,16,27 and 28 to ensure self assessment outcomes were clearly linked to evidence, and that progress made against the improvement plan were updated. It was found that the Local Health Board had

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observed a sound process in completing the self assessment tool, with appropriate evidence attached in terms of annual policy / procedural review, and developments made in year. Links were evident to the Healthcare Inspection review, in terms of addressing issues raised within the report. For standard 14, the LHB should consider ensuring the progress made is embedded within the organisation, and provide evidence in terms of improvements being made following board decisions to validate movement on the maturity matrix to ‘Practising’ in this area. With regard to standard 16, it appears an error has been made on the scoring matrix with 16.1 being marked down to ‘developing’ rather than ‘practising’ as in the previous year. This requires review by the LHB to ensure correct notification. The Local Health Board have an agreed improvement plan for 2008/09, which has been subject to continuous review with updates on progress reported to Regional office on a quarterly basis and these are presented to the Audit & Integrated Governance Committee. Current transitional arrangements require the LHB to produce a new Improvement plan linked into the 08/09 submission by the End of May 09 to take forward to the new organisation, with outstanding actions on the 08/09 improvement plan to be addressed by Quarter 5 (June 09). Board engagement has been developed through training sessions provided by the Clinical Governance Manager, operational papers on Clinical Governance provided for review at Board meetings, and progress on Healthcare standards reported via the integrated governance and audit committee. Read only access was provided to non officer board members to the on line tool, with this review process built into the LHB timetable as a formal QA process. Evidence was available to view from one Non officer Board member, providing useful feedback. Follow up of the outstanding exceptions raised from the previous review found that the Local Health Board had made progress in both of their implementation. Assurance Statement

We are required to provide an opinion on the adequacy and effectiveness of internal control in relation to the area under review. Our opinion is based on the work performed as set out in the agreed objectives and is subject to the inherent limitations set out in the limitations and responsibilities (Appendix B Table B.3) sections of this report. We also provide an assurance statement for the area under review.

Assurance statement The assurance levels applied to this review have been classified as ‘high’, ‘significant’, ‘limited’ or ‘no’. Full definitions are provided in Appendix A Table A.1. Limited to the objective, and based on the findings of this review, the following assurance level has been applied: As a result, significant assurance can be given on the adequacy and operating effectiveness of controls in place over Accounts Receivable at the time of our audit.

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Internal control Internal control, no matter how well designed and operated, can provide only reasonable and not absolute assurance regarding achievement of an organisation's objectives. The likelihood of achievement is affected by limitations inherent in all internal control systems. These include the possibility of poor judgement in decision-making, human error, control processes being deliberately circumvented by employees and others, management overriding controls and the occurrence of unforeseeable circumstances. Future periods The assessment of controls relating to Healthcare Standards was undertaken May 2009. Historic evaluation of effectiveness is not always relevant to future periods due to the risk that:

The design of controls may become inadequate because of changes in the operating environment, law, regulation or other; or

The degree of compliance with policies and procedures may deteriorate. 2. Detailed Findings, Recommendations and Follow-up

Detailed findings and recommendations Our detailed findings and recommendations are set out in the findings and recommendations section of this report (Appendix A). Management responses are included which identify actions to be taken, responsibility and timeframe.

Follow-up No Follow up review will be conducted on this audit.

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Follow Up 08/09 1. Quality Assurance

Issue Identified – A quality assurance process for the self assessment submission evidencing review by lead Directors does not provide for a clear audit trail.

Previous Recommendation – It is recommended that a quality assurance process is developed, which is documented within a procedure, and formally timetabled within the submission timetable.

Risk Rating Medium

Orig

inal

Rev

iew

Previous Management Response – Agreed. A formal sign off form for all Lead Directors evidencing review and approval has been developed, to provide quality assurance to the Chief Executive prior to formally submitting the HCS self – assessment to Healthcare Inspectorate Wales. Once the LHB receive the Welsh Health Circular on HCS reporting for 08/09 a timetable for the LHB will be developed incorporating the QA process. Current Position – Quality Assurance processes have been timetabled within the various stages of the submission. A more formalised QA by lead directors has been introduced and timetabled, however this could have been improved by sign off and return of the form prior to the submission.

Status – Implemented

Follo

w-u

p

Responsibility for Action –

2. Non Executive Director Engagement

Issue Identified – Their are currently no non officer board members set up with read only access to review the LHBS self assessment on line.

Orig

inal

Rev

iew

Previous Recommendation – The LHB to endeavor to engage non executive board

Risk Rating Medium

members through review of the on line self assessment.

Previous Management Response – The LHB to identify non-executive board members of the Audit and Integrated Governance Committee as board member leads for Healthcare Standards for Wales. The LHB to identify themes, allocate leads, provide on-line access and confirm timescales for completion of self assessment verification. Current Position – Non officer board members have been set up on the online tool, with a process for QA by NEDs timetabled within the submission timetable. A clear audit trail was available for one non executive director providing feedback on standards they had been allocated.

Status – Implemented

Follo

w-u

p

Responsibility for Action –

Table B.1 Assurance Level

Level of assurance

Description

High Our work found some low impact control weaknesses which, if addressed would improve overall control. However, these weaknesses do not affect key controls and are unlikely to impair the achievement of the objectives of the system. Therefore we can conclude that the key controls have been adequately designed and are operating effectively to deliver the objectives of the system, function or process.

Significant There are some weaknesses in the design and/or operation of controls which could impair the achievement of the objectives of the system, function or process. However, either their impact would be minimal or they would be unlikely to occur.

Limited There are weaknesses in the design and / or operation of controls which could have a significant impact on the achievement of the key system, function or process objectives but should not have a significant impact on the achievement of organisational objectives.

No There are weaknesses in the design and/or operation of controls which [in aggregate] have a significant impact on the achievement of key system, function or process objectives and may put at risk the achievement of organisational objectives.

Table B.2 Risk Classification Each of the issues identified have been categorised according to risk as follows:

Risk rating Assessment rationale

Critical Control weakness that could have a significant impact upon, not only the

system, function or process objectives but also the achievement of the organisation’s objectives in relation to:

the efficient and effective use of resources the safeguarding of assets the preparation of reliable financial and operational information compliance with laws and regulations.

High Control weakness that has or is likely to have a significant impact upon the achievement of key system, function or process objectives.

This weakness, whilst high impact for the system, function or process does not have a significant impact on the achievement of the overall organisation objectives.

Medium Control weakness that:

• has a low impact on the achievement of the key system, function or process objectives;

• has exposed the system, function or process to a key risk, however the likelihood of this risk occurring is low.

Low Control weakness that does not impact upon the achievement of key system, function or process objectives; however implementation of the recommendation would improve overall control.

Table B.3 Responsibilities of management and internal auditors It is management’s responsibility to develop and maintain sound systems of risk management, internal control and governance and for the prevention and detection of irregularities and fraud. Internal audit work should not be seen as a substitute for management’s responsibilities for the design and operation of these systems.

We shall endeavour to plan our work so that we have a reasonable expectation of detecting significant control weaknesses and, if detected, we shall carry out additional work directed towards identification of consequent fraud or other irregularities. However, internal audit procedures alone, even when carried out with due professional care, do not guarantee that fraud will be detected. The organisation’s Local Counter Fraud Officer should provide support for these processed.

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Annex 2

Healthcare Standards for Wales

Patient Experience Standard 1 The views of patients, service users, their carers and relatives and the public are sought and taken into account in the design, planning, delivery, review and improvement of health care services and their integration with social care services. Standard 2 The planning and delivery of healthcare:

a. reflects the experiences, views and preferences of patients and service users;

b. reflects the health needs of the population served; c. is based on nationally agreed evidence and best practice; and d. ensures equity of access to services.

Standard 3 Patients with emergency health needs access appropriate care promptly and within national time-scales set annually by the Welsh Assembly Government. Standard 4 Healthcare premises are well-designed and appropriate in order to:

a. promote patient and staff well-being; b. respect different patients’ needs, privacy and confidentiality; c. have regard for the safety of patients, users and staff; and d. provide a safe and secure environment which protects patients,

staff, visitors and their property, and the physical assets of the organisation.

Standard 5 Healthcare services are provided in environments, which

a. are well maintained and kept at acceptable national levels of cleanliness;

b. minimise the risk of healthcare associated infections to patients, staff and visitors, achieving year on year reductions in incidence; and

c. emphasise high standards of hygiene and reflect best practice initiatives.

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Standard 6 Healthcare organisations, in recognising different language, communication, physical and cultural needs:

a. make information available and accessible to patients, service users, their carers and relatives and the public on their services;

b. provide patients and service users with timely information on their condition; the care and treatment they will receive as well as after-care and support arrangements; and

c. provide patients and service users with opportunities to discuss and agree options relating to their care.

Standard 7 Patients and service users, including those with long-term conditions, are encouraged to contribute to their care plan and are provided with opportunities and resources to develop competence in self-care. Standard 8 Healthcare organisations ensure that:

a. staff treat patients, service users, their relatives and carers with dignity and respect;

b. staff themselves are treated with dignity and respect for their differences;

c. informed consent is obtained appropriately for all contacts with patients and service users and for the use of confidential patient information; and

d. patient information is treated confidentially, except where authorised by legislation to the contrary.

Standard 9 Where food is provided there are systems in place to ensure that:

a. patients and service users are provided with a choice of food which is prepared safely and provides a balanced diet; and

b. patients and service users’ individual nutritional, personal, cultural and clinical dietary requirements are met, including any necessary help with feeding and having access to food 24 hours a day.

Standard 10 Healthcare organisations ensure that people accessing healthcare are not unfairly discriminated against on the grounds of age, gender, disability, ethnicity, race, religion, or sexual orientation.

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Clinical Outcomes Standard 11 Healthcare organisations ensure that:

a. clinical care and treatments are delivered by healthcare professionals who make clinical decisions based on evidence based practice;

b. clinical care and treatments are carried out under appropriate clinical supervision and leadership;

c. clinicians continuously update skills and techniques relevant to their clinical work including peer reviews; and

d. clinicians participate in regular audit and review of clinical services. Standard 12 Healthcare organisations ensure that patients and service users are provided with effective treatment and care that:

a. conforms to the National Institute for Clinical Excellence (NICE) technology appraisals and interventional procedures, and the recommendations of the All Wales Medicines Strategy Group (AWMSG);

b. is based on nationally agreed best practice and guidelines, as defined in National Service Frameworks, NICE clinical guidelines, national plans and agreed national guidance on service delivery;

c. takes account of patients’ physical, social, cultural and psychological needs and preferences; and

d. is integrated to provide a seamless service across all organisations that need to be involved, including social care organisations.

Standard 13 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. Healthcare Governance Standard 14 Healthcare organisations continuously and systematically review and improve all aspects of their activities that directly affect the safety and health of patients, service users, staff and the public. They will not only comply with legislation, but apply best practice in assessing and managing risk. Standard 15 Healthcare organisations, recognising different language and communication needs, ensure that patients, service users, relatives and carers:

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a. can provide feedback on their experiences and the quality of services;

b. have their complaints looked at promptly and thoroughly in accordance with complaints procedures;

c. are given information about complaints advocacy support provided by Community Health Councils in Wales; and

d. receive assurance that organisations act on any concerns and make appropriate changes to ensure improvements in service delivery.

Standard 16 Healthcare organisations have systems in place:

a. to identify and learn from all patient safety incidents and other reportable incidents;

b. to report incidents to the National Patient Safety Agency’s (NPSA) National Reporting and Learning System and other bodies in line with existing guidance;

c. to demonstrate improvements in practice based on shared local and national experience and information derived from the analysis of incidents; and

d. to ensure that patient safety notices, alerts and other communications concerning safety are acted upon within required time-scales.

Standard 17 Healthcare organisations comply with national child protection and vulnerable adult guidance within their own activities and in their dealings with other organisations. Standard 18 Healthcare organisations have planned and prepared, and where required practiced, an organised response to incidents and emergency situations, which could affect the provision of normal services. Standard 19 Healthcare organisations ensure that:

a. all risks associated with the acquisition and use of medical devices are minimised;

b. all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed;

c. quality, safety and security issues of medicines are managed; and d. the prevention, segregation, handling, transport and disposal of

waste are managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment.

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Standard 20 Healthcare organisations work to enhance patient care and to continuously improve staff satisfaction by providing best practice in human resources management. Standard 21 Healthcare organisations:

a. undertake all necessary employment checks and ensure that all employed or contracted professionally qualified staff are registered with the relevant bodies;

b. require that all employed professionals abide by their published codes of professional practice and conduct; and

c. address where appropriate under-representation of minority groups. Standard 22 Healthcare organisations ensure that staff:

a. are appropriately recruited, trained and qualified for the work they undertake;

b. participate in induction and mandatory training programmes; and c. participate in continuing professional and occupational

development. Standard 23 Healthcare organisations ensure that staff are supported by:

a. processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management; and

b. organisational and personal development programmes which recognise the contribution and value of staff.

Standard 24 Healthcare organisations work together with social care and other partners to meet the health needs of their population by:

a. having an appropriately constituted workforce with appropriate skill mix across the community; and

b. ensuring the continuous improvement of services through better ways of working.

Standard 25 Healthcare organisations use effective information systems and integrated information technology to support and enhance patient care, and in commissioning and planning services.

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Standard 26 Healthcare organisations have effective records management processes in place to ensure that:

a. 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; and

b. patient confidentiality is maintained. Standard 27 Governance arrangements representing best practice are in place which:

a. apply the principles of sound clinical and corporate governance; b. ensure sound financial management and accountability in the use

of resources; c. actively support all employees to promote openness, honesty,

probity, accountability, and the economic, efficient and effective use of resources;

d. include systematic risk assessment and risk management; and e. are integrated across all health communities and clinical networks.

Standard 28 Healthcare organisations:

a. ensure that the principles of clinical governance underpin the work of every team and every clinical service;

b. have a cycle of continuous quality improvement, including clinical audit; and

c. ensure effective clinical and managerial leadership and accountability.

Public Health Standard 29 Healthcare organisations promote, protect and demonstrably improve the health of the community served and reduce health inequalities by:

a. collaborating and working in partnership with local authorities and other agencies in the development, implementation and evaluation of health, social care and well being strategies; and

b. ensuring that needs assessment and sound public health advice informs their policies and practices.

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a. have systematic and managed disease prevention and health promotion programmes, which include staff, which meet the requirements of the National Service Frameworks, national plans and health promotion and prevention priorities; and

b. take fully into account current and emerging policies and knowledge on public health issues in the development of their public health programmes, health promotion and prevention services, and the commissioning and provision of services.


a. have plans in place to mobilise resources to protect the public in the event of significant infectious disease outbreaks and other health emergencies;

b. identify and act upon significant public health problems and health inequality issues, with Local Health Boards taking the leading role;

c. implement effective programmes to improve health and reduce health inequalities; and protect their populations from identified current and new hazards to health; and

d. encourage and support individuals to recognise their own responsibilities in maintaining their health and well being.

Standard 32 Healthcare organisations achieve the Corporate Health Standard, the national quality mark for workplace health, moving to a higher level on reassessment.

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Annex 3

Maturity Level Definitions

Aware Responding Developing Practising Leading

Corporate

The Board is aware of the issues to be addressed but are unable to demonstrate decisions/ actions to address them.

The Board recognises the key issues and has identified options that are prioritised, although there is no evidence of strategic direction.

The Board is taking steps to address the key issues through the development of strategic plans with evidence of good practice across the organisation.

The strategic agenda is being progressed and monitored by the Board with significant evidence of continuous improvement across the organisation.

The Board is leading the strategic agenda through the implementation of innovative practice that is shared across and beyond the organisation to others, enabling realisation of long term sustainability.

Operational

There is awareness of the issues to be addressed, but no approaches have been developed to address them.

There is recognition of the key issues to be addressed and there is a range of options identified to address them.

Steps are being taken to address the key issues with evidence of practical application across the organisation.

There are well-developed plans being implemented throughout the organisation that address the key issues with evidence of evaluation and benchmarking leading to continuous improvement.

There is evidence of innovative practice, which is being shared across and beyond the organisation to others. They are further developing their approaches to ensure long term sustainable improvement.

User Experience

The individual(s) experience is generally poor and no approaches have been developed within the service to address them.

The individual(s) experience is generally not good although approaches have been developed within the service to address them.

The individual(s) experience is improving in many areas, although this is not yet consistent across the organisation.

The individual(s) experience is generally good across all areas.

The individual(s) experience is generally excellent and the service can demonstrate clear evidence of good practice, which can be shared.

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Annex 4 Area for Improvement:

1. The LHB needs to ensure information is available in an appropriate range of minority languages for the local population.

2. Patients and service users with sensory impairments should have

consistent access to information and communication processes across all healthcare settings.

3. Independent translators, rather than family members or friends, should

be used for communication to do with an individual’s care or treatment. 4. The LHB must ensure that all staff are properly trained in the protection

of vulnerable adults. 5. Policies and procedures in relation to the protection of vulnerable adults

should be available and accessible for all members of primary care staff. 6. The LHB should continue to monitor, support and encourage GP

practices to ensure that all practice staff receive an enhanced check by the Criminal Records Bureau.

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Anglesey Local Health Board

Documents

Transcript of Anglesey Local Health Board