Format for Reports
UNITED HOSPITALS TRUST
Contents Page
Overview of Findings 3
1 SETTING THE SCENE
1.1 The role and responsibilities of the Regulation 4 and Quality Improvement Authority
1.2 The standards 4 - 5
1.3 The review methodology5 - 6
1.3.1The review team6
1.3.2Lay reviewers6
1.3.3Peer reviewers6
1.3.4The review process6
1.3.5Self-assessment7
1.3.6Pre-visit analysis7
1.3.7 The review visit7
1.3.8The report7
2 THE FINDINGS
2.1Overview of local service provision8
Findings and recommendations
2.2Corporate Leadership and Accountability of Organisations
2.2.1How the organisation demonstrates accountability9 - 10
2.2.2Leadership11
2.2.3Financial management12
2.2.4Compliance with legislative requirements13
2.2.5Risk management 14 - 15
2.2.6Service user and public involvement16 - 17
2.2.7Human resources and workforce planning18 - 19
2.2.8Appraisal and supervision systems20
2.2.9Staff training21 - 22
2.2.10Policies and procedures 23 - 24
2.2.11Corporate Leadership and Accountability pertaining to25 - 27
appraisal of Medical Staff
2.3Safe and Effective care
2.3.1Promoting effective care 28
2.3.2Safe and effective discharge of older people from the acute29 - 30
to the community setting
Contents Page
2.3.3 Safe and effective post-operative care for patients in the acute31 - 32
hospital setting
2.4Identification of risk by the organisation33
2.5Follow up on recommendations on specific reviews / incidents 34 - 35
being dealt with by the Regulation and Quality Improvement
Authority.
2.6 Recommendations36 - 37
3APPENDICES
(i)Quality Standards for Health and Social Care38 - 44
(ii)Membership of the review team45
(iii)Areas visited by the review team 46
(iv)Summation presentation 47 - 49
4Glossary of terms and abbreviations used in the report 50 - 52
Overview of Findings
Reviewers recognise that the Trust has given a great deal of attention to developing Clinical and Social Care Governance arrangements in accordance with DHSS&PS framework throughout the organisation. These arrangements are well documented and appear to be well structured. However, reviewers noted that some aspects of the framework are yet to be fully implemented.
The Trust appears to have a comprehensive approach to effective dissemination of information. Reviewers were satisfied that there are also mechanisms in place for communicating with key stakeholders including staff and members of the public. However reviewers were unable to obtain evidence to confirm that there is effective communication, for example within the risk management process.
Reviewers were impressed that the Trust has placed a high priority on the development of service user and carer involvement in planning, delivery and evaluation of services. It was noted that there is some further scope for this way of working to become even more embedded in the culture of the organisation.
This review has found that further work needs to be undertaken to develop a coherent infrastructure to support staff appraisal and the provision of a learning and development strategy.
1SETTING THE SCENE
1.1The role and responsibilities of the Regulation and Quality improvement Authority
The Regulation and Quality Improvement Authority (RQIA) is a non-departmental public body, established with powers granted under the Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003. It is sponsored by the Department of Health, Social Services and Public Safety, with overall responsibility for assessing and reporting on the availability and quality of health and social care services in Northern Ireland and encouraging improvements in the quality of those services.
The Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003 places a statutory duty of quality on Health and Personal Social Services (HPSS) organisations, and requires the RQIA to encourage continuous improvement in the quality of care and services throughout all sectors in Northern Ireland.
In order to fulfill it's statutory responsibilities the RQIA has developed a planned three year programme of clinical and social care governance reviews of all HPSS organisations.
Clinical and Social Care Governance
Clinical and social care governance is described as a framework within which HPSS organisations can demonstrate their accountability for continuous improvement in the quality of services and for safeguarding high standards of care and treatment. Organisations must ensure that there are visible and rigorous structures, processes, roles and responsibilities in place to plan for, deliver, monitor and promote safety and quality improvements in the provision of health and social care.
1.2The Standards
Published in March 2006, The Quality Standards for Health and Social Care, underpin the duty of quality on HSS Boards and Trusts. They complement standards and other guidelines already in use by organisations and give a measure against which organisations can assess themselves and demonstrate improvement.
The five quality themes on which the standards have been developed were identified through consultation with service users, carers and HPSS staff and through a review of standards developed elsewhere at local, national and international level.
The five quality themes are:
1. Corporate Leadership and Accountability of Organisations
2. Safe and Effective Care
3. Accessible, Flexible and Responsive Services
4. Promoting, Protecting and Improving Health and Social Well- being
5. Effective Communication and Information.
The 2006/07 Review has assessed the achievement of Health and Personal Social Services (HPSS) organisations against the first two themes of the HPSS Quality Standards [2006]: -
- Theme 1 - Corporate Leadership and Accountability of Organisations
- Theme 2 - Safe and Effective Care.
Within these two themes, a detailed review has been undertaken in the following areas:
1. Corporate Leadership and Accountability of Organisations
- Appraisal of medical staff.
2. Safe and Effective Care
- Safe and Effective Discharge of older people from the acute to the community setting
- Safe and Effective Post-operative care of patients in the acute hospital setting
1.3The Review Methodology
The RQIA operates within a value system that supports the belief that learning is at the heart of improvement. To ensure a clear focus on improvement, organisations need to have effective systems which can identify performance standards and support the learning necessary for improvement.
Committed to a culture of learning, the RQIA has developed an approach which uses self assessment, a critical tool for learning, as a method for preliminary assessment of achievement of the HPSS Quality Standards. The distilled information from the completed self assessment pro-forma is subjected to reality testing when review teams visit organisations.
This review was undertaken during a period of major transition for organisations further to the Review of Public Administration (RPA). The management structures within which organisations were operational during the time that review visits were undertaken have been reconfigured, and different management structures are now in place. The review team have taken account of these developments within this report.
In developing the methodology, consideration was given to previous review methodologies used by equivalent national and international bodies.
To avoid duplication of effort the review took into consideration evidence submitted by organisations to demonstrate compliance with Controls Assurance Standards.
1.3.1The Review Team
Review teams are multidisciplinary, and include both Health and Social Care professionals (Peer Reviewers) and members of the public (Lay Reviewers) who have undertaken training provided by the RQIA. Review teams are managed and supported by RQIA Project Managers and Project Administrators.
1.3.2Lay Reviewers
Lay reviewers come from a range of backgrounds and from all over Northern Ireland. They each play a vital role in review teams, bringing new insights and providing a lay person's perspective on all aspects of the provision of health and social care services.
1.3.3Peer Reviewers
Peer reviewers work at a senior level in both clinical and non-clinical roles in the HPSS. They have a particular interest in the area of governance and a commitment to improving health and social care.
There is an identified team leader for each review team who works closely with the RQIA project manager for each review to guide the team in its work and ensure that team members are in agreement about the assessment reached.
1.3.4The Review Process
The process of review has three key parts: - local self-assessment, pre-visit analysis and the review team visit.
1.3.5Self-assessment
The first stage in the process of the clinical and social care governance review is a self assessment by each organisation on performance against the two quality standard themes, using a pro-forma developed by the RQIA. The completed self assessment pro-forma and evidence documents is submitted to the RQIA for analysis.
1.3.6Pre-visit analysis
Further to analysis of the self assessment pro-forma and submitted evidence documentation, a pre-visit analysis report is produced. This report is sent to the review team and the organisation being reviewed.
1.3.7The Review Visit
The review team assesses the breadth and depth of an organisation's achievements against the standards by undertaking a site visit. At the start of the site visit, the review team meets key personnel responsible for the service being reviewed. Reviewers then speak with local stakeholders, including staff, patients, clients and carers about the services provided. Information can also be obtained by observation of the physical surroundings and by looking at documentation such as policies and procedures. After these meetings, the team assesses the performance of the organisation against the standards, based on the information gathered during both the self-assessment exercise, pre-visit analysis and the on-site visit. The visit concludes with the team providing feedback on its findings to the organisation. This includes specific examples of good practice drawn to the attention of the review team, together with an indication of any particular challenges.
1.3.8The Report
After each review visit, the RQIA project manager, with input as appropriate, drafts a local report detailing the findings of the review team and recommendations for improvement. This draft report is sent to the review team for comment, and then to the organisation to check for factual accuracy.
Once agreed the RQIA compiles a composite report for the DHSS&PS on the overall findings of the review across all organisations.
The overview report is made available to the general public in print, the RQIA web site and other formats on request.
2THE FINDINGS
2.1Overview of local service provision
United Hospitals Health and Social Services Trust was established on
1 April 1996 and provides general acute hospital services at Antrim, Braid Valley, Mid-Ulster, Moyle and Whiteabbey Hospitals.
The Trust provides services to an area comprising the local government districts of Antrim, Ballymena, Carrickfergus, Cookstown, Larne, Magherfelt and Newtownabbey.
The Trust serves a population of 327,823 (this represents 77% of the population for the NHSSB area).
The Trust is one of three trusts within the Northern Health and Social Services Board area, sharing the same geographical area as Homefirst Community Trust. Trust Headquarters is at Bush House on the Antrim Area Hospital site.
It also provides Care of the Elderly and palliative care inpatient services in Braid Valley Hospital, Ballymena and Moyle Hospital, Larne. Outpatient clinics are provided on all five of these sites and also at Carrickfergus Health Centre.
The Trust, comprising 5 hospitals, has over 800 in-patient beds and employs approximately 3500 staff across a full range of disciplines and professions.
FINDINGS AND RECOMMENDATIONS
2.2Corporate Leadership and Accountability of Organisations
2.2.1 How the organisation demonstrates accountability
Based on the criteria within The Quality Standards for Health and Social Care (DHSS&PS 2006) the RQIA assessed the organisation's status in relation to the following.
The organisation has in place clear objectives, sound practices and arrangements which help it to:-
- focus on the organisation's purpose and on outcomes for the public and service users
- perform effectively in clearly defined functions and roles
- make informed, transparent decisions and manage risk
- engage stakeholders and make accountability real
- develop the capacity and capability of the governing body to be effective.
The organisation gives equal priority to the obligations of governance across all aspects of the organisation's business to ensure that governance is a part of the organisation's culture.
Findings:
It is the responsibility of the Trust Board to ensure that objectives are reviewed regularly and communicated throughout the organisation by means of an Annual Business Plan and that an Annual Report describing the Trust’s activity and performance is published on a yearly basis and distributed widely throughout the organisation and to stakeholders in the local community.
The review team found evidence of a coherent and integrated organisation. This was evident through discussions with staff at Executive Directorate and Directorate Management level. There would appear, however, to be less clarity about corporate strategy at operational level and the contribution that clinical staff have to make to its’ development.
The Trust aspires to having an integrated Governance approach. The Governance Support Unit was established in September 2004 under the leadership of the Medical Director and the Trust Governance Manager was appointed in February 2005. There are two governance committees at Board level, (Audit Committee and Risk Management Committee) with standing items covering governance issues arising from all areas. These committees meet quarterly.
Recent changes to directorate structures and accountability arrangements were outlined by the Chief Executive. From November 2006 the Trust established monthly Directorate Performance Review meetings to monitor Governance arrangements. The Trust Hospital Council has also been established since September 2006. It meets monthly and provides an opportunity for Clinical Directors to get corporate ownership of any issues requiring major decision making. These changes will strengthen clinical leadership through devolved accountability and corporate ownership.
The Governance Controls Assurance Standard was verified by internal auditors as being substantive. The review team noted that a significant number of actions within the Controls Assurance Standards were to be achieved in 2006 and that the controls assurance action plans were not costed.
Recommendation:
The Trust should seek evidence to ensure support and show the involvement of practice and clinical staff in the development and review of organisational aims and objectives.
2.2.2Leadership
Based on the criteria within The Quality Standards for Health and Social Care (DHSS&PS 2006) the RQIA assessed the organisation's status in relation to the following.
The organisation has in place processes to develop leadership at all levels, including identifying potential leaders of the future.
Findings:
The Clinical Directors Leadership Programme has been established since June 2006 and would appear to make a significant contribution to the identification and development of clinical leaders within the organisation.
In addition, the Trust submitted evidence of a range of programmes offered to nurses, for example, the Ward Managers Leadership Development Programme, Induction for New Managers and the Nursing Leadership Development Programme for Senior Nurses. Access to these programmes was verified through discussions with staff at ward level.
The Directorate Management Team presented examples of a range of leadership programmes accessed by other professional groups within the Trust. Records of staff attending these leadership programmes are held within Directorates and the review team were unable to access these records through the HR department at the time of the review.
A training team, made up of the Chief Executive and Directors, meets quarterly and has responsibility for determining the overall training and development priorities for the Trust.
Recommendation:
Develop a central database for all training.
2.2.3Financial Management
Based on the criteria within The Quality Standards for Health and Social Care (DHSS&PS 2006) the RQIA assessed the organisation's status in relation to the following.
The organisation has in place a system of internal financial control based on a framework of regular financial information, administrative procedures including the segregation of duties and a system of delegation and accountability which operates within guidelines set down by the Department of Health, Social Services and Public Safety that includes:-
- a comprehensive budgeting system with an annual budget which is reviewed and agreed by the organisation's Board
- the setting of targets to measure financial and other performance
- clearly defined capital investment control guidelines.
Findings:
The organisation ensures financial management, achieves economy, effectiveness, efficiency and probity and accountability in the use of resources. The Trust has achieved substantive compliance with financial management Controls Assurance Standards and this has been verified by Internal Audit.
2.2.4Compliance with legislative requirements
Based on the criteria within The Quality Standards for Health and Social Care (DHSS&PS 2006) the RQIA assessed the organisation's status in relation to the following.
The organisation demonstrates awareness of relevant legislative requirements and can provide:-
- a range of quantitative and qualitative information demonstrating how legislative requirements are being met
- information about emerging issues for each area of operation
- action plans to meet any deficits.
In addition, it can demonstrate that the organisation/Board periodically reviews compliance with legislative requirements.
Findings:
At the time of the review there appeared to be a lack of departmental awareness of statutory requirements under Health and Safety legislation. This was evidenced by a lack of knowledge on the part of ward staff with regard to their responsibilities under mandatory Health & Safety risk assessment. For example there was no COSHH, manual handling or general risk assessments in some of the clinical areas visited.
Health and safety policies and risk assessments require updating in line with extant guidance.
Reviewers were pleased to hear that the Trust has been successful in being accepted for the second phase of the Safer Patients Initiative.
Recommendations:
The Trust should ensure that all staff are aware of their responsibilities under Health & Safety legislation.