Review of Progress Against Healthcare Standards for Wales

DRIVING IMPROVEMENT THROUGH INDEPENDENT AND OBJECTIVE REVIEW

RThrevieeweof-Pyroeargress against Healthcare Sptarogndarrammeds for Wales 2009 - 2012

North Wales NHS Trust

1JAulpyri2l0200908 - 31 March 2009

Contents Page

Executive Summary iii

1. Introduction and Background 1

2. Findings 3

3. Conclusion and Next Steps 25

Annex 1: North Wales NHS Trust Internal 27 Audit Report

Annex 2: Summary of Healthcare Standards 41 for Wales

Annex 3: Maturity Level Definitions 49

Annex 4: Areas for Improvement 51

i ii 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 and placing them at the centre of the way in which services are planned and delivered, providing a basis for continuous improvement.

North Wales NHS Trust is a new organisation, formed from the former North East Wales NHS Trust and the Conwy and Denbighshire NHS Trust. This is the first year in which the Trust has self-assessed its performance against each of the 32 standards and submitted its assessment to Healthcare Inspectorate Wales (HIW) for testing and validation. The reports for the two former organisations for the years 2006-07 and 2007-08 can be accessed from our website. As noted at paragraph 3.3, the North Wales NHS Trust will be dissolved as part of the current reorganisation of the NHS in Wales, its functions being assumed by the new Betsi Cadwaladr University Local Health Board. Section 1 of this report provides full details of the assessment process adopted and the methodology used to test and validate Trusts’ self-assessment.

Between 9 and 12 March 2009, HIW undertook unannounced visits to North Wales NHS Trust. The purpose of these was to validate and test compliance and performance against Healthcare Standards by looking at how care is delivered to patients and service users. We conducted unannounced visits to Ysbyty Glan Clwyd and Ysbyty Maelor (Wrexham). We also visited Glan Traeth (Rhyl), Holywell Hospital, Flint Hospital, Mold Hospital, Denbighshire Infirmary and Ruthin Community Hospital. These visits focused on 10 of the 32 standards that relate to dignity and respect, child protection and vulnerable adults.

iii Overall, North Wales NHS Trust performed reasonably well against these 10 standards. It was assessed as providing a standard of care that is a maturity of Developing or above at the User Experience1 levels. The Trust demonstrated particular strengths in relation to Standard 9 (Nutrition) which is assessed as Practising across the User Experience level.

It is clear that the Trust is committed to providing high quality care and respecting individuals’ privacy and dignity. We are satisfied that, in general, a good standard of care is delivered to patients and service users attending the Trust’s hospitals and we identified a number of areas of notable practice that should be shared across the Trust to support the Trust’s approach to improving the experience of its patients.

It was evident that there was good teamwork amongst staff and that they were committed to ensuring high standards of care for patients and service users. The patients and service users we spoke to were extremely positive about their experiences of the Trust’s services. Staff morale was generally high in the acute hospitals, although there were concerns in the community hospitals in Mold and Flint because of the uncertainty about their future.

Overall, while there are a number of issues for the Trust to address, there are many aspects of its activities which work well and the adaptability and willingness of staff means that generally the Trust presents a welcoming and effective face to its patients and service users.

1 User Experience is the term used throughout this report to represent the experience of patients, service users and carers.

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.org.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 tell 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:

1 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 important to patients’ and service users’ experience and should matter to us all.

1.5 As part of our visit to North Wales NHS Trust we undertook observational visits to:

The Accident and Emergency (A&E) Departments at Wrexham Maelor and Ysbyty Glan Clwyd The Medical Assessment Units at Wrexham Maelor and Ysbyty Glan Clwyd The Paediatric/Children’s Wards at Wrexham Maelor and Ysbyty Glan Clwyd The Acute Medical Wards at Wrexham Maelor and Ysbyty Glan Clwyd The Elderly Mental Health Wards at Wrexham Maelor, Ysbyty Glan Clwyd, Glan Traeth (Rhyl), The Holywell Hospital, Flint Hospital, Denbighshire Infirmary and Ruthin Community Hospital The Minor Injuries Unit at Holywell Hospital, Flint Hospital, Mold Hospital, Denbighshire Infirmary and Ruthin Community Hospital.

1.6 We have also worked closely with the Mersey Internal Audit Agency, the Internal Auditors of North Wales NHS Trust and have where possible used their findings in our validation work. Their report can be found at Annex 1.

2 2. Findings

2.1 To enable us to assess how well North Wales NHS Trust 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 Children 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 appropriate are the Trust’s healthcare environments: i.e. are the structures and layout of wards and departments fit for purpose? How clean are the Trust’s healthcare environments? The usefulness and suitability of information provided by the Trust to patients and service users.

3 Whether patients and service users are appropriately involved in their care planning. Whether consent is appropriately sought from patients and properly documented. Whether patients and service users are treated with dignity and respect. Whether patient information is treated confidentially. Whether the Trust provides food that is of good quality and whether patients’ and service users’ are provided with the support they need to eat. Whether the care provided by the Trust takes account of patients’ and service users’ physical, cultural and psychological needs and preferences. Whether the Trust has appropriate systems and procedures in place to ensure that children and vulnerable adults are appropriately safeguarded and protected.

The details of our findings are set out below.

Standard 4: Environment of Care

2.4 North Wales Trust has taken adequate measures to ensure privacy, dignity and respect for all patients and service users, such as through the use of curtains or single rooms, if available. However the availability and access to single rooms, segregated toileting and shower facilities vary throughout the Trust and in the medical admission unit mixed sex bays were identified.

2.5 The layout of some departments in the organisation, such as the accident and emergency at Glan Clwyd hospital, presents challenges in ensuring privacy for patients and service users. The departments design is outmoded which results in all patients and visitors, including Blue Light emergencies, accessing

4 the department through the same single entrance. The waiting areas for patients and their companions are close to the entrance and it is often necessary for the staff to use makeshift curtains to shield people in the waiting room from viewing potentially distressing scenes. The Trust has identified the issues and has instigated an acute service redevelopment project to address the issues.

2.6 The Accident and Emergency Department in Wrexham Maelor hospital was very busy on the day of the visit and suffered from delays in moving patients to inpatient beds. On the morning of the visit, 12 March 2009, the department was very busy, staff confirmed that there were 25 ambulances waiting to move patients to the department and that they had been waiting up to a couple of hours; this was an exceptional and unusual event..

2.7 We found that Flint and Denbigh Community Hospitals have challenges in maintaining a suitable environment due to the age of the building. The Trust is well aware of this. Staff recognise the potential issues in relation to the environment and make every effort to preserve the dignity and privacy of the service users in their care. This was endorsed by the response of patients and service users who provided minimal adverse comments and generally felt they had been treated with great consideration. We were particularly impressed with how staff maintained the environment on the wards at both hospitals.

2.8 Within the Medical Assessment Units (MAU) at both Wrexham Maelor and Glan Clwyd, there is a feeling among staff that the high throughput of patients compromises their ability to maintain privacy and dignity as they would wish. This is further complicated by the use of mixed sex bays. .

2.9 Elderly and Elderly Mentally Ill (EMI) wards were mixed sex. However patients were in single sex bays and had lockable cabinets; most bays had en suite facilities. Each ward had shared communal rooms and dining rooms.

5 2.10 Clutter was apparent in some locations within the Trust, also discussed in para 2.12. This is mainly associated with areas in Glan Clwyd, Flint and Mold Hospitals and included an amount of bulky equipment used by staff and where the premises were not designed in anticipation of the storage space needed.

2.11 Staff told us that mechanisms for them to highlight issues affecting the environment of care are in place, that they feel that they will be listened to and that changes to the environment will be made where practicable as a result. Patients interviewed were very satisfied with the systems in place to protect privacy, dignity and confidentiality. However curtains are used around patients’ and service users’ beds in the bay areas to provide dignity and respect, but privacy is not ensured as discussions involving sensitive, personal or clinical information can be overheard. This was a particular problem within the more cramped areas within A&E departments.

2.12 The Trust has assessed itself as Practising at the User Experience level across this standard. However, as described above, we consider that, based on the results of the unannounced visit, the maturity level of Developing is justified.

6 Areas for Improvement:

1. The Trust should aim to eliminate mixed sex bays within hospital/ward areas. There should be improved communication with patients and service users when mixed sex bays are unavoidable to inform them of processes to ensure privacy and dignity.

2. Measures should be put in place to identify that activity is taking place behind curtains in bedded areas. The use of dignity cards should be considered and used in all areas.

3. The Trust should continue to take in to account measures to improve the entrance to the accident and emergency department at Glan Clwyd Hospital and consider the outcome of the Acute and Community Service Review.

Standard 5: Maintenance and Cleanliness

2.13 The majority of areas across the Trust were observed to be well maintained and free from clutter and, in general, cleanliness was satisfactory. However standards of cleanliness varied within and across hospital sites.

2.14 In those areas where clutter was observed as being a problem including equipment and trolleys in corridors this was usually linked to a lack of storage space in EMI wards and elderly care wards. The MAUs at both Wrexham Maelor and Glan Clwyd and Cunliffe ward at Wrexham Maelor Hospital were found to have storage problems and appeared cluttered.

7 2.15 The general comments made by patients and service users regarding the state of maintenance and cleanliness were positive. Virtually without exception, all the patients and service users we spoke to commented on the high standard of cleanliness, the standard and timeliness of maintenance.

2.16 In December 2008 cleanliness spot checks were undertaken across North Wales NHS Trust. The results of the spot checks have been reported to the Trust and detailed action plans have been developed. The spot checks highlighted that:

Generally all wards visited were found to have an acceptable level of cleanliness. Our observations and discussions with staff in relation to their knowledge and practice of infection control prevention demonstrated acceptable practices. Good hand hygiene was well promoted throughout the Trust and hand hygiene facilities were clearly visible at the entrances of all wards visited. A number of staff indicated that they had received infection control training in the last year but some indicated that they had not. In four of the wards visited a commode had not been cleaned to an acceptable standard. In four of the wards visited we found communal toiletry items. If these are used by a number of patients there is a potential for them to become contaminated. The provision of domestic waste bins was poor on all wards visited.

2.17 The Trust has assessed itself as Developing at the User Experience level across this standard. We consider that, based on the results of the unannounced visit and the cleanliness spot check, this maturity level is justified.

8 Area for Improvement:

4. All equipment and stock should be stored in ways that avoid them being left in corridors.

Standard 6: Information and Communication

2.18 Patients and service users are able to access general information about services and their condition, care and treatment, although this was not always available in a suitable language or format, especially in the case of ethnic minority groups. However the Trust does have processes in place to provide leaflets in suitable language and format including a leaflet library, and translation service.

2.19 There are identified staff that are able to sign for patients and service users who are deaf, but there is an inconsistent approach to this across the Trust. There are gaps in the provision of support for patients and service users who have sensory impairment. Most staff were aware of how to access translators via switch board or a more senior member of staff and some were aware that information can be provided in Braille.

2.20 There are information systems across the Trust to support the development, availability and provision of information to patients and service users. The Trust has undertaken Picker Institute In and Out-Patient Satisfaction Surveys. Comment cards schemes are in place across the Trust. Comments are collected and a response given and/or action taken if appropriate.

9 2.21 Information on services and health related conditions were mostly available only in English or Welsh, with very little information provided to patients or available during the visit in any other languages even though there is a large Polish community in North East Wales. The Trust has a database of staff who speak other languages and who are willing to assist with translation and communication with patients.

2.22 Signage in the majority of areas was clear. Display boards were clear and free from clutter.

2.23 The Trust has assessed itself as Developing at the User Experience level across this standard. We consider that, based on the results of the unannounced visit, this maturity level is justified.

Area for Improvement:

5. The availability of information on services and conditions should be provided for patients and service users in languages relevant to the local community.

Standard 7: Patients and Service Users contribution to Care Planning

2.24 There was mixed evidence of care planning taking place from admission to discharge that includes the involvement of the patients, service users, their relatives and carers. Patients and service users do have the opportunity to discuss and agree treatment options. However, the attention given to written care plans, particularly in respect of recording clinical, psychological, spiritual and equality needs, was found to vary: for example, on the paediatric ward (Rupert) at Glan Clwyd hospital, there was evidence that clinical, personal, psychological and spiritual needs were considered and planned for, although in other areas of the hospital the emphasis appeared to be very much on clinical information.

10 2.25 Staff knowledge of how to plan care in the round was variable across the Trust and, although there was evidence of Stroke and Renal pathways being used on ward 14 in Glan Clwyd hospital, this was an exception.

2.26 Patients and service users we spoke to stated they were satisfied with their involvement in and the discussions held relating to their condition, care and treatment. However the involvement of patients and service users varied across the Trust.

2.27 On Cunliffe ward at Wrexham Maelor hospital there were inconsistent recordings within care plans of the discharge plans, multi disciplinary team entries, nutritional assessments, informed consent, correspondence with social care providers and evidence of agreement with the service users of the care plans. However on Alyn and Gwenfro EMI wards, it was evident that care plans reflected service users’ identified needs and that comprehensive risk assessments were carried out.

2.28 The Trust has assessed itself as Developing at the User Experience level across this standard. We consider that, based on the results of the unannounced visits, this maturity is justified.

Area for Improvement:

6. The Trust should: • Address inconsistencies in relation to the care planning approach. • Ensure that patients’ records are up to date and accurate. • Ensure that all information, from initial assessment to discharge. Including oral discussions, is suitably recorded and that discharge plans are developed where relevant.

Standard 8: Dignity, Respect, Consent and Confidentiality

2.29 It was clear from our observations and discussions that patients and service users who use the services of North Wales NHS Trust are treated with dignity and respect. Assessments of capacity for users to make decisions are being carried out. However, staff training in areas related to the Mental Capacity Act is variable.

2.30 The staff we spoke to recognised the importance of ensuring that dignity and respect of patients and service users was maintained and patients and service users indicated that they were treated well by staff. It was apparent in the Trust that, despite the best efforts of staff, it was not possible to have single sex bays all the time. The availability of single sex bathrooms or toilets was often possible, but, even then, minor improvements such as the installation of extracting fans, could assist patients’ comfort. On speaking to patients and staff, it seems that the lack of confidentiality afforded by curtains was of more concern to staff than to patients.

12 2.31 The Trust has employed a discharge liaison officer to work in the Wrexham Maelor A&E Department to help move patients and service users to inpatient beds, reducing the time patients and service users have to spend on trolleys.

2.32 Appropriate mental stimulation for patients and service users on the Ablett Unit in Glan Clwyd hospital is provided by an occupational therapist. However, less priority is given to this on Tawel Fan the EMI ward in the Ablett Unit, where there was no structured programme of activities and patients were not taken out of the building. On the female ward at Flint community hospital, patients and service users gave a mixed response when asked if staff were courteous. However patients stated that they were happy with the care that they received.

2.33 Guidance on informed consent is being followed and the confidentiality of patient and service user information is being maintained. Care plans indicate that consent is appropriately obtained. While most senior staff has a reasonable understanding of consent issues, more junior staff (e.g. nursing assistants or auxiliary nurses) reported to us that this subject is outside their area of responsibility. Given the importance of the issues involved, this lack of knowledge ought to be addressed, even though all patients and service users interviewed, as well as carers, were extremely positive about practice in this area, believing that they had been treated sensitively and that consent had been sought appropriately.

2.34 It was rare to find patients’ and service users’ spiritual needs or equality preferences recorded in the care plans and it was evident in one of the EMI settings (Glan Traeth) that access to ministers of the faith or to Chapel on Sunday mornings was not easily provided. These shortcomings need to be rectified.

13 2.35 We observed that confidentiality was being maintained, with wipe boards being used appropriately, medical records used confidentially and staff aware of the importance of ensuring their discussions with services users were confidential. Records are kept securely in a variety of areas depending on the clinical setting.

2.36 There is a lack of consistency in the provision of staff training relevant to patient confidentiality. For example, on wards 9 and 14 at Glan Clwyd, we identified that no training had taken place for mental capacity assessment and there was limited knowledge of integrated care pathways (ICPs).. Of the 40 staff interviewed 35 had not had customer care training and 27 had not had training in race relations, equality, or cultural awareness.. However the Trust does provide training for complaints handling, Negotiation and Conflict Resolution and Delivering Effective Customer Service and Communication which include aspects customer care. Only one member of staff referred to the equality and diversity resource folder available on each ward in the Central part of the Trust, however the staff were not asked about this initiative. On Cunliffe ward and the A&E department at Wrexham Maelor, whilst there had been no recent training, all staff interviewed were aware of the policies and procedures for child and adult protection. Facilities and estates staff in the Central area of the Trust have undertaken dignity and respect training.

2.37 The Trust has assessed itself as Developing at the User Experience level across this standard. We consider that, based on the results of the unannounced visit, this maturity level is justified.

14 Areas for Improvement: 7. The Trust needs to improve the level of provision, attendance and monitoring of staff training in relation to: • The assessment of patients’ and service users’ capacity and the Mental Health Act. • Race relations, cultural awareness, and equality. • Customer care. • Informed consent. • Confidentiality. • Customer care.

Standard 9: Nutrition

2.38 The nutritional needs of patients and service users at North Wales NHS Trust are assessed and met. There is good quality and choice of food and drinks, and patients receive assistance to eat when needed.

2.39 Patient records reviewed within the inpatient areas visited verify that the dietary needs of patients and service users are assessed when necessary. There was also evidence of food and fluid charts being maintained as required. Service users confirmed that they were satisfied that their dietary needs had been met.

2.40 Patients and service users we spoke to were very pleased and positive about the quality of the food and drinks available confirmed that nutritional assessments were routinely carried out, assistance was appropriately provided and the variety of food available was good. Regular drinks are available outside meal times; fresh water is readily available and the jugs changed frequently. However the choice of food and drinks available in the A&E departments varied.

15 2.41 Staff assist patients and service users where appropriate. Staff who are not regularly on the ward, either agency staff or staff helping for the shift, scrutinise nutritional charts, fluid balances and other clinical measures to assess nutritional requirements. Staff often encourage relatives and carers to assist at meal times. Parents on the paediatric wards were also encouraged to attend at meal times to assist with feeding their children if necessary. We observed that on some EMI wards meals were served in the dining room to encourage patients to interact. . Where the patients were less mobile and/or less sociable, meals were served by their beds.

2.42 There was protected meal times on most of the wards observed, although this was sometimes appropriately compromised when clinicians or relatives visited a very ill patient.

2.43 The Trust has assessed itself as Practising at the User Experience level across this standard. We consider that, based on the results of the unannounced visit and the evidence submitted, this maturity is justified.

Standard 10: Access to Healthcare

2.44 Steps are being taken to identify patients’ and service users’ personal information to ensure that they are not unfairly discriminated against on the grounds of age, disability, ethnicity, race, religion or sexual orientation.

2.45 Care plans are comprehensive in recording patients’ personal details; however the emphasis is largely on recording demographic and clinical information and those aspects which relate to emotional well being tend to be neglected. Thus, as previously noted, psychological, spiritual and equality needs are often missed.

16 2.46 The general mechanism for arranging visits by faith specific pastors is for staff to ring “the switchboard” rather than there being more detailed local information that staff, patients and service users can refer to. However, no adverse comments from patients and service users were received in relation to addressing their spiritual and cultural needs.

2.47 We observed that there was a very low throughput of patients and service users in the Minor Injuries Units (MIU) at Denbigh, Flint and Mold community hospitals. These facilities appear, in the main, to be providing local phlebotomy and dressing change services. The Trust should consider and review the use of these units ensuring that patients and service users are aware of the function of the MIU.

2.48 The Trust confirmed that its appointment booking system has been further developed this year. This enables patients and service users to request an appointment at a time and venue suitable to themselves and invites them to identify any reasonable adjustments necessary in respect of access or communication.

2.49 The Trust has assessed itself as Practising at the User Experience level across this standard. However, as the unannounced visit identified that the full needs of patients are not always identified, we assess the maturity level as Developing.

Area for Improvement:

8. The Trust should ensure that the psychological, spiritual and equality needs of patients are identified, assessed, recorded and addressed.

17 Standard 12: Care and treatment meets the needs of patients and service users.

2.50 Evidence of a multi disciplinary approach to addressing patients’ and service users’ clinical care needs was inconsistent within the Trust. Staff work hard to bring together professional colleagues for multi disciplinary discussions: for example, care plans reviewed and staff spoken too confirmed that there are individual links to district nurses, social workers and allied health professionals, but there appears to be no consistent organisational framework or structure to assist with this.

2.51 There were examples of delayed discharge planning, including poor recording of discharge plans and poor recording of multi disciplinary team meetings. Care plans should be audited to identify the reasons and solutions to improve this process. There were delays in discharging patients at Wrexham Maelor due to the difficultly in reaching an agreed discharge date. An “expected date of discharge” system did not seem to be in place and significant delays were experienced in organising multi disciplinary teams to discuss mental health discharges. Discharge delays from the acute sector, delays in transferring patients from A&E departments and variation in consultant practice in Medical Admission Units should be audited and rectified.

2.52 The A&E department in Wrexham Maelor hospital was very busy and suffered from delays in moving patients to inpatient beds. As noted at paragraph 2.6, on the day of our visit, there were up to 25 ambulances waiting to transfer patients to a suitable ward.

2.53 We were pleased to note that plans were evolving to improve the A&E facilities in Wrexham Maelor by developing a clinical decision unit. Although staff had been consulted and involved with the design, there were concerns amongst them regarding the final lay out, the staffing implications and whether there would be separate children’s waiting area.

2.54 It is apparent that there are some serious issues of capacity at various places within the Trust. For example the single rooms in the MAU at Glan Clwyd are often used, as a matter of priority, for isolating patients who may pose an infection control risk.

2.55 We were told that, on Cunliffe ward at Wrexham Maelor hospital, there were six patients who, it was considered by the staff, should be in more suitable accommodation, such as a specialist stroke unit or nursing care homes. Discharge to community hospitals from ward 9 at Glan Clwyd hospital was regularly delayed, due to the discharge assessment process. Despite these problems, staff seem to manage well enough and continue to meet the care needs of their patients.

2.56 The Trust has assessed itself as Developing at the User Experience level across this standard. We consider that, based on the results of the unannounced visit, this maturity is justified.

Area for Improvement:

9. There should be systems to address and improve the discharge and transfer of patients and service users between A&E, other wards, care homes and patients’ own homes.

10. There should be effective planning for timely discharge of patients.

19 Standard 15: Feedback, Compliments and Complaints

2.57 Patients and service users are given the opportunity to feed back on their experience. However, there was variable evidence of staff being made aware of comments and changes made as a result.

2.58 Access to and the availability of written material on how to complain varied across the Trust. Complaints procedures were clearly visible, well publicised and accessible to service users and visitors in most areas. However in some areas complaint information was less visible. A considerable number of cards expressing appreciation from patients, service users and their families were evident in all areas visited.

2.59 Staff are generally aware of the procedures relating to complaints, both formal and informal, and report concerns through their manager or incident reporting procedures.

2.60 The process for providing feedback to staff in respect of complaints and concerns received from patients and service users and the lessons learnt from a complaint were unclear. There did not appear to be a universal, systematic or consistent approach across the Trust. Staff could not provide specific examples of any changes made recently in their areas as a result of concerns raised by patients and service users.

2.61 There was evidence of alternative mechanisms being used to gain patients’ and service users’ feedback, such as news and views boards which include comment cards; these are being implemented across the Trust.

20 2.62 The Trust has assessed itself as Practising at the User Experience level across this standard. However, as the unannounced visit identified a lack of feedback to staff in relation to comments from patients and service users, we assess the Trusts maturity level as Developing.

Area for Improvement:

11. The Trust should systematise the provision of feedback to staff in respect of comments from patients and service users and lessons learnt.

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

2.63 North Wales NHS Trust has a system that enables staff to identify, assess, manage and communicate an issue relating to a vulnerable adult or child and to identify what action should be taken.

2.64 There was plenty of evidence to show high levels of understanding of child and vulnerable adult protection issues and appropriate training had taken place across all the hospitals visited. The staff we spoke to were aware of the policies and procedures that were in place. They were able to locate them via the Internet or by accessing hard copies on the ward and departments. Training in relation to POVA and POCA is mandatory across the Trust.

2.65 On the day of the visit to the A&E department at Ysbyty Glan Clwyd, there was one child trained staff nurse on duty. It was reported that there were recruitment difficulties for child trained nurses and it was therefore not possible to have a child trained staff member on every shift. Under these circumstances, the paediatric ward provides assistance if necessary.

21 2.66 At the children’s ward 18 in Wrexham, staff were concerned about the low staffing levels compared to national guidance and the over reliance on the parents. However it was clear that the staffing levels at the time of the visit were appropriate and that staff were a caring and a dedicated team delivering high quality care under difficult circumstances.

2.67 Staff knowledge of the “alert triggers” for detecting a potentially vulnerable adult varied and there were inconsistencies in the understanding of the procedures for following up an issue relating to a vulnerable adult. The Trust is waiting for the outcome arising from the review of ‘In Safe Hands’ to provide further guidance and a consistent approach to referral processes and case management.

2.68 The MAU at Wrexham Maelor hospital had a “Designated Champion for Adult Protection” and was the only area within the Trust that appeared to have made this innovative appointment. This was an example of good practice which is replicated in a number of other areas across the Trust including mental health, cancer services and community service.

2.69 On Rupert ward in Glan Clwyd, there was a high level of awareness of child and vulnerable adult protection and the staff had been subject to checks by the Criminal Records Bureau (CRB). Amongst the staff interviewed there was anecdotal evidence of their having experience in recognising potential child abuse and acting upon their suspicions.

2.70 Generally, staff were aware that a vulnerable adult would not always be elderly and understood that almost anyone could potentially be a vulnerable adult. We found staff to have a good understanding of the indicators suggesting a potential child protection problem might exist. The knowledge of staff of how to follow up concerns (such as via the duty social worker, child protection team or consultant in charge) was consistent in areas where staff are more likely to be

22 exposed to child protection issues (A&E, MIU, paediatrics). Junior staff consistently told us that they would report concerns to the nurse in charge of the ward.

2.71 Although staff working on adult wards reported that, in general, child protection issues have no relevance to them, they were aware that the presence of children in the Trust (e.g. child visitors to a ward) may represent a child protection issue.

2.72 We found that staff were unaware of audit activity in relation to protection of vulnerable adults training and CRB checks. However training in relation to the protection of vulnerable adults and child is audited and a report provided to the Board. CRB checks were applied and all staff interviewed had had a CRB check, although there did not appear to be a consistent approach to the regularity of such checks.

2.73 The Trust has assessed itself as Practising at the User Experience level across this standard. However, as the unannounced visit identified inconsistencies in the processes for following up concerns, variable knowledge amongst staff and inconsistencies in CRB checking, we assess the maturity level as Developing.

Area for Improvement:

12. The Trust has “Designated Champions for Vulnerable Adults” in three areas that are Trust wide and many areas in the Central part of the Trust. With the revised structure comprising of two former NHS Trusts and the formation of the Bestsi Cadwaladr University LHB the challenge is to continue to roll out this good practice initiative.

13. The Trust should ensure mechanisms are in place to audit Protection of Vulnerable Adults and Protection of Children Act procedures on a regular basis.

14. The Trust should ensure that all staff have a Criminal Records Bureau check in line with national guidance and that re-checking is carried out at consistent intervals.

24 3. Conclusion and Next Steps

3.1 This year’s assessment has demonstrated that North Wales NHS Trust is improving in relation to issues such as nutrition. The Trust’s own self assessment was largely borne out by what we saw during our unannounced visits, although, in four areas in which the Trust has assessed the level of maturity as Practising, we have substituted a level of Developing. An improvement to the Trust’s communication and information mechanisms across hospital sites is needed. Discharge and transfer processes and attendance at training, especially in relation to patient documentation and confidentiality, should be improved.

3.2 The Trust will need to consider the areas that have been highlighted as requiring further improvement by this assessment process and that of its Internal Auditors when developing its 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, North Wales NHS Trust will be dissolved and a new Betsi Cadwaladr University Local Health Board (LHB) established. This new LHB will be constituted from the former North Wales NHS Trust, North West Wales NHS Trust, Gwynedd LHB, Anglesey LHB, Conwy LHB, Denbighshire LHB, Flintshire LHB and Wrexham LHB and the development of a Healthcare Standards Improvement Plan should be a consolidation of areas highlighted for improvement across all eight organisations.

25 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 Betsi Cadwaladr LHB’s website.

26 Annex 1

NORTH WALES NHS TRUST

INTERNAL AUDIT REPORT

HEALTHCARE STANDARDS

27 MIAA Audit and Assurance

Healthcare Standards Validation and Risk Maturity Review

Internal Audit Report 2009-10

Report No. 114NWT_0910_001

NHS Restricted

Regatta Place HM Stanley Hospital 1829 Building Salford Royal Hospital Brunswick Business Park Upper Denbigh Road Countess of Chester 10th Floor, Summers Road St Asaph Health Park Worthington House Liverpool North Wales Liverpool Road Hope Hospital Tel: 0151 285 4500 Tel: 01745 589735 Chester Salford Fax: 0151 285 4501 Fax 01745 589796 Tel: 01244 364473 Tel: 0161 2061909 Fax: 01244 364471

WEB SITE WWW.MIAA.CO.UK

28 CONDUCT OF THE REVIEW Client Liaison

Report Distribution Name Title Distribution Audit Committee Members PDF Wayne Harris Director of Finance PDF Jill Galvani Director of Nursing and Patient PDF Services Cathy Howe Head of Clinical Governance PDF Ken Dawes Risk Manager PDF

Review Completion Action Planned Date Actual Date Fieldwork Start 11-May-2009 11-May-2009 Fieldwork Complete 20-May-2009 20-May-2009 Discussion Document to Client 27-May-2008 21-May-2009 Responses by Client 10-June-2008 Final Report 15-June-2008

Discussion Meeting held with Name Title Date Cathy Howe Head of Clinical Governance Ken Dawes Risk Manager

Review Preparation

Review prepared on behalf of MIAA by Name Title Denise Roberts Audit Manager 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.

29 CONTENTS AND REVIEW

Introduction and Background The review of Risk Maturity and Healthcare Standards for Wales system has been conducted in accordance with the requirements of the Internal Audit Plan, as approved by the Audit Committee. Published in 2005, Healthcare Standards for Wales sets out the Welsh Assembly Government's common framework of healthcare standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings.

Healthcare Inspectorate Wales (HIW) was established on 1 April 2004 and is responsible for reviewing the quality and safety of patient care commissioned and provided by healthcare organisations in Wales. HIW works closely with other inspection, regulation and audit bodies operating in Wales and has a statutory duty of collaboration with the Healthcare Commission in England to ensure the quality and safety of cross border services. The need to manage risks has become recognised as an essential part of effective corporate governance. While the responsibility for identifying and managing risks belongs to management, one of the key roles of internal audit is to provide assurance regarding the effectiveness of the risk management processes being applied. In order for us to best comply with this role we are required to develop links between your own risk management processes and our audit work. This is only possible where risk management processes are sufficiently robust so that reliance may be placed upon them for the purposes of audit planning.

Welsh Health Circular WHC (2008) 01, Healthcare Standards Assessment 2007-2008, was published on the 1st February 2008. The document clearly states that from 2007/08 onwards the Healthcare Standards will underpin the organisations Statement of Internal Control (SIC). We have therefore undertaken a review to assess the “Risk Maturity” of the organisation and focused on the systems and processes in respect of the organisation’s self assessment for core Healthcare Standards.

Objective and Scope The review objectives can be divided into two main areas which can be defined as follows:

1. To provide the Trust with an assessment of risk maturity of the organisation and to inform our audit strategy and approach. We considered the following factors in order to reach our assessment: Culture; Roles & Responsibilities; Processes; and Monitoring & Feedback

Our review has considered evidence relating to the current structure and approach to risk management as at the time of the completion of our fieldwork. 2. To ensure the Trust has utilised robust systems and processes to underpin its conclusions regarding the Healthcare Standards in Wales self assessment declaration (2008/09). This was broken down into the following sub objectives:

Roles and Responsibilities are clearly defined; Awareness Raising in respect of key updates has been undertaken; Standards have been mapped to the Trusts objectives;

30 Sound processes underpin the completion of the assessment and identification of supporting evidence; There is a sound approach to identify the Boards Assurance, including utilisation of existing assurance mechanisms.

Opinion The overall level of assurance is limited to the scope and objective of the review as defined (Section 2) 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 A, Table A.1. The assurance level for this review is:

Risk Maturity - Risk Defined

Healthcare Standards - Significant Assurance

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

Critical High Medium Low Total 0 1 0 0 1

Management Summary Conwy and Denbighshire NHS Trust (Central) and North East Wales NHS Trust (East) merged in July 2008 to became the North Wales NHS Trust (NWT). The process for ensuring an effective risk management process and effective completion of the self-assessment of Healthcare Standards takes account of working practices across both the East and Central Areas. Committee and reporting structures had been centralised but both areas still worked in accordance with their individual Risk Management and Strategy policies.

Risk Maturity

Culture The Risk Management and Strategy policies across both the East and Central areas are clearly defined. Risk management is done proactively to anticipate risks and develop mitigating plans. Risk management is an integral part of strategic and business planning at departmental/divisional and operational level. This includes usage of an Assurance Framework in order to understand and take actions in relation to the key corporate risks.

31 The Trust has developed a cyclical training programme that provided training on Risk Management, Incident Reporting and Risk assessment. In addition training on risk management is offered as part of in the induction programme and Health and Safety mandatory training. Roles & Responsibilities The reporting and committee structures with NWT changed. The Trust established the Safety and Standards Committee to oversee the development and scrutiny of the healthcare standard within the Trust. The Standards and Safety Committee is represented by Non-Executive and Executive Board members. The Committee received issues of significance from the Risk Management Committee.

The Director of Nursing and Patient Services has been appointed as the Executive Lead for Risk Management. Relevant job descriptions set out clear responsibilities and roles.

Processes Defined processes for risk management have been established at both a corporate and divisional level. The risk register is currently held and maintained centrally by the Risk Management Team. The Trust Board including Executive Directors and Divisional Managers report and respond to risks.

Monitoring and Feedback The risk management governance structure provides a clear approach to assessing the effectiveness of risk management processes with reporting on activity throughout the year, culminating in the production of an annual report against the Risk Management Strategy. The organisation receives regular assurance both internally and externally regarding the effectiveness of its risk management system.

Healthcare Standards for Wales The following core standards where reviewed against the 2008-09 self assessment:

· Healthcare standard 14 · Healthcare standard 16 · Healthcare standard 27 · Healthcare standard 28 The following assurances can be provided: • Each standard has been allocated against a Non-Executive and Executive Committee, with each standard having a designated lead. • A detailed ‘Star Chamber’ process was introduced to ensure the adequate collection, review and submission of each standard. • Supporting evidence provided within the self assessment was adequate and relevant. • A Healthcare Standards Improvement Plan was developed and approved by the Board in September 2008. • Presentations, reports and updates regularly reported to the Trust Board.

Good practice should be recognised in that the self-assessment review process where Board involvement, both Non-Executive and Executive members, took an active part

32 to ensure the quality of submission of standards. However instances were found were evidence provided did not reflect the current financial year.

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 (Section 2) and responsibilities (Appendix A) sections of this report. We also provide an assurance statement for the area under review. Assurance/ Opinion statement – Risk Maturity The opinion applied to this review has been classified as Risk Managed; Full definitions are provided in Appendix A Table A.1. Limited to the objective, and based on the findings of this review, the following opinion has been applied:- Given the findings of the review, we consider that Staff throughout the organisation is aware of the importance and the organisations response to risk/ Enterprise approach to risk management developed and communicated. The organisation is therefore assessed as Risk Managed. In this context, our audit strategy is to facilitate risk management / liaise with risk management and use management assessment of risk where appropriate.

Assurance statement: Healthcare Standards The assurance levels applied to this review have been classified as ‘high’, ‘significant’, ‘limited’ or ‘no’. Full definitions are provided in Appendix B. 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 Risk Maturity and Healthcare Standards for Wales at the time of our audit.

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 the Healthcare Standards Validation and Risk Maturity process is that at 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

Follow-up In light of the findings of this audit we would recommend that follow-up work to confirm the implementation of agreed management actions is conducted within the next Error! Unknown document property name..

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

34 No. Issue Identified Recommendation Risk Management Response, Responsibility and Classification Deadline for Action NWT is currently in a transitional Adequate reporting and process High a) To embed risk management within CPGs stage with the imminent merger with mapping should be undertaken to during the CPG development process. North West Wales NHS Trust taking ensure that risk is assessed at all Responsibility: Chiefs of Staff place in October 2009. NWT has levels within the organisation to made a number of changes to their ensure control and assurance Deadline: September 2009 reporting and committee structures to processes to manage those risks ensure a robust system to manage and internal controls are fully b) To monitor and scrutinise CPG risk management processes via Risk both risks and develop and scrutinise embedded. Management Committee. healthcare standards. Responsibility: Director of Nursing Deadline: September 2009 c) To monitor and scrutinise risk management processes at corporate level through risk management committee and via routine and exception reporting to the Board through Safety & Standards Committee. Responsibility: Director of Nursing Deadline: September 2009

Tale B.1 Assurance Level

The overall conclusions are made against the following risk maturity definitions:

Level of Description assurance Level 5 - Risk enabled Driven by the Board, staff at all levels High Our work found some low impact control weaknesses actively consider issues of risk in all which, if addressed would improve overall control. areas of activity and develop control However, these weaknesses do not affect key controls and and assurance processes to manage those risks/ Risk management and are unlikely to impair the achievement of the objectives of internal controls fully embedded into the the system. Therefore we can conclude that the key operations. controls have been adequately designed and are operating effectively to deliver the objectives of the system, function or process Level 4 – Risk managed Staff throughout the organisation are Significant . There are some weaknesses in the design and/or aware of the importance and the operation of controls which could impair the achievement organisations response to risk/ of the objectives of the system, function or process. Enterprise approach to risk management developed and However, either their impact would be minimal or they communicated. would be unlikely to occur.

Level 3 – Risk defined The organisation has considered risk Limited There are weaknesses in the design and / or operation of management, and put in place controls which could have a significant impact on the strategies led from a risk achievement of the key system, function or process management team/ Strategy and policies in place and communicated. objectives but should not have a significant impact on the Risk appetite defined. achievement of organisational objectives.

Level 2 – Risk aware The organisation is aware of risk No There are weaknesses in the design and/or operation of management responsibilities, and controls which [in aggregate] have a significant impact on needs to embed systems/ Scattered silo the achievement of key system, function or process based approach to risk management. objectives and may put at risk the achievement of organisational objectives.

36 Level 1 – Risk naïve The organisation has little or no awareness of the importance of risk management/ No formal approach developed for risk management.

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 processes.

38 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.

39 40 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.

41 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.

42 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:

43 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.

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.

45 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.

46 Standard 30 Healthcare organisations: 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.

Standard 31 Healthcare organisations: 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.

48 Annex 3

Maturity Level Definitions Aware Responding Developing Practising Leading The Board is aware The Board The Board is taking The strategic agenda The Board is leading the of the issues to be recognises the key steps to address the is being progressed strategic agenda through addressed but are issues and has key issues through the and monitored by the the implementation of unable to identified options that development of Board with significant innovative practice that is Corporate demonstrate are prioritised, strategic plans with evidence of shared across and decisions/ actions to although there is no evidence of good continuous beyond the organisation address them. evidence of strategic practice across the improvement across to others, enabling direction. organisation. the organisation. realisation of long term sustainability. There is awareness There is recognition Steps are being taken There are well- There is evidence of of the issues to be of the key issues to to address the key developed plans innovative practice, which addressed, but no be addressed and issues with evidence of being implemented is being shared across approaches have there is a range of practical application throughout the and beyond the been developed to options identified to across the organisation. organisation that organisation to others. Operational address them. address them. address the key They are further issues with evidence developing their of evaluation and approaches to ensure benchmarking long term sustainable leading to continuous improvement. improvement. The individual(s) The individual(s) The individual(s) The individual(s) The individual(s) experience is experience is experience is improving experience is experience is generally generally poor and no generally not good in many areas, generally good excellent and the service User Experience approaches have although approaches although this is not yet across all areas. can demonstrate clear been developed have been developed consistent across the evidence of good within the service to within the service to organisation. practice, which can be address them. address them. shared.

50 Annex 4

Areas for Improvement:

2. Measures should be put in place to identify that activity is taking place behind curtains in bedded areas. The use of dignity cards should be considered and used in all areas.

4. All equipment and stock should be stored in ways that avoid them being left in corridors.

5. The availability of information on services and conditions should be provided for patients and service users in languages relevant to the local community.

6. The Trust should: • Address inconsistencies in relation to the care planning approach. • Ensure that patients’ records are up to date and accurate. • Ensure that all information, from initial assessment to discharge, including oral discussions, is suitably recorded and that discharge plans are developed where relevant.

7. The Trust needs to improve the level of provision, attendance and monitoring of staff training in relation to: • The assessment of patients’ and service users’ capacity and the Mental Health Act. • Race relations, cultural awareness, and equality. • Customer care. • Informed consent. • Confidentiality. • Customer care.

8. The Trust should ensure that the psychological, spiritual and equality needs of patients and service users are identified, assessed, recorded and addressed

9. There should be systems to address and improve the discharge and transfer of patients and service users between A&E, other wards, care homes and patients’ own homes.

10. There should be effective planning for timely discharge of patients.

11. The Trust should systematise the provision of feedback to staff in respect of comments from patients and service users and lessons learnt.

12. The Trust has “Designated Champions for Vulnerable Adults” in three areas that are Trust wide and many areas in the Central part of the Trust. With the revised structure comprising of two former NHS Trusts and the formation of the Betsi Cadwaladr University LHB the challenge is to continue to roll out this good practice initiative.

13. The Trust should ensure mechanisms are in place to audit Protection of Vulnerable Adults and Protection of Children Act procedures on a regular basis.

14. The Trust should ensure that all staff have a Criminal Records Bureau check in line with national guidance and that re-checking is carried out at consistent intervals.