SEQOHS Accreditation - 27 July 2011SEQOHS Accreditation - 27 July 2011

Halina Greer Halina Greer Practice Development ManagerPractice Development Manager

NHS Plus Quality Strategy Facilitator – North NHS Plus Quality Strategy Facilitator – North WestWest

The Pennine Acute Hospitals The Pennine Acute Hospitals TrustTrust

North-East sector of Greater Manchester North-East sector of Greater Manchester Serves the communities of North Manchester, Bury, Rochdale and Oldham, Serves the communities of North Manchester, Bury, Rochdale and Oldham,

Hospitals - Approximately 9,000 staffHospitals - Approximately 9,000 staff Fairfield General Hospital, Bury; Fairfield General Hospital, Bury; North Manchester General Hospital; North Manchester General Hospital; Royal Oldham Hospital; Royal Oldham Hospital; Rochdale InfirmaryRochdale Infirmary

Largest NHS OH Service in North WestLargest NHS OH Service in North West Large NHS client base includingLarge NHS client base including

• Acute Trust, Mental HealthTrust's, Primary Care TrustsAcute Trust, Mental HealthTrust's, Primary Care Trusts• North West Deanery – STr screeningNorth West Deanery – STr screening

Large public sector client base includingLarge public sector client base including• Local authoritiesLocal authorities• Police servicesPolice services• EducationEducation

Large private sector client base includingLarge private sector client base including• ManufacturingManufacturing• ChemicalChemical• RetailRetail

Headcount of approx 80,000 employeesHeadcount of approx 80,000 employees Trading name of Trading name of “Mediscreen”“Mediscreen”

OH TeamOH Team 5 Consultant Occupational Physicians- 5 Consultant Occupational Physicians- FFOM – MFOMFFOM – MFOM 1 Locum Speciality Physician1 Locum Speciality Physician- - AFOMAFOM 4 Specialist Registrars 4 Specialist Registrars – 1 – 1 MFOM 2 MFOM(Pt1) 1 VacancyMFOM 2 MFOM(Pt1) 1 Vacancy 1 Specialty Physician 1 Specialty Physician - - AFOMAFOM 1 Practice Development Nurse Manager 1 Practice Development Nurse Manager 2 Clinical Nurse Managers 2 Clinical Nurse Managers 8 Occupational Health Advisors 8 Occupational Health Advisors 2 Occupational Health Technicians2 Occupational Health Technicians 8 Counsellors – 8 Counsellors – BACP accreditedBACP accredited Business Manager Business Manager IT system managerIT system manager Large Secretarial and administration teamLarge Secretarial and administration team

Collecting the EvidenceCollecting the Evidence

What will demonstrate that you are doing it right? What will demonstrate that you are doing it right?

Consider what formats you want to use – does it need to Consider what formats you want to use – does it need to be a policy? Can a flow chart, statement, email etc be a policy? Can a flow chart, statement, email etc provide evidence you need?provide evidence you need?

Policies, Documents and statements needed from IT, Policies, Documents and statements needed from IT, Finance, HR .Finance, HR .

There is a lot of information you could use There is a lot of information you could use

If submitting a large Trust wide policy highlight the If submitting a large Trust wide policy highlight the section which is relevant and you want the assessors to section which is relevant and you want the assessors to focus on.focus on.

Domain A Business Probity Domain A Business Probity A.1 A.1

Link to OH WebsiteLink to OH Website Leaflets & Published materialsLeaflets & Published materials Poster/Information sheet for External Poster/Information sheet for External

ClientsClients Poster/Information sheet for Trust StaffPoster/Information sheet for Trust Staff

To be noted

PC available on day of visit – view webpage

Domain A1.2, 1.3Domain A1.2, 1.3

A1.2A1.2 Conduct & Disciplinary PolicyConduct & Disciplinary Policy HR Recruitment and Selection PolicyHR Recruitment and Selection Policy Conflict of Interest PolicyConflict of Interest Policy Criminal Records Bureau Disclosure PolicyCriminal Records Bureau Disclosure Policy Disciplinary Procedure for Medical StaffDisciplinary Procedure for Medical Staff Recruitment Code of PracticeRecruitment Code of Practice Use of Temporary Staff PolicyUse of Temporary Staff PolicyA1.3A1.3 Handling Concerns about the Performance of the Health Care Handling Concerns about the Performance of the Health Care

ProfessionalProfessional Whistle Blowing – Trust policyWhistle Blowing – Trust policy Whistle Blowing – RCN Whistle Blowing – RCN Referrals to External Service ProvidersReferrals to External Service Providers

To be noted

Mostly Trust Policies

Domain A1.4Domain A1.4

Department Guidance to Research PolicyDepartment Guidance to Research Policy List of ResearchList of Research List of staff undertaking research, title and date. List of staff undertaking research, title and date.

Excel spreadsheetExcel spreadsheet Ethical approval consentEthical approval consent Ethical Guidelines and Trust Research PolicyEthical Guidelines and Trust Research Policy

To be noted

Only if research undertaken

Domain A2.1,2.2Domain A2.1,2.2

2.12.1 Trust Annual Report – last 3 yearsTrust Annual Report – last 3 years Trust Business Case HandbookTrust Business Case Handbook Trust Financial Procedures PolicyTrust Financial Procedures Policy Trust Easy Guide For Managers for Financial GovernanceTrust Easy Guide For Managers for Financial Governance Trust Financial Standing Instructions Trust Financial Standing Instructions Evidence of meetings with Directorate AccountantEvidence of meetings with Directorate Accountant Demonstration of income and expenditure are trackedDemonstration of income and expenditure are tracked

2.22.2 Price List 2011-2012Price List 2011-2012 DOH Revised Guidelines on NHS Plus Income Generation 2006DOH Revised Guidelines on NHS Plus Income Generation 2006 Use of costing modelUse of costing model SLASLA

To be noted

Statement from finance may be needed

Domain B Information Governance Domain B Information Governance B1.1 B1.1

Trust Governance Information Record Keeping and Trust Governance Information Record Keeping and Safeguarding FactsheetSafeguarding Factsheet

Trust Policy Access to Manually Held RecordsTrust Policy Access to Manually Held Records Trust Health Records PolicyTrust Health Records Policy Documentation Keeping Protocol Documentation Keeping Protocol Nursing Records Audit x 2Nursing Records Audit x 2 Occupational Health Record Keeping AuditOccupational Health Record Keeping Audit HSE factsheet – Health Records & Medical HSE factsheet – Health Records & Medical

Confidentiality Confidentiality

To be noted

Trust procedures may not fit with OH service i.e. missing case notes

Domain B1.2,1.3Domain B1.2,1.3

1.21.2 Trust email Policy & PosterTrust email Policy & Poster Guidance for staff – Keep it SafeGuidance for staff – Keep it Safe Trust Information Governance PolicyTrust Information Governance Policy Trust Information Security Advice Trust Information Security Advice IT Continuity Plan for Trust & OHIT Continuity Plan for Trust & OH Training Compliance RegisterTraining Compliance Register

1.31.3 Transfer of OH Notes ProcedureTransfer of OH Notes Procedure Transfer of OH Notes Template letter to staffTransfer of OH Notes Template letter to staff Transfer of OH Notes Template to CompanyTransfer of OH Notes Template to Company Transfer of Records FormTransfer of Records Form Evidence of Confidentiality agreement with 3Evidence of Confidentiality agreement with 3rdrd Party regarding record transfer Party regarding record transfer

To be noted

Statement from IT regarding backup etc

Domain B2.1,2.2Domain B2.1,2.2

2.12.1 Trust & OH Confidentiality PolicyTrust & OH Confidentiality Policy BACP, NMC, RCN, GMC Confidentiality Code of EthicsBACP, NMC, RCN, GMC Confidentiality Code of Ethics Email sent to staff – regarding OH PolicyEmail sent to staff – regarding OH Policy Examples of Signed Confidentiality StatementsExamples of Signed Confidentiality Statements OH Information Governance GuidanceOH Information Governance Guidance Training Compliance RegisterTraining Compliance Register2.22.2 DOH Records ManagementDOH Records Management OH Documentation Record Keeping ProtocolOH Documentation Record Keeping Protocol Register of Key Holders including leaversRegister of Key Holders including leavers

To be noted

National Policies & Guidance are not evidence of compliance

Domain B2.3,2.4Domain B2.3,2.4

2.32.3 Trust Guidance & Information for Staff – Constructing Secure Trust Guidance & Information for Staff – Constructing Secure

PasswordsPasswords OH Procedure for emailing Confidential MatterOH Procedure for emailing Confidential Matter Records of Old Computers Disposal within Last 12 months – Data Records of Old Computers Disposal within Last 12 months – Data

RemovedRemoved Data Protection PolicyData Protection Policy

2.42.4 Example of Form of Undertaking – Intellectual Property Rights Example of Form of Undertaking – Intellectual Property Rights Signed Contract Incorporating Intellectual Property RightsSigned Contract Incorporating Intellectual Property Rights

To be noted

Statement from IT regarding disposal of computers

Domain C PeopleDomain C People1.1,1.2 1.1,1.2

1.11.1 Excel Spreadsheet of Professional Expiry DatesExcel Spreadsheet of Professional Expiry Dates Statement from Lead Consultant regarding ComplianceStatement from Lead Consultant regarding Compliance Example of email Sent to Staff Member Example of email Sent to Staff Member Trust Professional Registration PolicyTrust Professional Registration Policy

1.21.2 Examples of Job DescriptionsExamples of Job Descriptions KSF Outlines KSF Outlines Clinical Protocol Training RecordsClinical Protocol Training Records Competency FrameworksCompetency Frameworks List of Staff and QualificationsList of Staff and Qualifications

To be noted

Statements, emails and ESR used as evidence

Domain C1.3,1.4Domain C1.3,1.4

1.31.3 Statement from Lead Consultant Regarding CPDStatement from Lead Consultant Regarding CPD CPD GuidanceCPD Guidance CPD Form CPD Form ESR Monitoring FormESR Monitoring Form Sample PDR FormSample PDR Form Trust Study Leave PolicyTrust Study Leave Policy Mediscreen Prospectus for STR’sMediscreen Prospectus for STR’s

1.4 1.4 Trust Guidance on PDR & KSFTrust Guidance on PDR & KSF 2010 PDR Register2010 PDR Register ESR Monitoring FormESR Monitoring Form PDR FormsPDR Forms Personal Checklist – Prior to PDRPersonal Checklist – Prior to PDR Example of PDR - AnonymisedExample of PDR - Anonymised

To be noted

Completed CPD & PDR forms requested for inspection on the visit

Domain C1.5, 2.1,2.2,2.3Domain C1.5, 2.1,2.2,2.3

1.51.5 Local Induction Checklist & Record of CompletionLocal Induction Checklist & Record of Completion Use of Temporary Staff policyUse of Temporary Staff policy Corporate Induction ManualCorporate Induction Manual Trust Recruitment Code of PracticeTrust Recruitment Code of Practice OH Confidentiality Policy & Signed StatementsOH Confidentiality Policy & Signed Statements Junior Doctors Induction ChecklistJunior Doctors Induction Checklist

2.12.1 Organisation ChartOrganisation Chart Staff ProfilesStaff Profiles Names & Qualifications of StaffNames & Qualifications of Staff

2.22.2 Example of Professional IndemnityExample of Professional Indemnity Trust Insurance - NHSLATrust Insurance - NHSLA

2.32.3 Organisational ChartOrganisational Chart

To be noted

Completed induction sheet and signed Confidentiality Statement requested at visit

Domain C2.4,2.5Domain C2.4,2.5

2.42.4 Audit Reports – Governance, Data Protection, Pre-Employment ScreeningAudit Reports – Governance, Data Protection, Pre-Employment Screening Nurse ProtocolsNurse Protocols OH Protocols & PoliciesOH Protocols & Policies Competency WorkbooksCompetency Workbooks Training RecordsTraining Records Example of Audit FormsExample of Audit Forms

2.5 2.5 Trust Conduct & Disciplinary GuidelinesTrust Conduct & Disciplinary Guidelines Trust Whistle Blowing policyTrust Whistle Blowing policy Trust Capability PolicyTrust Capability Policy Trust & OH Complaints PolicyTrust & OH Complaints Policy OH Complaints LeafletOH Complaints Leaflet

To be noted

Ensure training records available and are up to date.

Consider how to demonstrate that nurses are competent

Domain D Facilities & Equipment Domain D Facilities & Equipment D1.1,1.2D1.1,1.2

1.11.1 Trust Risk Management PolicyTrust Risk Management Policy Trust Risk Assessment Guidance Trust Risk Assessment Guidance OH Risk AssessmentsOH Risk Assessments Trust Major Incident Plan ,Flu Pandemic PlanTrust Major Incident Plan ,Flu Pandemic Plan Trust Lone Working Policy Trust Lone Working Policy Example of External OH Information including Risk AssessmentExample of External OH Information including Risk Assessment

1.2 1.2 Trust Equality & Diversity Annual ReportTrust Equality & Diversity Annual Report Trust Equality & Diversity PolicyTrust Equality & Diversity Policy Example of OH Policy with Equality Impact Assessment.Example of OH Policy with Equality Impact Assessment. Work Health Assessment Form – Statement highlightedWork Health Assessment Form – Statement highlighted Department Information Department Information Disability Assessment of Accommodation (if available)Disability Assessment of Accommodation (if available)

To be noted

If multiple sites, photographs may be useful

Equality Impact Assessment statement used from OH Policy

Domain D1.3,1.4,1.5, 2.1,2.2Domain D1.3,1.4,1.5, 2.1,2.2

1.3 & 1.4 – Assessed at Accreditation1.3 & 1.4 – Assessed at Accreditation

1.51.5 Rooms checked at visitRooms checked at visit Hand Hygiene PolicyHand Hygiene Policy

2.12.1 Medical Equipment LogMedical Equipment Log

2.22.2 Trust Medical Equipment & Devices PolicyTrust Medical Equipment & Devices Policy Calibration ReportsCalibration Reports Example of Maintenance Payment Confirmation Example of Maintenance Payment Confirmation

To be noted

Physical check of rooms, calibration reports made available. Dates checked on Equipment. Ensure Pat testing up to date.

Domain D2.3,3.1Domain D2.3,3.1

2.32.3 OH Cold Chain Policy – Vaccine StorageOH Cold Chain Policy – Vaccine Storage Fridge Recording SheetFridge Recording Sheet Pharmacy Notification SheetsPharmacy Notification Sheets Vaccine Tracking FormVaccine Tracking Form

3.13.1 Trust Medicine Management PolicyTrust Medicine Management Policy Signed PGD’sSigned PGD’s PSDPSD Consent FormsConsent Forms Vaccine Tracking FormVaccine Tracking Form Pharmacy Ordering ProcedurePharmacy Ordering Procedure

To be noted

Physical check of drug fridge. Recording sheets for cold chain etc checked at visit

Domain D3.2, 3.3,3.4Domain D3.2, 3.3,3.4

3.23.2 Drug ProtocolsDrug Protocols Competency Sign off RecordsCompetency Sign off Records Records of TrainingRecords of Training Local Audit Local Audit

3.33.3 Anaphylaxis Flow Chart Anaphylaxis Flow Chart PGD – AdrenalinePGD – Adrenaline Emergency Equipment ListEmergency Equipment List ILS Training RecordsILS Training Records

3.43.4 PGD’sPGD’s Vaccine Storage ProtocolVaccine Storage Protocol Trust Medicines Management PolicyTrust Medicines Management Policy

To be noted

Examples of completed signed off PGD’s competency documents requested

To be noted

Physical check of crash equipment undertaken on visit

Risk assessment to identify procedure and equipment

Domain E Relationship with Domain E Relationship with PurchasersPurchasers

E1.1, 1.2, 1.3, 1.4,2.1E1.1, 1.2, 1.3, 1.4,2.1

1.1, 1.2 & 1.3 – Assessed by Customer Questionnaire1.1, 1.2 & 1.3 – Assessed by Customer Questionnaire

1.41.4 Fact Sheet on Referrals to OH Fact Sheet on Referrals to OH Fact Sheet for Managers on Role of Case ConferencesFact Sheet for Managers on Role of Case Conferences SLA’s / Policies– Which Include Information Regarding RiddorSLA’s / Policies– Which Include Information Regarding Riddor

2.1 - Assessed by Customer Questionnaire2.1 - Assessed by Customer Questionnaire

To be noted

Customer questionnaire by Survey Monkey

Domain E2.2, 2.3,2.4Domain E2.2, 2.3,2.4

2.22.2 KPI’sKPI’s SLA SLA Performance ReportsPerformance Reports

2.32.3 Workplace Risk AssessmentsWorkplace Risk Assessments Workplace Visits FeedbackWorkplace Visits Feedback Workplace Meeting RecordsWorkplace Meeting Records

2.4 Assessed by Customer Questionnaire2.4 Assessed by Customer Questionnaire

Domain F - Relationship with Domain F - Relationship with PurchasersPurchasers

F1.1,1.2 F1.1,1.21.11.1 Work Health Assessment FormWork Health Assessment Form OH Access to Medical RecordsOH Access to Medical Records Link to Web SiteLink to Web Site Leaflet for Trust & External CompaniesLeaflet for Trust & External Companies Copies of Leaflets Defining Workers RightsCopies of Leaflets Defining Workers Rights Minutes of Health & Safety MeetingsMinutes of Health & Safety Meetings Consent to Release Report to ManagerConsent to Release Report to Manager

1.21.2 Trust Absence Management policyTrust Absence Management policy Consent for Release to EmployerConsent for Release to Employer OH Service LeafletOH Service Leaflet Protocols for Health ConsultationsProtocols for Health Consultations Consent FormsConsent Forms

To be noted

Include any documents that refer to how personal health information is used etc.

Domain F1.3,1.4,2.1,2.2Domain F1.3,1.4,2.1,2.21.31.3 Leaflet on Functions of OH & ServiceLeaflet on Functions of OH & Service Health Surveillance Information SheetHealth Surveillance Information Sheet Leaflets on InterventionsLeaflets on Interventions

1.41.4 Trust Equal Opportunities PolicyTrust Equal Opportunities Policy Equality Impact Assessment GuidelinesEquality Impact Assessment Guidelines

2.12.1 OH Complaints Policy & LeafletOH Complaints Policy & Leaflet Patient Survey LetterPatient Survey Letter Patient Survey Questionnaire & ResultsPatient Survey Questionnaire & Results Complaints/Compliment RegisterComplaints/Compliment Register

2.22.2 Information for Customers LeafletInformation for Customers Leaflet Health & Safety Committee & Infection Control Committee Minutes MeetingsHealth & Safety Committee & Infection Control Committee Minutes Meetings Health & Well Being Minutes MeetingsHealth & Well Being Minutes Meetings User Survey ResultsUser Survey Results

Domain G NHS StandardsDomain G NHS StandardsG1.1G1.1

Absence Management Policy Absence Management Policy Leaflets – Counselling, Physiotherapy etcLeaflets – Counselling, Physiotherapy etc Training Presentations – HAVS, Stress, FluTraining Presentations – HAVS, Stress, Flu Health & Well Being Strategy & Meeting MinutesHealth & Well Being Strategy & Meeting Minutes KPI Service Standards KPI Service Standards Website LinkWebsite Link Role of OH InformationRole of OH Information SLA including services declinedSLA including services declined

To be noted

Some duplication of information

Highlight on Policies relevant section

Domain G1.2,2.1,2.2Domain G1.2,2.1,2.2

1.21.2 Template Customer SLATemplate Customer SLA Minutes of Meetings Minutes of Meetings

2.12.1 Costing Model LicenseCosting Model License SLA’sSLA’s Annual ReviewAnnual Review

2.22.2 Business Plan for 5 YearsBusiness Plan for 5 Years OH ObjectivesOH Objectives Reconfiguration MeetingsReconfiguration Meetings

To be noted

Evidence may be needed from Finance regarding costing model

Domain G3.1,3.2,4.1Domain G3.1,3.2,4.1

3.13.1 KPI’sKPI’s Performance ReportsPerformance Reports SLASLA

3.23.2 Performance ReportsPerformance Reports SLASLA

4.1 4.1 Audit ReportsAudit Reports Evidence of National Audit – Report and RecommendationsEvidence of National Audit – Report and Recommendations Records of Two clinical Audits Per Year & RecommendationsRecords of Two clinical Audits Per Year & Recommendations

To be noted

What is host Trust does not want an SLA in place?

Last Minute PreparationsLast Minute Preparations Tidy up of DepartmentTidy up of Department Final staff briefing reminding where policies, Final staff briefing reminding where policies,

documents etc could be found documents etc could be found Nurses requested to have portfolio of evidence Nurses requested to have portfolio of evidence

available on the day- training records etcavailable on the day- training records etc Check all forms/leaflets are up to date in all areasCheck all forms/leaflets are up to date in all areas Catering and parking arranged, directions sentCatering and parking arranged, directions sent Networked laptop and projector set up in quiet Networked laptop and projector set up in quiet

room for Assessors useroom for Assessors use Hard copies of evidence and selected personal Hard copies of evidence and selected personal

files, training records etc ready for inspectionfiles, training records etc ready for inspection

Key Learning PointsKey Learning PointsDon’t Don’t under-estimateunder-estimate the time you need to prepare and complete the the time you need to prepare and complete the accreditation processaccreditation process

Involve everyone, Share the workInvolve everyone, Share the work

Upload as much information as possibleUpload as much information as possible

If evidence needed in more than one Domain upload into it both If evidence needed in more than one Domain upload into it both

To save time zip files when uploading informationTo save time zip files when uploading information

When replying to assessors pre-visit questions check replies together, keep When replying to assessors pre-visit questions check replies together, keep emails for day of visitemails for day of visit

Ensure that on day of visit that relevant people involved Ensure that on day of visit that relevant people involved

Continue to build on current standards and improve themContinue to build on current standards and improve them

Keep staff informed – its their accreditation to!Keep staff informed – its their accreditation to!

CelebrateCelebrate

Any questions?Any questions?