West Hertfordshire Hospitals NHS Trust Item 4 3

West Hertfordshire Hospitals NHS Trust Item 4. 3 DRAFT CORE & DEVELOPMENTAL STANDARDS DECLARATION – 2007/8 GRAHAM RAMSAY MEDICAL DIRECTOR / PATIENT SAFETY DIRECTOR

West Hertfordshire Hospitals NHS Trust CONTEXT – STANDARDS FOR BETTER HEALTH (S 4 BH) • S 4 BH Published by Do. H in July 2004 • Seven Domains • Two Types of Standards - Core & Development • 2007/8 - 42/44 Core Standards (end of year) Compliant

West Hertfordshire Hospitals NHS Trust Hygiene Code • Benchmarking against Hygiene Code (11 Duties) • Action plan • Significant reduction in C. Diff

MANAGEMENT PROCESS & MONITORING West Hertfordshire Hospitals NHS Trust • Overall Executive Lead – Medical Director • Domains Allocated to Executive Directors and Non-Executive Directors • Individual Standards Delegated to Operational Leads • S 4 BH Domain Action Plans Developed • Monthly Monitoring Meetings • Datix Utilised to Store Evidence

West Hertfordshire Hospitals NHS Trust COMPLIANCE 2007/8 • Core Standards : 2005/06 (30/44) 2006/07 (40/44) 2007/8 /43 3 Standards declared as ‘Not Met’ for full year 5 Standards achieving end of year compliance • • • Non-compliant for C 4 c (decontamination), C 20 b (mixed sex accommodation) and C 23 Public Health • • Developmental Standards D 1 - Good Developmental Progress D 2 a - Fair Progress

West Hertfordshire Hospitals NHS Trust CHALLENGES AHEAD TO ENSURE COMPLIANCE • C 4 c – Decontamination Need to drive forward work with our partners in the Confederation to provide regional decontamination services and ensure we meet compliance with all statutory regulations on locally led decontamination • C 20 b – Mixed sex accommodation Current focus must be on patient safety • C 23 – Public Health Strategy in place, work programme to be take forward and monitored by Trust & PCT Public Health Forum • D 1 - Detailed Review 7 Steps to Pt Safety • D 2 a - Ensure Full Compliance with Identified NSF’s and NICE Guidance

West Hertfordshire Hospitals NHS Trust Assurance for 2008/9 • Quarterly Board Reports for all Domains • Non-compliant action plans to be fed up to the Trust Board • Greater engagement with Nonexecutive Directors

West Hertfordshire Hospitals NHS Trust

West Hertfordshire Hospitals NHS Trust C 6: Multi-disciplinary Working • MDT Coordinators for Cancer and Acute Medicine • Bed management and Discharge planning team • Lead Nurse and Clinician for Child Protection • Lead Nurse for Care of Vulnerable Adults

West Hertfordshire Hospitals NHS Trust C 13 a: Dignity and Respect • Bi-annual Trust Privacy & Dignity Audits • National Inpatient Surveys • Reports to the Trust Board

West Hertfordshire Hospitals NHS Trust C 13 b: Ensuring appropriate consent is obtained • Consent to Treatment Policy based on Do. H Model • Policy for Production of Patient Information Policy/Database • Regularly review consent related incidents and complaints • Post Mortem Policy

West Hertfordshire Hospitals NHS Trust C 13 c: Ensuring Patient Confidentiality • Data Protection Policy / Audits / Training • Health Records Policy • Safe Haven Policy • Information Security Policy • Caldicott Guardian

West Hertfordshire Hospitals NHS Trust C 17: Seeking views of patients and others • Patients Panel • Patient & Public Involvement Forum • i. HUGS • Patient Involvement and Experience Strategy • Patient Feedback System

West Hertfordshire Hospitals NHS Trust C 18: Access to Services • Equalities Framework • Interpreting and Translation Services • Choose & Book • Voluntary Transport Scheme

West Hertfordshire Hospitals NHS Trust C 23: Working in Partnership • Partnership Matrix • Health & Social Care Partnerships (access to LSPs) • Crime & Disorder Partnership • Trust Public Health Forum