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Standards for Better Health – update for Overview & Scrutiny Committee

Standards for Better Health – update for Overview & Scrutiny Committee. Jacqui Evans Clinical Governance Manager 22 February 2006. HCC standards for better health interim (draft) declaration. Draft declaration. Thank you for your comments

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Standards for Better Health – update for Overview & Scrutiny Committee

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  1. Standards for Better Health – update for Overview & Scrutiny Committee Jacqui Evans Clinical Governance Manager 22 February 2006

  2. HCC standards for better healthinterim (draft) declaration

  3. Draft declaration • Thank you for your comments • Also received favourable comments from the PPI Forum and the SHA • Action planning based upon comments in the declaration • We have not been chosen for an inspection by the HCC

  4. Decontamination (C4c) Units have centralised during 4/5 February Further building of office space Fully operational before end of March 2006 External validation booked for April 2006 Draft declaration – not met Should be fully compliant by 31 March 2006

  5. Patient safety notices (C1b) Child protection (C2) Infection control (C4a) Medical devices (C4b) NICE compliance (C5a) Records management (C9) Dignity and respect (C13a) Consent (C13b) Confidentiality (C13c) Patient information (C16) Environment/H&S (C20a) Privacy and confidentiality (C20b) Cleanliness (C21) Draft declaration – insufficient compliance

  6. Interim action plan • Leads for each item of insufficient / non compliance • Action over last few months to implement action plan • Progress reported to Trust Board Assurance Committee • Progress reported to SHA • Good progress on all items

  7. Specific issues • Cleanliness (C21) – insufficient assurance • Infection control (C4a) – insufficient compliance • Discharge arrangements (C6)

  8. Specific issues - cleanliness • No specific external validation • New contract in 2005 • Scheduled ‘technical’ audits by contractors • Scheduled ‘managerial’ audits by dedicated monitoring officers • Comparison of results discussed at penalty group meeting • Complaints decreased to 2-3 per month • Pre-PEAT assessment (30/1 & 3/2) led by nurses and inc patient representative • PEAT (environment rather than cleanliness)

  9. Specific issues – infection control • Trust Infection Control Committee with DIPC • Reporting to the Board (outcomes & actions) • IC annual programme (inc. Winning Ways) • Range of policies approved by DIPC • Care bundles (Saving Lives, 2005) • Audits – handwashing, environmental, commodes • Range of education opportunities – induction, link programme, doctors • Serious outbreaks - C. Difficile (Jan 06) • Surveillance (weekly) on C. Diff, MRSA, VRE • MRSA (national target) – hand hygiene & IV lines

  10. Specific issues – discharge arrangements • Range of multi-agency meetings • Discharge facilitators group • Quadrant strategy meetings • Countywide delayed transfer meetings • Discharge Policy (Feb 05) – multi-agency • Expanded team of discharge co-ordinators • Current focus on planning & discharge dates • Programme of audits • Integrated care pathways - • Single assessment process (eSAP) rollout continues

  11. Summary • Good progress in all areas of insufficient or non compliance • End of year position improved • Greater understanding of the Standards by the organisation

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