SEQOHS Accreditation - 27 July 2011

1. SEQOHS Accreditation - 27 July 2011 Halina Greer Practice Development Manager NHS Plus Quality Strategy Facilitator – North West

2. The Pennine Acute Hospitals Trust • North-East sector of Greater Manchester • Serves the communities of North Manchester, Bury, Rochdale and Oldham, • Hospitals - Approximately 9,000 staff • Fairfield General Hospital, Bury; • North Manchester General Hospital; • Royal Oldham Hospital; • Rochdale Infirmary • Largest NHS OH Service in North West • Large NHS client base including • Acute Trust, Mental HealthTrust's, Primary Care Trusts • North West Deanery – STr screening • Large public sector client base including • Local authorities • Police services • Education • Large private sector client base including • Manufacturing • Chemical • Retail • Headcount of approx 80,000 employees • Trading name of “Mediscreen”

3. OH Team • 5 Consultant Occupational Physicians- FFOM – MFOM • 1 Locum Speciality Physician- AFOM • 4 Specialist Registrars – 1 MFOM 2 MFOM(Pt1) 1 Vacancy • 1 Specialty Physician - AFOM • 1 Practice Development Nurse Manager • 2 Clinical Nurse Managers • 8 Occupational Health Advisors • 2 Occupational Health Technicians • 8 Counsellors – BACP accredited • Business Manager • IT system manager • Large Secretarial and administration team

4. Collecting the Evidence • What will demonstrate that you are doing it right? • Consider what formats you want to use – does it need to be a policy? Can a flow chart, statement, email etc provide evidence you need? • Policies, Documents and statements needed from IT, Finance, HR . • There is a lot of information you could use • If submitting a large Trust wide policy highlight the section which is relevant and you want the assessors to focus on.

5. Domain A Business Probity A.1 • Link to OH Website • Leaflets & Published materials • Poster/Information sheet for External Clients • Poster/Information sheet for Trust Staff To be noted PC available on day of visit – view webpage

6. Domain A1.2, 1.3 To be noted Mostly Trust Policies A1.2 • Conduct & Disciplinary Policy • HR Recruitment and Selection Policy • Conflict of Interest Policy • Criminal Records Bureau Disclosure Policy • Disciplinary Procedure for Medical Staff • Recruitment Code of Practice • Use of Temporary Staff Policy A1.3 • Handling Concerns about the Performance of the Health Care Professional • Whistle Blowing – Trust policy • Whistle Blowing – RCN • Referrals to External Service Providers

7. Domain A1.4 To be noted Only if research undertaken • Department Guidance to Research Policy • List of Research • List of staff undertaking research, title and date. Excel spreadsheet • Ethical approval consent • Ethical Guidelines and Trust Research Policy

8. Domain A2.1,2.2 To be noted Statement from finance may be needed 2.1 • Trust Annual Report – last 3 years • Trust Business Case Handbook • Trust Financial Procedures Policy • Trust Easy Guide For Managers for Financial Governance • Trust Financial Standing Instructions • Evidence of meetings with Directorate Accountant • Demonstration of income and expenditure are tracked 2.2 • Price List 2011-2012 • DOH Revised Guidelines on NHS Plus Income Generation 2006 • Use of costing model • SLA

9. Domain B Information Governance B1.1 To be noted Trust procedures may not fit with OH service i.e. missing case notes • Trust Governance Information Record Keeping and Safeguarding Factsheet • Trust Policy Access to Manually Held Records • Trust Health Records Policy • Documentation Keeping Protocol • Nursing Records Audit x 2 • Occupational Health Record Keeping Audit • HSE factsheet – Health Records & Medical Confidentiality

10. Domain B1.2,1.3 To be noted Statement from IT regarding backup etc 1.2 • Trust email Policy & Poster • Guidance for staff – Keep it Safe • Trust Information Governance Policy • Trust Information Security Advice • IT Continuity Plan for Trust & OH • Training Compliance Register 1.3 • Transfer of OH Notes Procedure • Transfer of OH Notes Template letter to staff • Transfer of OH Notes Template to Company • Transfer of Records Form • Evidence of Confidentiality agreement with 3rd Party regarding record transfer

11. Domain B2.1,2.2 To be noted National Policies & Guidance are not evidence of compliance 2.1 • Trust & OH Confidentiality Policy • BACP, NMC, RCN, GMC Confidentiality Code of Ethics • Email sent to staff – regarding OH Policy • Examples of Signed Confidentiality Statements • OH Information Governance Guidance • Training Compliance Register 2.2 • DOH Records Management • OH Documentation Record Keeping Protocol • Register of Key Holders including leavers

12. Domain B2.3,2.4 To be noted Statement from IT regarding disposal of computers 2.3 • Trust Guidance & Information for Staff – Constructing Secure Passwords • OH Procedure for emailing Confidential Matter • Records of Old Computers Disposal within Last 12 months – Data Removed • Data Protection Policy 2.4 • Example of Form of Undertaking – Intellectual Property Rights • Signed Contract Incorporating Intellectual Property Rights

13. Domain C People1.1,1.2 To be noted Statements, emails and ESR used as evidence 1.1 • Excel Spreadsheet of Professional Expiry Dates • Statement from Lead Consultant regarding Compliance • Example of email Sent to Staff Member • Trust Professional Registration Policy 1.2 • Examples of Job Descriptions • KSF Outlines • Clinical Protocol Training Records • Competency Frameworks • List of Staff and Qualifications

14. Domain C1.3,1.4 To be noted Completed CPD & PDR forms requested for inspection on the visit 1.3 • Statement from Lead Consultant Regarding CPD • CPD Guidance • CPD Form • ESR Monitoring Form • Sample PDR Form • Trust Study Leave Policy • Mediscreen Prospectus for STR’s 1.4 • Trust Guidance on PDR & KSF • 2010 PDR Register • ESR Monitoring Form • PDR Forms • Personal Checklist – Prior to PDR • Example of PDR - Anonymised

15. Domain C1.5, 2.1,2.2,2.3 To be noted Completed induction sheet and signed Confidentiality Statement requested at visit 1.5 • Local Induction Checklist & Record of Completion • Use of Temporary Staff policy • Corporate Induction Manual • Trust Recruitment Code of Practice • OH Confidentiality Policy & Signed Statements • Junior Doctors Induction Checklist 2.1 • Organisation Chart • Staff Profiles • Names & Qualifications of Staff 2.2 • Example of Professional Indemnity • Trust Insurance - NHSLA 2.3 • Organisational Chart

16. Domain C2.4,2.5 To be noted Ensure training records available and are up to date. Consider how to demonstrate that nurses are competent 2.4 • Audit Reports – Governance, Data Protection, Pre-Employment Screening • Nurse Protocols • OH Protocols & Policies • Competency Workbooks • Training Records • Example of Audit Forms 2.5 • Trust Conduct & Disciplinary Guidelines • Trust Whistle Blowing policy • Trust Capability Policy • Trust & OH Complaints Policy • OH Complaints Leaflet

17. Domain D Facilities & Equipment D1.1,1.2 To be noted If multiple sites, photographs may be useful Equality Impact Assessment statement used from OH Policy 1.1 • Trust Risk Management Policy • Trust Risk Assessment Guidance • OH Risk Assessments • Trust Major Incident Plan ,Flu Pandemic Plan • Trust Lone Working Policy • Example of External OH Information including Risk Assessment 1.2 • Trust Equality & Diversity Annual Report • Trust Equality & Diversity Policy • Example of OH Policy with Equality Impact Assessment. • Work Health Assessment Form – Statement highlighted • Department Information • Disability Assessment of Accommodation (if available)

18. Domain D1.3,1.4,1.5, 2.1,2.2 To be noted Physical check of rooms, calibration reports made available. Dates checked on Equipment. Ensure Pat testing up to date. 1.3 & 1.4 – Assessed at Accreditation 1.5 • Rooms checked at visit • Hand Hygiene Policy 2.1 • Medical Equipment Log 2.2 • Trust Medical Equipment & Devices Policy • Calibration Reports • Example of Maintenance Payment Confirmation

19. Domain D2.3,3.1 To be noted Physical check of drug fridge. Recording sheets for cold chain etc checked at visit 2.3 • OH Cold Chain Policy – Vaccine Storage • Fridge Recording Sheet • Pharmacy Notification Sheets • Vaccine Tracking Form 3.1 • Trust Medicine Management Policy • Signed PGD’s • PSD • Consent Forms • Vaccine Tracking Form • Pharmacy Ordering Procedure

20. Domain D3.2, 3.3,3.4 To be noted Examples of completed signed off PGD’s competency documents requested 3.2 • Drug Protocols • Competency Sign off Records • Records of Training • Local Audit 3.3 • Anaphylaxis Flow Chart • PGD – Adrenaline • Emergency Equipment List • ILS Training Records 3.4 • PGD’s • Vaccine Storage Protocol • Trust Medicines Management Policy To be noted Physical check of crash equipment undertaken on visit Risk assessment to identify procedure and equipment

21. Domain E Relationship with PurchasersE1.1, 1.2, 1.3, 1.4,2.1 1.1, 1.2 & 1.3 – Assessed by Customer Questionnaire 1.4 • Fact Sheet on Referrals to OH • Fact Sheet for Managers on Role of Case Conferences • SLA’s / Policies– Which Include Information Regarding Riddor 2.1 - Assessed by Customer Questionnaire To be noted Customer questionnaire by Survey Monkey

22. Domain E2.2, 2.3,2.4 2.2 • KPI’s • SLA • Performance Reports 2.3 • Workplace Risk Assessments • Workplace Visits Feedback • Workplace Meeting Records 2.4 Assessed by Customer Questionnaire

23. Domain F - Relationship with Purchasers F1.1,1.2 1.1 • Work Health Assessment Form • OH Access to Medical Records • Link to Web Site • Leaflet for Trust & External Companies • Copies of Leaflets Defining Workers Rights • Minutes of Health & Safety Meetings • Consent to Release Report to Manager 1.2 • Trust Absence Management policy • Consent for Release to Employer • OH Service Leaflet • Protocols for Health Consultations • Consent Forms To be noted Include any documents that refer to how personal health information is used etc.

24. Domain F1.3,1.4,2.1,2.2 1.3 • Leaflet on Functions of OH & Service • Health Surveillance Information Sheet • Leaflets on Interventions 1.4 • Trust Equal Opportunities Policy • Equality Impact Assessment Guidelines 2.1 • OH Complaints Policy & Leaflet • Patient Survey Letter • Patient Survey Questionnaire & Results • Complaints/Compliment Register 2.2 • Information for Customers Leaflet • Health & Safety Committee & Infection Control Committee Minutes Meetings • Health & Well Being Minutes Meetings • User Survey Results

25. Domain G NHS StandardsG1.1 • Absence Management Policy • Leaflets – Counselling, Physiotherapy etc • Training Presentations – HAVS, Stress, Flu • Health & Well Being Strategy & Meeting Minutes • KPI Service Standards • Website Link • Role of OH Information • SLA including services declined To be noted Some duplication of information Highlight on Policies relevant section

26. Domain G1.2,2.1,2.2 To be noted Evidence may be needed from Finance regarding costing model 1.2 • Template Customer SLA • Minutes of Meetings 2.1 • Costing Model License • SLA’s • Annual Review 2.2 • Business Plan for 5 Years • OH Objectives • Reconfiguration Meetings

27. Domain G3.1,3.2,4.1 3.1 • KPI’s • Performance Reports • SLA 3.2 • Performance Reports • SLA 4.1 • Audit Reports • Evidence of National Audit – Report and Recommendations • Records of Two clinical Audits Per Year & Recommendations To be noted What is host Trust does not want an SLA in place?

28. Last Minute Preparations • Tidy up of Department • Final staff briefing reminding where policies, documents etc could be found • Nurses requested to have portfolio of evidence available on the day- training records etc • Check all forms/leaflets are up to date in all areas • Catering and parking arranged, directions sent • Networked laptop and projector set up in quiet room for Assessors use • Hard copies of evidence and selected personal files, training records etc ready for inspection

29. Key Learning Points Don’t under-estimate the time you need to prepare and complete the accreditation process Involve everyone, Share the work Upload as much information as possible If evidence needed in more than one Domain upload into it both To save time zip files when uploading information When replying to assessors pre-visit questions check replies together, keep emails for day of visit Ensure that on day of visit that relevant people involved Continue to build on current standards and improve them Keep staff informed – its their accreditation to! Celebrate

30. Any questions?