Purpose

1. North Staffordshire Combined Healthcare NHS TrustApplication for Registration under the Health & Social Care Act 2008Presentation to the Trust Board 28 January 2010

2. Purpose • To build on the presentation to the Trust Board in October 2009 • To support Members to reach a decision regarding the application to the Care Quality Commission • To supplement the paper presented by providing current information and the full outcome of the self assessment process

3. Application for Registration2009-10 Timetable • Audit Committee 15 January 2010 • Q&G Committee 19 January 2010 • Trust Board 28 January 2010 • Application Before midday on 29 January 2010 • CQC Assessment From 29 January to 31 March 2010 • Once the application is assessed, the CQC has three options: • Register without conditions • Register with conditions • Refuse all or part of the registration • The organisation will then be issued with either: • A Notice of Decision – if the application is approved • A Notice of Proposal – if the application is refused

4. Recommendations • Recommendation 1: Review progress to date and the key actions still to be delivered as identified in the Project Plan • All key stages achieved – note the following: • CRB for Chief Executive • Documented Service / Trust Profile • Evidence • Recommendation 2: Delegate responsibility to the Q&G Committee to finalise the narrative Trust Profile • Recommendation 3: Review and approve the Self Assessment Methodology – Attached at Appendix C

5. Self Assessment Methodology App C – Section 4 • Undertake a high level self assessment: • Quality and Risk Profile (QARP) provided by the CQC • Standards for Better Health 2009/10 self assessment • Assurance Framework • Performance and Quality Management Framework (PQMF) • Divisional / location level self assessments; • Key External Assurance (eg Internal Audit; Patient Survey; Staff Survey etc) • In addition to the above: • Each outcome area has been reviewed by a nominated operational lead • Each outcome area has a nominated director(s) who has reviewed the findings • Collective review by the Executive Team (including Clinical Directors)

6. Recommendations • Recommendation 4: Note the 7 risks identified by the Care Quality Commission • All responded to by lead directors • Trust response / information accepted by the Care Quality Commission • Recommendation 5: Note the outcome of the self-assessment process and receive a position statement on the day of the meeting in relation to Outcome 4 and Outcome 9

7. Outcome of the Self Assessment Process • 1:Mod / Sig Respecting and Involving people who use services • 2: ModConsent to care and treatment • 4: Mod / Sig Care and welfare of people who use services • 5: LowMeeting nutritional needs • 6: Mod / SigCooperating with others • 7: ModSafeguarding people who use services from abuse • 8: ModCleanliness and infection control • 9: ModManagement of medicines • 10: LowSafety and suitability of premises • 11: ModSafety, availability & suitability of equipment • 12: ModRequirements relating to workers • 13: LowStaffing • 14: Mod / SigSupporting workers • 15: WIPStatement of purpose • 16: LowAssessing and monitoring the quality of service provision • 17: LowComplaints • 21: LowRecords

8. Recommendations • Recommendation 6: Review the completed application form at Appendix D, and the outcome of the assessment in relation to Outcome 4 and 9 and give approval for the contents to be submitted to the CQC • To declare compliance with all outcomes / regulations • Recommendation 7: Delegate responsibility to the Trust’s Chief Executive to review, approve and submit the completed application and to sign the final version on behalf of the Trust Board

9. Thank you.Any questions?