governing council – july 2008 ref: 08/07/7 patients ...learning from patients’ comments and...

GOVERNING COUNCIL – JULY 2008

REF: 08/07/7

I:\Governing Council\Meetings\2008\18 Jun 08\7_Chief Nurse(a).doc

7

PATIENTS SERVICES AND EQUALITY – OVERVIEW

1. INTRODUCTION The Trust continues to develop a pro-active approach to improving services for its patients. The enclosed reports highlight some of the routes currently available to us to do so – eg by learning from patients’ comments and complaints, taking part in national surveys, initiating local surveys, and working with partners across the community, etc. The following reports have all been presented to, and discussed with, the Trust’s Governance Committee and the Board of Directors. I appreciate the opportunity to present them to the Governing Council and, through yourselves, issue them more widely into the public domain. It is extremely regrettable that, due to other diary commitments, I am unable to attend the Governing Council’s general meeting in July and I would ask you to accept my sincere apologies for this. If agreeable to the Governing Council, however, I would be pleased to attend the next Access & Patient Interface sub-group (which I understand is currently scheduled for 28th July), to expand on the reports, to highlight key issues arising from the reports and to respond to any queries or comments that you would like to explore further.

2. REPORTS 2.1 Patient Surveys

The outcomes and action plans relating to two patient surveys – outpatients and inpatients – were presented to the Board of Directors in June 2008. The report on inpatients was part of a national survey conducted recently; the survey on outpatients was commissioned by the Trust to provide a current position as the last survey had been conducted in 2004.

Based on the surveys’ findings, a number of actions have been identified to further improve our services to in- and outpatients. The Board supported the proposed action plans and requested progress to be reported to them on a quarterly basis.

2.2 Annual Complaints A summary version of the report presented to the Complaints Review Group, the Governance Committee and the Board of Directors is enclosed. The Board was asked to review and support the report, issues from which are progressed via the Governance Committee throughout the year as and when they arise.

Representatives of the Governing Council have a standing invitation to attend the Complaints Review Group and Governance Committee; Governor comments at these meetings are welcomed. A full copy of the report has been provided to the governors under separate cover as usual.

2.3 Safeguarding Adults and Children These two (separate) reports were presented to the Board of Directors in late May. They highlight the Trust’s commitment to ensuring the safety of vulnerable patients as a key aspect of its work and emphasise the value of multi-agency partnership working.

As can be seen from the enclosed reports, both documents were accompanied by a range of appendices. Rather than inundate the Governing Council with paperwork, copies of the appendices are available on request or via the Trust’s website (www.bhnft.nhs.uk) where the full reports will be posted shortly.

3. RECOMMENDATION

The Governing Council is asked: a) to receive and consider the enclosed reports b) to consider the Chief Nurse’s offer to discuss any issues or points arising from the

enclosed papers at the Access and Patient Interface meeting on 28th July.

Juliette Greenwood Chief Nurse and Director of Quality & Standards July 2008

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http://www.bhnft.nhs.uk/

7(b)

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT Subject: PATIENT SURVEYS Summary This paper will provide the Board with an update and analysis of the Trust’s performance in the recent Healthcare Commission (HCC) Acute Inpatient Survey and local Picker Outpatient Survey. It will identify performance against previous survey results and also against neighbouring Trusts. It will present areas for action and recommendations arising from these.

1. Introduction or Background 1.1 In order to promote continuous improvement in healthcare for the benefit of patients

and the public the Healthcare Commission (HCC) mandates that each acute and specialist NHS Trust undertake an annual in-patient survey to ask patients who have recently used services about their experiences.

1.2 To support the Trust in delivering this required work-stream the Trust continues to employ the services of the Picker Institute to coordinate, deliver and report upon what is the 5th annual survey of adult inpatients.

1.3 In line with the ongoing commitment to improve quality and engage the public in shaping services the HCC in-patient survey is part of a wider programme of surveys that currently include: • Review of maternity services 2007 (First such survey) • http://www.healthcarecommission.org.uk/_db/_documents/RFFScoredAssessme

nt.pdf • Emergency department survey 2008 (results anticipated in late Autumn 2008) • Anticipated annual acute in-patient survey – to commence Autumn 2008

1.4 In addition to the suite of three HCC patient surveys scheduled to run across 2007 and 2008 the Trust voluntarily opted to commission a survey of patients’ experiences of the outpatient services (this was also undertaken by the Picker institute). This decision was based on a number of factors • The last HCC survey of outpatients was 2004 • The Trust recognised the incident of complaints linked to patients’ experience in

outpatients (64 complaints, equalling 26.7% of all complaints in 2007/08, although only 12 of these related to the main OPD) coupled with the lack of Matron or Senior Nursing input into this area contributed to a decision to actively seek patients’ views of their experiences.

Due to the limited number of other Trusts that opted to undertake an outpatient survey through Picker it is not possible to apply national benchmarks against the Trust’s outpatient Picker survey. However, Appendix 1 identifies the findings and action plan in response to these.

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http://www.healthcarecommission.org.uk/_db/_documents/RFFScoredAssessment.pdf

http://www.healthcarecommission.org.uk/_db/_documents/RFFScoredAssessment.pdf

2. Issues 2.1 The annual inpatient survey consists of a total of 78 questions, divided into eight

sections. 2.2 Demographics

This is the 5th annual survey of adult inpatients in NHS Trusts in England, it involved 166 acute and specialist NHS Trusts, 850 patients who were in-patients in a given time period over the summer of 2007 were selected from each Trust. The national response rate was 56% whilst the response from patients who were in-patients at Barnsley was 53%, slightly less than the national average (this equates to 429 respondents). The gender split was 42% male 58% female, 50% of the total respondents being over the age of 66 years. 94% were white, 5% ethnic origin not known. The results of the surveys were published by the HCC on 14th May and are therefore in the public domain. Whilst in the main the HCC surveys follow a similar pattern there are always some questions that are either discontinued or new variations introduced. Each survey year on year has some minor differences thus it is not feasible to make a direct comparison against each of the questions, however the themes remain constant with other surveys and fall into 8 domains; • Admission to hospital • The hospital and ward • Doctors • Nurses • Your care and treatment • Pain • Operations and procedures • Leaving hospital • Overall

3. Findings 3.1 The HCC apply a traffic light system to the scores from each of the questions of red,

amber and green. Those questions of which the mean score is highlighted in red, this means the Trust lies within the 20% of trusts with the lowest scores for that question. These trusts scores fell on or below the 20th percentile threshold score nationally. If the mean is highlighted in green, this means the Trust lies within the 20% of trusts with the highest scores for that question. These trusts scores fell on or above the 80th percentile threshold score nationally. Whilst the questions for whom the mean is highlighted in amber, indicates the trust's score is within the range of scores for the remaining 60% of trusts. Direct comparisons with the 2006 annual survey are not easily applicable due to the nature and numbers of the questions – a total of 68 were used in the 2006 survey. However the feedback at that time was for 9 questions to be rated red and 7 questions to be rated green.

3.2 The Trust scored in the best 20% of Trusts in questions located across the 6 areas below • Privacy in A&E - ‘Were you given enough privacy when being examined or treated

in the Emergency Department?’ • Admission to hospital ‘Were you offered a choice of hospital for your first hospital

appointment?’ • Admission date – ‘Was your admission date changed by the hospital?’ • Choice of food – ‘Were you offered a choice of food?’


• Care and treatment - ‘Were you given enough privacy when being examined or treated?’

• Explanations of procedures – ‘Before the operation or procedure, did the anaesthetist or another member of staff explain how he or she would put you to sleep or control your pain in a way you could understand?’

3.3 Following targeted work in clinical areas there has been a reported improvement on the previous year’s results in the following three areas: • Noise at night • Number of nurses on duty • Inclusion in decisions about care

3.4 On comparison to similar questions on the 2006 survey there has been little or no improvement in two areas relating to leaving hospital, these are: • Medication (information on side effects) – ‘Did a member of staff tell you about

medication side effects to watch for when you went home?’ • Information to families - ‘Did the doctors or nurses give your family or someone

close to you all the information they needed to help care for you?’ Work undertaken locally has been championed by the Matrons, and includes work in collaboration with Pharmacy to establish a patient medication information card (as used in Sheffield Teaching Hospitals). This is used with positive results in some areas of the Trust, a roll out of this system across the organisation together with other actions applicable to local areas is being considered. The patient bedside information booklet is currently being updated, systems implemented locally to promote communication with patients and relatives include communication books at the patients bedside, raising staff awareness and discussion on admission with relatives and patients regarding their needs. This work is currently nursing focussed and work with medical staff will follow a presentation at Medical Staff Committee shortly.

These will be priority work areas, to be targeted across all in-patient areas and led by the Matrons reporting in both at divisional level and corporately. Whilst there has been a marked deterioration against the question ‘Did the hospital staff give you the information you needed to do this’ (i.e. how to complain about care) the response rate and trend was consistent with the national response of 73%. For the Trust the number of responses against this question only equated to 31 – therefore some caution should be exercised over this issue. However, actions have already been taken to address this within the organisation and include: • Paper information leaflets were circulated to all wards and clinical areas at the

beginning of May. • These are also available from Complaints, PALS or directly from the Risk

Management Website. Proofs for 'glossy' versions of the leaflet and posters on how to make a complaint are awaited.

• In addition, the information on the Trust's internet site has been updated with advice on how to make a complaint, the information should have been included within the Annual Report.

• Matrons are currently revising the Bedside Information Packs to include updated information on how to complain.

• The Outpatient information booklet/leaflet is also under review. • The Complaints Manager met with BBEMI and Barnsley Arena earlier in the year,

they were satisfied with the service and had no issues to raise; neither had ICAS who are also regularly consulted. It was highlighted by these groups that there was no specific need for leaflets in any foreign languages, but in conjunction with


PALS the complaints office is looking at better 'signposting' of the translation service.

• An initial impact assessment has been completed as part of the recent training and screening process, it was considered that a full impact assessment was not indicated (based on current information and the actions above).

• Awareness training for complaints is in place monthly through the Corporate Curriculum and an investigation into the need for further training for Lead Nurses and other Investigators is underway.

3.5 Within the questions rated red in 2007 a total of 4 have seen a deterioration from a 2006 amber rating (Appendix 2), the areas these relate to are ‘your care and treatment (n=3) and ‘operations and procedures’ (n=1)

3.6 A high level comparison of the Trust’s traffic light score has been undertaken and reveals the following findings

Barnsley Rotherham Doncaster Mid Yorkshire

Red 11 2 3 23

Green 6 19 20 2

It is clear from these statistics that serious work is required by all disciplines across a number of areas. Notably the questions rated red or one point away from a red rating (see Appendix 2, table 2) relate to the areas of: • Doctors • Your care and treatment • Leaving Hospital Appendix 2 provides further detail by questions for the Trust. Table 1 indicates the 2006 areas scored red and their comparative rating in 2007 – a total of 10 questions. Table 2 indicates those areas in 2007 rated amber but that on analysis are only 1 point above a red rating (i.e. an area of risk) whilst Table 3 indicates those areas rated amber that are only 1 point away from a green rating – a total of 7 questions – an area of opportunity for improvement.

4. Impact on Business Plan/Vision 4.1 The results of all HCC patient surveys are utilised by the HCC to cross reference

organisations’ self declarations against the Annual Health Check. In addition there is a specific performance target that equates to a determined percentage improvement in patients’ feedback. Therefore the HCC surveys underpin a number of the elements of the business plan and as such are one of the key streams of evidence for patients’ experience of the Trust’s services.

5. Options 5.1 To note the areas for improvement and to undertake a proactive organisational focus

on improvement across all avenues of patient experience.

6. Implications 6.1 Public and patient involvement

The method and findings form one of the key aspects of PPI and identify priorities for future work.

6.2 Resources N/A


6.3 Equality/Diversity The random sampling has drawn a relatively reflective sample in line with the local population. However the small proportion of individuals surveyed from ethnic origin not known - serves to highlight the importance of ensuring comprehensive spread and focus on equality and diversity and is forming a key strand of the PPI work that Matrons are leading.

6.4 Reputation/communications The results of the national in-patient survey were published on 14th May 2008 and are in the public domain on the HCC website. The information will be used to inform future Patients Choice, the Annual Health Check and Monitor’s view of the Trust.

7. Conclusion 7.1 The 2007 inpatient survey has highlighted a number of areas of concern not least the

gap between the feedback from Barnsley patients to that from Doncaster or Rotherham patients. The importance of the feedback should not be underestimated, the data and messages it presents about the Trust are the subject of considerable scrutiny by the Healthcare Commission, Department of Health and Monitor. Of most importance the outputs of these agencies to this information will further influence the opinions of the public and the commissioners.

7.2 A clear focus for 2008 will be a review of the mechanisms for monitoring patient experience activities across the Trust. This work will be led by the Matrons and will benefit from the sponsorship within their Divisions from the Divisional Medical Directors.

7.3 The issues highlighted in the current survey results will be incorporated with the current patient experience interview topics, identifying gaps and areas for improvement. An action plan is being developed by the Matrons to address the issues raised in the 2007 survey, this will be monitored and reported upon monthly at the Senior Nurses Forum and consideration of how the exception reports can be factored into the Trust performance dashboard quarterly will be explored as a priority.

7.4 Likewise regular feedback of performance to the consultant establishment via the MSC will be explored.

8. Recommendations 8.1 The Board of Directors is asked to

• receive the above report • discuss the findings and endorse the initial planned actions • require regular feedback on progress through a timeframe to be agreed

9. Appendices 9.1 Appendix 1 - Outpatient Department action plan and update report 9.2 Appendix 2 – Inpatient Survey 2007 analysis


OUTPATIENT SURVEY 2007 BHNFT - Update May 2008 Questions where respondents reported room for improvement

Identified Issues Objective/Goal Work needed Timescale Responsibility Monitoring Link with other

work Identify the issue raised by the patient survey results

What do we hope to achieve? How will changes improve patient care?

What work will have to be done to achieve this goal?

When do we plan to reach this goal? Define major milestones along the way

Who will take the lead for this issue? Who is responsible for taking the work forward?

How and when will progress be measured?

How does this link with other work going on within our Trust?

Not told accurately how long would have to wait (30 mins +)

Patients will not wait over 30 mins An understanding that all staff will inform patients if a delay is expected

Staff to monitor clinicians attendance on time into clinic Map the patient flow into and out of OPD to avoid delays /unnecessary waits

ongoing

Gail Guest and lead nurse OPD

Monthly With results fed back to general managers

Reputation of the Trust Patient choice Productivity and throughput/capacity planning

Not fully aware what would happen during appointment Significantly worse

Patients attend with an awareness of what to expect in OPD

Information to patients has been updated to cover general expectations

Completed April 2008 now to print

Gill waddington monthlyreview Reduce DNA’s Reputation of the Trust Patient choice Productivity and throughput/capacity planning

Not given choice of appointment time Significantly worse

All follow up patients will receive an appointment before leaving the Trust

All staff have been instructed by Karen Sharman supervisor that no patient leaves a clinic without a negotiated time and date as from 2nd Jan 2008

ongoing

Karen Sharman Monthly review


Do not always see the same Dr/other staff member (been to this O/P dept. for same condition)

Patients will understand that it is not always possible to see the same doctor

Information to patients updated that they may not see the same doctor but they are one of a team

Feedback audit Gill Waddington monthly Reputation of the Trust Patient choice Productivity and throughput/capacity planning

Did not receive copies off all letters sent between hospital and GP

All new patients will receive correspondence

Pre registration clerks to ensure that all new patient notes have a form attached prior to clinic

Audit in March2008

Karen Sharman Karen Sharman

monthly Reputation of the Trust

Not told about danger signals to

Patients and staff will communicate

Information to patients in all clinic areas to include a check list to ask the Doctor

Use the NHS ‘questions to ask

Lead nurses

ongoing Patient and staff

APPEN

DIX

1

watch out for (felt they needed this information)

regarding individual needs following consultation

Focus group in OPD due commence June 2008

leaflet’ Gill Waddington

involvement

Not told of side effects of medication

Patients and staff will communicate regarding individual needs following consultation

Information to patients to alert them to ask in pharmacy OPD staff not allowed to photocopy leaflets

Ongoing Lead nurses ongoing Patient and staff involvement

Results were significantly worse than the 2004 survey

Identified Issues Objective/Goal Work needed Timescale Responsibility Monitoring Link with

other work Identify the issue raised by the patient survey results







GP: did not explain reason for treatment/action in understandable way

raised at the choose and book project group and super uses group Discussed with commissioners Feb. 2008

June 2008

Gill Waddington Justine Britton Katy Hanna

Monthly feedback from patients

Patients expectations and choice

Doctors/other staff talked in front of you as if you weren’t there

All clinical staff to introduce themselves All medical students to be introduced prior to consultation Minimal interruptions whilst consulting to be made by nursing and other medical staff

ongoing

Gail Guest Lead Nurses OPD

Monthly feedback from patients

Reputation of the Trust

Did not receive copies of all letters sent between hospital/GP

All new patients will receive correspondence

Pre registration clerks to ensure that all new patient notes have a form attached prior to clinic

Audit in March2008

Karen Sharman

monthly Reputation of the Trust Patient choice Patient involvement in their care

Overall- outpatient department not at all/fairly organized

All patients attending will have a smooth journey into the department with minimal waits and clear information

Managers and lead nurse to agree a pathway of care for all patients attending Meeting with director of estates and manager to agree a refurbishment plan following the installation of the escalator Environmental assessments start in June

April2008

Gill Waddington OPD supervisors and lead nurses

monthly

Reputation of the Trust Patient choice Patient involvement in their care

2008 For all outpatient areas

Results were significantly worse than the ‘Picker average’ for the following:

Identified Issues Objective/Goal Work needed Timescale Responsibility Monitoring Link with

other work Identify the issue raised by the patient survey results







Not given choice of appointment time

All follow up patients will receive an appointment before leaving the Trust

All staff have been instructed by Karen Sharman supervisor that no patient leaves a clinic without a negotiated time and date as from 2nd Jan 2008

Feedback audit DNA report

Karen Sharman monthly Reputation of the Trust Patient choice Productivity and throughput/capacity planning

Not fully aware what would happen during appointment

Patients attend with an awareness of what to expect in OPD

Information to patients requires updated to cover general expectations updated april 2008 to incorporate new procedures in OPD. NHSUK requires more information regarding specific services.

Look to using the nhs questions to ask leaflet to be inserted into all new appointments

Gill Waddington Duncan Graham

monthly Reduce DNA’s Reputation of the Trust Patient choice Productivity and throughput/capacity planning

Reputation – hospital rated as ‘very poor, ‘poor’ or ‘fair’

Barnsley Hospital will be the first choice for patients and will be rated very good or excellent

The overall patient experience needs to be challenged and staff needs to be aware of how the influence the way the public views our services.

Instil to staff the importance of first impressions and the code of conduct for staff Training programme for supervisors in customer care being developed

All OPD managers/lead nurses

Monthly Via newly designed questionaiire


by learning and development team and cascade to staff

Not all staff introduce themselves

Patients will be aware of who is attending to their needs

All staff to wear correct uniform and name badges, but to also verbally introduce themselves.

Managers to invoke this in all OPD areas

Gill Waddington

Monthly audit Reputation of the Trust

Overall- outpatients department not at all/fairly organised

Overall- outpatient department not at all/fairly organised

All patients attending will have a smooth journey into the department with minimal waits and clear information

Feedback from patients Environmental assessments

Gill Waddington Supervisors Lead nurses

Monthly audit


Gillian Waddington General Manager Highlights May 2008 The Outpatient Team have worked to find more efficient ways of capturing patient feedback given that some 300,000 patients access our service each year. A total of 11 formal complaints have been received in 2007/8 to the main OPD area 64 throughout the Trust Informal complaints through PALS average 40 per quarter. A very small sample of patients some 40 patients per month have been surveyed over the past year and reported into the PMG report. Recurring themes Negative Positive Car Parking Friendly staff Waiting time to see Dr All would choose BHNFT Dr talking over patient Areas were clean Noisy waiting area/better waiting areas Privacy and dignity maintained A newly designed questionnaire is being used for the June audit which takes into account the areas in which we need to improve from the Piker Report a much larger sample size will be used Audit of letters to patients first part of the process 100% compliance that notes contained the correct documentation for staff to ask the patient and to inform secretaries to copy the letter to the patient. A newly designed Outpatient Leaflet incoporates comments from governors and staff regarding content The new entrance area will give us the opportunity to streamline patients through to their given OPD area without the need for constantly waiting in different areas. Due to open the end of June the governing council members have been invited to visit the weekend before to walk through as we will be preparing the area on the Saturday before.(28th June) Customer care training is to be designed in conjunction with managers / supervisors from all areas of the hospital in order to align this to different patient groups. This involves a patient representative who has had experience in customer care and as a patient Environmental Audits have been undertaken in the medical outpatient area in April 08 but the Team are conducting a timetable of their environmental audits that cover the whole of the department including admin areas and action plans developed to initiate change. Taking the Lean Principles (5 S) methodology will again address some concerns that patients have regarding environment and process and as series of events will be running over the next 3 months.

Inpatient Survey 2007 Table 1 -

Question

Rating 06 Rating 07 Progress

Upon arrival, did you feel that you had to wait a long time to get a bed on a ward Red

Amber Marked improvement

Were you bothered by noise at night from the hospital staff?

Red Amber Improvement

Did Doctors talk in front of you as if you weren’t there? Red

Red Improvement

Did Nurses talk in front of you as if you weren’t there?

Red

Red Improvement

In your opinion, were enough nurses on duty to care for you in hospital?

Red Amber Improvement

How much information about your condition or treatment was given to you? Amber

Red Deterioration

Did your family of someone close to you have the opportunity to talk to a Doctor? Question not included in survey

Red

Did you find someone on the hospital staff to talk to about your worries and fears? (1)

Amber

Red Deterioration

Were you given enough privacy when discussing your condition or treatment? (1)

Amber

Red Deterioration

Afterwards, did a member of staff explain how the operation or procedure had gone? Amber Red

Deterioration

Did a member of staff tell you about the medication side effects to watch for? Red

Red Slight deterioration

Were you given clear written information about your medicines? (1)

Red

Red Slight deterioration

Did a member of staff tell you about any danger signals to watch for?

Red Amber Marked improvement

Did hospital staff give your family or someone close to you all of the information you needed?

Red Red Slight improvement

If you wanted to complain, did hospital staff give you the information you needed to do this?

Question not included in survey

Red

Only 31 respondents eligible to answer this question

APPEN

DIX 2

(1) = on the line for a red rating

Table 2 – Question scores only 1 point from a red rating Question Trust rating score 2007 Red rating score

2007 Were you ever bothered by noise at night by hospital staff? 77 76

Did you feel threatened during your stay in hospital by other patients or visitors? 96 95

Did you get enough help from staff to eat your meals? 65 64

When you had questions to ask a doctor, did you get answers you could understand? 79 78

Did you have confidence and trust in the doctors treating you? 88 87

In your opinion, were there enough nurses on duty to care for you in hospital? 69 68

Were you involved as much as you wanted to be in decisions about your care? 68 67

Did hospital staff explain the purpose of the medicines you were to take home

82 81

Were you told how to take your medication in a way you could understand?

82 81

Did a member of staff tell you about any danger signals you should watch for?

45 44

Table 3 Question scores only 1 point from a green rating Question

Trust rating score - 2007 Green rating score

How much information about your condition did you get in the emergency department?

84 85

Overall, how long did you wait to be admitted?

54 55

Were you ever bothered by noise at night from other patients?

65 66

Did a member of staff say one thing and another say something different?

81 82

Did a member of staff explain the risks and benefits of the operation or procedure?

90 91

Did a member of staff explain what would be done during the operation or procedure?

86 87

How long was the delay to discharge? (from hospital)

81 82

In-patient Survey 2007 Initial high level actions required Action

Objective Responsible

officer Timescale Progress

1. Discussion of results of in-patient survey across the organisation

• To share the findings of the 2007 in-patient survey, discuss implications, identify actions and improve patient experience.

CN&DQ&S SNF June 2008 MSC July 2008 Governing Council – to be agreed

Discussed at SNF 12.6.08 actions minuted

2. Update local patient surveys • Identify areas for improvement as highlighted in Picker survey, re-phrase questionnaire to gather information required.

• Establish further areas per Division to

target work-streams

Asst. to CN&DQ&S & Matrons Divisional ADN & Matrons

June 2008 July 2008

3. Patient information • Update patient bedside information folder in consultation with other officers to provide up to date, relevant information

Matrons

Ongoing

4.

Review complaints procedure and promote patient feedback.

• Provide information to patients of how to complain.

• Consult with BBEM to identify gaps and

potential inequalities for minority groups locally.

• Liaise with PALs to signpost and

promote the translation service, in order to improve communication with BME groups.

Complaints Manager

June 2008 Completed

• Consult with T&D in order to provide

awareness training for Lead Nurses and complaints investigators’.

5.

Explore issues around lack of information regarding medication and potential side effects

• To liaise with patients / public and Governors to identify the best solution to providing written information of medication and side effects

Matrons July 2008 Ongoing

Juliette Greenwood Beverley Geary Chief Nurse & Director of Quality & Standards Assistant to Chief Nurse and Medical Directors June 2008

7(c)

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT (abridged) Subject: ANNUAL COMPLAINTS REPORT 2007/08 Summary This paper will provide the Board with the Trust’s Annual Report of Complaints Activity. The report identifies key performance data, analysis of trends and themes emerging. For the first time the report also incorporates the annual report of PALS (Patient and Liaison Service) activity.

1. Introduction 1.1 This report provides a summary of Complaints Activity for the year 1st April 2007 to

31st March 2008. The report identifies key performance data, analysis of trends and themes emerging. The summary of complaints activity is made within the context of the overall Trusts patient contacts/activity and table 1 indicates the comparative activity data for 2006/7 to 2007/8.

Activity between 2006/07 and 2007/08 2006/07 2007/08 Elective (including day cases) 23527 23741 Non Elective (Unscheduled) 28054 28723 Outpatient appointments 227909 243938 A&E Attendances 70949 70075 Other Activity * (see below) 954504 1985000

*The increase is partly due to changes in the methodology for recording activity following a review of pathology. Against the overall Trust activity profile the 240 formal complaints equates to a complaint rate of approximately 0.0065%.

1.2 Complainants have the opportunity to access the Trust’s complaint process through three points, locally within the area of concern to immediate staff, via the Patient, Advice and Liaison Service (PALS) and finally through the formal complaints process. The Trust policy is where ever possible to aim for local resolution of patient / visitors concerns however it is not possible to identify the volume of issues that are addressed successfully at the front line by all staff. Contact details are maintained of PALS activity (Appendix 1) and formal complaint activity, thus the Trust should not be complacent regarding the figures presented through this report.

1.3 Complaints are one of the mechanisms service users have to provide feedback on their experience of the Trust’s service likewise the Annual Patient Survey (Healthcare Commission) attached at paper 7 provides a public benchmark method of feedback regarding patient experience. This latter method allows for areas of concern or dissatisfaction to be highlighted that may not have led to formal complaints however the feedback is of significant importance and will be used in tandem with the issues emerging from this paper to inform future Trust wide work-streams.

1.4 This report has previously been presented at the Quarterly Complaints Review Group and the Governance Committee.

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1.5 Response times/Performance targets • 240 complaints were received in the full year • 210 were responded to within the 25 day target to date (87.5%) • 19 were responded to outside the target with agreement:-

A&E - 3 with agreement Inpatient - 15 with agreement Outpatient - 1 with agreement

• 11 were responded to outside the target without agreement A&E - 1 without agreement Inpatient - 5 without agreement Maternity - 2 without agreement Outpatient - 3 without agreement

The response rates have been maintained to a high standard throughout the year. Those that have been substantively delayed has been due to the complexity or difficult nature of the complaint and in some instances, co-existing investigations and actions taking place.

1.6 Activity The number of formal complaints received in the year has shown a 2% increase against the previous year, (i.e. 236 in 2006/07). The spread of complaints between specialties remains broadly similar with notable exceptions being an increase in A&E and Outpatient services. Appendix 1 provides a report detailing PALS activity and contacts including the PALS volunteer service.

1.7 Independent Reviews The Healthcare Commission (HCC) undertakes independent reviews of complaints

under the second stage of the complaints procedure. The Trust recorded 5 requests for information from the HCC, only one of which has been uphend (one investigation is still ongoing) but from which actions have been identified and implemented in response to the concerns raised by complainants. 1.8 Ombudsman's Investigations

No Ombudsman investigation took place in 2007/08.

2. Themes and Trends 2.1 From a general analysis of the data, themes have been identified is some aspects of

clinical care, communications, staff attitudes, hotel services and administration. 2.2 Activity and Performance Targets by Specialty (figures in brackets are 2006/07 data)

A&E 46 (35) complaints 42 (35) within target (91%)

Critical Care 4 (1) complaints 4 (0) within target (100%)

Other 6 (3 ) complaints 6 (3) within target (100%)

Estates & Facilities/Hotel Services 11 (3) complaints 9 (3) within target (82%

General Medicine 71 (64) complaints 63 (58) within target (89%)

General/Special Surgery 54 (66) complaints 50 (49) within target (93%)

Gynaecology 7 (11) complaints 4 (10) within target (57%)

Medical Imaging/Medical Physics 2 (4) complaint 1 (4) within target (50%)

Obstetrics 7 (9) complaint 5 (8) within target (71%)


Ortho/Rheumatology 13 (18) complaints 12 (15) within target (92%)

Outpatients 12 (15) complaints 12 (15) within target(100%)

Paediatrics 7 (4) complaints 5 (4) within target (71%)

2.3 Diversity & Equality The analysis of the ethnicity of patients confirms that 1% of complainant/patients where data has been collected are Pakistani and Indian. The remaining 99% are White /British. Whilst the Trust has a small ethnic population no information either formally or informally has been reported to suggest that these groups have been unable to access the complaints procedure. Age profiles of patients can raise interesting considerations, but to an extent are subjective. Some elementary findings are: • 9% (7%) approximately involve patients of 16 years or younger • 12% (14%) approximately involve patients of 80 years and above • 36% (47%) approximately are brought by complainants on behalf of another

person. • (15%) 10% approximately concern deceased patients

2.4 Improvements following Complaints Quarterly reports have been identified throughout the year and significant changes have been identified from individual case reviews and corporate trends. A detailed report is attached at Appendix 2.

2.5 Review Group for Complaints & Procedures The Trust holds quarterly meeting to review complaints and PALS activity; performance monitoring, learning and improving from complaints, Healthcare Commission reviews and progress, and individual case reviews. Reports are made directly to the Governance Committee for escalation to the Board of Directors.

3. 2008/09 Action Plan There are specific individual action plans linked to all complaints that are monitored through departmental/Divisional governance groups and in addition action plans developed in response to HCC independent reviews are now reported to the Board and monitored through the Complaints Review Group. However a key action for this year is for a review of the function and fit of the current Complaints Review Group to be undertaken in line with the lessons arising from the HCC recent publication ‘Spotlight on Complaints’ (2008). Appendix 3 provides an overview of the findings arising from this publication.

4. Recommendation The Board of Directors to receive the annual complaints and PALS report and associated appendices, noting the activity and issues raised and the improvements to services instigated as a result of complaint activity

5. Appendices (available separately) Appendix 1 – PALS activity

Appendix 2 – Improvements Appendix 3 – Overview of findings from ‘Spotlight on Complaints’


7(d)

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT Subject: SAFEGUARDING ADULTS ANNUAL REPORT Summary This report provides an annual overview of progress within the Safeguarding Adults agenda, identifies challenges and provides the Board with reassurance that ensuring the safety of vulnerable patients is a key aspect of work within the Trust. Multi-agency partnership working is an integral part of the progress made.

1. Introduction or Background 1.1 Multi-agency work regarding adult protection has been taking place in Barnsley since

2001. This work is lead by the Local Authority and includes health, social care, police and voluntary sector organisations. The original work was guided by No Secrets (DoH 2000) and is currently influenced by Safeguarding Adults: A National Framework of Standards for Good Practice and Outcomes in Adult Protection Work (DoH 2005) and links strongly with the Mental Capacity Act (2005). The Care Standards Act (2000) introduced the requirement for a vetting and barring scheme against a Protection of Vulnerable Adults (POVA) list, as part of criminal records bureau (CRB) disclosures. However this POVA check does not apply to NHS organisations. The Safeguarding Vulnerable Groups Act (2006) is due to be implemented in Autumn 2008 and will introduce a new vetting and barring scheme for those working with children and vulnerable adults and will replace the current Protection of Children Act (POCA) and Protection of Vulnerable Adults (POVA) schemes. This new scheme will cover both health and social services.

1.2 There is now a move to undertake a wider role of safeguarding. This shift in service philosophy and practice has been driven in order to be more pro active and to empower those who may be vulnerable. The term “Vulnerable Adult” can, in itself, be disempowering and can infer that abuse is located with the victim rather than acts and omissions of others, it can also imply a paternalistic approach.

1.3 The strategic approach to safeguarding adults within the Trust is lead by the Deputy Director of Nursing, who also represents the organisation within the multi agency context, being a member of the Barnsley Multiagency Safeguarding Adults Board and the Chair of the multiagency Operational Management Group, which links with the work of the multiagency performance management, training and practice learning sub groups.

1.4 The operational management lead within the Trust is the Matron for Older Peoples Services who delivers local training regarding Safeguarding Adults and provides operational guidance and support to professionals within the hospital as necessary. Information is also collated for all suspected incidents regarding safeguarding adults and is reported through to the multiagency performance management sub group.

2. Issues/Assessment/Proposal As statutory changes take place, it is envisaged that more investment in training and audit will be required as the profile and operational requirements of safeguarding adults is increased.

I:\Governing Council\Meetings\2008\18 Jun 08\7_Chief Nurse(d).doc (2)

2.1


Operational Management: Operational work is currently co-ordinated and delivered through the Matron for Older People’s Services. However, it is recognised that with the growing agenda for Matrons, this causes some capacity problems and introduces risks to the continuance of effective and thorough Trust wide overview, co-ordination and training in relation to Safeguarding Adults work-streams. Work is progressing to appoint a dedicated Lead Nurse for Safeguarding Adults and Privacy and Dignity Champion. This is especially important, in order to address the increased workload as a result of implementation of the Mental Capacity Act and to avoid compromise of the other work undertaken by the Matron.

3. Impact on Business Plan/Vision Ensuring the safety of vulnerable adults is an integral part of health care provision and effectively meeting this agenda is an important facet of influencing patients to choose the Trust for their treatment. Work undertaken in the last year includes: The Deputy Director of Nursing has worked with the multiagency team towards the

implementation of the Association of Directors of Social Services (ADSS) 11 Standards from ‘Safeguarding Adults’ A National Framework of Standards for good practice and outcomes in adult protection work.

The BHNFT Safeguarding Adults Steering Group had its first meeting in March 2007 and continues to meet quarterly, to guide and monitor the operational implementation of safeguarding work. The group membership includes a public member (Terms of Reference attached).

Basic awareness training for Safeguarding Adults is held each month as part of the corporate curriculum and a drop in training day in November 2007 was highly successful, with attendance of over 80 staff.

Staff have attended multiagency training sessions regarding the new South Yorkshire Policy and Procedures, which were implemented in January 2008.

Formulation and dissemination of Practice Guidance took place in April to support staff dealing with issues related to the Mental Capacity Act.

Multi agency training days have been held regarding Mental Capacity Act implementation and requirements, with 140 Trust staff attending. In addition basic awareness training is held each month as part of the corporate curriculum.

In October 2007 a Safeguarding Adults awareness day was held in the Trust to highlight adult protection issues to both the public and staff. This incorporated Safeguarding Adults, Mental Capacity Act and patient dignity issues.

A BHNFT Safeguarding Adults Policy was formulated in 2007 and has been approved by the Board of Directors.

4. Implications 4.1 Public and patient involvement

Public involvement has been established in the multi-agency context through links with Barnsley Arena and locally through membership of the Trust Safeguarding Adults Steering group.

4.2 Resources none


4.3 Equality/Diversity Links are well established with learning disability services, with particular emphasis on implications of the Mental Capacity Act. Involvement of Barnsley Black and Minority Ethnic group is currently being established.

4.4 Reputation/communications Active support of the Safeguarding Adults agenda plays an important part in securing a positive reputation for the Trust.

4.5 Legal The Mental Capacity Act (2005) places a legal requirement for organisations to take due regard of the capacity of patients and clients to make decisions. It is imperative that staff are aware of the implications of this Act and of what constitutes best practice. The Deprivation of Liberty requirements within the Act are envisaged to come into force in 2009. The Safeguarding Vulnerable Groups Act (2006) is due to be implemented in Autumn 2008 and will introduce a new vetting and barring scheme for those working with children and vulnerable adults and will replace the current POCA and POVA schemes.

5. Conclusion 5.1 The Trust is actively involved within a multi agency context in ensuring that vulnerable

adults are safeguarded. The appointment of a dedicated operational lead will further strengthen and improve this important work. Capacity to release staff for training is challenging but this is a crucial element of ensuring successful implementation of policy and procedure and in keeping vulnerable patients safe in practice. Support from clinical managers is therefore essential to facilitate staff training and diverse methods of delivery are being explored to help with this, in the context of e-learning packages.

6. Recommendations 6.1 The Board of Directors is asked to note the progress made and support the ongoing

work being undertaken.

7. Appendices 7.1 Appendix 1 - Terms of Reference for the Safeguarding Adults Steering Group


7(e)

REPORT TO THE BOARD OF BARNSLEY HOSPITAL NHSFT Subject: SAFEGUARDING CHILDREN ANNUAL REPORT Summary This report provides an annual overview of progress within the Safeguarding Children agenda, identifies challenges and provides the Board with reassurance that ensuring the safety of vulnerable children is a key aspect of work within the Trust. Multi-agency partnership working is an integral part of the progress made.

1. Introduction

Working Together to Safeguard Children was published in 2006 to replace the 1999 edition. The main triggers for the revised guidance were the first joint Chief Inspectors Report on Safeguarding Children (2002), Lord Laming statutory review into the death of Victoria Climbié (2003) and the Government’s response to these documents i.e. Every Child Matters – Change for Children, National Service Framework (NSF) for Children, Young People and Maternity Services and The Children Act 2004. BHNFT has a key role to play in actively promoting the health and wellbeing of Children. Section 11 of the Children Act 2004 places a statutory duty to make arrangements to ensure that, in discharging their functions, they have regard to the need to safeguard and promote the welfare of children.

2. Operational Management

In April 2007 one of the named nurses for safeguarding children retired, interim arrangements included the remaining named nurse undertaking a full time role, a midwife took up a secondment to support the service which lasted until January 2008. Since this time we advertised for and recruited a new named nurse who commences this position in June 2008. There is full time admin and clerical support in place until August 2008.

3. Impact on business

The quality of the safeguarding service within BHNFT is compliant with Core Standard C2 and takes full account of the NSF. All policies, procedures, audits and other relevant items are regularly uploaded onto the Healthcare Commission website as evidence of compliance. Barnsley Safeguarding Children Board (BSCB) has clear priorities for safeguarding and promoting the welfare of children which are explicitly stated in the Children and Young People Plan and Business Plan. The Director of Nursing is the executive member of the Barnsley Safeguarding Children Board and ensures board level commitment to and leadership of safeguarding processes.

The Safeguarding Children Team undertakes safeguarding children training and provides advice and support to health staff to ensure that Barnsley Hospital NHS Trust have effective processes in place to safeguard and promote the welfare of children. The Team aim to ensure that all affected children receive appropriate and timely therapeutic and preventative interventions. The safety and health of the child are intertwined aspects of their wellbeing; many “health” interventions also equip a child to “stay safe”. Work streams through the Barnsley Safeguarding Children Board ensure that arrangements for the protection of children join up with those of other local organisations. BHNFT representation attached.

Key achievements include:

3.1 Training

• Training for all staff at BHNFT has continued to be delivered in accordance with

the Safeguarding Children Training Strategy 2006. A rolling programme of training has been developed (training data included) to ensure healthcare professionals at BHNFT who come into contact with children and their families are aware of the predisposing factors, signs and indicators of child harm. They should also have the knowledge and skills to collaborate with other agencies and disciplines in order to safeguard the welfare of children.

• Safeguarding children training is delivered to all staff at induction.

• All staff undertake basic awareness training either as a taught lesson or e-

learning package and staff who have significant contact with children build on their skills and knowledge by attending mandatory training (one day per year).

• An area of concern was the result of the annual Child Health Mapping Exercise

where for the second year a lack of compliance with accessing safeguarding children mandatory training at consultant level was highlighted. This referred specifically to non-paediatric specialties – orthopaedics, ENT, surgery, critical care and anaesthetics. The Named Doctor undertook to deliver some specific awareness and training sessions to attempt to address this before the end of March 2008.

• The Common Assessment Form (CAF) has been implemented and CAF

awareness sessions have been delivered to ensure staff recognise the needs of parents who may need extra help in bringing up their children.

Number of Employees who have attended specific courses relating to Safeguarding Children in the period 1 April 2007 to 31 March 2008

Course TotalSafeguarding Children Mandatory Training Multi Agency Training Safeguarding Children Multi Agency Risk Assessment Conference Safeguarding Children Common Assessment Framework Training Safeguarding Children Corporate Training Safeguarding Children Induction Corporate Induction Doctors Induction

1031827

218108358 46911

This is the first year that data has been inputted onto the Electronic Staff Record (ESR) therefore previous comparative data is not available. It would appear that a good number of staff have accessed training. However, an area for further focus and development is medical staff training compliance.

3.2 Clinical Supervision

• Staff at BHNFT should also feel supported in their work relating to child protection and children in need. The Named Nurse provides child protection supervision to staff in the Children’s Community Nursing Team and Community Midwifes on a regular basis, and ad hoc to other staff as requested, however due to capacity with the current Named Nurse this is one area of work that will require further attention and re-focus on the arrival of the new Named Nurse.

3.3 Barnsley Safeguarding Children Policy and Procedure

• Following the establishment of Barnsley Safeguarding Children Board and in line with the Children Act 2004, child protection procedures have been revised and circulated to all wards and departments within the Trust.

• A BHNFT Safeguarding Children Policy – NHSLA Safe Environment (SE) 3.2

was formulated in 2007 and has been approved by the Board of Directors. 3.4 Child Death Overview Panel

One of the objectives of Barnsley Safeguarding Children Board in line with the Children Act 2004 was to establish a Child Death Overview Panel to be operational by 1 April 2008.

The Panel will be responsible for:

• Investigating unexpected infant and child deaths requiring a combination of rapid response and detailed investigation including links with both internal and external agencies;

• Conducting an overview of all child deaths (under 18 years) in the Barnsley area.

During 2007 the following has been undertaken:

• Funding for this has been obtained; • The Panel has been established; • Protocols have been developed.

The functions of the Panel commenced in April 2008.

The significant contribution of the Named Doctor for Safeguarding Children should be acknowledged. His time and commitment to this work is commendable and he has been instrumental in Barnsley achieving this position.

3.5 HR Issues

3.5.1 BSCB has a responsibility for ensuring that there are effective inter agency procedures in place for dealing with allegations against people who work

with children and for monitoring and evaluating the effectiveness of those procedures.

BHNFT has developed a procedure “Allegations of abuse made against a person who works with children”. The Director of Nursing is the Senior Officer who has overall responsibility for:- • ensuring BHNFT operates the procedure in accordance with appendix 5

of Working Together 2006; • Resolving any inter-agency issues; • Liaising with BSCB on the subject. In the past year there have been no reported cases at BHNFT. However there is a general lack of number of reported incidents within health and this is being recognised throughout the country.

3.5.2 BSCB also has a responsibility for ensuring that there are effective

interagency procedures in place for checking the suitability of people working with children.

BHNFT have developed safer recruitment procedures in accordance with

Working Together. During 2007/08 a total of 1700 CRB checks have been undertaken, of which

250 were new employees. The remaining checks undertaken as part of the commitment to update all staff checks every 3 years. The checks had identified approximately 15-18 employees having undisclosed convictions which were being taken forward via the disciplinary process and working with staffside. One individual was identified as being on the Protection of Vulnerable Adults (POVA) list although it was noted that they do not have contact with patients. This work is almost complete.

3.6 Safer Recruitment Training

Now being delivered to managers of staff at BHNFT to ensure safe recruitment and prevent unsuitable people from working with children and vulnerable patients. Staff trained during 2007 33

3.7 Steering Group The BHNFT Safeguarding Children Steering Group was established in 2007 and

meets every 2 months to guide and monitor the operational implementation of safeguarding work - See Appendix 2.

3.8 Safeguarding Children Special Interest Group The BHNFT Safeguarding Children Special Interest Group meets on a monthly

basis. Representatives from all areas of the Trust enable comprehensive information sharing, discussion and action planning in support of the internal and external safeguarding agenda – See Appendix 3

3.9 Serious Case Reviews

Two reviews have been undertaken following the death or serious injury of infants.

Their findings highlighted a number of issues which have now been addressed, including domestic abuse training for all staff in the Emergency Department.

3.10 Activity

2006/07

2007/08

Number of acute cases in which the Safeguarding Nurses have given advice and support

315

426

35% increase

Child Protection Medical Assessments undertaken 74 60

19% decrease

As demonstrated the number of acute cases in which the Safeguarding Children

Nurses have given advice and support has risen from the previous year, This may be a positive result of the effectiveness of training enabling staff to recognise safeguarding children issues.

The number of Child Protection Medical Assessments from the previous year has

fallen this may be a direct result of the positive work of the Common Assessment Framework which aims to prevent low level concerns escalating to acute child protection.

3.11 MARAC MARAC stands for Multi-Agency Risk Assessment Conference and is attended in

Barnsley once a month. This is a new national requirement and consists of a meeting where agencies share information about the risk of serious harm, or homicide, to people experiencing domestic abuse. Multi-Agency safety plans are developed to support those most at risk. The aim is to increase the safety and well-being of the adults and children involved, and reduce the likelihood of repeat victimisation.

Number of cases dealt with by MARAC – April 07 – March 08 (inc) 165 Two areas where MARAC has impacted are Maternity and the Emergency

Department. Safeguarding children practices within the Emergency Department, especially in relation to MARAC have significantly improved. Their excellent work with MARAC has been recognised nationally as an area of good practice.

MARAC is a new work stream and has had a significant impact on the

Safeguarding Children Team in terms of time and resources. Staff in the Trust have required training in recognising and responding to victims of domestic abuse and specifically how to use the assessment tool, this training has been undertaken by the Named Nurse. The research required prior to each meeting takes an average of 8 hours of additional admin/clerical time. Attendance at this monthly meeting requires at least an average of 4 hours additional of Named Nurse Safeguarding Children time. Any actions arising from the meeting are then completed, again with resource implications. This has all been achieved without additional resources.

3.12 Audit Regular audit of compliance with processes and procedures take place and are

reported to the Governance Committee (at least once annually) and Quality Assurance and Performance Management Sub Group of the Barnsley Safeguarding Children Board. Any incidents are reported via IR1 incident reporting system and where appropriate to the Named Nurse Safeguarding Children. Any Serious Untoward Incidents (SUIs) are reported in line with the Trust’s SUI process.

When a child dies, and abuse or neglect is known or suspected to be a factor in

the death, local organisations should consider immediately whether there are other children at risk of harm who require safeguarding (eg siblings, or other children in an institution where abuse is alleged). Thereafter, organisations should consider whether there are any lesions to be learning about the ways in which we work together to safeguard and promote the welfare of children, either multi-agency as a Serious Case Review under section 8 of Working Together, or as an Individual Management Review. Any lessons are incorporated into training as appropriate.

During 2007 the following reviews were undertaken:- Serious Case Reviews 1 Internal Management Reviews (BHNFT) 1 Serious Untoward Incidents 1 An audit work plan has been developed and is under continual review to ensure a

strategic approach and evidence of ongoing compliance and identification of improvement.

During 2007 the following audit work was undertaken:- Medical Assessment Pack Medical Staff Audit Safeguarding Children Audit Record Keeping Audits Emergency Department Audit Bullying Audit HCC self assessment Further details of this work is available from the Safeguarding Children Team. 4. Challenges for 2008

• Without a doubt the Safeguarding Children Agenda will continue to grow and will therefore require additional service delivery. Ongoing evaluation of these needs will have to be made, and resources will need to be made available to support the Safeguarding Children Team.

• Following the appointment of the new Named Nurse Safeguarding Children a work

plan will be agreed in order to develop the service further.

• Following the recent national Child Health Mapping exercise conducted in collaboration with Durham University and the Healthcare Commission and a medical staff audit, it has become apparent that safeguarding children training for medical staff is a significant issue and plans should be developed to address this to meet the requirements of the Safeguarding Children Training Strategy. More accurate data should also be available from ESR to indicate which areas of staff need to be targeted for training

• The interface between Safeguarding Adults and Safeguarding Children should be recognised. Work towards establishing a ‘Safeguarding Team’ which would include the integration of Safeguarding Adult and Safeguarding Children Services should be considered, including the appointment of a Named Doctor for Safeguarding Adults and appropriate levels of admin/clerical support staff.

• Child Protection Clinical Supervision should be addressed and developed to enhance

support given to staff.

• Children and Young People’s mental health should be supported. Recent involvement with children with mental health problems have highlighted significant gaps in service and further work needs to be undertaken on a multi-agency level to address this situation.

• Audit work will continue in accordance with the Safeguarding Children Audit Plan to

ensure that safeguarding children processes at BHNFT remain effective. Part of the work will include developing an audit tool to assess our compliance against Section 11 of the Children Act 2004 responsibilities.

• The implementation of NSF Standard 5, is being monitored for the Children and

Young People’s Strategic Partnership by Barnsley Safeguarding Children Board and an audit undertaken at BHNFT on this standard found the Trust to be mainly compliant. There is however a need to re-audit and address any actions as necessary.

• The Independent Safeguarding Authority Scheme (ISA) has been created as a result

of the Bichard Inquiry into the 2002 Soham murders.

It is a new, improved checking and monitoring scheme aiming to prevent unsuitable people from working or volunteering with children and/or vulnerable adults. There is a legal requirement for all Trust employees and volunteers to be entered onto the ISA register. The ISA scheme will go live on 12 October 2009 and we are working towards this transition already. There will be cost implication to the Trust.

5. Conclusion 2007 has been an incredibly challenging year, coupled with an increasing national

agenda and local delivery requirements. The delivery of the MARAC and Child Death Overview Panel workstreams have added

significant pressures to the Safeguarding Children Team and the Trust. It is a credit to the team that the Trust finds itself in a strong position across all areas of Safeguarding Children work and in particular the strong delivery of the above two issues.

6. Recommendations The Board of Directors is asked to note the progress made and support the ongoing work

being undertaken. 7. Appendices

Appendix 1 Safeguarding Children Training Strategy Appendix 2 Safeguarding Children Steering Group Terms of Reference Appendix 3 Safeguarding Children Special Interest Group Terms of Reference Appendix 4 BHNFT Representation at Barnsley Safeguarding Board

governing council – july 2008 ref: 08/07/7 patients ...learning from patients’ comments and...

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