substance misuse service and system improvement · substance misuse treatment providers 9. the...
TRANSCRIPT
Substance Misuse Service and System Improvement
NationalCoreStandardsforSubstance
MisuseServicesinWales
May2010
ISBN9780750456098©Crowncopyright2010WAG10-03143F0461011
1
Contents
Introduction 2
DevelopmentoftheCorestandartds 2
TheCoreStandards 3
ApplyingtheCoreStandards 3
SubstanceMisuseTreatmentProviders 4
Implementation 4
MonitoringandAssessment 4
Annex1 39
Annex2 41
2
Introduction
1. ThisguidancecontainstheCoreStandardsfortheplanninganddeliveryofsubstancemisuseservicesinWales.ThestandardsareapplicabletotheResponsibleAuthorities1oftheCommunitySafetyPartnershipsandallprovidersofsubstancemisusetreatmentservicesinWales.Thestandardsarealsointendedtohelpinformcitizensaboutwhatcanbeexpectedoflocalservicesforsubstancemisuse.
2. Since2003,thestatutoryresponsibilityforplanningandperformancemanagingthedeliveryofsubstancemisuseservicesinWaleshasrestedwithCommunitySafetyPartnerships.TheircommitmenthasbeenpivotalintheprogressthathasbeenmadeinWalesintacklingthisagendaoverrecentyears.TheWelshAssemblyGovernmentintendstocontinuetobuildonandenhancethesestrongpartnershiparrangementstomovethechallengingagendaforwardthatissetoutinthe“WorkingTogethertoReduceHarm”10yearstrategyforsubstancemisusepublishedin2008andsecurefurtherimprovementsinthequalityofsubstancemisuseservicesdeliveredacross Wales.
3. TheSubstanceMisuseCoreStandardscontainedinthisguidanceaimtosupportpartnersindeliveringthecommitmentinthestrategytoimprovingthequalityandconsistencyofsubstancemisuseservicesinWalesandrespondingtothefindingsofthefirstcomprehensivereviewofsubstancemisuseservicesinWalesundertakenbyHealthcareInspectorateWales2.ThereportofthatreviewoutlinedseveralareasthatneededstrengtheningtoensurethatafullrangeofgoodqualityservicesaredeliveredconsistentlythroughoutWalestomeettheneedsofthepopulation.
Development of the Core Standards
4. ThedraftCoreStandardsweredevelopedfromtheoriginalHealthcareStandardsusedbyHealthInspectorateWalestoundertakethefirstreviewofsubstancemisuseservices.TheywerealsocrossreferencedagainstthereviseddraftHealthcareStandardsforWalestoensuresynergyofapproach.FollowingextensiveconsultationwithstakeholdersfromacrossWales,the CoreStandardshavebeenrefinedandre-checkedagainstthefinal,revisedHealthcareStandardsforWaleswhichhaverecentlybeenpublished.These arereproducedatAnnex1forinformation.
1LocalHealthBoards,LocalAuthorities,PoliceForce,PoliceAuthoritiesandFireService2HealthCareInspectorateWales-SubstanceMisuseServices:AllWalesReviewOfSubstitutePrescribing
Services2009
3
The Core Standards
5. Thereare25CoreStandardsforSubstanceMisusepresentedinthisdocument.Thestandardsarenotinpriorityorderandhavebeengroupedtoreflecttheendtoendprocessofserviceplanninganddelivery.Embedded throughouttheCoreStandardsarethekeythemesofcitizeninvolvement,accountability,governance,safeguarding,riskmanagement,equity,diversity,safety,qualityassuranceandeffectiveness.
6. TheCoreStandardsdonotreplaceorprecludeotherstandardssuchasprofessionalstandards,clinicalguidelinesandstandardsforhealthandsocial care.TheaimoftheCoreStandardsisto:
•Strengthenthegovernanceandaccountabilityofsubstancemisuseserviceplanninganddelivery;
•Ensurethatacitizenfocussedapproachisintegratedintoallkeyactivitiesrelatedtoserviceplanning,reviewanddelivery;andultimately,
•Ensurethatthefullrangeofservicesaredeliveredeffectively,safelyandconsistentlyacrossWales.
Applying the Core Standards
Responsible Authorities
7. AlloftheCoreStandardsandtherelatedminimumrequirementswillapplytoeachCommunitySafetyPartnershipsinWales.OnceSubstanceMisuseAreaPlanningBoardshavematured,itisenvisagedthatCommunitySafetyPartnershipwillbeabletodischargeandevidencetheachievementoftheseCoreStandardsattheSubstanceMisuseAreaPlanningBoardlevel.The CoreStandardsapplytoHealthBoardsinthecontextofdischargingtheirstatutoryresponsibilitiesasaResponsibleAuthoritywithinaCommunitySafetyPartnership/Substance MisuseAreaPlanningBoard.TheHealthcareStandardsforWalesaretheoverarchingstandardsfordrivingimprovementwithintheNationalHealthServiceWales.ThesestandardswillcontinuetobetheprimarymechanismsformonitoringNationalHealthServiceperformancewithinthecontextoftheNationalHealthServicePerformanceImprovementFrameworkandtheAnnualOperatingFramework.EvidencetodemonstratecompliancewiththeHealthcareStandardsforWalescanalsobeusedatCommunitySafetyPartnership/SubstanceMisuseAreaPlanningBoardleveltodemonstratecompliancewiththeCoreStandardsforSubstanceMisuse.
8. ForeaseofreferencetherevisedHealthcareStandardsforWaleshavebeenmappedagainsttheCoreStandardsforSubstanceMisuse.Thekeylegislative,policyandbestpracticethatunderpintheCoreStandardsarereferencedatAnnex2.
4
Substance Misuse Treatment Providers
9. TheapplicabilityofaCoreStandardandaminimumrequirementwithinastandardwilldependuponthetypeofservicesbeingprovidedandnotallwillapplyineverycasetoalltreatmentproviders.AnyexclusionsmustbesupportedbyawrittenagreementbetweentheserviceproviderandtheCommunitySafetyPartnerships/SubstanceMisuseAreaPlanningBoards.
Implementation
10. Community Safety Partnerships, Substance Misuse Area Planning Boards, other partner agencies and service providers must with immediate effect, begin embedding the Core Standards into local policies, practice and governance arrangements.ThisworkshouldbuildupontheimprovementplanningalreadytakingplacetorespondtoHealth InspectorateWales’first comprehensivereviewofsubstancemisuseservicesin Wales.
Monitoring and Assessment
11. TheWelshAssemblyGovernment’sSubstanceMisuseAdvisoryRegionalTeamswillmonitorprogresstoachievetheCoreStandardsthroughtheroutineperformancemonitoringsystem;thiswillincludeanannualreportofprogress.Inaddition,HealthInspectorateWaleswill,infuturereviews,use theSubstanceMisuseCoreStandardstomeasureandassessthesafetyandqualityofsubstancemisuseservicesinWales.
5
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
Serv
ice P
lannin
g
1Go
vern
ance
arr
ange
men
ts re
pres
entin
g be
st
prac
tice
are
in p
lace
at C
omm
unity
Saf
ety
Partn
ersh
ip a
nd S
ubst
ance
Misu
se A
rea
Plan
ning
Boa
rd le
vels
whi
ch a
pply
the
prin
ciples
of
sou
nd co
rpor
ate
and
finan
cial g
over
nanc
e.
i.Or
ganis
ation
al/Bo
ardC
odeo
fCon
duct
base
donN
olan
princ
iples
anda
syste
mfor
comm
unica
tingt
heC
ode.
ii.Pa
rtners
hipfr
amew
orkag
reeme
ntwh
ichm
usti
nclud
ea s
hared
fina
ncial
riskp
rotoc
ol,de
cision
mak
ingst
ructur
es
and t
hero
lesan
dres
pons
ibiliti
esof
keyo
fficers
and p
artne
rs.
iii.A
llpart
nero
rganis
ation
sofC
ommu
nityS
afety
Partn
ership
san
dSub
stanc
eMisu
seA
reaPl
annin
gBoa
rdsm
usta
greea
mi
nimum
leve
lofr
epres
entat
ionat
whic
hform
alde
cision
ma
kingw
illbe
quora
te.
iv.A
llpart
nero
rganis
ation
smus
tber
epres
ented
atan
ap
propri
ately
senio
rleve
lat7
5%of
Com
munit
ySafe
tyPa
rtners
hipan
dSub
stanc
eMisu
seA
reaPl
annin
gBo
ard m
eetin
gs.
v.Ac
rosst
heC
ommu
nityS
afety
Partn
ership
andS
ubsta
nce
Misu
seA
reaPl
annin
gBoa
rdthe
resh
ould
be:
•Ind
uctio
nproc
esse
sfor
new
direc
torsa
ndse
nior s
taff
•Ind
uctio
nproc
esse
sfor
allst
aff
•Re
gister
ofin
teres
ts
•Int
ernal
audit
arran
geme
ntsto
inclu
deno
nfina
ncial
audit
an
dman
agem
enta
udit
Heal
thca
re S
tand
ards
for W
ales
1 :Go
verna
ncea
ndA
ccoun
tabilit
yFram
ework
.
Heal
thca
re S
tand
ards
for W
ales
4 :Civ
ilCon
tinge
ncya
ndEm
ergen
cyPl
annin
gArra
ngem
ents.
Heal
thca
re S
tand
ards
for W
ales
22:
Mana
gingR
iskan
dHea
lthan
dSafe
ty.
6
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•St
ateme
ntof
intern
alco
ntrol
which
iden
tifies
thes
ource
sof
assu
rance
•Sy
stem
ofris
kasse
ssmen
tand
riskm
anag
emen
tofr
isks
affec
tingp
lannin
gord
elive
ryof
subs
tance
misu
sese
rvice
s
•Em
ergen
cypl
annin
gsys
temsa
ndco
nting
ency
ma
nage
ment
plans
inpl
acet
ores
pond
appro
priate
ly
toan
emerg
ency.
•Ris
kReg
ister
•Go
verna
ncea
ndRi
skCo
mmitte
e(s)
foral
lserv
ices
•St
affco
nsult
ation
andc
ommu
nicati
onsy
stem
•Pe
rform
ance
Man
agem
ents
ystem
•St
akeh
older
cons
ultati
onsy
stem
•Arr
ange
ments
fore
xterna
laud
it
2A
Com
miss
ioni
ng s
trate
gy, a
nnua
l deli
very
an
d ex
pend
iture
pla
ns a
re in
pla
ce, a
gree
d an
d pu
blish
ed.
Strat
egya
ndre
lated
deliv
eryan
dexp
endit
urepl
ansr
eflec
tan
asse
ssmen
tofn
eedw
ithin
tende
dmea
surab
leou
tcome
sare
produ
cedi
nline
with
natio
nalg
uidan
ce.
i.Tre
atmen
tSys
temde
signi
nclud
esal
ltier
soft
reatm
ent,
demo
nstra
tesIn
tegrat
edC
arePa
thway
s(ICP
)an
d acce
ss po
ints.
ii.Th
eCom
missi
oning
Stra
tegym
usti
nclud
eana
nnua
lrev
iew cy
cle.
Heal
thca
re S
tand
ards
for W
ales
1 :Go
verna
ncea
ndA
ccoun
tabilit
yFram
ework
.
Heal
thca
re S
tand
ards
for W
ales
8 :Ca
rePla
nning
and P
rovisio
n.
7
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
iii.S
ervice
users
,fam
iliesa
ndca
rersm
ustb
einc
luded
inth
ede
velop
ment
andr
eview
ofst
rateg
iesan
d plan
s.
iv.T
hene
edso
fdive
rsegr
oups
aret
aken
into
acco
unt
appro
priate
lyan
ddem
onstr
ateco
mplia
ncew
ith
relev
ant l
egisla
tion.
v.Th
enee
dsof
vulne
rable
group
sare
taken
into
acco
unt
appro
priate
lyan
ddem
onstr
ateco
mplia
ncew
ith
relev
ant l
egisla
tion.
vi.A
lldeli
very
plans
mus
tbeu
nder-
pinne
dbya
loca
lwork
force
de
velop
ment
plan,
inlin
ewith
theS
ubsta
nceM
isuse
Wo
rkforc
eDev
elopm
entA
ction
Plan
ando
therr
eleva
ntwo
rkforc
eplan
s.
vii.A
llinte
rventi
onsc
ommi
ssion
edm
ustb
ebas
edup
onev
idenc
eof
effec
tiven
esso
rdem
onstr
atean
evalu
ation
proc
ess,
coup
ledw
itha
riskm
anag
edex
itstr
ategy
.
viii.D
ecisio
nson
inve
stmen
tand
disin
vestm
entm
ustb
eevid
ence
ba
sed,
taken
with
inan
agree
dfram
ework
forp
rioriti
satio
nan
dsub
jectt
oapp
ropria
teco
nsult
ation
.
ix.S
trateg
iesan
drela
tedpl
ans,
servi
cesp
ecific
ation
s,co
ntrac
ts an
dServ
iceLe
velA
greem
ents
(SLA
s)mu
stref
lect
theC
ore S
tanda
rdsfo
rSub
stanc
eMisu
se.
x.All
fund
edse
rvice
smus
tbes
uppo
rtedb
yserv
ice
spec
ificati
onsa
ndha
veag
reeda
ndsi
gned
contr
acts
orSL
As in
plac
e.
8
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
xi.A
llserv
icesw
ithin
thetr
eatm
ents
ystem
ares
ubjec
ted
tofor
mal,
quart
erlyr
eview
sand
find
ingsr
eport
edto
the
appro
priate
Sub
stanc
eMisu
seA
reaPl
annin
gBoa
rd/Co
mmun
ityS
afety
Partn
ership
.
3Co
mm
unity
Saf
ety
Partn
ersh
ip/S
ubst
ance
M
isuse
Are
a Pl
anni
ng B
oard
wid
e pl
ans
are
in
plac
e to
i. Id
entif
y he
alth
impr
ovem
ent r
equi
rem
ents
re
late
d to
sub
stan
ce m
isuse
;
ii. R
espo
nd a
ppro
pria
tely
; and
,
iii. M
easu
re im
prov
emen
ts a
nd th
e re
ducti
on in
in
equa
lities
.
iA
Comm
unity
Safe
tyPa
rtners
hip/S
ubsta
nceM
isuse
Area
Pla
nning
Boa
rdwi
desy
stem
inpla
cew
hichc
ontai
ns
acco
untab
ilityl
evels
andd
ecisio
nmak
ingpr
otoco
lsfor
the
colla
tion,
analy
sisan
dapp
licatio
nofi
nform
ation
for
asse
ssing
andr
espo
nding
tosu
bstan
cem
isuse
relat
edhe
alth
issue
s.As
ami
nimum
thes
ystem
shou
lden
able
there
gular
an
drou
tiner
eview
ofth
efoll
owing
:
•Th
eCom
missi
oning
Stra
tegya
ndre
lated
plan
.
•De
livery
andi
mpac
tasse
ssmen
toft
hean
nual
subs
tance
mi
suse
servi
ceim
prove
ment
ande
xpen
diture
plan
•Co
ntribu
tiont
othe
deliv
eryof
relat
edst
rateg
ies;
e.g.H
ealth
andW
ellbe
ingS
trateg
ies,S
trateg
icAs
sessm
ent
andP
lanfo
rActi
onof
Crim
e,Dis
order
andS
ubsta
nce
Misu
se,H
ousin
g Stra
tegy.
Heal
thca
re S
tand
ards
for W
ales
3 :He
althP
romoti
on,P
rotec
tion a
ndIm
prove
ment.
Heal
thca
re S
tand
ards
for W
ales
4 :Civ
ilCon
tinge
ncya
ndEm
ergen
cyPl
annin
gArra
ngem
ents.
9
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Pro
gress
toward
sach
ieving
theW
elshA
ssemb
lyGo
vernm
entK
eyPe
rform
ance
Indic
ators
for
subs
tance
misu
se.
•An
alysis
ofda
tafro
mthe
Trea
tmen
tOutc
omeP
rofile
(TOP
)
•Re
sults
ofpu
blica
nd/o
rserv
iceus
erco
nsult
ation
s
•Re
sults
ofse
rvice
user
satis
factio
nsurv
eys
•Su
bstan
cem
isuse
relat
edpu
blich
ealth
data
includ
ing:
-pre
valen
cean
dinc
idenc
eofb
loodb
orne v
iruse
s
-up
takeo
fdiag
nosis
andt
reatm
entf
orblo
od
borne
virus
es
-co
verag
eofH
epati
tisB
vacci
natio
nint
he
vulne
rable
popu
lation
-pre
valen
ceof
prob
lemati
cand
injec
tingd
rug us
e
-pre
valen
ceof
alco
holre
lated
morb
idity
and m
ortali
ty
•Dr
ugre
lated
death
sand
near
fatal
incide
nts
•Ad
verse
even
tsan
dnea
rmiss
es
•Re
sults
ofca
se&
clini
cala
udits
•Wo
rkforc
edev
elopm
entp
lans
10
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
ii.Co
mmun
ityS
afety
Partn
ership
s/Su
bstan
ceM
isuse
Area
Pla
nning
Boa
rdsm
usth
avei
nplac
eagre
edpl
answ
ith
treatm
entp
rovide
rsfor
resp
ondin
gto e
merge
ncys
afety
alerts
onco
ntami
nated
batch
esof
illicit
drug
sand
iden
tified
blo
odbo
rnevi
rusth
reats.
iii.C
ommu
nityS
afety
Partn
ership
/Sub
stanc
eMisu
seA
rea
Plann
ingB
oard
wide
plan
sfor
there
ducti
onof
drug
relat
ed
litter
thatc
ompli
esw
ithcu
rrent
legisla
tiona
ndgu
idanc
eco
verin
gasa
mini
mum:
•Re
cordi
ngan
dmap
pingo
fincid
ence
sand
hot-s
pots
for
drugr
elated
litter
•Ma
ximizi
ngap
propri
atesa
feco
mmun
itydi
spos
al
•Ed
ucati
onan
dtrai
ning
•Pro
vision
ofho
tlines
forr
eport
ing
•Co
nside
ration
ofpu
blics
pace
desig
n
•Co
mmun
icatin
gwith
thep
ublic
11
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
4Ha
rm re
ducti
on a
ppro
ache
s ar
e co
mpl
iant
with
leg
islat
ion
and
guid
ance
and
are
em
bedd
ed
thro
ugho
ut th
e tre
atm
ent s
yste
m.
i.All
comm
ission
ingst
rateg
iesan
dplan
smus
tens
ureth
eav
ailab
ilityo
fthe
fullr
ange
ofsu
bstan
cem
isuse
harm
red
uctio
nserv
icesb
ased
upon
anob
jectiv
easse
ssmen
tof
need
.
ii.Se
rvice
Leve
lAgre
emen
ts(S
LAs)
andc
ontra
ctsm
ust
reflec
t curr
entg
uidan
ce,c
linica
lbes
tprac
tice,
andl
egisla
tive
requir
emen
ts.
iii.S
ervice
users
andt
heirf
amilie
s/ca
rersa
repro
vided
with
ad
vicea
ndin
forma
tiono
nself
-care
which
asa
minim
um
shou
ldinc
lude:
•ov
erdos
eprev
entio
n
•sa
fety-
theh
ome
•rel
apse
prev
entio
n
•sa
ferin
jectin
g
•Sa
fese
x
•Se
xual
healt
h
•Ne
edle
stick
injur
y
•Sa
fedis
posa
lofu
sede
quipm
ent
Heal
thca
re S
tand
ards
for W
ales
8 : Ca
rePla
nning
andP
rovisio
n.
12
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•wo
undc
are
•ora
lhyg
iene
•he
althy
eatin
g
iv.S
ervice
users
mus
tbep
rovide
dwith
infor
matio
nand
whe
reap
propri
ate,t
rainin
gont
heus
eofm
edica
lequ
ipmen
t,de
conta
mina
tion,
medic
inesa
nddi
spos
alof
waste
.
5Pl
anni
ng a
nd d
elive
ry o
f tre
atm
ent e
nsur
es
timely
and
equ
itabl
e ac
cess
to s
ervi
ces
i.Ac
hieve
ment
again
stthe
Nati
onal
Subs
tance
Misu
seK
ey
Perfo
rman
ceIn
dicato
rs1
-6an
dthe
irrela
tedta
rgets
andt
heTr
eatm
entO
utcom
eProf
ileda
taare
mon
itored
an
drep
orted
atS
ubsta
nceM
isuse
Area
Plan
ningB
oard/
Comm
unity
Safe
tyPa
rtners
hiple
velo
naqu
arterl
ybas
is.
ii.All
servi
cesh
avep
ublish
edW
aiting
List
Mana
geme
ntPo
licies
inc
luding
prior
itisati
oncr
iteria
andm
anag
emen
tofw
aiting
list
sinl
inew
ithW
elshA
ssemb
lyGu
idanc
e (20
07).
iii.F
ullco
mplia
ncew
ithth
erep
orting
requ
ireme
ntsof
theW
elsh
Natio
nalD
ataba
sefo
rSub
stanc
eMisu
se(W
NDSM
).
iiiv.A
servi
ceus
erac
cess
policy
that
hasb
eend
evelo
peda
nd
agree
dwith
servi
ceus
ersis
publi
shed
.
v.Th
ereis
apu
blish
edup
toda
tese
rvice
direc
torya
vaila
bleat
aS
ubsta
nceM
isuse
Area
Plan
ningB
oard/
Comm
unity
Safe
tyPa
rtners
hiple
vel.
Heal
thca
re S
tand
ards
for W
ales
8 : Ca
rePla
nning
andP
rovisio
n
13
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
6Ef
fecti
ve in
form
atio
n sy
stem
s an
d in
tegr
ated
in
form
atio
n te
chno
logy
is u
sed
to in
form
an
d su
ppor
t the
pla
nnin
g an
d de
liver
y of
tre
atm
ent s
ervi
ces.
i.All
orga
nisati
onst
ocom
plyw
ithth
erep
orting
requ
ireme
nts
ofthe
Wels
hNati
onal
Datab
asef
orSu
bstan
ceM
isuse
and
theTr
eatm
entO
utcom
eProf
ile D
ataba
se.
ii.All
comp
rehen
sivea
ssessm
ents
must
includ
easa
mini
mum
thedo
mains
conta
inedw
ithin
theW
elshI
n-dep
thInt
egrat
ed
Subs
tance
Misu
seA
ssessm
entT
ool (
WIIS
MAT)
.
iii.
Allas
sessm
ents
must
beca
pable
ofbe
ingsh
areda
nd
utilise
dbetw
eent
reatm
entp
rovide
rs.
iv.I
nform
ation
shari
ngpr
otoco
lsare
inpl
acea
tCom
munit
ySa
fetyP
artne
rship
andS
ubsta
nceM
isuse
Area
Plan
ning
Board
leve
land
subje
ctto
syste
matic
testi
ngan
drev
iew.
v.Inf
ormati
onsh
aring
proto
cols
arein
plac
ebetw
eens
ervice
pro
viders
with
inat
reatm
ents
ystem
(inc
luding
prov
iders
ofsu
pport
ingse
rvice
ssuc
hash
ousin
g)w
hicha
resu
bject
tosy
stema
ticte
sting
andr
eview
.
Heal
thca
re S
tand
ards
for W
ales
19:
Inform
ation
Man
agem
enta
ndC
ommu
nicati
onTe
chno
logy.
14
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
vi.
Subs
tance
Misu
seA
reaPl
annin
gBoa
rds/
Comm
unity
Safe
tyPa
rtners
hipsh
aved
evelo
ped,
and i
mplem
ented
aco
mpreh
ensiv
eperf
orman
cein
forma
tion
mana
geme
ntfra
mewo
rktha
tena
blest
heas
sessm
ent
ofse
rvice
perfo
rman
ceag
ainst
natio
nala
ndlo
cal
perfo
rman
ce in
dicato
rs.
7Pe
ople
acce
ssin
g tre
atm
ent a
re n
ot u
nfai
rly
disc
rimin
ated
aga
inst
on
the
grou
nds
of a
ge,
gend
er, d
isabi
lity,
eth
nicit
y, ra
ce, r
eligi
on,
or s
exua
l orie
ntat
ion.
i.All
orga
nisati
onsm
usth
avep
olicie
sand
proc
edure
sin
place
that
includ
e:
•Ar
ecog
nised
lead
offic
erwi
thde
signa
tedac
coun
tabilit
yan
dres
pons
ibility
•An
asse
ssmen
tofn
eedb
ased
upon
aneq
uality
impa
ctas
sessm
entt
hatin
clude
saco
mmun
itypr
ofile
ofag
e,ge
nder
ande
thnic
group
s
•Se
rvice
user
surve
ys
•Sy
stems
fora
ssessi
ngth
esuit
abilit
yofp
remise
sfor
disab
ledpe
ople
•Me
chan
ismst
oide
ntify
andr
espo
ndto
loca
lnee
dsof
sp
ecific
grou
ps,s
ucha
sAge
Conc
ernan
dloc
alEth
nic
Mino
rityCo
mmun
ityLe
aders
.
•Me
chan
ismst
orais
e,inv
estig
atean
drep
ortco
ncern
san
d com
plaint
s
Heal
thca
re S
tand
ards
for W
ales
2 : Eq
uality
,Dive
rsity
andH
uman
Righ
ts.
15
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
8Th
e vi
ews
of s
ervi
ce u
sers
, car
ers,
rela
tives
an
d th
e pu
blic
are
take
n in
to a
ccou
nt in
the
desig
n, p
lann
ing,
deli
very
and
revi
ew o
f all
subs
tanc
e m
isuse
ser
vice
s, in
cludi
ng g
ener
al
advi
ce a
nd in
form
atio
n.
i.Co
mmiss
ioning
plan
s,se
rvice
spec
ificati
onsa
ndth
eir
asso
ciated
SLA
s/Co
ntrac
tsmu
stinc
ludep
olicie
sand
pro
cedu
resfo
reng
agem
entw
ithth
ecom
munit
y,se
rvice
users
:
•Co
nsult
ation
mec
hanis
msw
ithth
epub
lic,se
rvice
users
,ca
rersa
ndin
teres
tgrou
pssu
chas
AgeC
once
rn,S
choo
ls,
Barna
rdos,
Mino
rityEt
hnic
Comm
unitie
s,loc
alres
ident
group
sand
Comm
unity
Hea
lthCo
uncils
•No
mina
ted“C
hamp
ions”
atCo
mmun
ityS
afety
Partn
ership
an
dSub
stanc
eMisu
seAr
eaPl
annin
gBoa
rd lev
els
•Me
chan
ismst
osys
temati
cally
revie
wfee
d-bac
kfrom
se
rvice
user
satis
factio
nsurv
eys,
feedb
ackf
ormsa
nd
sugg
estio
nsch
emes
•Ed
ucati
on/t
rainin
gprog
ramme
fork
eyst
affin
volve
din
cons
ultati
onw
orkal
igned
toth
erele
vant
Natio
nal
Occu
patio
nalS
tanda
rds
Repo
rton
how
feedb
ackh
asbe
enus
ed
Heal
thca
re S
tand
ards
for W
ales
5 : Cit
izenE
ngag
emen
tand
Feed
back
16
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
9Th
e pr
incip
les o
f qua
lity
and
safe
ty u
nder
pin
the
deliv
ery
of s
ervi
ces.
i.A
clinica
leffe
ctive
ness
strate
gyis
inpl
acet
hati
ncorp
orates
clin
icalg
overn
ance
andc
linica
laud
itfor
ensu
ringt
hatu
pto
date,
evide
nceb
ased
prac
ticei
smain
taine
d.
ii.Ag
reean
orga
nisati
onw
idere
portin
gsys
temw
hichc
ontai
ns
mech
anism
sand
acco
untab
ilityl
evels
fort
heef
fectiv
ega
therin
gand
useo
finfo
rmati
onfo
rqua
lityan
dsafe
tymo
nitori
ngan
d dec
isionm
aking
purpo
ses.
Thes
ystem
shou
ldcle
arlyi
ndica
tewh
atinf
ormati
onis
requ
ireda
t wha
tlev
elan
dthe
purpo
sefo
rwhic
hiti
sbein
g prov
ided.
iii.A
sam
inimu
m,th
esys
temsh
ould
includ
eare
view
and
report
of:
•Ca
sean
d/or
clinica
laud
itfind
ingsa
ndou
tcome
s
•Nu
mbers
ofm
ulti-d
iscipl
inary/
agen
cyau
dits,
level
ofpa
rticipa
tion,
findin
gsan
doutc
omes
•Ad
verse
even
trep
ortsa
ndou
tcome
s
•Im
pleme
ntatio
nofe
viden
ce-ba
sedp
ractic
e
•Pro
gress
again
stthe
Sub
stanc
eMisu
seW
orkfor
ce
Deve
lopme
ntAc
tionp
lan
•Pe
rform
ance
again
stSL
As/C
ontra
cts
•Ra
tiona
lean
dcos
tsof
using
agen
cy,ba
nkan
dloc
um st
aff
Heal
thca
re S
tand
ards
for W
ales
1 :Go
verna
ncea
ndA
ccoun
tabilit
yFram
ework
.
Heal
thca
re S
tand
ards
for W
ales
7 :Sa
fean
dClin
ically
Effec
tiveC
are
Heal
thca
re S
tand
ards
for W
ales
19:
Inform
ation
Man
agem
enta
ndC
ommu
nicati
onsT
echn
ology
.
17
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
10Se
rvice
use
rs a
re p
rovi
ded
with
evi
denc
e ba
sed
inte
rven
tions
and
care
that
conf
orm
s to
all
relev
ant,
exta
nt g
uida
nce.
i.Me
chan
ismsa
rein
place
forr
outin
eand
regu
larca
se
audit
, clin
icala
udit
andr
eview
inclu
dings
ystem
sto
imple
ment
chan
ges.
ii.All
servi
cesp
ecific
ation
s,SL
Asan
dcon
tracts
refle
ctsp
ecific
rel
evan
tguid
ance
.
iii.S
ystem
sare
inpla
cefo
rens
uring
that
best
practi
ceis
rou
tinely
iden
tified
andi
mplem
ented
.
iv.S
ervice
sprov
ideed
ucati
onan
dtrai
ningp
rogram
mesf
orsta
fftha
trefl
ectb
estp
ractic
eand
guide
lines
.
v.Po
licies
arei
nplac
efor
theco
ntinu
ingpr
ofessi
onal
deve
lopme
ntof
staff.
Heal
thca
re S
tand
ards
for W
ales
7 :Sa
fean
dClin
ically
Effec
tiveC
are
Heal
thca
re S
tand
ards
for W
ales
26:
Workf
orceT
rainin
gand
Orga
nisati
onal
Deve
lopme
nt
11Se
rvice
use
rs a
re p
rovi
ded
with
resp
onsiv
e,
appr
opria
te a
nd s
eam
less
inte
rven
tions
an
d ca
re th
at re
flects
their
phy
sical
, soc
ial,
psyc
holo
gica
l nee
ds a
nd p
refe
renc
es.
i.All
indiv
iduals
enter
ingst
ructur
edtr
eatm
entm
odali
ties
receiv
eaco
mpreh
ensiv
easse
ssmen
tofn
eedt
hata
sa
minim
umin
clude
sthe
relev
antd
omain
scon
taine
dwith
inthe
W
IISMA
Tasse
ssmen
ttoo
l.
ii.Th
easse
ssmen
tmus
tcon
sider
andr
ecord
them
ost
appro
priate
orpr
eferre
dtrea
tmen
tand
care,
irres
pecti
ve
of wh
ether
thatt
reatm
enti
sava
ilable
.
iii.F
ollow
ingC
ompre
hens
iveA
ssessm
ent,
aCare
Plan
is ag
reed
betw
eent
hetr
eatm
entp
rovide
rand
thes
ervice
user.
Heal
thca
re s
tand
ards
for W
ales
8 :Ca
rePla
nning
and P
rovisio
n.
Heal
thca
re s
tand
ards
for W
ales
9 :Pa
tient
Inform
ation
andC
onse
nt
Heal
thca
re s
tand
ards
for W
ales
18:
Comm
unica
ting
Effec
tively
.
18
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
iv.M
echa
nisms
mus
tbei
nplac
efor
thesy
stema
ticre
view
ofca
repla
ns(m
inimu
m3
month
ly)w
ithth
eserv
iceus
er.
Revis
edca
repla
ns,f
inding
sand
outco
mess
hould
beag
reed
betw
eent
hetr
eatm
entp
rovide
rand
thes
ervice
user.
v.Th
erem
ustb
eapu
blish
edD
irecto
ryof
Servi
cest
hati
nclud
es
acce
ssinf
ormati
onan
dcrite
ria.
vi.M
echa
nisms
mus
tbei
nplac
etoc
ondu
ctan
dlea
rnfro
mse
rvice
user
satis
factio
nsurv
eys.
vii.M
echa
nisms
mus
tbei
nplac
etom
onito
rand
addre
ssdro
p-out
rates
,re-a
dmiss
ionra
tes,p
lanne
dand
unpla
nned
dis
charg
edata
.
viii.R
eferra
land
infor
matio
nsha
ringp
rotoc
olsm
ustb
einp
lace
forre
spon
dingt
oani
ndivi
duals
’non
-subs
tance
misu
se
spec
ificne
eds.
Asa
minim
umth
ismu
stinc
lude:
•Pre
gnan
cy
•Co
-occu
rringm
ental
healt
hnee
ds
•Ch
ildPr
otecti
on
•Pro
tectio
nofV
ulnera
bleAd
ults
•Ho
using
•Ge
neral
healt
h,inc
luding
oral
healt
h
•Ed
ucati
on
19
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
12Se
rvice
pro
vide
r pre
mise
s ar
e en
viro
nmen
tally
sa
fe, s
ecur
e an
d pr
oper
ly a
cces
sible
and
as a
m
inim
um ta
ke a
ccou
nt o
f:
•Pu
blic
and
staf
f saf
ety
and
well
bein
g
•Di
ffere
nt se
rvice
use
rs n
eeds
, for
exa
mpl
e w
heelc
hair
acce
ss
•Pr
ivac
y an
d Co
nfide
ntia
lity
•Pr
otec
t peo
ple,
pro
perty
and
ass
ets
Allsi
tesfr
omw
hichs
ubsta
ncem
isuse
servi
cesa
rede
livere
dmus
tha
veth
efoll
owing
inpl
ace:
i.He
altha
ndS
afety
policy
.
ii.Bu
ilding
cond
itions
urvey
s.
iii.F
iresa
fetya
udits
.
iv.H
ospit
alPa
tient
Envir
onme
ntas
sessm
ents
forho
spita
lba
sed s
ervice
s.
v.Mo
nitori
ngof
haza
rd/de
fectl
ogsf
orfre
quen
cyan
dtim
efro
mrep
ortto
repa
ir.
vi.R
eport
sofp
ractic
esan
ddrill
s
vii.C
ompli
ance
with
main
tenan
cepl
ans.
viii.E
viden
ceof
cons
ultati
onw
ithse
rvice
users
andt
he
local
publi
c.
ix.R
eview
incid
ents,
comp
laints
andc
laims
whic
hcite
build
ing
desig
n,co
nditio
n,en
viron
menta
lperf
orman
ceor
secu
rityas
ac
ontrib
utory/
rootc
ause
.
x.Dis
abilit
yimp
acta
ssessm
ent.
Heal
thca
re S
tand
ards
for W
ales
12:
Envir
onme
nt
20
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
xi.E
nviro
nmen
talm
anag
emen
tsys
temis
inpl
acea
nd
subje
ctto
syste
matic
revie
wan
dimp
rovem
entw
hich
comp
liesw
ith le
gislat
ionan
dbes
tprac
ticei
nasse
ssing
an
d man
aging
risk)
.Toi
nclud
e:
•AR
iskRe
gister
•Tra
inedi
ndivi
duals
•Sy
stem
forlo
gging
andr
eview
ingco
mplai
nts
•Re
portin
gmec
hanis
m,an
dacco
untab
ilityl
evel
for
monit
oring
repo
rtsan
drem
edial
actio
n
xii.P
olicie
sand
proc
edure
sinp
laceg
overn
ingth
econ
trolo
fvis
itors
such
asco
ntrac
tors.
xiiip
olicie
sand
proc
edure
stos
afegu
ardou
treac
hwork
ers.
13Se
rvice
use
rs a
re tr
eate
d w
ith d
igni
ty a
nd
resp
ect t
hat i
s se
nsiti
ve to
indi
vidu
al n
eed,
in
cludi
ng la
ngua
ge, c
ultu
ral a
nd p
hysic
al n
eeds
.
i.Co
mmun
icatio
nskil
lstra
ining
prog
ramme
isin
plac
efor
staff.
ii.Div
ersity
train
ingpr
ogram
mesa
rein
place
fors
taff.
Heal
thca
re S
tand
ards
for W
ales
8 :Ca
rePla
nning
andP
rovisio
n.
Heal
thca
re S
tand
ards
for W
ales
9 :Pa
tient
Inform
ation
andC
onse
nt.
Heal
thca
re S
tand
ards
for W
ales
10:
Dignit
yand
Res
pect
21
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
iii.P
olicie
sand
proc
edure
sond
ignity
andr
espe
ct,in
forme
dco
nsen
tand
theu
seof
infor
matio
nand
itsc
onfid
entia
lity
are de
velop
ed,a
greed
,and
their
appli
catio
ninp
ractic
erou
tinely
audit
ed.
iv.A
norga
nisati
onw
ideC
ontra
ctof
Care
isin
place
sign
ed
byea
chse
rvice
user
andk
eyw
orker.
Asa
mini
mum,
the
Con
tract
ofCa
resh
ould
cove
rthe
stan
dards
ofco
nduc
tan
dbeh
aviou
rfor
servi
ceus
ersan
dstaf
fand
inclu
de
mech
anism
sfor
deali
ngw
ithin
appro
priate
beha
viour.
It
shou
ldbe
revie
weda
spart
ofor
ganis
ation
alsta
ffma
nage
ment
syste
msan
dproc
esse
s.
v.Po
licies
andp
roced
uresm
ustb
einp
lacet
hati
nclud
eas
a mini
mum:
•We
lshLa
ngua
gere
quire
ments
.
•Ot
herla
ngua
gesa
ndcu
ltures
comm
onto
thea
rea.
•Co
mmun
icatio
nwith
nomi
nated
relat
ives,
carer
sor f
riend
s.
22
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Co
mmun
icatio
nwith
blind
and/
orde
afse
rvice
users
.
•Se
rvice
Use
rRea
dingP
anels
oflo
cally
prod
uced
writt
en
inform
ation
.
•En
surin
gpriv
acya
ndco
nfide
ntiali
ty.
•Th
erou
tinea
nalys
isof
comp
laints
relat
edto
poor
comm
unica
tion.
vi.P
roces
sesi
nplac
etom
onito
rand
revie
wco
mplia
ncew
ith
equa
lityan
ddive
rsity
legisla
tion.
14Se
rvice
use
r inf
orm
atio
n is
treat
ed
conf
iden
tially
, exc
ept w
here
aut
horis
ed b
y leg
islat
ion
to th
e co
ntra
ry.
i.Pu
blish
edpo
licies
andp
roced
uresm
ustb
einp
lacet
hata
sa m
inimu
mco
vert
hefo
llowi
ng:
•Se
rvice
users
aref
ullyi
nform
edab
outt
heirr
ights
toco
nfide
ntiali
tyon
routi
nely
colle
ctedc
lient
inform
ation
su
chas
theT
reatm
entO
utcom
eProfi
le(T
OP),
inform
ation
dis
close
dduri
ngco
mpreh
ensiv
easse
ssmen
t,an
dme
dical
record
s.
•Th
euse
ofpe
rsona
land
confi
denti
alinf
ormati
on.
•Le
gislat
ivere
quire
ments
such
asth
osec
ontai
nedw
ithin
theFr
eedo
mof
Inform
ation
Act(
2000
),Da
taPro
tectio
nAc
t(199
8),t
hePr
otecti
onof
Child
renAc
t(19
99),
Acce
ssto
Healt
hRec
ordsA
ct(1
990)
andP
ublic
Intere
stDis
closu
reAc
t(19
98).
Heal
thca
re S
tand
ards
for W
ales
9 :Pa
tient
Inform
ation
andC
onse
nt
23
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Inf
ormati
onsh
aring
proto
cols
betw
eena
genc
iesin
lin
e with
theW
alesA
ccord
forS
harin
gofP
erson
alInf
ormati
on(W
ASPI)
.
ii.St
affed
ucati
onpr
ogram
mesi
nclud
edea
lingw
ith
confi
denti
ality.
iii.S
taffg
uidan
cein
plac
efor
them
anag
emen
tand
acce
ssof
inform
ation
tose
rvice
users
,fam
ilies,
carer
sand
the
gene
ral pu
blic.
iv.S
ystem
sare
inpla
cefo
rstaf
fand
/ors
ervice
user
report
ing
ofbre
ache
sinc
onfid
entia
lity.
v.Sy
stems
arei
nplac
efor
inves
tigati
ng,r
eport
ingan
dlea
rning
les
sons
from
brea
ches
inco
nfide
ntiali
ty.
24
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
15W
here
food
and
drin
k is
prov
ided
with
in
inpa
tient
or r
esid
entia
l car
e se
tting
s, th
e nu
tritio
nal a
nd fl
uid
need
s of
ser
vice
use
rs a
re
asse
ssed
, rec
orde
d an
d ad
dres
sed
in a
ccor
danc
e w
ith le
gisla
tion
and
guid
ance
.
i.S
ervice
users
arep
rovide
dwith
:
•Ac
hoice
offo
odw
hichi
sprep
areds
afely
inac
corda
nce
with
legisla
tiona
ndgu
idanc
eand
prov
idesa
balan
cedd
iet
thatc
aters
fornu
trition
al,pe
rsona
l,cult
urala
ndcl
inica
ldie
taryr
equir
emen
ts
•An
ynec
essa
rysu
pport
with
eatin
gord
rinkin
gisi
denti
fied
andp
rovide
d
•Ha
veac
cess
tofoo
dand
drink
24
hours
ada
y
Heal
thca
re S
tand
ards
for W
ales
14:
Nutrit
ion
16Or
gani
satio
ns co
mpl
y w
ith n
atio
nal c
hild
pr
otec
tion
guid
ance
with
in th
eir o
wn
activ
ities
an
d in
dea
ling
with
oth
er o
rgan
isatio
ns.
i.Po
licies
andp
roced
uresi
nplac
etha
trefl
ectl
egisla
tive
requir
emen
tsan
dcom
plyw
ithna
tiona
lguid
ance
.Th
is mu
st inc
lude:
•De
signa
tedle
adro
lesan
dres
pons
ibiliti
es
•All
ocati
onof
reso
urces
,e.g.
budg
etan
dstaf
f
•Ma
inten
ance
andr
eview
ofre
levan
tdoc
umen
tation
for
child
prote
ction
•Int
erage
ncyw
orking
&in
forma
tions
harin
gprot
ocols
•Co
nsen
tand
infor
medc
onse
nt
•Av
ailab
ilityo
fserv
iceus
erinf
ormati
on
•Int
erage
ncyt
rainin
gand
educ
ation
prog
ramme
sfor
staff
align
edto
relev
antN
ation
alOc
cupa
tiona
lStan
dards
Heal
thca
re S
tand
ards
for W
ales
11:
Safeg
uardi
ngC
hildre
nand
Safe
guard
ingV
ulnera
bleA
dults
.
25
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Arr
ange
ments
toen
sure
thata
pprop
riatel
yqua
lified
staff
de
liver
care
inlin
ewith
theS
ubsta
nceM
isuse
Work
force
De
velop
ment
Actio
nPlan
,and
othe
rwork
force
plan
s
•Ap
propri
atesu
pervi
siono
fstaf
f
•Re
ferral
proc
esse
sand
mec
hanis
ms
•Ad
voca
cyar
range
ments
•Wo
rking
with
carer
sand
relat
ives
•Me
chan
ismsf
orrev
iewan
dinv
estig
ation
ofca
ses
•Ch
ildfr
iendly
envir
onme
nts
•Sa
ferec
ruitm
enta
ndse
lectio
nproc
esse
sofs
taff
•Ra
isingc
once
rns/m
aking
comp
laints
•Me
chan
ismsf
orinv
estig
ation
andr
eport
ingof
co
ncern
s/co
mplai
nts
•Ra
isingc
once
rns/m
aking
comp
laints
•Me
chan
ismsf
orinv
estig
ation
andr
eport
ingof
co
ncern
s/co
mplai
nts
26
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
i.A
Comm
unity
Safe
tyPa
rtners
hipan
dSub
stanc
eMisu
seA
rea
Plann
ingB
oard
wide
repo
rtings
ystem
tom
onito
rand
revie
wthe
arran
geme
ntsfo
rsafe
guard
ingch
ildren
andc
ompli
ance
wi
thleg
alan
dbes
tprac
ticer
equir
emen
ts.Th
issh
ould
conta
inde
tails
oflin
kage
stoL
ocal
Safeg
uardi
ngC
hildre
n’s’
Board
sand
Chil
drena
ndYo
ungP
eople
’sPa
rtners
hipsa
nd
spec
ifyro
les,r
espo
nsibi
lities
anda
ccoun
tabilit
ylev
elsfo
rthe
eff
ectiv
egath
ering
andu
seof
infor
matio
nfor
monit
oring
and
decis
ionm
aking
purpo
ses.
Asa
minim
umth
ismu
stinc
lude
there
port
andr
eview
of:
•Nu
mber
ofch
ildad
missi
onst
oadu
ltward
s
•Ad
verse
and/
orcri
tical
incide
nts
•Pro
gress
toward
achie
vings
tafft
rainin
gplan
align
edto
the
Subs
tance
Misu
seW
orkfor
ceD
evelo
pmen
tActi
onPl
an
•An
alysis
ofth
eoutc
omeo
frefe
rrals
totre
atmen
t
•Co
mplia
ncew
ithle
gislat
ivere
quire
ments
and
natio
nal g
uidan
ce
•Im
pleme
ntatio
nofr
ecom
mend
ation
saris
ingfr
omre
views
an
d/or
inves
tigati
ons
27
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
17Or
gani
satio
ns co
mpl
y w
ith s
afeg
uard
ing
requ
irem
ents
for t
he p
rote
ction
of v
ulne
rabl
e ad
ults
with
in th
eir o
wn
activ
ities
and
in d
ealin
g w
ith o
ther
org
anisa
tions
.
i.Po
licies
andp
roced
uresa
rein
place
that
reflec
tleg
islativ
ereq
uirem
ents
andc
omply
with
natio
nalg
uidan
ce.
This
must
includ
e:
•De
signa
tedle
adro
lesan
dres
pons
ibiliti
es
•All
ocati
onof
reso
urces
,e.g.
budg
etan
dstaf
f
•Ma
inten
ance
andr
eview
ofre
levan
tdoc
umen
tation
for
safeg
uardi
ngvu
lnerab
lead
ults
•Int
erage
ncyw
orking
andi
nform
ation
shari
ngpr
otoco
ls
•Co
nsen
tand
infor
medc
onse
nt
•Av
ailab
ilityo
fserv
iceus
erinf
ormati
on
•Jo
inttr
aining
ande
duca
tionp
rogram
mesf
orsta
ff
•Arr
ange
ments
toen
sure
appro
priate
lyqu
alifie
dstaf
fde
liver
care
•Ap
propri
atesu
pervi
siono
fstaf
f
•Re
ferral
proc
esse
sand
mec
hanis
ms
•Ad
voca
cyar
range
ments
•Wo
rking
with
carer
sand
relat
ives
•Me
chan
ismsf
orrev
iewan
dinv
estig
ation
ofca
ses
•Se
curity
arran
geme
nts
•Sa
ferec
ruitm
enta
ndse
lectio
nproc
esse
sofs
taff
Heal
thca
re S
tand
ards
for W
ales
11:
Safeg
uardi
ngC
hildre
nand
Safe
guard
ingV
ulnera
bleA
dults
.
28
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Ra
isingc
once
rns/m
aking
comp
laints
•Me
chan
ismsf
orinv
estig
ation
andr
eport
ingof
co
ncern
s/co
mplai
nts
ii.A
Comm
unity
Safe
tyPa
rtners
hipan
dSub
stanc
eMisu
se
AreaP
lannin
gBoa
rdwi
dere
portin
gsys
temto
mon
itora
nd
review
thea
rrang
emen
tsfor
prote
cting
vulne
rable
adult
san
dcom
plian
cew
ithle
gala
ndbe
stpra
ctice
requ
ireme
nts.
This
shou
ldsp
ecify
roles
,res
pons
ibiliti
esan
dacco
untab
ility
levels
fort
heef
fectiv
egath
ering
andu
seof
infor
matio
nfor
monit
oring
andd
ecisio
nmak
ingpu
rpose
s.As
ami
nimum
thi
smus
tinc
ludet
here
port
andr
eview
of:
•Nu
mber
ofch
ildad
missi
onst
oadu
ltward
s
•Ad
verse
and/
orcri
tical
incide
nts
•Pro
gress
toward
achie
vings
tafft
rainin
gplan
align
edto
the
Subs
tance
Misu
seW
orkfor
ceD
evelo
pmen
tActi
onPl
an
•An
alysis
ofth
eoutc
omeo
frefe
rrals
totre
atmen
t
•Co
mplia
ncew
ithle
gislat
ivere
quire
ments
and
natio
nal g
uidan
ce
•Im
pleme
ntatio
nofr
ecom
mend
ation
saris
ingfr
omre
views
an
d/or
inves
tigati
ons
29
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
18Ca
se re
cord
s ar
e cr
eate
d, m
aint
aine
d,
stor
ed a
nd d
ispos
ed o
f in
acco
rdan
ce w
ith
exta
nt le
gisla
tion
and
natio
nal g
uida
nce
that
sa
fegu
ards
ser
vice
use
r con
fiden
tialit
y.
i.Op
eratio
nalp
olicie
sand
proc
edure
sare
inpla
ceco
verin
gthe
cre
ation
ofre
cords
toth
eirul
timate
disp
osal.
Asa
mini
mum
polici
esan
dproc
edure
smus
tcov
erthe
follo
wing
:
•Inf
ormati
onse
curity
policy
inclu
dingF
reedo
mof
Inform
ation
•Inf
ormed
cons
entp
roces
sesf
orus
eofin
forma
tion
•Se
curity
arran
geme
ntsfo
rrec
ordsi
nclud
ing
contr
olled
acce
ss
•Im
pleme
ntatio
noft
heCa
ldico
ttpri
ncipl
es
•En
viron
menta
llysa
festo
ragef
orrec
ords
•Pro
tocols
fort
here
trieva
lofr
ecord
swith
inse
ttim
esca
les
•Me
chan
ismsa
ndpr
oces
sesf
orthe
tran
sport
ation
of
record
s
•Re
cords
arch
ivean
ddisp
osal
policy
•Int
ernal
ande
xterna
laud
itofr
ecord
s
ii.Ind
uctio
nand
refre
sher
traini
ngfo
ralls
taffc
overi
ng
legisla
tivea
ndna
tiona
lguid
ance
onre
cord
keep
ing.
iii.S
ystem
sinp
lacef
orthe
regu
larm
onito
ringa
ndre
view
of rec
ordsm
anag
emen
tsys
tems.
Heal
thca
re S
tand
ards
for W
ales
20:
Reco
rdsM
anag
emen
t.
30
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
19Sy
stem
s ar
e in
pla
ce to
iden
tify,
repo
rt,
inve
stig
ate
and
learn
from
adv
erse
eve
nts
and
near
miss
es in
volv
ing
serv
ice u
sers
.
i.Po
licyan
dproc
edure
sinp
lacew
ithin
servi
cepr
ovide
rorg
anisa
tions
toid
entify
andr
eport
adve
rseev
ents
toCo
mmun
ityS
afety
Partn
ership
/Sub
stanc
eMisu
seA
rea
Plann
ingB
oard
inat
imely
man
ner.
Asa
minim
um
to inc
lude:
•Co
mplia
ncew
ithal
lresp
onsib
leau
thoriti
es’r
equir
emen
tsfor
repo
rtinga
ndin
vesti
gatin
gadv
ersee
vents
•Inv
olving
servi
ceus
ersan
dthe
irfam
ily/c
arers
where
ap
propri
ate,in
inve
stiga
ting,
report
ingan
dlea
rning
from
an
adve
rseev
ento
rnea
rmiss
•Pro
cedu
resin
plac
etol
earn
from
adve
rseev
ents
andn
ear
misse
sand
tran
slate
learni
ngin
torem
edial
actio
n
•Ap
ublish
edin
ciden
trep
orting
policy
andp
roced
ures.
•St
affed
ucati
onpr
ogram
meso
nrep
orting
,inv
estig
ating
andl
earni
ngfr
omad
verse
even
ts
Heal
thca
re S
tnad
ards
for W
ales
23:
Deali
ngw
ithC
once
rnsan
dMan
aging
Incid
ents
20Co
mpl
aint
s ab
out s
ervi
ce p
rovi
sion
and
deliv
ery
are
inve
stig
ated
pro
mpt
ly a
nd th
orou
ghly
and
th
e ou
tcom
e re
porte
d ba
ck to
the
com
plai
nant
.
i.A
publi
shed
comp
laints
proc
edure
inpl
acet
hati
ssub
jectt
oreg
ularr
eview
cove
ringt
hefo
llowi
ng:
•Ho
wto
make
aco
mplai
nt
•No
mina
tedle
adin
dividu
alsw
ithin
each
Comm
unity
Safe
tyPa
rtners
hip/S
ubsta
nceM
isuse
Area
Plan
ningB
oard
anda
llse
rvice
prov
idero
rganis
ation
s
Heal
thca
re S
tnad
ards
for W
ales
23:
Deali
ngw
ithC
once
rnsan
dMan
aging
Incid
ents
31
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
•Inv
estig
ation
andr
eport
ingpr
oced
urean
dtim
esca
le
•Se
rvice
user
group
invo
lveme
nt
•Su
pport
mec
hanis
msfo
rtho
sein
dividu
alsw
hom
ayne
ed
help
inma
kinga
comp
laint.
•Cri
teria
tode
termi
neth
esev
erity
andp
riority
of
comp
laints
.
•Co
nsen
tand
confi
denti
ality
•Ac
cess
torec
ords
•Se
rvice
Use
rsati
sfacti
onsu
rveys
•Re
view
syste
mto
learn
from
comp
laints
andt
ransla
telea
rning
into
servi
cech
ange
s
•Sy
stem
forfe
eding
back
toth
ecom
plaina
nt.
•St
affed
ucati
onpr
ogram
me
Mech
anism
atC
ommu
nityS
afety
Partn
ership
/Sub
stanc
eMisu
se
AreaP
lannin
gBoa
rdlev
elto
review
comp
laints
conc
erning
se
rvice
prov
isiona
ndde
livery
.
32
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
Mana
geme
nt o
f Med
icine
s, Me
dical
devic
es, e
quipm
ent a
nd w
aste
21Th
e m
anag
emen
t of m
edici
nes
inclu
ding
use
an
d st
orag
e w
ill co
mpl
y w
ith co
ntro
lled
drug
s leg
islat
ion,
oth
er le
gisla
tion,
lice
nsin
g an
d gu
idan
ce.
i.Re
portin
gand
revie
wpo
licies
andp
roced
uresa
rein
place
cove
ring:
•Ris
kasse
ssmen
t
•Pro
curem
ents
ystem
sand
proc
edure
s
•Dis
pens
ing,p
rescri
binga
ndad
minis
tratio
nofm
edicin
es
•St
orage
,sec
urity
anda
ccess
•Inc
ident
andh
azard
s
•Ad
verse
even
ts
ii.St
affar
equa
lified
andt
raine
dinp
rescri
binga
nd/o
rad
minis
tering
med
icines
with
inthe
irsco
peof
prac
tice.
iii.S
taffe
duca
tionp
rogram
mesa
rein
place
cove
ringl
egisla
tive
requir
emen
ts,na
tiona
lguid
ance
inclu
dingh
ealth
ands
afety
regula
tions
comm
ensu
ratew
ithth
eirro
le.
iv.A
pprop
riate
inform
ation
avail
able
tose
rvice
users
,fam
ilyan
dca
rerso
nthe
usea
ndsa
festo
rageo
fmed
icines
.
Heal
thca
re S
tand
ards
for W
ales
1 :Me
dicine
sMan
agem
ent.
33
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
22Th
e pr
ocur
emen
t, us
e an
d di
spos
al o
f med
ical
equi
pmen
t and
dev
ices
are
man
aged
pro
perly
w
ithin
curr
ent g
uide
lines
and
legi
slativ
e re
quire
men
ts.
i.Re
portin
gand
revie
wpo
licies
andp
roced
uresa
rein
place
cove
ring:
•Ris
kasse
ssmen
t
•Ad
verse
even
tsan
dnea
rmiss
es
•Ma
inten
ance
,ster
ilisati
on,c
leans
ing&
calib
ration
•Fa
ultre
portin
g,res
pons
eand
conti
ngen
cy
•De
conta
mina
tionf
orreu
sable
items
•Pla
nned
repla
ceme
ntpro
gramm
esfo
requ
ipmen
t
•Ap
propri
atepr
otecti
veeq
uipme
nt
•Pro
curem
ents
ystem
sand
proc
edure
s
•Us
eofe
quipm
ent
•St
orage
,sec
urity
anda
ccess.
•Iss
uean
ddisp
osal
ofsh
arps
•Inc
ident
andh
azard
s
ii.St
affed
ucati
onpr
ogram
mesa
rein
place
cove
ringl
egisla
tive
requir
emen
ts,na
tiona
lguid
ance
inclu
dingh
ealth
ands
afety
regula
tions
comm
ensu
ratew
ithth
eirro
le.
Heal
thca
re S
tand
ards
for W
ales
13:
Infec
tionP
reven
tiona
ndC
ontro
l(IPC
)and
Dec
ontam
inatio
n.
Heal
thca
re S
tand
ards
for W
ales
16:
Medic
alDe
vices
,Equ
ipmen
tand
Diag
nosti
cSys
tems.
34
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
iii.A
pprop
riate
advic
eand
infor
matio
nisr
outin
elyav
ailab
leto
servi
ceus
ers,f
amily
andc
arers
onth
euse
ands
afest
orage
of
equip
ment.
23Or
gani
satio
ns h
ave
hum
an re
sour
ce
man
agem
ent s
yste
ms
in p
lace
that
:
i. Su
ppor
t sta
ff an
d va
lue
the
indi
vidu
al
cont
ribut
ion;
and
ii. T
reat
sta
ff w
ith d
igni
ty a
nd re
spec
t, va
lue,
un
ders
tand
and
resp
ect d
iver
sity.
i.A
forma
l,an
nual
perfo
rman
cere
view
syste
mis
inpla
ce
foral
lstaf
fwhic
hinc
ludes
arev
iewof
perso
nala
nd
profes
siona
ldev
elopm
entn
eeds
.Alls
taffs
hould
have
ape
rsona
ldev
elopm
entp
lanin
linew
ithth
eSub
stanc
eMisu
se
Workf
orceD
evelo
pmen
tActi
onPl
an.
ii.All
staff
rece
ivetr
aining
inpe
rform
ance
revie
wap
propri
ateto
the
irlev
elan
drole
with
inthe
orga
nisati
on.
iii.P
erform
ance
andd
evelo
pmen
talre
view
islin
kede
xplici
tly
tothe
targe
tsco
ntaine
dint
heS
ubsta
nceM
isuse
Work
force
De
velop
ment
Actio
nPlan
ando
therp
rofes
siona
ldev
elopm
ent
requir
emen
tsas
appro
priate
andt
heor
ganis
ation
s’wo
rkforc
ede
velop
ment
plan.
iv.S
ervice
shav
eequ
ality
schem
esan
dpoli
ciesi
nplac
e,tha
t ens
ureth
atall
aspe
ctsof
servi
cede
livery
confo
rmst
oeq
ualiti
esle
gislat
ionan
dguid
ance
v.Hu
manr
esou
rcepo
licesa
resu
bject
tope
riodic
equa
lity
impa
ctas
sessm
ent.
Heal
thca
re S
tand
ards
for W
ales
25:
Workf
orceR
ecrui
tmen
tand
Emplo
ymen
tPrac
tices
35
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
vi.M
echa
nisms
inpl
acew
ithin
servi
cepr
ovide
rorga
nisati
ons
thate
nable
sstaf
ftor
aisec
once
rnsin
confi
denc
eand
wi
thout
prejud
iceto
their
posit
ion,a
bout
anya
spec
tof
servi
cede
livery
,trea
tmen
torm
anag
emen
t.As
ami
nimum
,pro
cedu
ressh
ould
includ
e:
•Co
nfide
ntiali
typo
licypr
otecti
ngin
dividu
alsta
ffwh
orai
se co
ncern
s
•Pu
blish
edpr
oced
uresf
orinv
estig
ating
andr
eport
ing
findin
gsw
ithin
treatm
entp
rovide
rorga
nisati
onsa
ndto
rel
atedS
ubsta
nceM
isuse
Area
Plan
ningB
oard
and/
orits
cons
tituen
tCom
munit
ySafe
tyPa
rtners
hips
•De
cision
mak
ingm
echa
nisms
toac
ton
inves
tigati
on fin
dings
36
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
24St
aff r
espo
nsib
le fo
r dev
elopi
ng a
nd d
elive
ring
serv
ices
are
appr
opria
tely
recr
uite
d, tr
aine
d an
d qu
alifi
ed fo
r the
wor
k th
ey u
nder
take
in li
ne
with
ext
ant n
atio
nal g
uida
nce.
i.Re
cruitm
entp
roced
uresi
nplac
einc
luding
defin
edpr
oces
ses
andc
riteria
fora
dvert
ising,
interv
iewan
dsele
ction
.
ii.Pro
cedu
resin
plac
etoe
nsure
that
allne
cessa
ryem
ploym
ent
chec
ksar
eund
ertak
enan
dtha
talle
mploy
edor
contr
acted
pro
fessio
nally
quali
fieds
taffa
rereg
istere
dwith
ther
eleva
ntbo
dies.
iii.T
here
sults
ofre
feren
cesa
ndpr
ofessi
onal
regist
ration
chec
ks
arere
corde
d,rev
iewed
whe
reap
propri
atean
dmain
taine
din
asec
urean
dcon
sisten
tway
.
iv.A
llcon
tracts
ofem
ploym
entt
oinc
ludea
duty
toco
mply
with
anyr
eleva
ntco
deso
fprof
essio
nalp
ractic
eand
cond
uct.
v.Tra
ining
prog
ramme
sare
inpla
cefo
rstaf
finv
olved
in
recrui
tmen
t.
vi.A
work
force
deve
lopme
ntpla
n,is
inpl
ace,
includ
ing
Induc
tion,
skills
train
ingan
dCon
tinuin
gProf
essio
nal
Deve
lopme
ntpro
gramm
es,m
appe
dacro
ssto
Natio
nal
Occu
patio
nalS
tanda
rds(N
OS)i
nline
with
Sub
stanc
eMisu
se
Workf
orceD
evelo
pmen
tActi
onPl
an.
vii.A
llserv
icesp
ecific
ation
sand
their
supp
orting
SLA
san
dcon
tracts
tode
tailt
heor
ganis
ation
alpo
licies
on
workf
orce d
evelo
pmen
t
Heal
thca
re S
tand
ards
for W
ales
25:
Workf
orceR
ecrui
tmen
tand
Emplo
ymen
tPrac
tices
37
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
viii.A
llserv
icesp
ecific
ation
stoi
nclud
eani
ndica
tiver
ange
of
appro
priate
roles
andq
ualifi
catio
nsco
mmen
surat
ewith
the
natur
eoft
hese
rvice
being
spec
ified.
ix.A
llpos
tsin
allor
ganis
ation
shav
eupt
odate
jobd
escri
ption
swh
ichid
entify
ther
equir
edpr
ofessi
onal
quali
ficati
ons,
comp
etenc
iesan
dskil
lslin
kedt
othe
Sub
stanc
eMisu
se
Workf
orceD
evelo
pmen
tActi
onPl
anan
dothe
rrele
vant
workf
orcep
lanse
.g.C
hildre
nand
Youn
gPeo
ples
workf
orce s
trateg
ies.
38
No.
Core
Stan
dard
Minim
um re
quire
ment
s to
Ac
hieve
Cor
e Sta
ndar
dRe
vised
Hela
thca
re St
anda
rd
For W
ales
25Al
l int
erve
ntio
ns a
re d
elive
red
by a
ppro
pria
tely
tra
ined
and
qua
lified
sta
ff th
at a
re s
uper
vise
d w
here
app
ropr
iate
.
i.Po
licies
inpl
acef
orthe
appro
priate
supe
rvisio
nan
dman
agem
ento
fstaf
fina
ccorda
ncew
ith
profes
siona
l guid
eline
s.
ii.Po
licies
inpl
acef
orthe
regu
larpe
rform
ance
revie
wof
staff
includ
inga
review
oftr
aining
andd
evelo
pmen
tnee
ds.
iii.M
echa
nisms
inpl
acef
orthe
intro
ducti
onof
new
guida
nce,
guide
lines
andp
ractic
es.
iv.A
llserv
icepr
ovide
rsare
able
toev
idenc
etha
tSLA
,Con
tract
andS
ervice
Spe
cifica
tiono
utcom
esar
each
ievab
lewi
ththe
avail
able
skills
mix
andt
hatr
obus
tsup
ervisio
nand
ma
nage
ment
arran
geme
ntsar
eimb
edde
dinto
thed
elive
ryof
servi
ces.
Heal
thca
re S
tand
ards
for W
ales
24:
Workf
orceP
lannin
g.
Heal
thca
re S
tand
ards
for W
ales
26:
Workf
orceT
rainin
gand
Orga
nisati
onal
Deve
lopme
nt.
39
Annex1
HealthcareStandardsforWales2010
ReferencesLegislativeReferences
No. Title
1 AccesstoHealthRecordsAct1990
2 AccesstoMedicalRecordsAct1988
3 AdoptionandChildrenAct2002
4 Carriageofdangerousgoods&useoftransportablepressureequipmentRegulations2007
5 Children’sAct1989
6 ComputerMisuseAct1990
7 ControlofSubstancesHazardoustoHealthRegulations1988
8 ControlledWaste(RegistrationofCarriersandSeizureofVehicles)(Amendment)Regulations1998
9 ControlledWasteRegulations1992
10 DataProtectionAct(1998)
11 EnvironmentProtectionAct1990
12 EnvironmentalProtection(DutyofCare)Regulations1991
13 EuropeanWorkingTimeDirective
14 FreedomofInformationAct2000
15 GenderRecognitionAct(2004)
16 HazardousWaste(EnglandandWales)Regulations2005
17 HealthandSocialcareAct(2001)
18 HumanFertilisationandEmbryologyAct1990/92
19 HumanRightsAct1998
20 HumanTissueAct(2004)
21 ListofWastes(Wales)Regulations2005
22 ManagementofHealthandSafetyatWorkRegulations1999
23 Medicines(Labelling)Regulations1976
24 MedicinesAct1968
25 MentalCapacityAct2005
26 MentalHealthAct1983
27 MisuseofDrugsAct1971
40
No. Title
28 PoisonsAct1972
29 PoliceandCriminalEvidenceAct1984
30 ProtectionofChildrenAct(1999)
31 PublicInterestDisclosureAct1998
32 ReportingofInjuries,DiseasesandDangerousOccurrencesRegulations1995(Not1999)
33 TheChildrenAct2004
34 TheHealthandSafetyatWork,etc.Act1974
35 WasteElectricalandElectronicsEquipmentRegulations,2006
36 WasteManagementLicensingRegulations1994
41
Annex2
NationalPolicy&GuidanceReferences
No. Title
1 (A revision of the Duthie Report (1988))Royal Pharmaceutical Society, 2005
2Aspoonfulofsugar,medicinesmanagementinNationalHealthServiceHospitals,AuditCommission,December2001
3AllWalesAreaChildProtectionCommittees(2002[Amended2004])All Wales Child Protection Procedures FundedbyWelshAssemblyGovernment
4 AllWalesChildProtectionProceduresReviewGroup(2002)[Amended2004and2005]
5 AllWalesNationalHealthServiceViolenceandAggressionTrainingPassportandInformationScheme
6AllWalesTrainingandDevelopmentManagers,Best Practice Guide toAuditCommissionSetting the Record Straight
7 BeyondBoundaries-Citizen-centredlocalservicesforWales,WelshAssemblyGovernment,2006
8BSISO/IEC17799:2000(BS7799-1:2000)Informationtechnology-Codeofpracticeforinformationsecurity management
9BSISO/IEC27001:2005(BS7799-2:2005)Informationtechnology-Securitytechniques-Informationsecuritymanagementsystems-Requirements
10 Commissioningguidanceforsubstancemisuseservices,WelshAssemblyGovernment,(2005)
11 ConfidentialityCodeofPracticeforHealthandSocialCareinWales(2005)
12 DepartmentforConstitutionalAffairs-PublicSectorDataSharing,GuidanceontheLaw
13 DepartmentofHealth(1992) Choosing with Care,London
14DepartmentofHealth(1997)The Caldicott Committee, Report of the review of patient-identifiable information,London
15DepartmentofHealth(2000)No Secrets, Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse,London
16DesignedforLife-creatingworldclasshealthandsocialcareforWalesinthe21stcenturyMay2005NationalHealthServiceWales
17 DesignedtoComplyNationalHealthServiceWales2006
18 DrugMisuseandDependence-UKGuidanceonClinicalManagement
19 EnvironmentalstrategyfortheNationalHealthService2006
20 EuropeanWorkingTimeDirective
21 GeneralMedicalCouncil(2000)Confidentiality, Protecting and Providing Information,London
22 GeneralMedicalCouncil(2003)A Licence to Practice and Revalidation
23 GuidanceanddefinitionsfortheWelshNationalDatabaseforSubstanceMisuse
24 HB228:2001Guidelinesformanagingriskinhealthcare
42
No. Title
28 HealthAdvisoryServiceThematicReviewofChildrenandYoungPeopleSubstanceMisuseServices1996
29 HealthTechnicalMemoranda(HTM)(SeeAppendix3)
30 GeneralMedicalCouncil(2003)A Licence to Practice and Revalidation
31 HealthcareWasteStrategyforWales,2006
32 HiddenHarm-Respondingtotheneedsofchildrenofproblemdrugusers2003-ThereportofaninquirybytheAdvisoryCouncilontheMisuseofDrugs
33 HiddenHarm-ThreeYearsOn:Realities,ChallengesandOpportunities(February2007)
34 HouseofCommons(2004) The Bichard Inquiry Report,HMSO
35 HSC1999/065ClinicalGovernance:InthenewNationalHealthService
36 InformationCommissioner(2003)The Freedom of Information Act 2000: An Introduction
37 InformationCommissioner’sOffice-UseandDisclosureofHealthData(2001)
38LearningfromBristol:TheReportofthePublicInquiryintochildren’sheartsurgeryattheBristolRoyalInfirmary1984-1995.(2001)
39 LordLaming(2003)The Victoria Climbie Inquiry: Report of an Inquiry by Lord Laming, HMSO,Norwich
40 MakingtheConnections,WelshAssemblyGovernment,2004
41MedicalDeviceAlertMDA2004/054(Wales)Reporting Adverse Incidents - Guidance on New Arrangements for National Health Service Wales Organisations,Wales
42MedicinesandHealthcareProductsRegulatoryAgency(MHRA)GuidanceNotes,andDeviceBulletins(DB)(SeeAppendix2)
43 MedicinesandHealthcareProductsRegulatoryAgency(MHRA)GuidanceModernisingMedicalCareers
44 ModernisingMedicalCareerswww.cardiff.ac.uk/pgmde/hospital_practice
45NationalAssemblyforWales(2001)InformingHealthinWales;ClinicalGovernance-developingastrategic approach
46 NationalAssemblyforWales(2001)InformingHealthinWales;ClinicalGovernance-atoolkitforclinicalteams
47 NationalAssemblyforWales(2003)InformingHealthinWales:AnIntroductiontoClinicalAudit
48NationalAssemblyforWales/HomeOffice(2000)In Safe Hands - Implementing Adult Protection Procedures in Wales
49 NationalPatientSafetyAgencyGuidance
50 NCASP(2002)SupportforNationalServiceFrameworksandClinicalGovernance.
43
No. Title
51 NationalInstituteforClinicalExcellenceGuidelines
52 NursingandMidwiferyCouncil,Guidelines for Records and Record Keeping, London
53 Personal Development Reviews and the Knowledge and Skills Framework
54 PuttingPatientsFirstNationalHealthServiceWales1998
55 QualityCareandClinicalExcellenceNationalHealthServiceWales1998
56 RecordsManagement-NationalHealthServiceCodeofPractice(2005)
57 RiskManagementintheNationalHealthService.
58SecurityManagementFrameworkforNationalHealthServiceTrustsinWales,2005
59 TheChildren’sCommissionersofWalesReport(2003)Telling Concerns
60 TheInstituteofDecontaminationSciences(IDSc)StandardsandPractice
61TheManagementofMedicalEquipmentinNationalHealthServiceAcuteTrustsinEngland,National Audit Office,1999
62 TheSafeandSecureHandlingofMedicines:ATeamApproach
63TheShipmanEnquiry-TheFifthReport(2004)-Safeguarding Patients: Lessons from the Past - Proposals for the Future
64 TooSeriousaThing:TheCarlileReview2002(TheNationalAssemblyfor Wales)
65 UnitedNationsConventionontheRightsoftheChild1989.
66 WalesAccordontheSharingofPersonalInformation(2006)
67Waterhouse(2000)Report of the Tribunal of Inquiry into the abuse of children in care in the former county council areas of Gwynedd and Clwyd since 1974 Lost in Care
68 WelshAssemblyGovernment(2000)Working Together to Safeguard Children
69 WelshAssemblyGovernment(2002)Reference Guide for Consent to Examination or Treatment,Cardiff
70WelshAssemblyGovernment(2003)Fundamentals of Care, Guidance for Health and Social Care Staff; Improving the quality of fundamental aspects of health and social care for adults,Cardiff
71WelshAssemblyGovernment(2005)National Service Framework for Children, Young People and Maternity Services in Wales
72 WelshAssemblyGovernment(2005)National Service Framework for Older People in Wales,Cardiff
73 WelshAssemblyGovernment(2006)Designed to Work: A workforce strategy to deliver Designed for Life
74 WelshAssemblyGovernment(2006)Safeguarding Children: Working Together under the Children Act 2004.
44
No. Title
75 WelshAssemblyGovernmentSubstanceMisuseTreatmentFrameworksfor Wales
76 WelshHealthCirculars(WHC)(SeeAppendix1)
77 WelshRiskPool:RiskManagementToolkit
78 WhenaPatientdies-AdviceonDevelopingBereavementServices
79 WorkingTogethertoReduceHarm:TheWelshNationalSubstanceMisuseStrategy2008-2018