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North Staffordshire Combined Healthcare NHS Trust Application for Registration under the Health & Social Care Act 2008 Presentation to the Trust Board 28 January 2010 North Staffordshire Combined Healthcare NHS Trust Application for Registration under the Health & Social Care Act 2008 Presentation to the Trust Board 28 January 2010
Purpose To build on the presentation to the Trust Board in October 2009 To support Members to reach a decision regarding the application to the Care Quality Commission To supplement the paper presented by providing current information and the full outcome of the self assessment process
Application for Registration 2009-10 Timetable Audit Committee15 January 2010 Q&G Committee19 January 2010 Trust Board28 January 2010 Application Before midday on 29 January 2010 CQC AssessmentFrom 29 January to 31 March 2010 Once the application is assessed, the CQC has three options: – Register without conditions – Register with conditions – Refuse all or part of the registration The organisation will then be issued with either: – A Notice of Decision – if the application is approved – A Notice of Proposal – if the application is refused
Recommendations Recommendation 1: Review progress to date and the key actions still to be delivered as identified in the Project Plan – All key stages achieved – note the following: – CRB for Chief Executive – Documented Service / Trust Profile – Evidence Recommendation 2: Delegate responsibility to the Q&G Committee to finalise the narrative Trust Profile Recommendation 3: Review and approve the Self Assessment Methodology – Attached at Appendix C
Self Assessment Methodology App C – Section 4 Undertake a high level self assessment: – Quality and Risk Profile (QARP) provided by the CQC – Standards for Better Health 2009/10 self assessment – Assurance Framework – Performance and Quality Management Framework (PQMF) – Divisional / location level self assessments; – Key External Assurance (eg Internal Audit; Patient Survey; Staff Survey etc) In addition to the above: – Each outcome area has been reviewed by a nominated operational lead – Each outcome area has a nominated director(s) who has reviewed the findings – Collective review by the Executive Team (including Clinical Directors)
Recommendations Recommendation 4: Note the 7 risks identified by the Care Quality Commission – All responded to by lead directors – Trust response / information accepted by the Care Quality Commission Recommendation 5: Note the outcome of the self-assessment process and receive a position statement on the day of the meeting in relation to Outcome 4 and Outcome 9
Outcome of the Self Assessment Process 1: Mod / SigRespecting and Involving people who use services 2: ModConsent to care and treatment 4: Mod / SigCare and welfare of people who use services 5: LowMeeting nutritional needs 6: Mod / SigCooperating with others 7: ModSafeguarding people who use services from abuse 8: ModCleanliness and infection control 9: ModManagement of medicines 10: LowSafety and suitability of premises 11: ModSafety, availability & suitability of equipment 12: ModRequirements relating to workers 13: LowStaffing 14: Mod / SigSupporting workers 15: WIPStatement of purpose 16: LowAssessing and monitoring the quality of service provision 17: LowComplaints 21: LowRecords
Recommendations Recommendation 6: Review the completed application form at Appendix D, and the outcome of the assessment in relation to Outcome 4 and 9 and give approval for the contents to be submitted to the CQC – To declare compliance with all outcomes / regulations Recommendation 7: Delegate responsibility to the Trust’s Chief Executive to review, approve and submit the completed application and to sign the final version on behalf of the Trust Board
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