1. 25th April 2006Southend-on-Sea PCT1 Healthcare Core Standards ANNUAL HEALTHCHECK Final Declaration 4 th May ’06 Community Services Scrutiny Committee 25.04.06

2. 25th April 2006Southend-on-Sea PCT2 GETTING THE BASICS RIGHT MAKING and SUSTAINING PROGRESS CORE STANDARDS EXISTING TARGETS USE OF RESOURCES (External Audit - ALE’s) PROGRESS AGAINST DEVELOPMENTAL STANDARDS NATIONAL TARGETS IMPROVEMENT REVIEWS Smoking / Substance Misuse Annual Health Check

3. 25th April 2006Southend-on-Sea PCT3 The Annual Health Check TWO RATINGS PROVIDED Use of Resources (Weak, Fair, Good, Excellent) Quality Element (Weak, Fair, Good, Excellent). The Core Standards A Trust will receive one of the following scores: Fully Met, Almost Met, Partly Met and Not Met. The Score aims to: –Reflect extent of Trusts’ compliance for entire year –Encourage insight and honesty –‘Reward’ trusts that have improved levels of compliance

4. 25th April 2006Southend-on-Sea PCT4 The Core Standards Compliance is determined by Reasonable Assurance without significant lapse. Reasonable assurance is not, by definition absolute assurance. Based on documentary evidence open to internal & external challenge. Greater clarity over definition of “Significant lapse”: “It is for trust boards to decide whether a given lapse is significant or not. However, in making this decision, we anticipate that boards will consider the extent of risk to patients, staff and the public, and the duration and impact of any lapse. The declaration is not intended as a medium for reporting isolated, trivial or purely technical lapses in respect of the core standards”.

5. 25th April 2006Southend-on-Sea PCT5 Scoring Thresholds Scores relate to the number of Standards reported as ‘Not Met’ or have ‘Insufficient Assurance’. Number of StandardsMaximum Score 0 to 4Fully Met 5 to 8Almost Met 9 to 13Partly Met 14 or moreNot Met

6. 25th April 2006Southend-on-Sea PCT6 Our Methodology Examine those Standards which were inspected by the Healthcare Commission (5) Examine those Standards which we declared as either being ‘Not Met’ or having ‘Insufficient Evidence’ in our Draft Declaration (5) Review all the remaining standards to see whether our declaration of Compliance in our Draft Declaration was still pertinent (37) NB There are 49 Standards overall but 2 of these are not applicable as they are subject to external evaluation.

7. 25th April 2006Southend-on-Sea PCT7 HCC Assessment Visit Standard InspectedRating C2 Health care organisations protect children by following national child protection guidance within their own activities and in their dealings with other organisations. Compliant C11 Health care organisations ensure that staff concerned with all aspects of the provision of health care b) participate in mandatory training programmes Compliant C13 Health care organisations have systems in place to ensure that b) appropriate consent is obtained when required for all contacts with patients and for the use of any patient confidential information Compliant C15 Where food is provided, health care organisations have system sin place to ensure that a) patients are provided with a choice and that it is prepared safely and provides a balanced diet. Compliant C22 Health care organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by b) Ensuring that the local Director of Public Health’s Annual Report informs their policies and practices. Compliant

8. 25th April 2006Southend-on-Sea PCT8 Draft Declaration (Not Met / Ins.Assur. ) Standard InspectedRating C1 Health care organisations protect patients through systems that b) Ensure that patient safety notices, alerts and other communications concerning patient safety, which require action, are acted upon within required time-scales. Compliant C4 Health care organisations keep patients, staff and visitors safe by having systems to ensure that e) the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. Compliant C9 Health care organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required. Compliant

9. 25th April 2006Southend-on-Sea PCT9 Draft Declaration (Not Met / Ins.Assur. ) Continued Standard InspectedRating C13 Health care organisations have systems in place to ensure that a) staff treat patients, their relatives and carers with dignity and respect; Compliant C21 Health care services are provided in environments, which promote effective care and optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and nonclinical areas that meet the national specification for clean NHS premises. Not Met

10. 25th April 2006Southend-on-Sea PCT10 Remaining Standards No significant issues to address. Only issue of note related to Standards C4c (C4cHealth care organisations keep patients, staff and visitors safe by having systems to ensure that c) all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed.) There was a view that as there is an Essex wide strategy to move to disposable equipment but contractors are still sterilizing & re-using, all PCTs must declare non-compliance until strategy implemented. All South Essex PCT’s oppose this view and will be declaring compliance. Satisfied therefore that all remaining Standards can be declared as Compliant.