Report to
Trust
Board
Date
Tuesday 6 April 2010
Agenda Number
S2
Agenda Item
NHS Constitution Baseline Assessment (Draft)
Sponsor
Maureen Bignell, Director of Personnel and Development
Prepared by
Maureen Bignell, Director of Personnel and Development
Presented by
Maureen Bignell, Director of Personnel and Development
EXECUTIVE SUMMARY
1
Purpose and key issues
The purpose of this paper is to inform the Board of the baseline assessment relating to staff
rights, expectations and legal duties.
Key issues include:
Engagement and involvement with staff
Staff have clear roles and responsibilities
Staff have opportunities for personal development and access to appropriate training for
their jobs to succeed
Staff have opportunities to maintain health, well being and safety
Staff have employment rights protected.
2 Supporting
Information
The NHS Constitution Baseline Assessment report is attached.
3
Controls and assurances
NHS Constitution Champion in place
Strategic Workforce Development Committee will monitor and review baseline
assessment
4 Legal Implications
Employment legislation provides rights of staff
5
Equality and Diversity Implications
The Trust aims to design and implement services, policies and measures that meet the
diverse needs of our service, population and workforce, ensuring that none are placed at a
disadvantage over others.
No adverse or positive impacts have been identified from this
report in relation to promoting and respecting rights of staff
6
Patient, Public and Staff Involvement
The Trust ensures that patients, the public and staff are involved in the decision-making
process when appropriate. The Joint Negotiation and Consultative Committee were
consulted on assessment and will be involved with the on-going development and review.
7 Cost
implications
There are no cost implications.
8 Potential risk to the organisation
Nil.
9 Board
prompts
Has the Board received the assurance it requires that the self assessment is a fair
reflection of the position relating to staff rights and expectations?
10 Recommendations
The Board is asked to
APPROVE
the report.
11 References
Staff Survey 2009
NHS
Constitution
12 Strategic Objectives
The Trust’s Strategic Objectives were reviewed by the Board in July 2009.
Effective care
Exceptional workforce
Financial health
Integrated care
Modern environments
Sustainable services
13 Principal
Risks
The Principal Risks have been identified through the Trust’s risk management processes.
They are updated as and when required.
Financial planning & management
Clinical records management
X
Strategic & business planning
X
Leadership & management
X
Workforce numbers
Unsafe behaviour
X
Workforce skills
External demands
Procedural management
Partnership arrangements
Equipment & facilities arrangements
South West Strategic Health Authority
NHS Constitution Baseline Assessment (draft)
Revised to include Staff rights, expectations and legal duties
This baseline assessment toolkit is intended to help NHS South West organisations to:
assess their position in relation to the 39 rights and pledges specific to working with patients and local communities;
report on actions from NHS South West Conference held on 11 December 2009
assess the workforce information relating to the staff rights, pledges and expectation, taking into account the National NHS
Health & Well-being Review ‘The Booorman Report’.
The assessment will also enable the South West Strategic Health Authority to report to the Department of Health on regional
progress.
For each action (A), pledge (P) and right (R) a short minimum assurance statement has been included. You may wish to add other
sources of assurance statements into these boxes. Please
Red
/
Amber
/
Green
rate your organisation against each of these
statements to demonstrate level of compliance. Where a right or pledge is only relevant to Primary Care Trusts this is reflected in
the assurance statement. Primary Care Trusts If your organisation is not fully compliant with a particular assurance statement
please indicate what actions you will take to reach compliance, by what date and include a named lead Director responsible for the
actions. You only need to
Red
/
Amber
/
Green
rate each action (A), pledge (P) and right (R) overall.
Please also include any other sources of evidence you can identify. For the other rights and pledges your evidence should offer
clear justification for each rating.
When the completed assessment has been agreed by your Board it should be returned to Jo Perry, Deputy Director of Corporate
Affairs, South West Strategic Health Authority by 26 February 2010.
Name of organisation………
PATIENT RIGHTS/PLEDGES
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the NHS Constitution.
The Primary Care Trust has a process in place to trigger referral to alternative providers if waiting times are exceeded.
Quarterly National Reporting Systems to the SHA on Waiting Times.
2. You have the right to drugs and treatments that have been
recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.
The Primary Care Trust has a process in place to ensure that NICE recommendations are implemented.
Quarterly report to the SHA.
3. You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme.
The Primary Care Trust commissions a vaccination programme in line with the recommendations of the Joint Committee on Vaccination and Immunisation.
Quarterly performance reports to the SHA on MMR and Flu vaccines and VSB10 (Immunisation).
Monthly data to the Health Protection Agency on vaccines.
4. The NHS commits to provide programmes as recommended by the UK Screening Committee
The Primary Care Trust commissions a screening programme in line with the recommendations of the UK Screening Committee.
Quarterly report to the SHA and VSA09 (Breast), VSA10 (Bowel), VSA15 (Cervical).
5. You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned by Parliament.
Fundamental NHS principle. Evidence not required but
please confirm compliance.
6. You have the right to access NHS services. You will not be refused access on unreasonable grounds.
A formal policy for dealing with violent and abusive patients has been adopted.
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
7. You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary.
The Primary Care Trust has undertaken a Joint Strategic Needs Assessment as part of the development and
implementation of its Local Strategic Plan.
8. You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner.
The Primary Care Trust has a process in place to manage the commissioning of treatments from European Economic Area countries.
9. You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age.
A single equalities scheme has been adopted, implemented and is monitored.
10. The NHS commits to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered.
Communications and engagement plans include actions to ensure decision making is communicated and understood.
11. The NHS commits to make the transition as smooth as possible when you are referred between services, and to include you in relevant discussions.
Patient pathways include processes to ensure effective transitions between services and organisations.
12. You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly
Knowledge and Skills Frameworks for all staff are in place.
sources of evidence]
complaint/not compliant
RED
approved or registered organisation that meets required levels of safety and quality.
The PCT only commissions from providers who have full CQC registration.
13. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide.
A measureable improvement can be shown against the five NHS South West domain of quality, which are:
Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. There is a health-economy agreed plan for further measureable improvement against these domains.
Reporting to the SHA on:
NPSA reporting system Annual Survey VSB 15 Reported against ambitions National Reporting Systems.
14. The NHS commits to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice.
Health services are provided in a clean and safe environment as reported to the Care Quality Commission and in accordance with the requirements of the Health and Safety Executive.
Monthly reporting of HCA1 database to the Health Protection Agency VSA01 (MRSA) and VSA03 (CDiff).
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
15. The NHS commits to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments.
A measureable improvement can be shown against the five NHS South West domain of quality, which are:
Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. There is a health-economy agreed plan for further measureable improvement against these domains.
There is a clear programme for publicising progress against both existing quality
improvement projections and plans for measureable quality improvement in the future.
Reports to the SHA on:
NPSA Reporting System Annual Survey VSB 15 Reporting against ambitions National reporting system.
16. You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you or your doctor feel would be right for you, they will explain that decision to you.
A process to manage decisions concerning the provision of exceptional treatments is in place.
A robust process is in place to make decisions on funding new medicines and other treatments. The PCT publishes clear information on the processes for local decision making, individual funding requests and the appeals process.
sources of evidence]
complaint/not compliant
RED
17. You have the right to be treated with dignity and respect, in accordance with your human rights.
A privacy, dignity and respect policy/statement has been adopted.
VSB15 (Patient experience) and VSB16 (public confidence).
Reports on mixed sex accommodation.
18. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests.
A policy on obtaining informed consent has been adopted.
19. You have the right to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing.
Procedures are in place to ensure that patients are able to make informed decisions about proposed treatments.
Patient information is regularly reviewed and updated.
20. You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure.
A records management policy has been adopted. The policy includes specific actions to ensure that confidential information is kept secure.
Reports to the SHA on completion of the Information Governance Toolkit.
21. You have the right of access to your own health records. These will always be used to manage your treatment in your best interests.
Procedures are in place to provide access to health records on request.
A process to manage complaints relating to access to health records is in place.
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
22. The NHS commits to share with you any letters sent between clinicians about your care.
Procedures are in place to ensure that clinician’s letters are shared with patients.
23. You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons.
There is a clear procedure in place for the public to register with the GP of their choice.
VSA06 (GP Access).
24. You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply.
Patient information on how to register with a GP includes this provision.
25. You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs.
The Primary Care Trust has arrangements in place to:
ensure that patients who need an elective referral are offered a choice of any clinically appropriate provider;
ensure that where a patient has not been offered that choice, and notifies the Primary Care Trust that they have not been offered that choice, that patient may choose any clinically appropriate secondary care provider.
National Choice Survey.
Monthly Choose and Book information for 18 weeks reported to the SHA.
26. The NHS commits to inform you about the healthcare services available to you, locally and nationally.
The Primary Care Trust communication plan includes actions to provide up to date information on healthcare services.
sources of evidence]
complaint/not compliant
RED
27. The NHS commits to offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available.
The communications plan includes actions to ensure decision making is
communicated and understood.
28. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this.
Procedures are in place to ensure that patients are routinely involved in discussions and decisions about their healthcare.
29. You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.
Communications, engagement and stakeholder relations plans include actions to ensure appropriate and proportionate involvement of patients and the public in service planning, development or change.
30. The NHS commits to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services.
Communications, engagement and stakeholder relations plans include the provision of clear and accessible information on planning and delivery of NHS services.
31. The NHS commits to work in partnership with you, your family, carers and representatives.
Working in partnership with families, carers and
representatives is part of the engagement plan.
32. You have the right to have any complaint you make about NHS services dealt with efficiently and to have it properly investigated.
A complaints policy has been adopted.
33. You have the right to know the outcome of any investigation into your
The complaints policy includes procedures to ensure the
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
complaint. communication of the outcomes of complaints investigations.
34. You have the right to take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS.
The complaints policy,
complaints literature and letters to complainants provide information on how to take complaints to the Health Services Ombudsman.
35. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body.
This is a legal right and as such does not require an assurance statement.
Rating not required
36. You have the right to
compensation where you have been harmed by negligent treatment.
A procedure for managing compensation payments is in place.
37. The NHS commits to ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment.
The complaints policy includes access to support and reassurance of the impact of a complaint on future treatments.
Complaints handling is monitored.
38. The NHS commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.
A clear process to provide timely information, feedback and apologies is in place. This is monitored and reported as part of the formal process for receiving and acting on lessons arising from complaints, claims or PALS.
39. The NHS commits to ensure that the organisation learns lessons from complaints and claims and uses these
A formal process to receive and act on lessons arising from complaints, claims or PALS is in
sources of evidence]
complaint/not compliant
RED
to improve NHS services. place. This process links directly to the Board.
ACTIONS FROM SOUTH WEST NHS CONSTITUTION CONFERENCE
& STAFF RIGHTS/EXPECTATIONS AND LEGAL DUTIES
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
Actions arising from NHS South West Constitution Conference held 11 December 2009
A1
NHS Boards must identify a Board level lead on the NHS Constitution
Board Level Champion identified; Board Report
Fully compliant
NHS Board Champion is:Mrs Carolyn Mills Director of Nursing
Name___________________________ Job Title: _______________________ ______________________________
Actions arising from NHS South West Constitution Conference held 11 December 2009
A2
Primary Care Trusts need to identify an NHS Constitution Champion to promote the Constitution and to act as an advocate on behalf of the public
NHS Constitution Champion identified;
Board Report
Not relevant
Primary Care Trust Champion is:
Name___________________________ Job Title: _______________________ ______________________________
A3
Primary Care Trusts need to work with NHS Providers and Third Sector organisations to ensure they have regard to the NHS Constitution in their activity for the NHS.
The organisation has a framework in place.
Board Compliance report.
Not relevant
A4
NHS organisations need to sign up to the NHS South West
Communications Strategy [attached]
The organisation has
implemented a Communications and engagement plan based on NHS South West Communications Strategy.
Board Compliance report.
Organisational
Communications strategy approved by board in 2008
Fully compliant
A5
Staff work with staff-side
representatives to ensure compliance with the Staff Pledges and Rights in the NHS Constitution
The NHS Constitution forms part of regular agenda at Staff-side and Staff Engagement meetings
Board Compliance Report; JNCC
Engagement Meetings; Values and vision
sources of evidence]
complaint/not compliant
RED
engagement eventsSTAFF PLEDGES, RIGHTS, EXPECTATIONS & LEGAL DUTIES
P1
Provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities.
The organisation has an up-to-date job description in place for all staff, which clearly outlines their roles and responsibilities;
The organisation will introduce the NHS Constitution in future Job Descriptions/person specifications.
Job descriptions are and continue to be evaluated under the Agenda for Change Terms and Conditions for Job Evaluation [except Medical and dental staff];
The organisation has promoted the NHS Constitution to all staff within the organisation.
Board report confirming compliance with the NHS Constitution for Staff rights and pledges.
Confirmation of application of National Agenda for Change Job Evaluation, or equivalent Job Evaluation process for FTs.
Banding process in place, consistency checking processes. Generic job descriptions for majority of posts.
NHS Constitution is incorporated into the organisations’ Induction arrangements;
NHS constitution is incorporated into OD plan
NHS Constitution is promoted on Trust Intranet;
The organisation has a Staff Charter, outlining staff rights, pledges and responsibilities.
The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on:
Partially compliant
Maureen Bignell – Director of
Personnel and Develom
Board report for April 2010
Induction processes to be
developed further to
incorporate NHS constitution
– April 2010
NHS staff rights and NHS
values to be incorporated
into recruitment literature
and promoted on job website
and intranet – April 2010
Joint work to be undertaken
with staff reps and wider staff
to finalise staff charter
May 2010
Guidance to managers to
support discussions during
appraisal process to ensure
that staff have a
understanding where there
roles makes a difference to
patients
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
KP3: % of staff feeling valued by work colleagues KP4: % of staff agreeing that they have an interesting job KP7 % of staff working in a well-structured team environment
Using e-rostering and
workforce reports analayse
working hours of staff
P2
Provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed.
The organisation has in place for all staff a personal development pan, supported by an individual KSF outline [for Agenda for Change staff];
The organisation has in place a mechanism which defines the relevant mandatory and developmental training required for specific roles;
The personal development plan clearly outlines appropriate development training to support the employee;
The organisation has in place appropriate training providers [internal /external] and training prospectus to satisfy individual and job requirements.
Board report on CARE QUALITY COMMISSION standards and compliance with staff receiving appraisal and personal development plans.
Evidence of an
Organisational Training Plan based on PDPs.
Evidence of an organisational Training programme and/prospectus.
Staff attitude survey results demonstrate Trust is in highest 20% in:
Number of staff appraised, having PDPs and having support from immediate managers
The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on:
KF13 - % of staff appraised in last 12 months KF15 - % appraised with PDPs in place KF16 – support from immediate managers
Partially compliant
Guidance to managers to
facilitate a discussion on
what opportunities are
available to develop
potential.
P3
Provide support and opportunities for
The organisation has
arrangements in place either by
Internal Occupational Health
sources of evidence]
complaint/not compliant
RED
staff to maintain their health, well-being and safety.
internal or external agreements to provide Occupational Health and Wellbeing arrangements for staff; The organisation has in place an action plan to deal with the recommendations from the Boorman Report.
Health and safety training reports
Board Report responding to the ‘Boorman Report’, including an action plan to develop Health and Wellbeing of staff;
Board level champion for Health and Wellbeing;
Violence and aggression action plan
Health and well-being promoted on Intranet and success in iniatives
Staff attitude survey results demonstrate Trust is in highest 20% in:
KP17 - % receiving H & S training in last 12 months KP27 - % experiencing harassment, bullying or abuse from staff in last months
KF28 – Perceptions of effective action from employer towards violence and aggression
KF30 - % feeling pressure in last 3 months to attend work when feeling unwell.
developed further into the
occupational health service
October 2010
Analysis on causes of
work-related stress and action plan
to be developed
P4
Provide the opportunity for all staff to Engage in decisions that affect them and the services they provide.
The organisation has a staff engagement strategy in place.
The organisation engages with staff through appropriate Trades Union machinery ie Joint Staff Committee.
Recognition Agreement with Trades Unions and
Professional Organisations.
Joint Staff Committee Facilities agreement.
Partially compliant
Staff engagement
involvement strategy to be
reviewed
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
The organisation has in place arrangements to engage with staff who are non-representatives of TU/Professional organisations.
Joint Staff Committee Terms of Reference.Consultation Working party minutes of management of change meetings
Staff attitude survey results demonstrate Trust is in highest 20% in: KF33 - % of staff able to contribute towards impreovements at work KF38 - % having equality and diversity training in last 12 months
arrangements to be reviewed
Guidance to managers to
facilitate a discussion with
employee to ensure staff
understand their role and
where it fits in.
Analyse areas in the Trust
where staff are reporting
poor communication between
senior management and staff
and develop an action plan
R1
The NHS has a good record of fair employment and respecting the rights of staff.
All Staff have a Contract of Employment based on National Terms and Conditions, and reflecting the rights of staff.
Staff Charter incorporating the rights of staff and the NHS constitution.
Contracts of Employment based on National Terms and Conditions.
Audit reports
Partially compliant
Staff charter to be finalised in
consultation with staff side
May 2010
R2
Rights embodied in general employment and discrimination law.
The organisation has in place arrangements to support Equality and Diversity and Equal
Opportunities.
The organisation has a framework of policies and procedures in place to comply with employment and discrimination legislation.
Equal Opportunities Policy;
Bullying and Harassment Policy;
Violence and Aggression Policy;
Grievance and Appeals Policy;
Involvement/Engagement Policy;
Health and Safety Policy;
Flexible Working Policy;
sources of evidence]
complaint/not compliant
RED
High level of staff trained in Equality and Diversity.
Arrangements to train all managers in key policies and procedures.
Whistle blowing policy.
Staff Charter, setting out the responsibilities and expectations of staff.
Board report satisfying compliance with the NHS Constitution Staff rights and pledges.
Board reports including extensive information on equality data and action plan
Training Plan OD Plan
Staff Survey results; Care Quality Commission evidence;
Human
Resources/Workforce Board Reports;
Care Quality Commission evidence;
Human
Resources/Workforce Board reports.
E1. Expectations and legal duties of Staff:
The Constitution also includes expectations that reflect how staff should play their part in ensuring the success of the NHS and delivering high-quality care.
Expectations:
The highest quality of patient care is delivered by staff who are ambitious in their expectations of themselves
The organisation has a framework which sets out the expectations of and makes clear the legal duties placed on staff.
JNCC minutes
Discussion and promotion at Staff Engagement meetings;
Staff Newsletters;
Staff Induction Programme;
Promotion through the organisations’ intranet;
Staff promotion material;
Partially compliant Build on JNCC discussions with staff
reps to develop a final staff charter and engage staff across the organisation through listening events
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
and their colleagues, and strive to achieve beyond what is legally required of them.
Legal duties:
Accept professional accountability; Take reasonable care of health and safety at work;
Act in accordance with the express and implied terms of the employment contract;
Not to discriminate against patients or staff;
Protect confidentiality; Be honest and truthful.
Staff signed up to the NHS Code of Conduct;
Staff Statement of Confidentiality ;
Staff comply with Professional Codes of Conduct /Professional Regulatory Body registration.
South West Strategic Health Authority
NHS Constitution Baseline Assessment (draft)
Revised to include Staff rights, expectations and legal duties
This baseline assessment toolkit is intended to help NHS South West organisations to:
assess their position in relation to the 39 rights and pledges specific to working with patients and local communities;
report on actions from NHS South West Conference held on 11 December 2009
assess the workforce information relating to the staff rights, pledges and expectation, taking into account the National NHS
Health & Well-being Review ‘The Booorman Report’.
The assessment will also enable the South West Strategic Health Authority to report to the Department of Health on regional
progress.
For each action (A), pledge (P) and right (R) a short minimum assurance statement has been included. You may wish to add other
sources of assurance statements into these boxes. Please
Red
/
Amber
/
Green
rate your organisation against each of these
statements to demonstrate level of compliance. Where a right or pledge is only relevant to Primary Care Trusts this is reflected in
the assurance statement. Primary Care Trusts If your organisation is not fully compliant with a particular assurance statement
please indicate what actions you will take to reach compliance, by what date and include a named lead Director responsible for the
actions. You only need to
Red
/
Amber
/
Green
rate each action (A), pledge (P) and right (R) overall.
Please also include any other sources of evidence you can identify. For the other rights and pledges your evidence should offer
clear justification for each rating.
When the completed assessment has been agreed by your Board it should be returned to Jo Perry, Deputy Director of Corporate
Affairs, South West Strategic Health Authority by 26 February 2010.
Name of organisation………
PATIENT RIGHTS/PLEDGES
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
1. The NHS commits to provide convenient, easy access to services within waiting times set out in the Handbook to the NHS Constitution.
The Primary Care Trust has a process in place to trigger referral to alternative providers if waiting times are exceeded.
Quarterly National Reporting Systems to the SHA on Waiting Times.
2. You have the right to drugs and treatments that have been
recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you.
The Primary Care Trust has a process in place to ensure that NICE recommendations are implemented.
Quarterly report to the SHA.
3. You have the right to receive the vaccinations that the Joint Committee on Vaccination and Immunisation recommends that you should receive under an NHS-provided national immunisation programme.
The Primary Care Trust commissions a vaccination programme in line with the recommendations of the Joint Committee on Vaccination and Immunisation.
Quarterly performance reports to the SHA on MMR and Flu vaccines and VSB10 (Immunisation).
Monthly data to the Health Protection Agency on vaccines.
4. The NHS commits to provide programmes as recommended by the UK Screening Committee
The Primary Care Trust commissions a screening programme in line with the recommendations of the UK Screening Committee.
Quarterly report to the SHA and VSA09 (Breast), VSA10 (Bowel), VSA15 (Cervical).
5. You have the right to receive NHS services free of charge, apart from certain limited exceptions sanctioned
Fundamental NHS principle. Evidence not required but
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
by Parliament.
6. You have the right to access NHS services. You will not be refused access on unreasonable grounds.
A formal policy for dealing with violent and abusive patients has been adopted.
7. You have the right to expect your local NHS to assess the health requirements of the local community and to commission and put in place the services to meet those needs as considered necessary.
The Primary Care Trust has undertaken a Joint Strategic Needs Assessment as part of the development and
implementation of its Local Strategic Plan.
8. You have the right, in certain circumstances, to go to other European Economic Area countries or Switzerland for treatment which would be available to you through your NHS commissioner.
The Primary Care Trust has a process in place to manage the commissioning of treatments from European Economic Area countries.
9. You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, religion or belief, sexual orientation, disability (including learning disability or mental illness) or age.
A single equalities scheme has been adopted, implemented and is monitored.
10. The NHS commits to make decisions in a clear and transparent way, so that patients and the public can understand how services are planned and delivered.
Communications and engagement plans include actions to ensure decision making is communicated and understood.
11. The NHS commits to make the transition as smooth as possible when you are referred between services, and to include you in relevant
Patient pathways include processes to ensure effective transitions between services and organisations.
sources of evidence]
complaint/not compliant
RED
discussions.
12. You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality.
Knowledge and Skills Frameworks for all staff are in place.
The PCT only commissions from providers who have full CQC registration.
13. You have the right to expect NHS organisations to monitor, and make efforts to improve, the quality of healthcare they commission or provide.
A measureable improvement can be shown against the five NHS South West domain of quality, which are:
Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. There is a health-economy agreed plan for further measureable improvement against these domains.
Reporting to the SHA on:
NPSA reporting system Annual Survey VSB 15 Reported against ambitions National Reporting Systems.
14. The NHS commits to ensure that services are provided in a clean and safe environment that is fit for purpose, based on national best practice.
Health services are provided in a clean and safe environment as reported to the Care Quality Commission and in accordance with the requirements of the Health and Safety Executive.
Monthly reporting of HCA1 database to the Health Protection Agency VSA01 (MRSA) and VSA03 (CDiff).
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
15. The NHS commits to continuous improvement in the quality of services you receive, identifying and sharing best practice in quality of care and treatments.
A measureable improvement can be shown against the five NHS South West domain of quality, which are:
Patient safety Patient experience Effectiveness of care Access to services Eradication of waste. There is a health-economy agreed plan for further measureable improvement against these domains.
There is a clear programme for publicising progress against both existing quality
improvement projections and plans for measureable quality improvement in the future.
Reports to the SHA on:
NPSA Reporting System Annual Survey VSB 15 Reporting against ambitions National reporting system.
16. You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you or your doctor feel would be right for
A process to manage decisions concerning the provision of exceptional treatments is in place.
A robust process is in place to make decisions on funding new
sources of evidence]
complaint/not compliant
RED
you, they will explain that decision to you.
medicines and other treatments. The PCT publishes clear information on the processes for local decision making, individual funding requests and the appeals process.
17. You have the right to be treated with dignity and respect, in accordance with your human rights.
A privacy, dignity and respect policy/statement has been adopted.
VSB15 (Patient experience) and VSB16 (public confidence).
Reports on mixed sex accommodation.
18. You have the right to accept or refuse treatment that is offered to you, and not to be given any physical examination or treatment unless you have given valid consent. If you do not have the capacity to do so, consent must be obtained from a person legally able to act on your behalf, or the treatment must be in your best interests.
A policy on obtaining informed consent has been adopted.
19. You have the right to be given information about your proposed treatment in advance, including any significant risks and any alternative treatments which may be available, and the risks involved in doing nothing.
Procedures are in place to ensure that patients are able to make informed decisions about proposed treatments.
Patient information is regularly reviewed and updated.
20. You have the right to privacy and confidentiality and to expect the NHS to keep your confidential information safe and secure.
A records management policy has been adopted. The policy includes specific actions to ensure that confidential information is kept secure.
Reports to the SHA on completion of the Information Governance Toolkit.
21. You have the right of access to your own health records. These will
Procedures are in place to provide access to health records
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
always be used to manage your treatment in your best interests.
on request.
A process to manage complaints relating to access to health records is in place.
22. The NHS commits to share with you any letters sent between clinicians about your care.
Procedures are in place to ensure that clinician’s letters are shared with patients.
23. You have the right to choose your GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse, in which case you will be informed of those reasons.
There is a clear procedure in place for the public to register with the GP of their choice.
VSA06 (GP Access).
24. You have the right to express a preference for using a particular doctor within your GP practice and for the practice to try to comply.
Patient information on how to register with a GP includes this provision.
25. You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs.
The Primary Care Trust has arrangements in place to:
ensure that patients who need an elective referral are offered a choice of any clinically appropriate provider;
ensure that where a patient has not been offered that choice, and notifies the Primary Care Trust that they have not been offered that choice, that patient may choose any clinically appropriate secondary care provider.
National Choice Survey.
Monthly Choose and Book information for 18 weeks reported to the SHA.
sources of evidence]
complaint/not compliant
RED
26. The NHS commits to inform you about the healthcare services available to you, locally and nationally.
The Primary Care Trust communication plan includes actions to provide up to date information on healthcare services.
27. The NHS commits to offer you easily accessible, reliable and relevant information to enable you to participate fully in your own healthcare decisions and to support you in making choices. This will include information on the quality of clinical services where there is robust and accurate information available.
The communications plan includes actions to ensure decision making is
communicated and understood.
28. You have the right to be involved in discussions and decisions about your healthcare, and to be given information to enable you to do this.
Procedures are in place to ensure that patients are routinely involved in discussions and decisions about their healthcare.
29. You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.
Communications, engagement and stakeholder relations plans include actions to ensure appropriate and proportionate involvement of patients and the public in service planning, development or change.
30. The NHS commits to provide you with the information you need to influence and scrutinise the planning and delivery of NHS services.
Communications, engagement and stakeholder relations plans include the provision of clear and accessible information on planning and delivery of NHS services.
31. The NHS commits to work in partnership with you, your family, carers and representatives.
Working in partnership with families, carers and
representatives is part of the engagement plan.
32. You have the right to have any complaint you make about NHS services dealt with efficiently and to
A complaints policy has been adopted.
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
have it properly investigated. 33. You have the right to know the outcome of any investigation into your complaint.
The complaints policy includes procedures to ensure the communication of the outcomes of complaints investigations.
34. You have the right to take your complaint to the independent Health Service Ombudsman, if you are not satisfied with the way your complaint has been dealt with by the NHS.
The complaints policy,
complaints literature and letters to complainants provide information on how to take complaints to the Health Services Ombudsman.
35. You have the right to make a claim for judicial review if you think you have been directly affected by an unlawful act or decision of an NHS body.
This is a legal right and as such does not require an assurance statement.
Rating not required
36. You have the right to
compensation where you have been harmed by negligent treatment.
A procedure for managing compensation payments is in place.
37. The NHS commits to ensure you are treated with courtesy and you receive appropriate support throughout the handling of a complaint; and the fact that you have complained will not adversely affect your future treatment.
The complaints policy includes access to support and reassurance of the impact of a complaint on future treatments.
Complaints handling is monitored.
38. The NHS commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.
A clear process to provide timely information, feedback and apologies is in place. This is monitored and reported as part of the formal process for receiving and acting on lessons arising from complaints, claims or PALS.
sources of evidence]
complaint/not compliant
RED
39. The NHS commits to ensure that the organisation learns lessons from complaints and claims and uses these to improve NHS services.
A formal process to receive and act on lessons arising from complaints, claims or PALS is in place. This process links directly to the Board.
ACTIONS FROM SOUTH WEST NHS CONSTITUTION CONFERENCE
& STAFF RIGHTS/EXPECTATIONS AND LEGAL DUTIES
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
Actions arising from NHS South West Constitution Conference held 11 December 2009
A1
NHS Boards must identify a Board level lead on the NHS Constitution
Board Level Champion identified; Board Report
Fully compliant
NHS Board Champion is:Mrs Carolyn Mills Director of Nursing
Name___________________________ Job Title: _______________________ ______________________________
Actions arising from NHS South West Constitution Conference held 11 December 2009
A2
Primary Care Trusts need to identify an NHS Constitution Champion to promote the Constitution and to act as an advocate on behalf of the public
NHS Constitution Champion identified;
Board Report
Not relevant
Primary Care Trust Champion is:
Name___________________________ Job Title: _______________________ ______________________________
A3
Primary Care Trusts need to work with NHS Providers and Third Sector organisations to ensure they have regard to the NHS Constitution in their activity for the NHS.
The organisation has a framework in place.
Board Compliance report.
Not relevant
A4
NHS organisations need to sign up to the NHS South West
Communications Strategy [attached]
The organisation has
implemented a Communications and engagement plan based on NHS South West Communications Strategy.
Board Compliance report.
Organisational
Communications strategy approved by board in 2008
Fully compliant
A5
Staff work with staff-side
representatives to ensure compliance with the Staff Pledges and Rights in the NHS Constitution
The NHS Constitution forms part of regular agenda at Staff-side and Staff Engagement meetings
Board Compliance Report; JNCC
Engagement Meetings; Values and vision
sources of evidence]
complaint/not compliant
RED
engagement eventsSTAFF PLEDGES, RIGHTS, EXPECTATIONS & LEGAL DUTIES
P1
Provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities.
The organisation has an up-to-date job description in place for all staff, which clearly outlines their roles and responsibilities;
The organisation will introduce the NHS Constitution in future Job Descriptions/person specifications.
Job descriptions are and continue to be evaluated under the Agenda for Change Terms and Conditions for Job Evaluation [except Medical and dental staff];
The organisation has promoted the NHS Constitution to all staff within the organisation.
Board report confirming compliance with the NHS Constitution for Staff rights and pledges.
Confirmation of application of National Agenda for Change Job Evaluation, or equivalent Job Evaluation process for FTs.
Banding process in place, consistency checking processes. Generic job descriptions for majority of posts.
NHS Constitution is incorporated into the organisations’ Induction arrangements;
NHS constitution is incorporated into OD plan
NHS Constitution is promoted on Trust Intranet;
The organisation has a Staff Charter, outlining staff rights, pledges and responsibilities.
The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on:
Partially compliant
Maureen Bignell – Director of
Personnel and Develom
Board report for April 2010
Induction processes to be
developed further to
incorporate NHS constitution
– April 2010
NHS staff rights and NHS
values to be incorporated
into recruitment literature
and promoted on job website
and intranet – April 2010
Joint work to be undertaken
with staff reps and wider staff
to finalise staff charter
May 2010
Guidance to managers to
support discussions during
appraisal process to ensure
that staff have a
understanding where there
roles makes a difference to
patients
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
KP3: % of staff feeling valued by work colleagues KP4: % of staff agreeing that they have an interesting job KP7 % of staff working in a well-structured team environment
Using e-rostering and
workforce reports analayse
working hours of staff
P2
Provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed.
The organisation has in place for all staff a personal development pan, supported by an individual KSF outline [for Agenda for Change staff];
The organisation has in place a mechanism which defines the relevant mandatory and developmental training required for specific roles;
The personal development plan clearly outlines appropriate development training to support the employee;
The organisation has in place appropriate training providers [internal /external] and training prospectus to satisfy individual and job requirements.
Board report on CARE QUALITY COMMISSION standards and compliance with staff receiving appraisal and personal development plans.
Evidence of an
Organisational Training Plan based on PDPs.
Evidence of an organisational Training programme and/prospectus.
Staff attitude survey results demonstrate Trust is in highest 20% in:
Number of staff appraised, having PDPs and having support from immediate managers
The key findings in the staff survey results demonstate that compared with other NHS Trusts NDHCT were in the top 20% on:
KF13 - % of staff appraised in last 12 months KF15 - % appraised with PDPs in place KF16 – support from immediate managers
Partially compliant
Guidance to managers to
facilitate a discussion on
what opportunities are
available to develop
potential.
P3
Provide support and opportunities for
The organisation has
arrangements in place either by
Internal Occupational Health
sources of evidence]
complaint/not compliant
RED
staff to maintain their health, well-being and safety.
internal or external agreements to provide Occupational Health and Wellbeing arrangements for staff; The organisation has in place an action plan to deal with the recommendations from the Boorman Report.
Health and safety training reports
Board Report responding to the ‘Boorman Report’, including an action plan to develop Health and Wellbeing of staff;
Board level champion for Health and Wellbeing;
Violence and aggression action plan
Health and well-being promoted on Intranet and success in iniatives
Staff attitude survey results demonstrate Trust is in highest 20% in:
KP17 - % receiving H & S training in last 12 months KP27 - % experiencing harassment, bullying or abuse from staff in last months
KF28 – Perceptions of effective action from employer towards violence and aggression
KF30 - % feeling pressure in last 3 months to attend work when feeling unwell.
developed further into the
occupational health service
October 2010
Analysis on causes of
work-related stress and action plan
to be developed
P4
Provide the opportunity for all staff to Engage in decisions that affect them and the services they provide.
The organisation has a staff engagement strategy in place.
The organisation engages with staff through appropriate Trades Union machinery ie Joint Staff Committee.
Recognition Agreement with Trades Unions and
Professional Organisations.
Joint Staff Committee Facilities agreement.
Partially compliant
Staff engagement
involvement strategy to be
reviewed
Rights/pledges/Actions
Assurance statement
- minimum expectations
Sources of evidence
[note: you may
reference other
sources of evidence]
Compliance with assurance
statement – fully
GREEN
compliant/partially
AMBER
complaint/not compliant
RED
If not fully compliant, actions
and deadline for achieve full
compliance
The organisation has in place arrangements to engage with staff who are non-representatives of TU/Professional organisations.
Joint Staff Committee Terms of Reference.Consultation Working party minutes of management of change meetings
Staff attitude survey results demonstrate Trust is in highest 20% in: KF33 - % of staff able to contribute towards impreovements at work KF38 - % having equality and diversity training in last 12 months
arrangements to be reviewed
Guidance to managers to
facilitate a discussion with
employee to ensure staff
understand their role and
where it fits in.
Analyse areas in the Trust
where staff are reporting
poor communication between
senior management and staff
and develop an action plan
R1
The NHS has a good record of fair employment and respecting the rights of staff.
All Staff have a Contract of Employment based on National Terms and Conditions, and reflecting the rights of staff.
Staff Charter incorporating the rights of staff and the NHS constitution.
Contracts of Employment based on National Terms and Conditions.
Audit reports
Partially compliant
Staff charter to be finalised in
consultation with staff side
May 2010
R2
Rights embodied in general employment and discrimination law.
The organisation has in place arrangements to support Equality and Diversity and Equal
Opportunities.
The organisation has a framework of policies and procedures in place to comply with employment and discrimination legislation.
Equal Opportunities Policy;
Bullying and Harassment Policy;
Violence and Aggression Policy;
Grievance and Appeals Policy;
Involvement/Engagement Policy;
Health and Safety Policy;
Flexible Working Policy;
sources of evidence]
complaint/not compliant
RED
High level of staff trained in Equality and Diversity.
Arrangements to train all managers in key policies and procedures.
Whistle blowing policy.
Staff Charter, setting out the responsibilities and expectations of staff.
Board report satisfying compliance with the NHS Constitution Staff rights and pledges.
Board reports including extensive information on equality data and action plan
Training Plan OD Plan
Staff Survey results; Care Quality Commission evidence;
Human
Resources/Workforce Board Reports;
Care Quality Commission evidence;
Human
Resources/Workforce Board reports.
E
