CO-ORDINATING
ASSESSMENTS & INSPECTIONS BY
EXTERNAL BODIES
&
Dealing with External Recommendations Specific to the
Trust
Originator
Governance Manager
Lead Director
Director of Nursing, Quality & Risk Management
Version No
V3
Ratified:
Corporate Governance Group
Implementation Date:
October 06
Date of Review
March 2012
Date of Next Review
March 2015
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1.0
INTRODUCTION
All healthcare organisations are subject to inspections/accreditations by external agencies.
This document describes the process the Trust uses to provide Board assurance that:
1.1
Formal visits, audits, inspections, assessments, reviews and accreditations by external bodies
are properly organised and communicated, (hereafter known as “events”)
1.2
External recommendations specific to the organization are reviewed and reported appropriately
1.3
Action plans are developed as a result of external recommendation and are monitored
1.4
A register is maintained centrally in the Trust of all formal events
2.0
Purpose
2.1
To ensure that the Trust executive team is able to provide Board assurance concerning a
formal event initiated by external bodies to the Trust.
2.2
To provide assurance to the Board of Directors and external stakeholders (including the
relevant external body) that follow-up actions are implemented and that consequent changes
have improved services and reduced risks.
2.3
To ensure the Board of Directors, via Clinical Governance, Corporate Governance or Hospital
Executive Board is aware of the actions plans related to these formal events.
2.4
To ensure that the Board of Directors via Clinical Governance, Corporate Governance, Audit
Committee or Hospital Executive Board, remains informed of major risks (ie that may
undermine the Trust‟s objectives and/or credibility) associated with the events and their follow
up action plans.
2.5
To support and demonstrate continuous improvement in response to the event.
3.0
Definitions
3.1
External body or agency
An organisation that has an official advisory or regulatory role concerning activities of NHS
Trusts or which otherwise has statutory rights to visit, audit or inspect the Trust‟s premises
and/or review and inspect its processes, whether in the Trust‟s capacity as an employer,
provider of healthcare, or as a statutory public body. (e.g. Care Quality Commission, HM
Coroner, NHSLA)
3.2
Accreditation
This encompasses audit and review activities of both internal and external bodies that are
required to deliver Board Assurance. Accreditation provides assurance that the services being
delivered by the Trust are “fit for purpose” and are achieving the intended results in
conformance with the Trust‟s strategies, policies and procedures.
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2012
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3.3
Inspection
An organized examination or evaluation comparing results to specific requirements or
standards
3.4
Internal Control
Systematic measures (such as reviews, checks, methods & procedures) implemented by an
organization to conduct its business in an orderly and efficient manner
3.5
Board Assurance
Boards need to be confident that the systems, policies they have put into place are operating in
a way that is effective, focused on the key issues and driving the delivery of objectives. It also
provides a structure for the evidence to support the Annual Governance Statement. This is
achieved by formal reporting to the Board, and the prioritisation of action plans which, in turn,
allow for more effective performance.
4.
Roles & Responsibilities
4.1
Board of Directors
The Board of Directors will need to consider the implications of the outcome of external
inspections and be assured that any recommendations are effectively addressed and managed
by the Trust. The majority of these reports will be considered by the relevant Board sub
committees and reported to the Board.
4.2
Chief Executive
The Chief Executive is ultimately responsible for ensuring that any recommendations that arise
from external visits, audits, inspections and accreditations are received, reviewed, considered
and, if appropriate, implemented within the Trust. These responsibilities are delegated to the
Executive Directors based on their portfolio of responsibilities.
4.3
Executive Directors
Executive Directors are responsible for ensuring that external reviews that fall within their
portfolio of responsibilities are managed and responded to in an effective and timely manner.
The Executive lead will be responsible for nominating a lead to coordinate the preparation
for and recommendations arising from the event.
The Executive lead will ensure the Board of Directors and its sub committees with
responsibility for assurance and risk receive and consider reports from any inspections
The Executive lead is responsible for ensuring that the either the Local or Corporate Risk
Register are populated with any significant risks identified from either the preparation for, or
recommendations from such an event.
4.4
The Nominated Lead
The Nominated Lead is responsible for ensuring that the Trust is suitably prepared for the
review and for coordinating the necessary activities to ensure that it runs smoothly. They are
responsible for:
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Communicating information about the event to the Trust and other staff likely to be involved
in the event
Identifying any risk issues in compliance that may undermine the success of the event and
communicating those risks to the Executive Lead
Assessment of the requirements for the visit including collation of the evidence required
and preparation of staff and environment to be inspected
Ensuring the responsible Executive Director/Committee is fully appraised on the
preparations for a visit, including welcoming procedures, how staff are to be informed of the
visit, catering, feedback etc
Following receipt of the report on the visit, ensuring all information included in the report is
accurate
Carrying out risk assessments for activities identified in the report recommendations and,
where appropriate, escalate significant risks for inclusion in a local or the Corporate Risk
Register
Developing a report and action plan to address any recommendations made in conjunction
with the Executive Lead and formally report to the Board of Directors or appropriate
Committee
Providing regular progress reports, as required, to the Executive Director and other
relevant groups and committees
4.5
Governance Manager
The Governance Manager is responsible for:
Liaising with the Nominated Lead for each specific event
Liaising with the Executive Director/Nominated Lead in relation to progress on the
implementation of the action plans
Ensuring that the Corporate Risk Register is populated with any significant risks identified
from external agency visits, inspections and accreditations
5.0
Process for Reviewing & Reporting on External Recommendations
Following a visit, the Trust will normally receive a formal written report containing the
findings and any recommendations from the visit
The Nominated Lead, in conjunction with the Executive lead, will be responsible for
reviewing any recommendations from the visit and ensuring that these and the report are
presented to the relevant stakeholder committee and, in some cases, to the Board of
Directors
Where the Trust is found to be non-compliant with statutory requirements, these
recommendations may require immediate attention
Other recommendations may be advisory and the Nominate Lead/Executive Director will
have to consider how it interprets and responds to the recommendations
6.0
Developing Action Plans
The Nominated Lead is responsible for reviewing the recommendations and, where
required, developing an action plan with timeframes to address the issues raised, in
conjunction with the Executive lead
The design of an action plan may vary but should include :
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A description of the recommendation
Action required to address the recommendation
Individual identified to lead on the action
Target date for completion
Progress against the required action
7.0
Monitoring of Action Plans
The action plan will be presented to the appropriate committee by the Nominated/Executive
lead and will be reviewed on an agreed basis.
The relevant committee will monitor the implementation of the action plan, ensure its
completion and identify any issues to be reported to the Board of Directors
If there are significant risks to the completion of the action plan these should be raised with
the relevant Executive Director and placed on a local risk register for evaluation at the
Corporate Governance Group and where necessary, placed on Corporate Risk Register
8.0
Process for Monitoring Compliance
The Governance Manager is accountable for preparing an annual monitoring report which will
be presented to the Corporate Governance Group in September of each year outlining levels
of compliance with the following requirements as a minimum:
Process for reviewing external recommendations specific to the organization
Process for reporting on external recommendations specific to the organization
Process for developing action plans as a result of external recommendations
Process for the follow up of action plans
The Corporate Governance Group will agree the actions or recommendations from the report
and monitor the action plans as required until all actions are complete.
9.0
References
Care Quality Commission (2011)
The state of health care and adult social care in England:
an overview of key themes in care in 2010/11
Health & Safety Commission (HSC)
(2004 A Strategy for workplace health & safety in
Great Britain to 2010 and beyond) London HSC
“Building an Assurance Framework”
Concordat „Working in Partnership‟
Intelligent Board Handbook
NHSLA Risk Management Standard 1 Governance
10.0
Associated Documentation
Risk Management Strategy
11.0
Equality Impact Assessment
This policy has been subject to an Equality Impact Assessment and is not anticipated to have
an adverse impact on any group.
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