5 Boroughs Partnership NHS Foundation Trust Annual ... - Monitor

Policy and Guidance
A range of clinical and non-clinical policies, procedures and guidance is
available to staff in electronic format on the intranet that all staff have access
to. This assists them in managing risk.
The review and ratification process ensures that all policies go through a
process of engagement and consultation with staff - including formal staff-side
consultation. They also undergo impact assessment in relation to training,
equality and diversity, safeguarding and NHSLA requirements. Appropriate
training and development requirements are identified at the impact
assessment stage and are added to the Training Needs Analysis database.
There is a system for ensuring due process has been followed before policies
are ratified by the Clinical Governance and Clinical Risk Committee.
When Knowsley Integrated Provider Services were incorporated into the Trust
portfolio, they brought some policies and procedures with them under TUPE.
These too are available on the intranet and identified as being for KIPS staff.
When policies are due for review policies are rewritten so as to apply to all
Trust staff - with separate procedures if they are warranted for mental health,
learning disability or integrated community services business streams as
appropriate.
The Trust was assessed against the National Health Service Litigation
Authority Risk Management Standards in December 2011 at Level 1 and
achieved 100 per cent compliance
Quality and Safety Learning
The Trust is proud to be a learning organisation and is continually striving to
improve. The Trust has a range of mechanisms in place to ensure the timely
and effective communication of lessons learned and changes made to
improve practice and Systems of Internal Control.
To ensure quality and safety learning is co-coordinated across the different
parts of the Trust, we have developed our Patient Safety Framework, which
consists of:
Patient Safety Panel (challenge meetings around Serious Untoward
Incident reports)
Safety and Quality Metrics reporting aggregated risk management data
Patient Safety walkabouts to visit clinical services
Thematic review using the Safer Mental Health Checklist
Monthly Business Stream Risk Reports providing bespoke risk
management data and analysis
Clinical Quality Dashboard to feed back key data to frontline staff.
Annual Report and Annual Accounts 2011-12 157