Health Care Commission Annual Health Check   Introduced in 2005 the Annual Healthcare check is the Health Care Commissions system for assessing health care organisations in England. It aims to measure the things that matter to patients and is designed to answer two questions firstly Are healthcare organisations getting the basics right? and secondly are they making and sustaining progress?   One part of the process is to ask healthcare organisations to state publicly the extent to which they are meeting the 24 core standards and where relevant a number of developmental standards set by the government.   To ensure that we get the full picture of how our hospital is performing we have a responsibility for inviting patients and the public to comment on our performance as part of the declaration process. These comments give us valuable feedback on the views and experiences of people within the community. Attached is the Annual Health check submission for 06/07 along with the Health Care Commissions report for 2006.   We would welcome any comments or feed back you may wish to make about our 06/07 submission or indeed any aspect of your experience of our hospital.   Please feel free to e mail your comments to the hospital manager at tony.gorman@nhs.net or by mail to the Hospital Manager, Tarporley War Memorial Hospital, 14,Park Road, Tarporley Cheshire CW6 OAP     Mr A Gorman Hospital Manager TEL 01829 732436 May 2007     Self-assessment: Acute hospital       Name of establishment:   Tarporley War Memorial Hospital Trust      Version history This is version 3.1 in use from February 2007. If you have already filled in version 3.0, we will continue to accept it: do not complete again. New in this version: •  new questions on decontamination (1.7) •  new questions on controlled drugs and piped gases (1.8)             Self-assessment: Acute hospital     Name and job title of person completing this self assessment Anthony Gorman Hospital Manager Contact details (address and telephone number) 14 Park Road, Tarporley. Cheshire CW6 OAP Date of completion of this self- assessment 01/03/07 Signature of registered manager   Mr A Gorman   By signing this self-assessment, you are confirming that the information contained within it is a fair and accurate reflection of your establishment. If submitted electronically, you will be asked to sign it in hard copy at the inspection.     Contents   Introduction and guidance What is the purpose of this self-assessment? Five steps of annual inspection Who should complete the self-assessment? Structure of self assessment sections How should I complete the self-assessment? When should I return the self-assessment? How will my information be used? Achievements Background information 1 Safety 1.1 Risk management 1.2 Safety notices 1.3 Child protection and protection of vulnerable adults 1.4 Interventional procedures 1.5 Infection control 1.6 Medical devices 1.7 Decontamination 1.8 Medicines management    1.9 Waste management 2 Clinical and cost effectiveness 2.1 Evidence-based practice 2.2 Children 2.3 Surgery 2.4 Cosmetic surgery 2.5 Anaesthesia and recovery 2.6 Critical care 2.7 Radiology 2.8 Pathology 2.9 Cancer services 2.10 Maternity 2.11 Termination of pregnancy 2.12 In vitro fertilisation 2.13 Lasers and intense pulsed lights 2.14 Dialysis 2.15 Hyperbaric oxygen chambers 2.16 Supervision 2.17 Updating in the light of new evidence 2.18 Clinical audit and monitoring quality    2.19 Transfer and discharge 3 Governance 3.1 Accountabilities 3.2 Workers’ concerns 3.3 Staff appraisal 3.4 Records 3.5 Human resources policies    3.6 Research 4 Patient focus 4.1 Dignity and respect for patients 4.2 Consent 4.3 Resuscitation 4.4 Complaints 4.5 Catering    4.6 Patient information 5 Accessible and responsive care 5.1 Views of patients 6 Care environment and amenities 6.1 Health and safety    6.2 Maintenance and cleanliness Document request   Introduction and guidance What is the purpose of this self-assessment? The Healthcare Commission’s method for annual assessments of independent healthcare establishments is divided into five steps (see below).  The self-assessment asks more pointed questions than previously, to give us information that we need to target inspections.   Establishments who have not been inspected before may be inspected against all applicable national minimum standards; for those who have been inspected before, we will no longer inspect against all standards every year, only those where the establishment has not demonstrated satisfactory arrangements.  The answers you provide in this questionnaire will help to reduce the areas that are inspected on site visit, in some cases a site visit may not be required at all in the inspection year 2007/08.  Establishments who do not answer questions or do not answer them fully will be assessed against more areas on site visits than those who do.   The self assessment is structured under the headings of the Government’s Standards for Better Health[1].  In the future, the current national minimum standards are expected to be replaced with new standards that follow the model of Standards for Better Health.  For the time being, we are still assessing against the existing national minimum standards.  The ordering of questions within each section shows – just for information – how the issues covered in national minimum standards will continue to apply when we move to the Standards for Better Health aligned model.  You do not need to do anything more as a result of this; it is simply to let you know that in the future, the order and wording of standards will change, but they will continue to cover the same aspects of care set out in the Regulations[2].     Five steps of annual inspection   1 Guidance and tools are published This enables establishments to prepare and use inspection tools for their own quality assurance 2 Self-assessment This asks establishments for evidence against the national minimum standards 3 Risk Assessment This enables us to corroborate establishments’ self assessment and decide which issues to prioritise.  Areas of self-assessment corroborated as meeting national minimum standards will not normally be inspected 4 Site visit (if necessary) This is used to inspect the areas we have prioritised (and to add other areas if needed) 5 Report and action plan These record any inspection findings and actions taken in response to them     Who should complete the self-assessment?   The registered manager must approve and formally submit the self-assessment to the Healthcare Commission.  However, many establishments ask different staff to fill in each section with one person coordinating the self assessment as a whole.   The self-assessment is a formal part of the regulatory process.  Completing it inadequately or dishonestly will cause us to review the fitness of the registered manager.   Please be aware at all times that all self-assessment documents are available to the public on request.  Therefore patient confidentiality must be maintained at all times.  There is also a need for commercial confidentiality.       Structure of the self-assessment How should I complete the self-assessment The self-assessment documents are available on the healthcare Commission website – www.healthcarecommission.org.uk.  The Healthcare Commission would prefer submissions to be made by e-mail rather than paper copy to your local regional office at the address in your notification letter.  Boxes expand as you type.   Regional offices can also be contacted by e-mail for further information at any stage of the inspection process.   In each section of this questionnaire we ask ‘trigger’ questions, the purpose of these is to help us to target inspection activity, they are not intended to cover every aspect of the national minimum standards.   The first part of this questionnaire invites you to put forward information about your strengths and achievements.  The next section asks a number of background questions about your establishment, this is followed by the main body of the questionnaire.   The main body of the self-assessment follows the structure of the domains of standards for Better Health:   Safety   Clinical and cost effectiveness   Governance   Patient focus   Accessible and responsive care   Care environment and amenities       Each section has a series of self-assessment statements, beneath these, in a shaded box, are a series of questions designed to act as prompts with space beside each for your answer (where applicable).   Beneath these are references to the national minimum standards that are covered by questions in this section and a short note that indicates the documents that we may use to corroborate your self-assessment.   The questions often ask for evidence such as audits.  This does not mean that we expect you to carry out formal audits of every area of activity: we want you to demonstrate by whatever evidence you can, how you know whether a policy is actually implemented or not, and how you detect any cases when it is not.   At the end of each section there is always space for you to add other contextual information or other evidence, and – just for information – a pointer to where this will fit into Standards for Better Health in the future.   This is your opportunity to demonstrate to us how effective your systems are: do not wait to be asked the ‘right’ question and if you have a better system than we have asked for in the prompts then say so.   You should include examples that show how you learn from experience and implement a quality cycle.  It is better to admit problems and demonstrate that you have prevented their recurrence, than to pretend that problems never happen.   You will almost certainly find that some questions are not relevant to your establishment.  In that case simply enter ‘not applicable’ and move on.   When answering the questions, first and foremost bear in mind that the answers should give evidence that demonstrates what you actually do: vague answers are not adequate.  Each set of questions has brief guidance on what we are looking for (unless it is self evident) and refers you to the relevant national minimum standard, which contains more detailed guidance on what we are looking for.  You should give specific examples of what you actually do in all cases.  Do not simply refer to the existence of policies and do not send examples of policies unless we specifically ask to see them.  If you provide services for children, please remember that the Healthcare Commission has a statutory duty to give attention to children’s needs.  Please make sure you include examples of how you assure standards for children as well as adults.     The final section is a list of documents.  These documents are requested by the Healthcare Commission to help on the process of pre-inspection targeting.  Full and completed document submission at this stage will contribute to a reduced burden on your establishment on inspection.  If the documents are available, we ask that they be sent to us at this stage rather than them being made available on the inspection visit.   Wherever possible please provide electronic documents.   When should I return the self-assessment?   The letter notifying you of your inclusion in a round of inspection activity will tell you the date by which the self assessment should be submitted.    You must return the form by the due date.  No extensions to the deadline are possible     How will my information be used?   Each set of questions refers to national minimum standards shown below them.  These are the standards that we may decide to inspect in detail, depending on your information.  Where there is more than one standard, it is because they overlap and we will normally inspect all the standards mentioned.   Beneath each set of questions, we have shown the main documents that we will read alongside your information to corroborate it and decide on priorities.  These might be, for example, previous inspection findings (by which we mean last year’s report and in some cases findings from other inspectorates) on minutes and data provided within this questionnaire or the documents that we ask you to provide.  In general if you provide convincing evidence and the other documents corroborate it, the issue will be de-prioritised and we will accept your self-assessment without inspecting further.  However we will still prioritise a few issues as random spot checks and observation on site will often add extra priorities.   Our methodology places emphasis on you demonstrating compliance upfront, so that we can plan inspections to have less breadth and more depth.  Without full completion of this self-assessment we cannot pre-plan and target inspections.   Please keep a copy of your completed self-assessment for your records, and keep a note of your experience with this self-assessment, as we will ask you for feedback and suggestions at the end of your inspection       Please save this form regularly when completing electronically         Achievements First of all, please tell us about your achievements by completing the box below. Although you can also discuss achievements with your inspector during the site visit, this is your main opportunity to make sure that you bring to our attention achievements that you believe should be recognised: telling us about them now will enable us to build time into the site visit to look at them. Do not use more than 250 words. Please give a short description of any progress and developments since your last inspection. This is an optional opportunity to demonstrate increased compliance with national minimum standards and year on year learning and improvement.      Unfortunately due to the long term ill health and recent death of the previous manager the hospital was without a substantive person until February of this year. As the recently appointed manager it was my priority to catch up and ensure that the outcomes from previous HCC inspections and work place risk assessments were acted upon. In conjunction with the Hospital Matron all actions plans were reviewed and acted upon. These now form part of the agenda at a new monthly management meeting. In order to gain knowledge from other health care settings stronger links have been developed with managerial and professional colleagues within Western Cheshire PCT and Acute hospital Trusts. The main areas of learning are around Infection control management, risk management essence of care, and patient involvement. As a result of this networking we have reviewed and relaunched our risk management reporting mechanism, introduced the North West Health Authority’s Essence of Care framework commencing with food and nutrition. Introduced a monthly multi disciplinary Team brief and commenced an appraisal system for all staff. In order to ensure compliance with the Medicines Management standards the matron has introduced quarterly audits.                             Background information Some questions ask for information up to 31 March 2007. If you are asked to complete this form before 31 March, please provide information up to as close as possible to that date.   1. How many inpatient beds are there? Seventeen       2. How many operating theatres are there? none   a) with laminar flow N/A b) without laminar flow N/A This question may not be applicable to some types of establishment. If this is the case please mark N/A   3. Have there been any changes to the premises in the last 12 months? If so, please describe. None   4. Please list the specialties provided and next to each the percentage of your total activity that they constituted between 1 April 2006 and 31 March 2007. Specialty % of total activity Rehabilation 54% Pallitative Care  5% Respite 18% Intermediate care 23%                         Please add any more specialties:   Finished episodes of care: Day care 1033, Minor Injuries 286, Redressings 1158, Specialist Clinic 1349, GP clinic 1320       E.g. General Surgery; Cardiothoracic Surgery; Accident & Emergency (A&E); Pain Management; General Medicine; Gastroenterology; Rehabilitation; Palliative Medicine; Dermatology; Termination of pregnancy; Medical Oncology; Paediatrics; Geriatric Medicine; Gynaecology; Radiology; Nursing; Obstetrics; Haemodialysis.   Please give proportions of all activity in the establishment, e.g. please do not include separate figures for inpatient and day care.     5. Please state the number of patients in each age group for the period 1 April 2006 to 31 March 2007. Age 0-4 nil Age 5-10 nil Age 11-17 nil Age 18-64  10 Age 65+ 272 Where possible, please use ages ranges specified above.   6. What was the ethnic mix of patients on 1 March 2007 as defined below? (Please specify proportions for each group). Ethnic Group