CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF …€¦ · Page 1 of 24 CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY Outcome 12 – Regulation 21 Requirement

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CARE QUALITY COMMISSION ESSENTIAL STANDARDS OF QUALITY AND SAFETY

Outcome 12 – Regulation 21

Requirement Relating to Workers

CQC Ref

CQC Prompt Lead Director / Lead Officer Response

Im L Level of Concern

Evidence of compliance / action required

Date

12A In relation to recruitment:

12A(1) Are honest, reliable, trustworthy and treat the people who use services with respect.

We have in place an Employment Policy that covers all aspects of recruitment. In addition we also have robust recruitment processes that comply with the Safe Recruitment Guidelines so that they are robust. Appointing officers are increasingly using behavioural skills interviewing techniques and interview against the person specification as criteria. Responses are captured and scored on standard documentation to ensure that recruitment decisions are objective.

M U Minor

• Recruitment documentation

• Employment Policy

• Behavioural skills questions and information including course content

• Recruitment processes and standard documents

Ongoing

12A(2) Are not discriminated against during the application or recruitment process.

In addition to the above, the Trust uses NHS jobs. Off line applications are also available for those who prefer to apply by paper application or who do not have internet access. We are accredited with the Two Ticks symbol.

M U Minor


• Two ticks documentation

• Monitoring reports from NHS jobs

Ongoing

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CQC Ref




Date

12A(3) Are qualified and competent to carry out their role and meet the needs of people who use services.

In addition to the above, the professional registration of candidates is checked against the register as well as documentary proof presented at interview.

M U Minor


• Sample Job description and person specification

• Professional registration Policy and reports

• Samples of recruitment documentation including checklists and scoring sheets

Ongoing

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CQC Ref




Date

12A(4) Have been subject to the necessary checks as described in Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2009, so that the provider is assured that the worker is suitable for their role.

We have a CRB policy that outlines the requirement for pre employment and post employment checks and re checks. The in house recruitment team audit documentation to ensure that it has been completed correctly prior to the conditional offer being made. Internal Audit also carries out audits of our processes and documentation to check for compliance against the standards especially for new starters and the authorisation process. L U Minor


• Pre-employment Guidance Document

• Sample Job description and person specification

• Professional registration Policy and reports

• of recruitment documentation including checklists and scoring sheets

• CRB policy

• Reports on CRB clearances

• Reports on offers withdrawn as a result of non satisfactory pre employment checks

• Audits by recruitment

• IA reports

• We are in discussions with Counter Fraud about them carrying out an audit to identify possible weaknesses in the system

Ongoing

•

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CQC Ref




Date

12A(5) Have been subject to a check that they are registered with the Independent Safeguarding Authority (ISA): –– where they are undertaking a Safeguarding Vulnerable Groups Act 2006 “regulated activity” or “controlled activity”; and –– are required to be registered under the Scheme’s phasing-in arrangements.

This relates to enhanced CRB checks as ISA has been deferred. The request to recruit to a vacancy asks Appointing officers to specify the level of CRB check required for the post. Guidance is available so that the relevant level of check is specified.

L U Minor


• CRB Policy


• Reports on enhanced CRB checks

• Recruitment documents

Ongoing

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CQC Ref




Date

12A(6) Are only allowed to start work before a full and satisfactory Criminal Records Bureau (CRB) check has been received if they are required to have one, in exceptional circumstances. Where this is the case the provider must have received an ISA Adult First check that confirms the staff member is not barred. This only applies to those staff who are required to be ISA Registered and only where they are employed to work with adults. In these exceptional circumstances the following safeguards are put in place: –– an appropriately qualified and experienced member of staff is appointed to supervise them –– wherever it is possible, this supervisor is on duty at the same time as the new worker, or is available to be consulted –– new workers do not escort people away from the premises unless accompanied by a staff member for whom a full and satisfactory CRB check has been received.

The policies and processes specify that candidates can only commence employment once all checks have been received and are satisfactory. This process is managed by the in-house recruitment team in conjunction with the appointing officer. Very occasionally CRB waivers are put in place which allow an employee to commence their induction whilst awaiting clearance. These are closely monitored by the recruitment team who notify the appointing officer once the CRB check has been received. M U Minor

• CRB Policy


• Evidence of checks

• Policy monitoring – how many people have been turned down for a role due to an unsatisfactory CRB check

• CRB waivers

• Recruitment checklist to demonstrate that appointing officer has seen the documentation. This process will need to be reviewed when the Trust moves to having a single start date to ensure that all clearances have been received before the employee starts and if not then a risk assessment and CRB waiver is put in place to allow the employee to commence their induction but not have patient contact.

Ongoing

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CQC Ref




Date

12A(7) Have demonstrated that they are legally entitled to work in the United Kingdom.

The Employment Policy sets out the requirements for employees to be able to work in the UK and again this is monitored by the recruitment department. The Trust is registered with the UKBA.

L U Minor



• RT07 Document (recruitment checklist re documents brought to interview)

• Monitoring reports

• reports, documents and audits

Ongoing

12A(8) Have demonstrated they meet the same standards of competency, qualification and experience for the role where they are recruited from outside the United Kingdom as they would have had they been trained in the United Kingdom.

DCHS recruits very few people from outside the United Kingdom. However the recruitment process is the same in terms of meeting the criteria in the person specification and job description. L U Minor



• RT07 Document (recruitment checklist re documents brought to interview)

• Monitoring reports

• reports, documents and audits

Ongoing

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CQC Ref




Date

12A(9) Are currently registered with the relevant professional regulator and/or professional body where appropriate, and only use a protected professional title where their qualifications and registration allows them to do so.

The Employment and Registration policies set out the requirements for staff to be registered with the relevant professional body. The requirement per job is contained within the job description. Candidates are required to bring their proof of registration to the interview for the appointing officer to check the registration and a further check is carried out by the recruitment department at the conditional offer stage. HR Services issue regular reports to managers on a proactive basis to remind them about forthcoming expiry dates of their employee’s registrations so that they can assure themselves that re registration has taken place.

M U Minor



• Registration and Re-registration Policy

• Reports such as registration checks and follow up action

• Documents and checklists

Ongoing

12A(10) Are aware of and adhere to any codes of professional conduct that apply to them.

Codes of conduct are covered in brief at the corporate induction and covered in more detail in the local. Codes of conduct are issued with offer of employment letters.

M U Minor


• Code of Conduct Policy

• Codes of conduct are sent out with offer letters. Samples as evidence.

• Local induction content.

Ongoing

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CQC Ref




Date

12A(11) Are physically and mentally able to carry out their role, with a plan of support including reasonable adjustment where necessary. This means staff: –– are not placed at risk by the work they will do because of an illness or medical condition they have –– do not present a risk to people who use services because of an illness or medical condition they have.

Until October 2010 DCHS carried out pre employment checks which involved candidates completing a health questionnaire that was sent to OH for them to assess and arrange a meeting with the employee if required. From October 2010 this has been replaced by a self declaration that the candidates complete and any questions that are answered positively result in the candidate being referred to OH for a more in depth discussion. OH carry out surveillance checks and also regular reviews of employees with on gong conditions or needs. Your Attendance Matters Policy was launched in early 2010 and was supported by a comprehensive programme of on line learning, training by ACAS as well as a communications plan and guidance documents. The training and the policy refer to managers being observant about their employee’s health and how to deal with it. There is the requirement within the policy to conduct return to work interviews after every sickness absence and a wellbeing meeting.

L P Minor


• OH PEHQ checks & self declaration (pre and post 1st October 2010) –

• Your Attendance Matters policy and guidance documents

• Your Attendance Matters E learning course content. End of course assessments to demonstrate learning

• ACAS Absence management course content

• A review of absence input to ESR

• Manager Self service is planned by Internal Audit for early 2011 to review the robustness of the information entered

• HR Services will be monitoring and auditing that return to work interviews and wellbeing meetings are taking place

• The Your Attendance Matters Policy has been reviewed and revised at Policy Working Group

Ongoing

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CQC Ref




Date

12A(12) Are able to communicate effectively with people who use services and other staff, to ensure that the care, treatment and support of people who use services is not compromised.

The Employment Policy and recruitment process stipulates that Appointing Officers recruit against the criteria in the job description and person specification. Competency based questions are used and responses recorded on an evaluation sheet to ensure that candidates meet the relevant criteria. KSF Core dimension 1 relates to communication and the KSF is reviewed at the annual appraisal.

M U Minor


• Interviews against JD & PS

• Recruitment documentation that shows we interview against the above and criteria

• KSF documentation

12A(13) Are clear about their responsibilities because they have an up-to-date job description.

As above. The Job Description is available as part of the recruitment process. Any role that is sent to recruitment must have a job description that is in the current standard template and must have a current evaluation. The annual appraisal and 6 monthly review ensures that staff are clear about their objectives and duties. It is an opportunity to review the job description if there have been changes. The AFC process states that roles must be reviews if there have been significant changes.

L U Minor


• Interview process and documentation

• AFC process and documents

12A(14) Are clear about the roles and responsibilities of other members of their team so that they know what they can expect from other staff.

As above. Many services and departments have team objectives that are linked to the DCHS strategy as well as individual objectives. L U Minor

• JD examples

• Local Induction

• Appraisal process and team as well as individual objectives

Ongoing

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CQC Ref




Date

12B In relation to qualifications, knowledge, skills and experience:

12B(1) Have relevant qualifications, knowledge, skills and experience to carry out their role.

As above. Annual appraisals and reviews include reviews against KSF outlines and inform the personal development plans. Employees whose performance is below that expected can receive support through the Performance Matters Policy to help them achieve the required standard.

M U Minor

• Examples of job descriptions and person specifications

• References

• Interview documentation –

• Performance Matters Policy

• Employee relations dashboards submitted to Partnership Forum

Ongoing

12B(2) Where this is not possible and does not impact on the safe delivery of the service the staff member agrees to work towards gaining the skills and qualifications necessary.

The Performance Matters policy outlines the process to follow to help employees achieve the required level of performance to fulfil their role. The policy includes identifying the underlying cause of the under performance and the support to be put in place to help achieve the required standard. This may involve re training both on and off the job or working towards a qualification. Where the recruitment arises as a result of organisational change, the Organisational Change policy may be used and this has similar support mechanisms.

L U Minor

• Examples of job description and person specifications

• Organisational change policy

• Redeployment examples

• Your Performance matters policy

• Employee relations dashboards submitted to Partnership Forum

Ongoing

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CQC Ref




Date

12B(3) Where trainees and students are working, they are only given tasks and provide care, treatment and support that is appropriate to the stage of their training and their competence.

• A Work Experience policy is under development

• All students allocated to clinical practice by the Learning and Development Team have an appropriately qualified mentor

• Students have supernumerary status

M U Minor

• Work Experience policy

• Mentor database on SharePoint

• Staffing Rotas

• Nursing and Midwifery Council and Health Professions Council guidance

• A Mentoring Policy is currently under development

Ongoing

12B(4) Have their qualifications, knowledge and skills reviewed on a regular basis to ensure they keep up to date with current practice.

• Appraisals are carried out annually and reviewed 6 monthly

• Evidence of continuing professional development is required by professional bodies for renewal of registration

• Requirements for posts are stated in job descriptions and person specifications

M U Minor

• Completed copies of Appraisal documentation

• Evidence of re-registration on Electronic Staff Record

• Information on Oracle Learning Management System (OLM)

• Job descriptions and person specifications for posts

Ongoing

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CQC Ref




Date

12B(5) Have an awareness and knowledge of diversity and human rights and have the competencies to support, appropriate to their role, the diverse needs and human rights of people who use services.

The workforce development priorities for diversity and human rights are aligned to the needs of the local population, enabling our staff to develop the knowledge and skills they need to respond to service users’ needs. Awareness is raised via Learning events on diversity and human rights via corporate programmes (Corporate Induction, Essential Learning, and Promoting Disability Equality), bespoke learning programmes for services and is embedded in in-house learning programmes.

L P Minor

Evidence of service staff demonstrating diversity and human rights’ competencies. Examples of best practice are provided in reports to the Equality and Inclusion Strategy Committee. Course materials. Some examples of workforce development priorities have included:

• Detailed training for Learning Disability staff to ensure the communication toolkit is implemented

• Communicating a clear process to staff on how to help address concerns with a service user’s communication skills

• Induction training for all staff that specifically covers both what an inclusive service entails and the support available to deliver this

• Mandatory equality and inclusion training

• Guidance for clinical staff on working with interpreters

• Makaton training

Ongoing

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CQC Ref




Date

Action: Increase emphasis on meeting competencies to support diverse needs and human rights of stakeholders. Action: Support the launch and use of e-learning and open learning modules.

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CQC Ref




Date

12B(6) Have a good understanding of the communication needs of the people who use the service.

Corporate training on the communication needs of different groups of people who use the service. (e.g. training on the needs of people with a LD via the Healthcare for All facilitator) and also embedded in in-house learning programmes. Induction and Promoting Disability Equality training provides guidance on communicating with people with a disability and people for whom English is their second language. Briefing sessions held within services.

L P Minor

Inclusion leads’ collate and provide evidence from services of sample good practices in meeting the communication needs of people who use services. Evidence of meeting communication needs of service users via reports to the Equality and Inclusion Strategy Committee which include good practice examples. Course materials. Action: Increase emphasis on meeting competencies to support communication needs of stakeholders.

Ongoing

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CQC Ref




Date

12B(7) Can identify and respond to the changing needs of people who use services.

Induction training, Promoting Disability Equality training and Equality and Inclusion training within services provides guidance on the changing needs of people who use services. Corporate training on the changing needs of different groups of people who use the service. (e.g. training on the needs of people with a LD via the Healthcare for All facilitator). .

L P Minor

Inclusion leads’ collate and provide evidence of services’ good practice in responding to the changing needs of people who use services. Evidence of meeting changing needs of service users via reports to the Equality and Inclusion Strategy Committee which include good practice examples.

Ongoing

12B(8) Are knowledgeable of the individual needs and preferences of the people who use the service.

PPI strategy in place. Services consult with service users to build knowledge of service users’ needs via PPI activities: Corporately liaise with consultation forums to build knowledge of service user needs e.g.:

• LD Good Health Group

• LGBT Forum

• Derbyshire Friend

• BME Health and Social Care Forum

• Carers’ Forum

L P Minor

Patient satisfaction surveys Complaints PEAT results Notes on service user needs in relevant patient records Need to work with inclusion leads to monitor the level of knowledge within services

Ongoing

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CQC Ref




Date

12B(9) Understand the physical and emotional needs of people who use services.

• Customer care, dignity at work, Equality and Diversity training are offered to staff

• In-house programmes delivered by the Learning and Development Team embed core values

• Knowledge and Skills (KSF) framework outlines are required for posts

M U Minor

• Lesson plans and course materials

• KSF outlines for posts

• Patient/ client care plans

Ongoing

12B(10) Recognise and promote the independence of people who use services.

• Customer care, dignity at work, Equality and Diversity training are offered to staff

• In-house programmes delivered by the Learning and Development Team embed core values

M U Minor

• Patient/ client care plans

• Patient satisfaction survey results

• Complaints received from service users, carers and the public

Ongoing

12B(11) Are aware of the services’ policies, procedures, legislation and standards.

• Attendance at induction and essential learning programmes is mandatory and is monitored and reported to DCHS Board

• Relevant information is embedded in in-house programmes delivered by the Learning and Development Team

• Policies identify any specific training required to implement

• This is part of the appraisal process which is carried out annually and reviewed 6 monthly

M U Minor

• “The deal” is under development, setting out DCHS’ expectations of staff


• Examples of policies

• Course Flyers


• Audit results and reports

• Incident reports and investigations

Ongoing

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CQC Ref




Date

12B(12) Know who they are able to contact, and how, when expert advice is needed.

• Relevant information is embedded in in-house programmes delivered by the Learning and Development Team

• Information may be held in patient records, or in a designated location in the work place, in some cases

• Clinical supervision may identify gaps

M U Minor



• Copies of Organisation structures

• Incident reports and investigations

• Patient records and information files in the workplace

Ongoing

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CQC Ref




Date

12C People who use services receive a service from a provider that has the right staff because:

12C(1) Staff are recruited following an effective recruitment and selection procedure that complies with legislation about employment, equalities and human rights. This includes as a minimum when recruiting new staff: –– application process including all of the necessary checks –– interview –– references –– records of the above.

The Employment Policy and the recruitment processes are robust and comply with the Safer Recruitment Standards. This includes ensuring that all pre employment checks are carried out by the appointing officers and the recruitment team. Offers of employment are conditional subject to pre employment checks being carried out to the satisfaction of the Trust before a date of commencement and firm offer is agreed.

L U Minor


• Pre-employment checks document

• Recruitment process

• recruitment documents

Ongoing

12C(2) The recruitment and selection process ensures that staff are fit and physically and mentally able to perform their role.

Until October 2010 DCHS carried out pre employment checks which involved candidates completing a health questionnaire that was sent to OH for them to assess and arrange a meeting with the employee if required. From October 2010 this has been replaced by a self declaration that the candidates complete and any questions that are answered positively result in the candidate being referred to OH for a more in depth discussion.

L P Minor



• Recruitment documents

Ongoing

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CQC Ref




Date

12C(3) Temporary, agency, bank and voluntary staff, and any practitioner working under practising privileges, are subject to the same level of checks and a similar selection criteria as staff recruited directly.

Employed temporary staff are subject to the same recruitment process as substantive employees. Agency employees are only sourced from PASA approved agencies and the contracts with them include assurance that the agency workers have been subject to a similar level of pre employment check to that required of our own employees and that they meet the minimum criteria in the person specification. Work is in progress to set up a more consistent co-ordination process for volunteers along with robust processes and a new Trust wide policy.

L U Minor



• CRB Policy


• Recruitment processes

• Reports to evidence the above

• Assurance re agencies and compliance with our standards

• Minutes of meetings from volunteer sub group

• Draft volunteer policy

Ongoing

12C(4) Other people providing additional services under arrangements made with the provider are subject to the necessary checks.

Lead / responsible person for contract is responsible that requirements are explicit in contract and that all appropriate checks have been undertaken

M U Minor

• Contracts

• Reports on assurance of compliance with the requirements of the contracts

Ongoing

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CQC Ref




Date

12C(5) Staff provided by an agency service are known to be fit and physically and mentally able to perform their role through: –– confirmation in writing from the agency that all necessary checks have been carried out in relation to each staff member being supplied –– the provider quality monitoring the contract they have with the agency, where the agency is used on an ongoing basis.

We only use agency workers from PASA approved agencies and the contracts. The contracts specify about the level of checks required for their workers.

L U Minor

• Contract monitoring reports with agencies. (to be obtained from Brian Summerfield)

• Copies of contracts

Ongoing

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CQC Ref




Date

12C(6) There are clear procedures followed in practice, monitored and reviewed, that are implemented when staff: –– are not well enough to work –– behave outside the policies and procedures of the service, or professional codes of conduct or practice that apply to them –– should be referred to their professional regulator or professional body, as appropriate –– are subject to investigations into suspected abuse –– are reasonably suspected to have caused harm or risk of harm to people who use services, and this includes the requirement for the person to be referred to the Independent Safeguarding Authority and/or regulatory body where the requirements for referral are met –– who are barred but are able to work in a Safeguarding Vulnerable Groups Act 2006 “controlled activity”. This includes the staff member being subject to tough safeguards including stringent supervision –– require specific plans of support, including any reasonable adjustments, to enable them to carry out their job

DCHS has in place a number of policies such as Employment policy, Registration, Performance, Disciplinary, Attendance and Codes of Conduct. These detail how to deal with situations that arise where employees are not meeting the required standards or contravene professional codes of conduct or Trust policy. The effectiveness of these policies is monitored through a number of monitoring reports. The Trust receives on a regular basis Alert Letters about people who have been subject to fraud and professional investigations/sanctions. These are checked against ESR and if any are employed by us then the relevant managers are notified.

L U Minor



• CRB Policy


• Attendance Matters

• Absence monitoring reports

• OH referrals

• Reports on RTW interviews and well being meetings are being developed now that ESR manager self service has been implemented and these will be reviewed to ensure the effectiveness of the policy.

• Your Performance Matters Policy

• Disciplinary Policy

• Codes of Conduct

• Employee relations dashboard

• Health and Safety Reports

• OH reports to H&S Committee

• alert letters re registration and safeguarding

Ongoing

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CQC Ref




Date

12C(7) –– are at risk of, or are, being exposed to physical, psychological or emotional hazards in the workplace in the course of their duties, and providing information about how those risks can be minimised.

Now that ESR Manager Self service is implemented within DCHS, reasons for absence are being recorded. This will enable the Trust to run report s to identify areas where work related issues are causing high levels of absence so that action plans can be put in place to address them. High level reports are submitted and reviewed at the Health and Safety Committee. Proactive measures such as training are available to staff to help deal with issues before they escalate.

L U Minor

• Health & Safety committee reports

• Conflict Resolution training

• Risk assessments

• Risk Treatment plans

• Resolve

• Managing Violence and Aggression training

• Managing Violence and aggression awareness leaflets sent out with payslips

• Reasons for absence reports from ESR

Ongoing

12C(8) They take into account relevant guidance, including that from the Care Quality Commission’s Schedule of Applicable Publications (see appendix B).

This is driven by DCHS’ Governance structure, including policies, procedures, guidelines and pathways. CQC issue guidelines about good practice and new ways of working. DCHS’ policies are based on current best practice and legal requirements and are reviewed regularly as appropriate as guidance and legislation changes

L P Minor

Minutes of relevant groups / committees.

Ongoing

12D People who use services can be confident that:

* This only applies to: Community – based Services for People with a Learning Disability.

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CQC Ref




Date

12D(1) Staff are only allowed to start work before a full and satisfactory CRB check has been received if they are required to have one, in exceptional circumstances. Where this is the case the provider must have received an ISA Adult First check that confirms the staff member is not barred. This only applies to those staff who are required to be ISA Registered and only where they are employed to work with adults. In these exceptional circumstances the following additional safeguards are put in place: –– the provider contacts people using the service, or others acting on their behalf, at weekly intervals to monitor their satisfaction with the care provided by the new worker and any complaints that may arise –– the provider informs people using the service, or others acting on their behalf, about the outstanding information, and tells them when it is received –– the provider ends the new worker’s contact with people using the service where the provider considers that the outstanding information (when received) is not satisfactory.

The policies and processes specify that candidates can only commence employment once all checks have been received and are satisfactory. This process is managed by the in-house recruitment team in conjunction with the appointing officer. Very occasionally CRB waivers are put in place which allow an employee to commence their induction whilst awaiting clearance. These are closely monitored by the recruitment team who notify the appointing officer once the CRB check has been received.

L U Minor • CRB Policy


• Evidence of checks

• Policy monitoring – how many people have been turned down for a role due to an unsatisfactory CRB check

• CRB waivers

• Recruitment checklist to demonstrate that appointing officer has seen the documentation This process will need to be reviewed when the Trust moves to having a single start date to ensure that all clearances have been received before the employee starts and if not then a risk assessment and CRB waiver is put in place to allow the employee to commence their induction but not have service user contact

• Local Induction for Ash Green

Ongoing

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CQC Ref




Date

12D(2) Staff are recruited with the involvement of people who use services where it is possible to do so.

Ash Green which is the Learning Disability service of DCHS actively involves service users in the recruitment of new staff and development of new roles.

L U Minor • Employment Policy

• Evidence of having service users on interview panels or any involvement in the recruitment process

Ongoing