SOMERSET PARTNERSHIP NHS FOUNDATION TRUST REVIEW OF SOMERSET PARTNERSHIP NHS FOUNDATION TRUST POLICIES IN RESPONSE TO THE LEEDS TEACHING HOSPITALS NHS TRUST REVIEW IN RELATION TO THE SAVILE INQUIRY Report to the Trust Board 27 January 2015 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director of Governance and Corporate Development. Director of Governance and Corporate Development. To provide the Board with assurance in relation to Trust policies in response to key recommendations arising from the Leeds Teaching Hospitals NHS Trust report in response to the Savile Inquiry. This report recommends a number of changes to the Trust s management of key policies, in particular: as part of its review of its Visiting Inpatients Policy, the Trust should develop a section in relation to celebrities and VIP visitors; the Trust should develop an integrated Volunteers Policy; this should cover volunteers employment checks, induction, training, access to the Trust and clarity about the boundaries of their roles; the Trust should review how it seeks the views of a wider range of stakeholders in developing policies where it is appropriate to do so; the Trust should undertake a review of the Developing and Managing Organisation-wide Procedural Documents Policy and Guidance to simplify the Trust policy template; the Trust should consider commissioning its internal auditors to monitor compliance against some of the key policy areas identified as part of its 2015/16 internal audit programme. Actions required by the Board: The Board is asked to discuss the report and approve the recommended actions. January 2015 Public Board - 1 -
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SOMERSET PARTNERSHIP NHS FOUNDATION TRUST REVIEW OF SOMERSET PARTNERSHIP NHS FOUNDATION TRUST POLICIES IN RESPONSE TO THE LEEDS TEACHING HOSPITALS NHS TRUST REVIEW IN RELATION TO THE SAVILE INQUIRY 1. INTRODUCTION 1.1 James Savile died in Leeds aged 84 in 2011. For over 50 years he had a close association with Leeds Royal Infirmary and its associated hospitals. Over the years, the nature of this association evolved through his roles as a volunteer, celebrity advisor to the hospital radio service, volunteer porter and significant fundraiser. 1.2 Initially highlighted in an ITV Exposure documentary first shown in October 2012, and then through subsequent investigations including Operation Yewtree led by the Metropolitan Police, it is now known Savile was also a prolific sexual predator, paedophile and rapist. He operated across the country through his work at the BBC, and in a number of NHS hospitals, including the Leeds Royal Infirmary. 1.3 Following the broadcast of the ITV documentary, Leeds Teaching Hospitals NHS Trust received a number of calls from former patients, staff and others who reported accounts of verbal, physical and sexual abuse at the hands of Savile. The incidents took place throughout his association with the hospital, with greater frequency during the 1960s and 1970s. 1.4 The Trust s immediate response was to conduct an urgent internal review of key areas of risk pertinent to Savile s alleged offences. Its Internal Audit department assessed a range of relevant current policies and practices and recommended a series of actions to address deficiencies. 1.5 In October 2012, the Secretary of State for Health commissioned independent investigations in the NHS organisations with which Savile was closely associated including Leeds Teaching Hospitals NHS Trust. 1.6 In December 2012, the Board of Leeds Teaching Hospitals NHS Trust commissioned an external team to investigate matters relating to Jimmy Savile and the Trust (and its predecessor bodies). 1.7 Chapter 10 of the review identified 14 policy areas which it considered relevant to the events considered by the inquiry. The policies, where they existed, were considered against the following criteria: January 2015 Public Board - 3 -
stakeholder engagement when a policy is being developed or reviewed; the scope of the policy; clarity; policy and practice; and monitoring of compliance. 1.8 This report, commissioned by the Chairman of Somerset Partnership NHS Foundation Trust, aims to provide assurance to the Board that it is has the necessary policy and governance arrangements in place to prevent something similar events happening in Somerset and will make recommendations, where necessary, for work which may be needed to achieve this. 2. POLICY REVIEW 2.1 The Leeds review compared the 14 key policies with those of NHS trusts that were rated highly by Monitor and the Care Quality Commission and with charitable organisations policies on the use of volunteers. 2.2 Table One below sets out a comparison of the policies Somerset Partnership NHS Foundation Trust has in place with those 14 policies reviewed in the Leeds report: Table One LEEDS TEACHING HOSPITALS POLICY Recruitment and selection Safeguarding children Conduct and discipline Whistleblowing Violence and aggression Safeguarding adults Complaints and concerns SOMERSET PARTNERSHIP POLICY September 2015. October 2016. Disciplinary Policy. Policy in place. Review date April 2017. August 2016. PMVA Policy. Policy in place. Review date October 2015. Safeguarding Adults at Risk. Policy in place. Review date October 2017. PALS and Complaints. Policy in place. Review date August 2015. January 2015 Public Board - 4 -
LEEDS TEACHING HOSPITALS POLICY Dignity at work Information governance Security Standards of business conduct Retention of Records Sanctioned visitors policy celebrities, VIPs and media contractors Volunteers policy SOMERSET PARTNERSHIP POLICY Privacy, Dignity and Respect Policy. December 2014. January 2017. October 2015. Ethical Standards and Code of Conduct Policy. Policy in place. Review date June 2016. Record Keeping and Records Management Policy. Policy in place. Review date October 2015. No equivalent policy in place. The Trust has a Visiting Inpatients Policy but this does not have specific provisions relating to celebrities or VIPs. Review date August 2015. No integrated Trust policy in place. The Trust has guidelines for volunteers developed jointly with Somerset County Council. 2.3 Somerset Partnership NHS Foundation Trust has policies or equivalent are in place with those reviewed in the Leeds report with the exception that it does not currently have a specific policy in relation to Sanctioned Visitors or an integrated Volunteers policy that applies to all services. 2.4 Recommendations: as part of its review of its Visiting Inpatients Policy, the Trust should develop a section in relation to celebrities and VIP visitors; the Trust should develop an integrated volunteers policy; this should cover volunteers employment checks, induction, training, access to the Trust and clarity about the boundaries of their roles. 3. STAKEHOLDER ENGAGEMENT 3.1 With the exception of the safeguarding adults and safeguarding children policies, which were pan-leeds policies developed in partnership with other health and social care organisations, the review found little evidence policies had been developed in consultation with patients, patient representative groups or external organisations with expertise in a particular area. Consultation with Trust staff was restricted to formal staff representatives. The Review recommended Leeds should consider the nature and purpose of its broader January 2015 Public Board - 5 -
community, including volunteers and non-executive directors, and ensure its corporate policies apply to the whole community. 3.2 Somerset Partnership NHS Foundation Trust has clear processes for consultation and engagement in the development of policies and, as in Leeds, some policies, such as for safeguarding, are developed as pancounty documents. However, there is limited evidence of wider involvement in the development of some policies which might benefit from consultation with patients, patient representative groups or external organisations with expertise in a particular area. 3.3 Recommendations: the Trust should review how it seeks the views of a wider range of stakeholders in developing policies where it is appropriate to do so. This may not be the case for all policies, particularly those driven by national guidance. 4. CLARITY 4.1 The Leeds Teaching Hospitals NHS Trust developed a template for its policies and a standardisation of approach. The Leeds policies when reviewed differed in style, length and whether and where they included detail on legal obligations and technical guidance; many were lengthy. Examples of policies from other NHS organisations looked at by the review were short and succinct and very clearly set out the salient points in plain language, using appendices for legal and technical details. The Review urged Leeds to learn from best practice elsewhere and work towards clear, succinct and understandable policies which can easily be communicated and implemented by staff and stakeholders. 4.2 Somerset Partnership NHS Foundation Trust uses its Developing and Managing Organisation-wide Procedural Documents Policy and Guidance document to inform the writing and production of its policies. The policy template was originally designed to conform with NHSLA Risk Management Standards requirements. These standards are no longer subject to annual review and monitoring but are considered a best practice template. All of the policies reviewed conformed to this approved procedure with only very minor variations to it. However, the length and complexity of policies vary. 4.3 Recommendations: the Trust should undertake a review of the Developing and Managing Organisation-wide Procedural Documents Policy and Guidance to simplify the Trust policy template; January 2015 Public Board - 6 -
on review, efforts should be made to ensure all Trust policies are succinct, use clear language and are easier to read by their intended audiences, including patients and members of the public. 5. POLICY AND PRACTICE 5.1 The review asserted that Boards need to receive assurance its policies are being adhered to and to have knowledge of any gaps between policy and practice. There were a variety of mechanisms in place in Leeds for monitoring the compliance with and effectiveness of the policies reviewed. These relied on reports of when policies had been invoked but the review found very little assessment of why procedures may not have been used and little analysis around this. 5.2 A review of Somerset Partnership NHS Foundation Trust s policies and procedures indicates clear evidence of systems for monitoring compliance and evidence from incident and complaints investigations of assessing why policies had not been used where things had gone wrong. 6. MONITORING COMPLIANCE 6.1 The policy areas considered in the review were monitored by one or more of a wide range of committees, sub-committees and groups. 6.2 The review considered the possibility that, within what was a complex corporate governance structure, the big picture could be unintentionally obscured, missing an opportunity to make connections between the various policy areas. 6.3 The review also suggested the role of Internal Audit in monitoring compliance with corporate policies should be reviewed. 6.4 Within Somerset Partnership NHS Foundation Trust, the policy areas considered were monitored by one or more of the following responsible committees/sub-committees/groups: Integrated Governance Committee; Audit Committee; Regulation Governance Group; Clinical Governance Group; Caldicott and Information Governance Group; January 2015 Public Board - 7 -
Senior Manager s Operational Group; Trust Board; Workforce Governance Group; Health, Safety and Security Management Group; Safeguarding Children and Adults Boards. 6.5 The Trust has historically commissioned its internal auditors to undertake compliance audits against key Trust policies and might consider. 6.6 Recommendations: the Trust should consider, as part of its review of its corporate governance structures, whether policy monitoring can be better managed and better connected to patient-centred carel the Trust should consider commissioning its internal auditors to monitor compliance against some of the key policy areas identified as part of its 2015/16 internal audit programme. 7. CONCLUSION 7.1 Somerset Partnership NHS Foundation Trust has clear processes in place for policy development and monitoring and no evidence but there are lessons to be learned from the Leeds Teaching Hospitals NHS Trust review which would provide greater levels of assurance, particularly in relation to VIP/celebrity visitors. January 2015 Public Board - 8 -
Links to Strategic Themes: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s) Quality and Safety x Innovation Viability and Growth Integration Service Delivery x Culture and People x Links to the Assurance Framework: Links to the NHS Constitution and Trust Values: Links to CQC Domains: Identify to which risks of the Assurance Framework this report relates not relevant to any specific risk on the Assurance Framework. Identify the Values to which the issues raised in this report relate by including a cross behind the relevant value(s) Working together for patients x Compassion x Respect and dignity x Improving lives x Commitment to quality Everyone x of care x counts Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s) Legal or statutory implications/ requirements: Public/Staff Involvement History: Previous Consideration: Is it safe? x Is it caring? Is it well-led? x Is it effective? Is it responsive to people s needs? Department of Health Guidelines staff have not been involved in the development of this report. not applicable. January 2015 Public Board - 9 -