Contents. Who we are, what we do, and how we do it 1. Targeting our work on what matters most: 8. Our Strategic Direction 8

Contents Page Number iii Foreword Who we are, what we do, and how we do it 1 Targeting our work on what matters most: 8 Our Strategic Direction ...
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Contents Page Number iii

Foreword Who we are, what we do, and how we do it

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Targeting our work on what matters most:

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Our Strategic Direction

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Deciding on our work programme

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What we will do every year

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Our development work

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Areas of special interest

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In 2011-12

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In 2012-13

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In 2013-14

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Making a difference

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Foreword On behalf of the citizens of Wales, Healthcare Inspectorate Wales (HIW) provides independent and objective assurance on the quality, safety and effectiveness of healthcare services, making recommendations to healthcare organisations to promote improvements. In July 2010 we published our programme for 2010-13 and in doing so gave a commitment to continually revise and update it in light of changes and developments across health services in Wales. Since then, the NHS reforms continue to change the landscape within which health services are planned and delivered across Wales, the regulatory framework for the independent sector has changed and the economic climate is placing significant financial pressures on both the public and independent sectors. Our work programme for 2011–2014 aims to respond to the key areas of concern facing patients, the public and other key stakeholders (including health services organisations) in these challenging times. In doing so, it reflects the feedback we have received throughout the year, from consulting on our plans as well as taking account of the work we have undertaken across Wales over the last few years. Over the next three years, the scope and approach to our work will be kept under review to ensure that we remain focused on those aspects that matter most to the citizens of Wales. We will continue to ensure that we are proportionate in the work we do and efficient in the way in which we do it in order that we are able to make the biggest impact in supporting improvement in the efficiency, effectiveness, quality and safety of healthcare in Wales. The Standards for Health Services will continue to underpin all our activity, and we will use the results of our overall programme of work carried out during the year to inform our assessment of how well individual health service organisations are performing against the Standards. We will report on our overall findings through the introduction of annual ‘State of Healthcare’ reports.

Peter Higson Chief Executive

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Who we are, what we do and how we do it Who we are ƒ ƒ ƒ ƒ

Healthcare Inspectorate Wales (HIW) is the leading regulator of all healthcare in Wales We carry out our functions on behalf of Welsh Ministers We are professionally independent We provide an objective and robust view of healthcare services that, taken as a whole, affect virtually everyone in Wales

The successful delivery of our work programme depends on the professionalism, skill and dedication of our workforce. Around 50 people are based at our office in Caerphilly. Our teams are organised on the basis of the functions they perform across both the NHS and independent healthcare sectors. Supported by a ‘matrix management’ approach, we are able to be flexible and agile, quickly moving the right people onto the right projects and providing learning to enhance skills as and when needed. To support our core staff, we have a pool of over 200 healthcare professionals and members of the public who are trained to help us carry out our reviews, and who bring a wealth of up to date and specific skills, knowledge and experience to our work.

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We regulate and inspect NHS and independent healthcare organisations in Wales against a range of standards, policies, guidance and regulations We focus on the safeguarding of those who are most vulnerable We identify where services are doing well, and highlight areas where services need to be improved 1

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We investigate where there may be systemic failures in delivering healthcare We take immediate action if we determine that the safety and quality of healthcare does not meet required standards We inform patients and the public about the standards of healthcare in Wales We drive improvement through shared learning

Our responsibilities are wide ranging:

NHS Inspection & Investigation

Deprivation of Liberty Safeguards (DOLS)

Independent Healthcare

Statutory Supervision of Midwives

Dentists

Mental Health Act Review Service

Clinical Reviews of Deaths in prison

Healthcare Inspectorate Wales

Homicide

Substance Misuse

Investigations

Nurse Agencies

Youth Offending Teams IR(ME)R

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How we do it Our Values Central to everything we do, our values establish the fundamental principles that govern the way we carry out our work. They are embodied in the behaviours of all our staff and external reviewers who carry out work on our behalf. They are

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Openness Honesty Centred on patients, service users and citizens Collaboration, sharing our experiences amongst ourselves and with other review bodies Efficiency, effectiveness and proportionality in our approach; and Supporting and encouraging learning, development and improvement

Working together Engaging and involving patients and the public We work closely with patients, service users, their families, carers and the public generally. This helps us to understand people’s needs and preferences, to learn from experiences and to promote openness and transparency about the quality of healthcare. Working in line with the National Principles for Public Engagement in Wales 1 , we involve citizens in our work by:

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The National Principles for Public Engagement were endorsed by the Welsh Government in March 2011. They are an overarching set of principles aimed at public service organisations across all sectors in Wales.

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Consulting on our overall plans and work programmes.

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Working with service users and representative organisations to develop new approaches to our work.

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Including members of the public as ‘lay reviewers’ within our review teams.

Seeking views and perspectives on specific aspects of healthcare, or within particular communities and areas in Wales.

Providing information on the quality and safety of healthcare through the publication of our reports.

Working with healthcare services and their staff ƒ We work with NHS local health boards and trusts and independent healthcare providers to create a common understanding of what we can do collectively to improve healthcare in Wales.

ƒ We encourage healthcare organisations to ‘get things right’ first time through the development of arrangements for self assessing how well they are doing and where they need to improve.

ƒ We engage and involve clinicians in our work to foster sustainable, self improvement.

Working with the Welsh Government and the National Assembly for Wales At an all Wales level, we inform the development of healthcare policy and practice through a wide range of activities. As well as the publication of our reports:

ƒ We provide independent advice to Welsh Ministers. ƒ We provide professional advice and input to inform policy development. ƒ We contribute to the development of standards and quality requirements for health services.

ƒ We share information to enable strong performance management of NHS organisations.

ƒ We submit oral and written evidence to Welsh Committees.

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Patients and public

HIW National Health Service and Independent Healthcare

Welsh Government

Working with other inspectors and regulators, professional bodies and improvement agencies ƒ

‘Working Collaboratively to Support Improvement: A Strategic Agreement 2 ’. We work together with the Wales Audit Office (WAO), Care and Social Services Inspectorate Wales (CSSIW), and Estyn to achieve the following objectives:

ƒ Joint and collaborative working guided by common vision and purpose, and supported where necessary by strategic agreements and operational protocols ƒ Planning and programming activities will be co-ordinated such that they result in proportionate programmes of work which avoid duplication and ensure key risks and concerns are being examined.

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Working Collaboratively to Support Improvement: A Strategic Agreement was signed by the four main inspection, audit and regulation bodies in Wales on 25th March 2011. The agreement is part of a framework of joint working activities being developed by the four organisations to support better coordination of external review activity and to develop further the existing arrangements for sharing knowledge and information.

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Developing approaches to information and knowledge sharing between our receptive organisations to guide our programmes of work and help ensure intelligence is actively and promptly shared. ƒ Identifying opportunities to bring together knowledge and intelligence collectively held on public services, and report this in ways to support service improvement, inform policy making and national scrutiny and strengthen public accountability. ƒ

Continuously monitoring the progress we are making with joint and collaborative working and report this openly and transparently to key stakeholders.

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We support the work of the Wales Concordat between bodies that inspect, regulate, audit and improve health and social care services in Wales.

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We maintain strong links with UK and European regulatory and professional bodies and other UK organisations to ensure our work is both informed by and influences the development of effective inspection, investigation and regulatory practice.

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We work together and share information with partner organisations working in Wales to support the delivery of high quality, safe healthcare – established within Memoranda of Understanding which define the circumstances in which and the process through which we co-operate in carrying out our respective duties.

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Our toolkit of approaches We adopt a wide range of approaches to enable us to effectively assess the quality and safety of healthcare provision. In doing so, we take a human rights based approach to all our work, ensuring active consideration of equality issues is embedded within all our inspection and investigation tools and techniques.

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Inspection visits

Special themed Reviews

Investigations/Special Exercises

Standards for Health Services assessments

Unannounced Cleanliness spot checks

Unannounced Dignity & Respect Checks

Healthcare Summits

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Targeting our work on what matters most Our Strategic Direction The landscape within which healthcare services are planned and delivered across the UK is changing at an almost unprecedented pace. This, together with the impact of the ongoing economic situation is a significant challenge for healthcare services in Wales and public services generally. The reforms that changed NHS structures in Wales are bedding in but the NHS needs to continue to develop and transform its ways of working with its statutory and third sector partners if it is to achieve its longer term ambition of developing an integrated care system through working across health and social care. For the independent healthcare sector, the introduction in April 2011 of new regulations and associated standards in Wales further establishes the divergence of the regulatory framework for independent healthcare across the UK, bringing with it particular challenges for providers operating across borders. In representing the interests of the public and patients, it is essential that our work continues to focus on how the changing environment is affecting the quality and safety of healthcare across Wales and whether, overall, healthcare provision is improving in line with the needs and expectations of citizens in Wales. We will continue to focus on ensuring that those who are most vulnerable are properly safeguarded and we will do this by seeing for ourselves how services are being delivered and listening to service users and their families about their experiences. We will continue to shift the balance of our own work so that we look at front line services delivered within primary and community care settings and not just hospitals – in line with the Welsh Government’s own ambitions to focus strongly on health prevention, promotion and the provision of primary and community care. We will encourage healthcare organisations to self assess their own performance more effectively and further strengthen their internal scrutiny so that they are better equipped to ‘get it right first time every time’ or to identify and respond quickly and effectively to issues affecting the quality and safety of services.

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We will engage and involve healthcare professionals more in our work in order to foster an environment of sustained self improvement in the quality and safety of healthcare provision. We will further strengthen our collaborative approach – focusing particularly on the path from the ‘diagnosis’ of problems or weaknesses in service provision to ‘improvement’ action - developing stronger links with support and improvement agencies so that healthcare organisations are able to access the help and support they need to make the changes they need to. We will avoid ‘over’ diagnosis of problem areas. Where others have already identified issues affecting the quality and safety of healthcare, our focus will be to build on that work rather than repeating it. This may mean for example, carrying out a more detailed assessment into a particular aspect or following up at a later stage to determine if improvements have been made. We will continue with our own extensive programme of organisational development, focusing on transforming the way we carry out our own work by further developing our people, our planning and our ways of working as well as enhancing the way we keep people informed and involved in our work through a new approach to engagement. Our plans for the next three years will focus on driving improvement through a balanced work programme that includes:

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A continuation of our routine regulation, inspection and assurance work designed to fulfil our statutory responsibilities and other priorities.

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A programme of all Wales assessments targeted at areas of special interest.

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Informing and influencing healthcare policy and practice through our contribution to key areas of development.

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Follow up work from earlier reviews and inspections.

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Deciding on our work programme The development of our work programme takes account of a number of considerations: ƒ ƒ

Much of our work is already defined through statutory requirement and can therefore be considered our ‘must do’s. We may be commissioned by others to carry out work, as is the case of the investigative work we do on behalf of Welsh Ministers for example, in relation to homicides, or our work with the Prison and Probation Ombudsman investigating deaths in Welsh Prisons. For these aspects, we have decided that it is important that we carry out this work because it contributes to our overall view on the quality and safety of healthcare services in Wales or because it drives improvement, as in the case of our work in support of the development of service standards and quality requirements.

For the remainder of our work, we take into account a range of factors to help us establish what we should look at, when, and how:

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The fact that some services, by their very nature, will always carry risks, either because of the vulnerability of the client group or the complex nature of the service. Our risk profile for a particular service or organisation may indicate areas of concern or worrying trends, perhaps as a result of concerns or complaints received. The outcomes from our previous work may identify areas where further work is needed. We may receive intelligence from other bodies, or the outcomes from others review work may suggest areas we need to look at. The area may be a recognised national priority for healthcare services. There may be new standards or quality requirements against which service provision can be assessed to identify improvements. There may be a recognised inequality in the provision of healthcare services, or a high proportion of the population may be affected. Performance data may indicate variations in quality or areas of major risk affecting particular areas or communities. 10

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There may be significant or increasing public concern. The impact of our work may be maximised through joint working with other inspection, audit or review bodies.

Because many of these are subject to change, our programme for the year ahead is set out in some detail, while that for the successive two years is more indicative, allowing us to remain responsive and to adapt to changing circumstances and priorities. We will publish a more detailed plan of work at the beginning of each of the 2010-12 and 201314 years. The terms of reference for all our review work, together with background information, can be found on our website. This Forward Work Programme and other HIW information can be provided in alternative formats or languages on request. There will be a short delay as alternative languages and formats are produced when requested to meet individual needs. Please contact us for assistance. Copies of all reports, when published, will be available on our website or by writing to:

Communications and Facilities Manager Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road CAERPHILLY CF83 3ED

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What we will do every year: Our overriding aim is to ensure safe and quality health services are provided to the citizens of Wales. To help us achieve this, we have in place a number of work programmes and review mechanisms that we undertake each year as a matter of routine. We target the design and conduct of our routine programmes of work in a way that enables us to use the results of this work and the information we gather in a number of different ways so that we can provide a broader, overall assurance on the quality and safety of healthcare services. Much of the evidence we will draw upon to reach our conclusions and report on areas of special interest will come from our routine work. As well as maximising the impact of our ongoing work, our approach also ensures the organisational and administrative impact of our work on health care organisations is kept to a minimum so that they may concentrate on delivering safe, high quality services.

Driving care that’s patient centred – Ensuring healthcare organisations are fit for purpose A key focus of our work is to ensure that health service organisations are fit for purpose and that they have the necessary management processes and governance arrangements in place. A map of the healthcare organisations in Wales, both NHS and independent healthcare, are set out in Annexes 1 and 2. Over the next three years we will, as part of a rolling programme:

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Undertake annual validation and testing of how health service organisations comply with Doing Well, Doing Better: Standards for Health Services in Wales 3 The standards for health services in Wales set out the Welsh Government's common framework of standards to support healthcare organisations in providing effective, timely and quality services across all health service settings. They set out the requirements of what is expected of all health services in all settings. This is a key mechanism for ensuring health service organisations’ fitness for purpose, as it highlights the progress they have made and examples of practice worthy of being shared with others, as well as identifying their shortcomings. All of the work we carry out during the year will inform our assessment of how well health care organisations are doing against the Standards. In the year ahead we will:

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Work with the WAO to validate NHS organisations’ first corporate level assessment of their performance against the Standards using the Governance and Accountability self assessment module.

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Continue to work with health service organisations and other stakeholders to facilitate the further development of a self assessment process designed to enable health service organisations to assess and assure themselves, as well as others, of how well they are performing against the standards in key services, including Maternity and Mental Health Services.

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Use the framework of the standards to check how well NHS organisations are complying with the Welsh Government’s guidance on Engagement and Consultation on Changes to Health Services.

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Doing Well Doing Better: Standards for Health Services in Wales was published by the Welsh Government on 1 April 2010 and sets out the requirements of what is expected of all health services in all settings.

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Regulate the Independent Healthcare Sector in Wales Through registration, inspection and, where necessary enforcement action, we will continue to regulate the Independent Healthcare Sector in Wales in line with the requirements of the Care Standards Act 2000, the Independent Health Care (Wales) Regulations 2011, the Independent Health Care (Fees) (Wales) Regulations 2011 and the Private Dentistry (Wales) Regulations (2008). The conduct of inspection visits are a key aspect of our assessment of the quality and safety of healthcare services provided by registered independent healthcare settings in Wales. Our inspections will focus on the extent to which independent healthcare organisations comply with the Welsh Government’s new National Minimum Standards 4 , (NMS) introduced in April 2011. Each registered establishment in Wales will be subject to a minimum of one inspection visit every year, and during the year we will further develop our risk based approach to determine the level and focus of inspection activity in the medium and longer term. We will further develop our systems and processes for the registration of new independent healthcare settings and the enforcement of compliance with the Care Standards Act 2000, including suspension, cancellation or prosecution. We will also work with the independent healthcare sector to develop a new approach to self assessment against the NMS using the framework of Doing Well, Doing Better: Standards for Health Services in Wales.

Dignity and respect We will continue to develop and roll out our programme of unannounced visits to healthcare settings focusing on issues relating to patient safety, dignity and respect.

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The National Minimum Standards for Independent Health Care Services in Wales were published by the Welsh Government in April 201 and form part of a broader Welsh Government policy to improve the quality of care to ensure that patients receive treatment and services that are safe and of an assured quality.

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Over the coming year we will publish an overview report of the outcomes from our earlier dignity and respect reviews. We will also extend our approach to carrying out these unannounced visits in the early morning, evening and at night and across healthcare settings. Each year our programme of unannounced visits will be designed to focus on particular aspects of safety, dignity and respect, and in doing so, will: ƒ

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Follow up on the concerns raised by the Older People’s Commissioner for Wales in her report “Dignified Care 5 ” which examined whether older people in NHS hospitals in Wales receive care in a dignified and respectful way and the Welsh Government’s response. Take account of the work carried out in 2010 by the WAO on Nutrition and consider the impact of the introduction of the All Wales Nutrition Care Pathway. Consider the impact of the introduction of the Fundamentals of Care audit tool on dignity and respect. Consider the impact of discharge planning on patient safety, dignity and respect.

We will also work closely with Community Health Councils in Wales to share intelligence and ensure our work programmes in this area are complementary.

Safeguarding the most vulnerable

We will safeguard the interests of all those who access Mental Health Services by the ongoing monitoring of compliance with the Mental Health Act 1983 and other relevant mental health legislation, such as the Mental Capacity Act and the requirements of the Deprivation of Liberty Safeguards. This work includes:

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‘Dignified Care?’ was published by the Older People’s Commissioner for Wales on 14 March 2011 and reports upon the findings of the Commissioner’s review of the experiences of older people in hospitals in Wales.

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Visits to patients subject to the powers of the Mental Health Act (MHA). During the year, we will review and further develop our approach to the conduct of our MHA visits to ensure they are effectively integrated within our overall routine work programme. The provision of a Second Opinion Appointed Doctor (SOAD) service which appoints independent doctors to give a second opinion as a safeguard for patients who either refuse to give consent for certain treatments or are incapable of giving such consent. During the year, we will assess our arrangements for the recruitment and use of our SOADs to ensure we get the most value from this sought after resource. Monitoring the implementation of the Deprivation of Liberty Safeguards (DOLS) by NHS and registered independent hospitals when caring for such patients and the role played by Health Boards in organising assessments and authorising applications. CSSIW will be undertaking a similar role with registered care settings and Social Service Departments. We will use the information we collect from our ongoing monitoring of compliance with the Mental Health Act 1983 and other relevant mental health legislation to review the effectiveness of the relationship between mental health services and medical services.

We will report on our findings in relation to these important elements of our work through the publication of Annual Reports in relation to our Mental Health Act Monitoring and Deprivation of Liberty Safeguards. We will work together with CSSIW to report on our findings in respect of DOLS across health and social care. . We will look in depth at Substance Misuse Services in Wales, following on from our work in 2010-11 which looked at service users’ journey through the care pathway, asking ‘What is it like for people using substance misuse services in different parts of Wales?’ We will work with the Criminal Justice Inspectorates and the Prison and Probation Ombudsman (PPO) to ensure that relevant clinical expertise and knowledge of Welsh health systems is fed into their reviews of Youth Offending Teams and Welsh Prisons. Our involvement in these reviews enables us to build a richer picture of health service provision across Wales and in particular to identify if young offenders and prisoners

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have equity of access to services in comparison to the general population. This work includes the conduct of reviews into: ƒ ƒ ƒ

Health care provision for Youth Offenders. The commissioning arrangements for health care in Welsh prisons. The healthcare provided to individual prisoners who have died whilst in custody. Our work in this area continues to increase.

We will undertake investigations into circumstances where a patient known to Mental Health Services is involved in a homicide. Welsh Ministers may commission us to undertake an independent external review of the case to ensure that any lessons that might be learnt are identified and acted upon. We will also identify key themes and findings arising from our reviews of homicides. We will continue to work jointly with CSSIW, Estyn and others to evaluate the effectiveness of Local Children’s Safeguarding Boards in Wales.

Driving improvement in the environment of care: Unannounced Cleanliness Spot Checks We will continue to develop and roll out our programme of unannounced visits to healthcare settings focusing on Cleanliness. This work is fundamental to our drive to strengthen infection control in healthcare organisations and improve overall patient experience. In carrying out this work, we will liaise with the Community Health Councils to link in with their Hospital Patient Environment programme.

Being treated by suitably trained and qualified staff We will monitor the Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R) in Wales through a programme of assessment and inspection of clinical departments that use ionising radiation in their work. During the year, we will review and further develop our approach to the conduct of this work.

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When notified of any specific incidents involving "exposure much greater than intended" we will investigate them. We will monitor the Controlled Drugs (Supervision of Management and Use) (Wales) Regulations. These arrangements require the publication of a list of ‘accountable officers’ and a close and collaborative approach among a wide range of regulatory partners and national agencies. We will undertake annual assessments of the fitness for purpose of those who are contracted to supply agency nurses, healthcare assistants and operating department practitioners to the NHS in Wales. During the year, we will review our approach to the delivery of this area of work. As the Local Supervising Authority (LSA) for Statutory Supervision of Midwives in Wales, we will continue to ensure that a local framework exists to provide equitable, effective statutory supervision of midwives working within the geographical boundary of Wales. We will report on our work as the LSA through the publication of an Annual Report.

The dates and details of the visits linked to our routine work will be placed on our website www.hiw.org.uk and the Concordat Scheduling tool which can be accessed via www.walesconcordat.org.uk.

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Our development work At an all Wales, UK and European level we inform and influence healthcare policy and practice through our contribution to key areas of development. As well as developments relating to key aspects of our routine programme of work, we will also contribute to the following areas of development: ƒ

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Introduce a new Peer Review programme to review compliance against the Cancer Standards using an approach developed with the Wales Cancer Coordinating Group. Working closely with the Palliative Care Implementation Board 6 , chaired by Professor Finlay, we will develop assessment criteria and outcome measures to support the introduction of the new Palliative Care Standards. This framework will be used as the basis of all our hospice inspections undertaken in 2011/12.

In tandem with the above we will also contribute to the development of a peer review approach to palliative care services, engaging clinicians from across Wales. ƒ

We will continue to support the Wales Armed Forces Community Expert Group to achieve its terms of reference by working together with service organisations and charities to capture the stories and experiences of Armed Forces personnel, their families and veterans in respect of: ƒ ƒ ƒ

The adequacy and availability of health provision. Access to health services and the effectiveness of priority treatment provision for veterans. Experiences when using healthcare services.

As well as contributing to the work of the expert group, we will use the information gathered to help develop and influence specific ‘quality requirements’ for Armed Forces personnel, their families and veterans and to improve our own assessment and reporting processes so that we maintain an ongoing focus in this important area. ƒ

Supporting Revalidation of Doctors: we will continue to work with Health service regulators from across the UK in relation to the role of regulators in

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The Palliative Care Implementation Board Report 2008-2011 – Dying Well Matters summarises the work undertaken over the last three years to improve palliative and end of life care across Wales.

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supporting the new arrangements established by the General Medical Council (GMC) for the revalidation of all doctors in the UK. We will work with professional groups to further develop an approach to self assessment in Primary Care through the introduction of an self assessment tool linked to the Doing well, doing better: Standards for heath services framework.

Developing our own ways of working We will continue with our comprehensive programme of organisational development designed to enhance the way in which we carry out our work. This programme is aimed at improving our overall efficiency and effectiveness. Our focus will be on developing the way we work to strengthen both our planning and our delivery; further developing our capacity and capability to deliver through our people; and making better use of the wealth of information available to us through improved arrangements for knowledge management and knowledge sharing. As well as the development work already referred to in respect of the delivery of our ongoing work programme, over the next three years we will also: ƒ

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Review our arrangements for effective public and patient engagement to ensure that citizen experience informs all of our work and is central to driving our work programme. In doing so, we will continue to develop and strengthen our communication networks and build new ones as opportunities arise. Review our role in assuring equality and human rights by exploring and responding to the practical implications of the Equality Act 2010 and other related laws. Strengthen the way we make information available electronically through the redevelopment of our website and the publication of regular e-Newsletters. Improve the guidance we make available to service users and their families as well as service provider. Better inform our strategic and annual planning through the ongoing development of our risk based approach, introducing a revised inspection needs assessment framework that incorporates an evidence based risk profile for each healthcare provider and type of service.

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Actively review our arrangements for collection, retrieval and targeted and timely sharing and use of information - and the provision of research and statistical services - to support the delivery of our functions and inform our work programme. Further develop our programme and project management approach to enable the successful delivery of our work programmes and ensuring the best use of our available resources, including our people. Review and revise our Standards of Professional Practice and related Professional Practice Guides in line with latest developments in inspection, investigation and regulatory practice. Continue to develop our staff by introducing a new Professional Skills Framework, carrying out a skills audit and addressing identified learning needs through the conduct of a comprehensive learning and development programme. Review our approach to the appointment and use of our external ‘peer and lay’ reviewers to maximise their contribution to our own work programmes, contribute to healthcare professionals ‘continuing professional development’ and transfer learning back into healthcare organisations. Further develop our collaborative working and partnership approach towards the introduction of an integrated programme of assurance for healthcare services in Wales.

We will look to maximise opportunities to work collaboratively with other inspection, audit and review bodies in taking forward our organisational development programme.

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Areas of special interest Ensuring that specific services are meeting the needs of their client group and are being delivered in line with national standards Each year we will report upon our assessments of the quality and safety of specific areas of health service provision. Each of these will have the same high level objectives and aims, specifically to ensure that services: ƒ ƒ ƒ

Meet the needs of the citizens of Wales. Are safe and of high quality. Are being delivered in the most efficient and effective manner.

Our work will be tailored to ensure that: ƒ ƒ ƒ

It focuses on the key issues. Appropriately involves key stakeholders including patients, service users, relatives and carers. Takes advantage of opportunities to work in partnership with other regulation, audit and inspection bodies, especially at the interface between health and other services for example, Social Services, Education Services.

To ensure our assessments of areas of special interest are delivered in the most efficient, effective and timely way, much of the evidence we will draw on to reach our conclusions will be obtained through the targeted design and conduct of our routine work programme. This approach will not only ensure the organisational and administrative impact of our review activity is kept to a minimum but will also maximise the impact of our routine work programme. Using the results of our work and the information we gather in a number of different ways will enable us to provide a broader overall assurance to citizens and other stakeholders. The following pages set out our proposed areas of special interest for each of the next three years with a summary of the key reasons why it has been highlighted as a priority. Further details of the scope and approach of our work in this area will be placed on our website as we take the work forward.

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In 2011 -12 we will focus on: Services for those who are vulnerable, including Learning disability services Responding to recent concerns following on from a Panorama programme identifying abuse in a UK specialist hospital providing care and rehabilitation to adults with learning disabilities, we are working with CSSIW to carry out a programme of unannounced visits to learning disability establishments in Wales. This will include visits ‘out of hours’ at night and in the early morning. Building on this programme, we will continue to work together with CSSIW to ensure that we have a strong focus on all services for those who are vulnerable, including: ƒ ƒ ƒ ƒ ƒ ƒ ƒ

Mental health services. Personality disorder services. Services for those with Autism and Asbergers. Older people’s services. Child and Adolescent Mental Health Services. Children’s services. End of life care.

Work on this started in the Summer, 2011.

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Risk Assessment in Mental Health

Our work, in particular our homicide reviews, has highlighted weaknesses in risk assessment and risk management in mental health. Poor risk assessment and risk management can result in individual service users not receiving the level of care and attention that they require and can result in serious and tragic consequences such as a homicide or suicide. Our work in this area is informed by the targeted analysis and evaluation of the information obtained through our routine work designed to monitor compliance with the Mental Health Act 2007 and other relevant mental health legislation, as well as that obtained through our homicide reviews. The publication of our report will co-incide with a programme of workshops designed to share learning and drive improvement amongst those services and agencies involved in the provision of care and support to mental health service users. We will report on this in Winter, 2011.

Maternity Services

In 2007 we undertook an all Wales review of maternity services focusing on how the services/units are run, staffed and managed. The review highlighted a number of areas requiring improvement. We will carry out a review of available data, including the outputs from self assessment activity (through the Doing well, Doing better: Standards for Health Services framework) in relation to maternity services across Wales to inform the targeting of some of our routine work activity to ensure that the necessary improvements have been made. We will start work on this in Winter, 2011-12.

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Management and Care of Patients with Fractured neck of Femur

For older people, especially women, fractured neck of femur is the most common traumatic condition requiring admission to adult orthopaedic wards. Hip fracture accounts for approximately 87% of total fragility fractures. Patients who suffer this trauma have a high mortality and morbidity rate with many needing long term care post fracture. At present the care provided to patients and attitudes to their length of stay in hospital are variable. We will undertake a review of whether the best outcomes for patients are being achieved and to ensure: ƒ ƒ ƒ ƒ ƒ

The pathway for patients is properly co-ordinated. Patients who are medically fit to do so receive surgery within 24 hours. Patients are got out of bed within 12-18 hours of their operation and receive relevant therapy on a daily basis, including at weekends. Strict criteria are set so that patients are discharged as soon as they are assessed as being fit enough and that long stays are avoided where there is no clinical need. Health and social care multi agency teams’ work together to provide an integrated service across the patient pathway.

Our approach to this work will involve seeking information and assurance from healthcare services themselves on the effectiveness of their arrangements. Our findings will inform our work in 2012-13 on Falls and Fractures. We will start work on this in Winter, 2011.

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Oxygen and Medical Devices

Oxygen, when used appropriately can save lives, but if not administered and managed effectively, there is a potential for serious harm and even death. The NPSA has worked with the NHS to develop guidance aimed at ensuring safer systems are in place to treat patients needing oxygen. The proposed review will look at how organisations across Wales have taken forward the NPSA guidance and how they ensure that safe systems are in place to support the use of oxygen. There are some 80,000 different types of devices and pieces of equipment used in hospitals, GP surgeries, residential care and in patients’ homes. They include most healthcare products other than medicines used for the diagnosis, prevention, monitoring and treatment of disease, injury or disability. This includes everything from artificial hips to wound dressings, incubators to insulin injectors and scanners to scalpels. The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medical devices in the UK under European legislation. The National Patient Safety Agency (NPSA) has highlighted that a large number of patient safety incidents are related to medical devices. We will liaise with the MHRA in defining the overall scope for this review, which will look at whether organisations have appropriate systems in place to ensure that all its devices have been approved by the MHRA and are properly monitored, regularly maintained and updated. We will start this work in, Winter, 2011-12.

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In 2012 -13 we will focus on: Action on Patient Safety Alerts

The National Patient Safety Agency (NPSA) is responsible for issuing alerts to health care staff and organisations on patient safety issues. These alerts indicate the urgency and nature of the actions required, ranging from immediate action through the provision of further information. Linked to our work on oxygen and medical devices, we will work with healthcare organisations to establish the adequacy of their arrangements in place to ensure patient safety alerts are acted upon appropriately.

Speech and Language Therapy

The majority of us take for granted the ability to communicate, but for many people problems with speech and language hinder their day to day lives. Many of these can be corrected with the right support and therapy, but they need to be identified and corrected at an early stage in a child’s development. Often, however, problems go undiagnosed or the appropriate therapy is either not provided or is unavailable. The provision of speech and language therapy appears to be varied around Wales, therefore, our review will aim to establish the level and suitability of this service. Our approach to this work will involve seeking information and assurance from healthcare services on the accessibility and effectiveness of their arrangements.

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Community Mental Health Services

Patients subject to a community treatment order (CTO) can be treated in the community for their mental disorder without their consent. There are various criteria which have to be met before an individual can be placed on an order – key to this is proper care planning and support in the community. These orders present significant challenges to mental health service providers in monitoring and managing service users who are subject to a CTO and this leads to pressures on community resources. Our review will focus on the effectiveness of the arrangements in place for the planning and monitoring of CTOs, and particularly on the provision of support in the community and recall arrangements. Our work in this area will be informed by the targeted analysis and evaluation of the information obtained through our routine work designed to monitor compliance with the Mental Health Act 2007 and other relevant mental health legislation, as well as the work carried out by our Second Opinion Appointed Doctors.

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Children’s palliative care services

Sadly, some children are born with life limiting conditions or may go on to develop life limiting illnesses. Hence, the palliative care needs of children and young people do differ from adults. Many children and their families require support for a significant period of time before they reach the end of their life. Hospices that provide palliative and end of life care services for children and young people need to ensure that they and their families are provided with the services they need, consistent with their wishes. Following the completion of the work led by Baroness Finlay to develop quality standards for the delivery of palliative care services, our work in this area will focus on reviewing services against the new standards to establish a baseline against which future developments may be measured.

Cancer Services: referral pathways

Most of us know someone who either has or had cancer or who is a cancer survivor. With advances in technology and drugs, more people are surviving cancer or living longer than they would have done previously. However, positive outcomes for cancer sufferers depend upon timely diagnosis and appropriate treatment. General practitioners (GPs) have a key role to play in the identification of possible cancers and ensuring that a timely and appropriate referral is made to cancer services. We will look at the referral pathway for cancer services focusing particularly on the role GPs play in early identification and referral of suspected cancers to secondary care.

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Diagnostic Services

Diagnostic services are those activities necessary to recognise and identify any

condition (and its cause) so that an appropriate form of care and treatment can be agreed. Such services are wide ranging and include procedures such as endoscopies, x-rays, clinical and laboratory tests. They are a critical part of care and treatment pathways. The failure to deliver timely and effective diagnostic services can lead to delays or the delivery of the wrong care and treatment. Our proposed review will therefore look at the timely referral, access and availability, of these services, particularly in relation to primary care. We will focus on a selection of specific diagnostic services, taking account of the results of our wider work and the work of others. Our approach to this work will involve seeking information and assurance from healthcare services themselves on the effectiveness of their arrangements.

Falls and fractures

Falling and breaking a bone can be painful and distressing for all of us, but for older people, it can have serious, life changing consequences. 50,000 people in Wales are affected by osteoporosis and are therefore more susceptible to fractures.

The Welsh Government has identified cutting the number of accidents and injuries as a priority for action, but recent work carried out by the Royal College of Physicians has highlighted inadequate and variable care across the UK for those suffering from falls and fractures.

In carrying out our work in this area, we will seek information from healthcare services themselves on their actions they have taken to make improvements, and will use the information gained from our routine work activity, (particularly our dignity and respect programme) to indicate the extent to which these actions are resulting in improved outcomes.

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Medication

Our work in relation to the Older People’s National Service Framework (NSF) identified continuing concerns amongst those working with older people in Wales around inappropriate medication. We are committed to following this up in more detail.

We will work with the Chief Pharmaceutical Officer for Wales to agree how we take this work forward and will also link in with the WAO in relation to their planned review of Medicines Management.

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In 2013 -14 we will focus on: Young people moving from child to adult health services

Children and young people experience many significant transition points between healthcare services. Coupled with this, there are significant differences in expectations, style and culture within children and adult services. Making an effective transition for young people entering adult services is key to avoid adding to what is already a stressful and complicated time for many young people.

Disabled Children: ‘Are disabled children and young people and their families provided with the necessary support to enable them to live an independent and fulfilled life?’ A lack of adequate support may hinder some children and young people from developing independence and living life to the full and for many, getting access to the right service or equipment can prove problematic. Our review will aim to establish the level and suitability of support provided to disabled children and young people and their families by health and social care organisations and identify any shortcomings in provision

We will work with disabled children and young people and their families to determine priorities to shape the detailed focus of this work.

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Provision of Care and Services to People with Autism

Autism is a lifelong developmental impairment that affects how a person communicates with, and relates to, other people. It also affects how they make sense of the world around them.

People with autism have often looked to learning disability or mental health services for support or care. However, the review we undertook in 2006 of the adequacy of learning disability services highlighted that it is often difficult to obtain the support they require because the criteria for access to learning disability and mental health services tend to result in their exclusion. The National Institute for Health and Clinical Excellence (NICE) is currently developing new guidelines to improve the recognition and diagnosis of autism for children and young people. These will be the first official clinical guidelines in England and Wales relating to autism. They aim to publish them in September 2011. Our aim is to undertake a baseline review against the published guidelines so that we can identify the main areas for improvement.

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Food, Fluid and Nutritional Care: ‘Are the food, fluid, nutritional and dietary needs of patients being met? Patients, relatives and staff all emphasise the importance to successful recovery of good levels and standards of fluid and nutrition. Our own work in this area has highlighted gaps in meeting the dietary and nutritional needs of patients, and variation of standards not only between organisations, but also across settings within the same organisation. The Welsh Government’s proposed new ‘All Wales Catering and Nutrition Standards for Food and Fluid Provision for Hospital Patients’ are aimed at improving food and fluid provision to hospital inpatients, and we will consider the impact of these standards on quality of care. Our work in this area will take account of the findings from the WAO’s review of Hospital Catering and Patient Nutrition and will be informed by our routine work activity, particularly the conduct of our dignity and respect spot checks.

Blood transfusion

There has been continual improvement in the quality and safety of blood products available for clinical use, but, as with any treatment, there will always be associated risks which, if realised, can prove fatal.

The majority of reported incidents surrounding the use of blood products are preventable and result from human error, often due to mistakes in patient identification or prescribing. Our work in this area will focus on the systems and procedures in place to ensure the safe administration of blood products.

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Putting things right

‘Putting things right’ aims to provide a single, more integrated and supportive process for people to raise concerns about NHS services, aiming to "investigate once, investigate well", and ensuring that concerns are dealt with in the right way, the first time round.

Our work will consider the extent to which the introduction of these new arrangements is having a positive impact on the quality and safety of healthcare, through learning and improvement, but also in terms of public and patient experience of having their concerns listened to and acted upon. Our work in this area will be informed by the information made available through the Doing well, doing better: Standards for Health Services framework.

Palliative Care: ‘Are palliative/end of life care Services supporting terminally ill patients to die with dignity, in comfort and without unnecessary pain?’ Although ideas vary about how to care for people at the end of their lives, many of those approaching death would want to be: ƒ ƒ ƒ ƒ

Treated as an individual, with dignity and respect. Without pain and other symptoms. In familiar surroundings. In the company of close family and/or friends.

Palliative and end of life care services should ensure that terminally ill patients and their families are provided with the care and support that is consistent with their needs and wishes. Our work will consider the impact of the introduction of the quality standards on palliative care services across Wales.

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Learning when things go wrong Special reviews

We may undertake special reviews of healthcare organisations or services in response to concerns that may arise from a particular incident or series of incidents. The scale and nature of any special review work will depend on the seriousness or frequency of occurrence. We will always publish our terms of reference for these reviews as well as ensuring we report on our findings.

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Making a difference Driving improvement through Healthcare summits The Welsh Concordat provides a platform upon which we are continuing to facilitate the development of more collaborative approach to information sharing in Wales. We have, for the past four years facilitated a programme of annual Healthcare Summits involving health and social care review bodies and improvement agencies working across Wales. This summit programme provides us all with a valuable opportunity to share intelligence and identify key challenges and priorities, resulting in the development of an overarching, cohesive assessment of NHS bodies in Wales. This provides a framework for the production of an integrated plan for assurance and improvement that focuses on the key areas of concern or challenge affecting NHS organisations in Wales and co-ordinates the respective work programmes of each of the participating organisations to respond to these challenges in order to drive improvement.

Encouraging change Publishing our reports is not the end of our work. We require organisations to produce action plans, we follow up on our findings and recommendations and we encourage change by working with organisations to support them to improve. Patient experience is at the heart of all our work. Therefore, if we don’t consider that organisations are making necessary improvements in a timely way, we will use our powers to ensure that they do so.

Reporting on the state of healthcare in Wales Responding to our key duty to inform citizens in Wales about the quality and safety of healthcare, we will publish on an annual basis a report that provides an overview of the state of healthcare in Wales. Our report will provide an independent assessment of healthcare in Wales both in terms of the provision of key services across Wales and the effectiveness of individual healthcare organisations. 37

Annex 1 Health Boards and Trusts within Wales

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Annex 2

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