[Skip to content]

Enter search here...
Worcestershire Key Documents
.
.

Audiology

The service implements and monitors systems to manage safe moving and handling 

SA3 Criteria

SA3 C1

There are defined roles and responsibilities for moving and handling

SA3 C2

There are systems in place to define, assess and manage risks associated with moving and handling

SA3 C3

There are systems in place to ensure that moving and handling aids are available, maintained and used appropriately

SA3 C4

There are systems in place to assure the safe transport of patients

SA3 C5

There are systems in place to ensure incidents and errors are reported, investigated, recorded and analysed with findings disseminated to relevant parties and acted upon

SA3 C6

There are systems in place to define, assess and manage the holding and restraint of patients including specific policies for children and vulnerable adults

The service implements and monitors systems to manage violence and aggresion

SA4 Criteria

SA4 C1

There are defined roles and responsibilities regarding the management of violence and aggression

SA4 C2

There are systems in place to define, asses and manage violence and aggression

SA4 C3

There are systems in place to ensure support for patients, staff and others who have been involved in an incident

SA4 C4

There are systems in place to ensure incidents and errors are reported, investigated, recorded and analysed with findings disseminated to relevant parties and acted upon

The service implements and monitors systems to ensure general health and safety of patients, staff and others,

SA5 Criteria

SA5 C1

There are defined roles and responsibilities for each area of general health and safety

SA5 C2

There are systems in place to define, assess and manage general health and safety risks

SA5 C3

There are systems in place to manage adverse healthcare events

SA5 C4

There are systems in place to maintain staff awareness and training on health and safety including fire

SA5 C5

There are systems in place to ensure health and safety equipment is available, maintained and used appropriately

SA5 C6

There are systems in place to ensure appropriate signage and hazard warnings

SA5 C7

There are systems in place to ensure incidents and errors are reported, investigated, recorded and analysed with findings disseminated to relevant parties and acted upon

The service implements and monitors to ensure patients are able to access patient friendly information about what happens before, during and after specific examinations procedures.

PE1 Criteria

PE1 C1

There are defined roles and responsibilities for each area of development and maintenance.

PE1 C2

There are systems in place to ensure that patients are provided with information within specified timescales about the details and purpose of their examination/procedure to allow preparation for each appointment

PE1 C3

There are systems in place to ensure patients are able to access information in relevant formats

PE1 C4

There are systems in place to ensure patients are aware who is present at and who is performing their examination/procedure

PE1 C5

There are systems in place to ensure patients know how, when and by whom results/reports will be communicated

PE1 C6

There are systems in place to ensure that patients have access to information about peer/self help and support groups.  

PE1 C7

There are systems in place to ensure patient information materials are developed, available and reviewed with lay/patient representatives and updated within specific timescales

The service implements and monitors systems to ensure the privacy, dignity, comfort and security of patients are respected throughout contact with the service.

PE2 Criteria

PE2 C1

There are defined roles and responsibilities for professional leadership and management with regards to privacy, comfort and security of the patient population

PE2 C2

There are systems in place to encourage the and support staff to be welcoming and to act with discretion and respect towards patients and carers

PE2 C3

There are systems in place to ensure that patients privacy, dignity and security are maintained

PE2 C4

There are systems in place to help maintain patients’ comfort

The service implements and monitors systems to ensure informed patient consent is obtained for each examinatio/procedure.

PE3 Criteria

PE3 C1

There are defined roles and responsibilities for obtaining informed consent

PE3 C2

There are systems in place to ensure that patients are able to discuss their examination/procedure  options with an appropriate staff member

PE3 C3

There are systems in place to enable patients to give or withhold informed consent for all examinations/procedures

PE3 C4

There are systems in place to arrange taking consent from children and patients with particular needs for all examinations/procedures

PE3 C5

There are systems in place to enable patients to give or withhold informed consent for access to and distribution of test results and reports

PE3 C6

There are systems in place to enable patients to give or withhold informed consent for their data to be used for searching and/or research purposes

The service implements and monitors systems to ensure that service delivery is patient focused.

PE4 Criteria

PE4 C1

There are defined roles and responsibilities for professional leadership and management to ensure patient focused care

PE4 C2

There are systems in place to ensure that the service is accessible to all patients and carers

PE4 C3

There are systems in place to ensure appointments are available tom meet patient needs and circumstances and co-ordinated with other appointments where possible.

PE4 C4

There are systems in place to ensure positive identification of patients

PE4 C5

There are systems in place to ensure specific requirements of patients and carers are identified and responded to

PE4 C6

There are systems in place to ensure that relevant information is communicated to individual patients during their contact with the service, including arrangements for transfer/continuity of care.

The service implements and manages systems to ensure that patients are able to feedback on their experience of the service and that the feedback is acted upon

PE5 Criteria

PE5 C1

There are defined roles and responsibilities for obtaining and managing feedback from patients, carers and relatives

PE5 C2

There are systems in place to develop, agree and maintain materials to support patient feedback, involving input from patient/lay people

PE5 C3

There are systems in place to ensure patients and carers are able to give feedback in a variety of formats and in confidence

PE5 C4

There are systems in place to ensure results of patient feedback are collated, analysed and findings are disseminated to relevant parties and acted upon.

The service implements and monitors systems to assure the delivery of the service from referral to discharge from the service, including follow ups.

CL1 Criteria

CL1 C1

There are defined roles and responsibilities for leadership and integrated governance for diagnostic/treatment pathways

CL1 C2

There are systems in place to manage diagnostic/treatment pathways from referral to discharge from the service within specified timescales, including the management of calls and cancellations

CL1 C3

There are systems in place to ensure a collaborative approach to define and deliver diagnostic/treatment pathways and to maintain communication within and outside the service

CL1 C4

There are systems in place to ensure clinically relevant information is received from referrers and patients

CL1 C5

There are systems in place to ensure vetting, justification and prioritisation of referrals

CL1 C6

There are systems in place to ensure the specific needs of children are met

CL1 C7

There are systems in place to manage unexpected diagnosis, red flags and implications of potential medical emergencies

The service implements and monitors systems to assure the quality of the diagnostic test.

CL2  Criteria

CL2 C1

There are defined roles and responsibilities for managing the quality of each group of diagnostic tests

CL2 C2

There are systems in place to develop, agree, maintain and apply protocols for each diagnostic test

CL2 C3

There are systems in place to ensure that all test protocols are accessible and communicated to all appropriate staff

CL2 C4

There are systems in place to assure the diagnostic quality of the test

 The service implements and monitors systems to assure the clinical and technical quality of the interpretation  of diagnostic results, and their reporting and communication in a timely manner

CL3 Criteria

CL3 C1

There are defined roles and responsibilities for interpreting and reporting test results  

CL3 C2

There are systems in place to develop and agree the structure and content of diagnostic reports to meet local needs

CL3 C3

There are systems in place to ensure that all appropriate staff are aware of the agreed formats for reporting/communication of results

CL3 C4

There are systems in place to assure the quality and accuracy of the interpretation and reporting of test results

CL3 C5

There are systems in place to ensure communication of diagnostic reports to referrers and multidisciplinary team meetings within specified timescales

CL3 C6

There are systems in place to manage alterations and amendments to diagnostic reports

The service implements and monitors systems to assure the clinical and technical quality of treatments, interventions and invasive procedures

CL4 Criteria

CL4 C1

There are defined roles and responsibilities for staff who carry out treatments and interventional procedures

CL4 C2

There are systems in place to define, assess and manage risks related to treatments or interventional procedures

CL4 C3

There are systems in place to develop, agree, maintain and implement protocols for all treatments and interventional procedures which should be evidence based, validated and objective

CL4 C4

There are systems in place to ensure that protocols for treatments and interventional procedures are accessible and communicated to all appropriate staff

CL4 C5

There are systems in place to assure and measure the quality and outcomes of treatments and interventional procedures

The service implements and monitors systems to manage, drugs, contrast media, gases and medical devices

CL5 Criteria

CL5 C1

There are defined roles and responsibilities for drugs and contrast media management

CL5 C2

There are systems in place to manage the prescription and administration of drugs and contrast media  

CL5 C3

There are systems in place to ensure the identification and management of patients at risk of adverse reactions to specific drugs and contrast media

CL5 C4

There are systems in place to manage the preparation, administration and withdrawal of drugs and contrast media

CL5 C5

There are systems in place to ensure the management and care of patients receiving drugs and contrast media, including response to adverse reactions.  

CL5 C6

There are systems in place to assure that drugs and contrast media are sensibly and safely stored

The service implements and monitors systems to assure the clinical and technical quality of the interpretation of diagnostic results, and their reporting and communication in a timely manner.

CL3 Criteria

CL3 C1

There are defined roles and responsibilities for interpreting and reporting test results

CL3 C2

There are systems in place to develop and agree the structure and content of diagnostic reports to meet local needs

CL3 C3

There are systems in place to ensure that all appropriate staff are aware of the agreed formats for reporting/communication of results

CL3 C4

There are systems in place to assure the quality and accuracy of the interpretation and reporting of test results

CL3 C5

There are systems in place to assure communication of diagnostic reports to referrers and multidisciplinary team meetings within specified timescales

CL3 C6

There are systems in place to manage alterations and amendments to diagnostic reports

The service implements and monitors systems to manage the physiological of specialism specific risks

CL9  Criteria

CL9

Set by individual physiological diagnostic discipline to describe the specific safety elements of the service

The service implements and monitors systems to review current and emerging clinical practices, implementing new and innovative practice as appropriate

CL8  Criteria

CL8 C1

There are defined roles and responsibilities for clinical governance including reviewing current practice and the development of new clinical practices

CL8 C2

There are systems in place to ensure regular audit of current clinical practice, review and dissemination of findings and appropriate action

CL8 C3

There are systems in place for reviewing clinical practices and implementing new practice as appropriate

CL8 C4

There are systems in place to ensure governance arrangements to support introductions  and audit of new clinical practices

CL8 C6

There are systems in place to support engagement in research and development activities

The service implements and monitors systems to manage clinical records

CL7  Criteria

CL7 C1

There are defined roles, responsibilities and accountabilities for each area of clinical records management

CL7 C2

There are systems in place to maintain patient confidentiality

CL7 C3

There are systems in place to ensure the secure and confidential storage, retrieval, transmission and transportation of patient records

CL7 C4

There are systems in place to manage sharing of patient data between organisations

CL7 C5

There are systems in place to ensure control and audit of access to patient data

The service implements and monitors systems to ensure the facilities and environment support delivery of the service

FRW1 Criteria

FRW1 C1

There are defined roles and responsibility for each area of facilities and environment management for supporting service delivery

FRW1 C2

There are systems in place to ensure that all areas used by the service meet the specific needs of the patient population ( including children and those with particular needs) and staff

FRW1 C3

There are systems in place to ensure the management of space to facilitate efficient working

FRW1 C4

There are systems in place to ensure that all areas used by the service are well maintained

FRW1 C5

There are systems in place to ensure that access to particular areas is restricted where appropriate

FRW1 C6

There are systems in place to ensure the management and control of environmental conditions

The service implements and monitors systems to procure and manage equipment to deliver the service

FRW2 Criteria

FRW2 C1

There are defined roles and responsibility for the procurement and management of all equipment and consumables

FRW2 C2

There are systems in place for the procurement of all equipment and consumables

FRW2 C3

There are systems in place to assure installation, calibration, operation and performance of equipment  

FRW2 C4

There are systems in place to ensure equipment is appropriate for patients, staff, children and those with particular needs

FRW2 C5

There are systems in place to ensure maintenance and quality assurance of all equipment with corresponding records

FRW2 C6

There are systems in place to ensure equipment failures and faults are monitored and managed

FRW2 C7

There are systems in place to ensure that equipment replacement is planned and implemented

The service implements and monitors systems to recruit, manage and support staff to deliver the service

FRW3 Criteria

FRW3 C1

There are defined roles and responsibilities for management and professional leadership

FRW3 C2

There are systems in place to ensure clear definition and management of tasks for staff to deliver the service

FRW3 C3

There are systems in place to ensure there are sufficient staff within the service with an appropriate mix of skills to enable delivery of the service

FRW3 C4

There are systems in place to ensure agreed contracts of employment, job description/job plans and that staff appraisals or personal development plan reviews are conducted for staff

FRW3 C5

There are systems in place to ensure that employment policies and any changes are communicated and consistently applied

FRW3 C6

There are systems in place to ensure to manage all out of hours service provision including staff rotas.

FRW3 C7

There are systems in place to that in collaboration between the employer and employee support is available to manage stress and achieve a work/life balance

FRW3 C8

There are systems in place for managing conflicts of interest

FRW3 C9

There are systems in place to ensure staff are able to feedback in confidence on the service and contribute to the service management

The service implements and monitors systems to ensure staff are fully trained and competent to deliver the service

FRW4 Criteria

FRW4 C1

There are defined roles and responsibilities for the management of staff competence

FRW4 C2

There are systems in place to support and manage the recruitment of staff

FRW4 C3

There are systems in place to ensure staff are competent to undertake the role to which they have been appointed, including a process for remedial action if concerns around staff competency have been raised

FRW4 C4

There are systems in place to check qualifications and registration of relevant staff are up to date

FRW4 C5

There are systems in place to ensure all staff are properly inducted into new roles, including any additional information

FRW4 C6

There are systems in place to ensure staff are adequately supervised while training

FRW4 C7

There are systems in place to ensure the service maintains competencies to address the requirements of providing the service (including where appropriate provision for children, and those with particular needs)

FRW4 C8

There are systems in place to ensure that all staff are supported in the maintenance of necessary skills, knowledge and levels of competence via CPO and develop new competencies to the level as defined by the relevant statutory or professional body

The service implements and monitors systems to engage in integrated service and workforce review, planning and development

FRW5 Criteria

FRW5 C1

There are defined roles and responsibilities for each area of service review, planning and improvement, and workforce planning and development

FRW5 C2

There are systems in place to support service review, improvement and planned developments with the involvement of patients, staff, users and others.

FRW5 C3

There are systems in place to ensure strategic service planning and workforce planning are integrated

FRW5 C4

There are systems in place to assess, agree and implement workforce development initiatives  which include the involvement of senior managers

FRW5 C5

There are systems in place to support engagement with content and delivery of relevant education and training

FRW5 C6

There are systems in place to support and mentor staff retention and ensure succession planning arrangements

The service implements and monitors systems to manage its budget and service contracts

FRW6 Criteria

FRW6 C1

There are defined roles and responsibilities for budget and contract management

FRW6 C2

There are systems in place to ensure regular monitoring and reporting of budgets

FRW6 C3

There are systems in place to ensure staff are aware of budget management processes and the implications of their areas of responsibility

FRW6 C4

There are systems in place to ensure engagement with wider financial planning processes

FRW6 C5

There are systems in place to procure, manage and monitor delivery of contracted services

FRW6 C6

There are systems in place to ensure arrangements for dealing with income generated by service activity and/or charitable donations

The service implements and monitors systems to manage complaints

FRW7 Criteria

FRW7 C1

There are defined roles and responsibilities for managing complaints

FRW7 C2

There are systems in place to manage verbal and written complaints

FRW7 C3

There are systems in place to investigate and respond to complaints within specified timeframes

FRW7 C4

There are systems in place to train staff in dealing with those wanting to make complaints

FRW7 C5

There are systems in place to ensure complaints are reported, investigated, recorded and analysed with findings disseminated to relevant parties and acted upon

Page last updated: 05 November 2018