1. NHSLA Risk Management Standards for Mental Health and Learning Disability Trusts
Level 1 Action Plan
[Andrew Brogan – Interim Executive Director of Integrated Governance/Executive Nurse]
STANDARD 1: GOVERNANCE
Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentation
Name
Responsible
Lead
Gaps in
Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
1.1.3
The organisation
has approved
terms of reference
for the high level
committee(s) with
overarching
responsibility for
risk.
As a minimum, the terms of
reference must include a
description of the:
a. duties
b. reporting arrangements to
the board
c. membership, including
nominated deputy where
appropriate
d. required frequency of
attendance by members
e. reporting arrangements into
the high level committee(s)
f. requirements for a quorum
g. frequency of meetings
h. process for monitoring
compliance with all of the
above.
CS1a
CS7a&c
Integrated
Governance
Committee Terms
of Reference
AB Does not
explicitly
describe
reporting
arrangements to
the Board and
other high level
committees (i.e.
minutes,
assurance
reports etc)
No description
of the process
for monitoring
compliance (i.e.
annual reports
to Board,
attendance
monitoring etc)
Terms of
Reference to
be amended
to include
missing
requirements
7th
October
2009
OH offered to amend
ToR to ensure
compliance
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
1

2. STANDARD 2: COMPETENT AND CAPABLE WORKFORCE
Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale for
Completion
Progress/Comments Compliance
RAG Rating
1.2.4
The organisation has
approved
documentation
which describes the
process for ensuring
that all clinical staff
receive appropriate
supervision.
As a minimum the
approved documentation
must include a description
of the:
a. duties
b. process for checking
that all clinical staff
receive appropriate
clinical supervision
c. process for checking
that all clinical staff
receive management
supervision
d. organisation’s
expectations in relation
to staff training as
identified in the training
needs analysis
e. process for monitoring
compliance with all of
the above.
CS5b GC24
Supervision
Policy (exp. Apr
2010)
JB Revised Policy
meets all minimum
requirements
Ensure policy is
ratified within
timescale
27th
August
2009
Submitted to CPGG
for sign-off at mtg
15.09.09
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
2

3. STANDARD 3: SAFE ENVIRONMENT
Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale for
Completion
Progress/Comments Compliance
RAG Rating
1.3.5
The organisation
has approved
documentation
which describes
the process for
managing the risks
associated with
slips, trips and falls
involving service
users, staff and
others.
As a minimum, the
approved documentation
must include a description
of the:
a. duties
b. requirement to
undertake appropriate
risk assessments for
the management of
slips, trips and falls
involving service
users (including falls
from height)
c. requirement to
undertake appropriate
risk assessments for
the management of
slips, trips and falls
involving staff and
others (including falls
from height)
d. organisation’s
expectations in relation
to staff training, as
identified in the training
needs analysis
e. process for raising
awareness about
preventing and
reducing the number of
slips, trips and falls
involving service users,
staff and others
f. process for monitoring
compliance with all of
the above.
CS1a
Cs20a
GC23 Slips,
Trips & Falls
Prevention
Policy (exp.
April 2010)
AB No requirement to
undertake risk
assessments is
evident
No description of
the processes for
monitoring
compliance is
evident
Amend the
policy to
incorporate the
missing
components
7th
October
2009
OH revised policy and
sent to OS (4.8.09)
1.3.6 As a minimum, the
CS4a
CS23
GC3 Infection
Control Policy
LC No description of
the process for
Incorporate a
description of
26th
August
2009
Policy has been
revised by OH and
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
3

4. Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale for
Completion
Progress/Comments Compliance
RAG Rating
The organisation
has approved
documentation
which describes
the process for
managing the risks
associated with
inoculation
incidents.
approved documentation
must include a description
of the:
a. duties
b. reporting arrangements
in relation to the
inoculation incidents
c. process for the
management of an
inoculation incident
(including
prophylaxis)
d. organisation’s
requirements in relation
to staff training, as
identified in the training
needs analysis
e. process for monitoring
compliance with all of
the above.
CS24 (exp. Sept
2009)
monitoring
compliance
evident
the process for
monitoring
compliance into
policy
forwarded to LC for
finalisation.
SLIPPAGE due to LC
off sick
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
4

5. STANDARD 4: CLINICAL CARE
Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
1.4.5
The organisation
has approved
documentation
which describes the
process for
managing risks
associated with the
observation of
service users.
As a minimum, the approved
documentation must include
a description of the:
a. duties
b. process for observation
at differing levels
c. organisation’s
expectations in relation to
staff training as identified
in the training needs
analysis
d. record keeping
e. process for monitoring
compliance with all of the
above.
CS5a (only
from NICE
guidance re:
observation
procedures)
CS5d (audit
monitoring re:
observation)
CS9
GC9
Observation
through Care
Engagement
(formerly
Observation
Policy) (exp.
Dec 2010)
JB None n/a n/a n/a
1.4.7
The organisation
has approved
documentation
which describes the
process for
managing the risks
associated with the
physical
assessment
examination and
ongoing physical
care of service
users.
As a minimum, the approved
documentation must include
a description of the:
a. duties
b. requirements for
physical assessment of
service users on
admission to service
c. process for ensuring
appropriate follow up of
physical symptoms
d. ongoing assessments
of physical needs for all
service users
e. process for monitoring
compliance with all of the
above.
CS5a (re: NICE
guidance)
CS17 (only
from patient
involvement
with their own
CPA)
GC35 Physical
Healthcare
(exp. Oct 2009)
LC Description of the
process for
monitoring
compliance to be
expanded
Strengthen
monitoring
statements by
describing how
compliance
with the policy
will be
monitored
26th
August
2009
Policy has been
revised by OH and
forwarded to LC for
finalisation.
SLIPPAGE due to LC
off sick
1.4.8 As a minimum, the approved
CS5a (re: NICE
guidance
GC5
Resuscitation
DT None n/a n/a Policy revised and
signed off by ET
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
5

6. Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
The organisation
has approved
documentation
which describes the
process for
managing the risks
associated with
resuscitation.
documentation must include
a description of the:
a. duties
b. initiation of resuscitation,
including the system for
summoning help
c. do not attempt
resuscitation orders
(DNAR)
d. process for ensuring
the continual availability
of resuscitation
equipment
e. training requirements for
all staff, as identified in
the training needs
analysis
f. process for monitoring
compliance with all of the
above.
compliance)
(Nb. see notes)
Policy (exp.
Sept 2009)
31.7.09
1.4.9
The organisation
has approved
documentation
which describes the
process for
managing the risks
associated with
infection prevention
and control.
As a minimum, the approved
documentation must include
a description of the:
a. infection control
assurance framework
b. details of, or cross
reference to, appropriate
core policies
c. information available to
service users and the
public about the
organisation’s general
processes and
arrangements for
preventing and controlling
healthcare acquired
infections
CS4a GC3 Infection
Control Policy
(exp. Sept
2009)
LC Details of the
infection control
assurance
framework is not
evident within the
policy
Incorporate
details of the
infection
control
assurance
framework into
the policy
26th
August
2009
Policy has been
revised by OH and
forwarded to LC for
finalisation.
SLIPPAGE due to LC
off sick
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
6

7. Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
d. training requirements for
all staff, as identified in
the training needs
analysis
e. process for monitoring
compliance with all of the
above.
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
7

8. STANDARD 5: LEARNING FROM EXPERIENCE
Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
1.5.8
The organisation
has approved
documentation
which describes
the process for
ensuring that
agreed best
practice as defined
in all NICE
guidance (where
appropriate), is
taken into account
in the context of
the clinical
services provided
by the
organisation.
As a minimum, the approved
documentation must include a
description of the:
a. duties including leadership for
all stages of the process
b. process for identifying relevant
documents
c. process for disseminating
relevant documents
d. process for conducting an
organisational gap analysis
e. process for ensuring that
recommendations are acted
upon throughout the
organisation
f. process for documenting any
decision not to implement
NICE recommendations
g. process for monitoring
compliance with all of the
above.
NB: For advice on recommended
processes, please refer to How to
put NICE guidance into practice,
available from the NICE website
www.nice.org.uk/usingguidance.
Guidance specific support tools
are also available.
CS5a GC39 National
Practice
Guidance
Implementation
policy (exp. Jul
2012)*
* - This policy
has been
finalised and
due to be
ratified
MN None Ratification by
CPGG
26th
August
2009
The policy was
submitted to the
Clinical Practice &
Governance Group
for ratification on 21st
July 2009 – meeting
was not quorate so
deferred to next
meeting
1.5.9
The organisation
has approved
documentation
which describes
the process for
ensuring that
agreed best
As a minimum, the approved
documentation must include a
description of the:
a. duties
b. process for identifying relevant
documents
c. process for disseminating
CS1a (NCE
re: suicides
&
homicides_
CS5d (NICE)
CS23 (NSFs)
GC39 National
Practice
Guidance
Implementation
policy (exp. Jul
2012)*
* - This policy
has been
MN None Ratification by
CPGG
26th
August
2009
The policy was
submitted to the
Clinical Practice &
Governance Group
for ratification on 21st
July 2009 – meeting
was not quorate so
deferred to next
meeting
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
8

9. Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
practice, as
defined in
nationally agreed
guidance, the
National Service
Frameworks,
National
Confidential
Enquiries and
other High Level
Enquiries that
make
recommendations
for patient safety,
is taken into
account in the
context of the
clinical services
provided by the
organisation.
relevant documents
d. process for conducting an
organisational gap analysis
e. process for ensuring that
recommendations are acted
upon throughout the
organisation
f. process for monitoring
compliance with all of the
above.
finalised and
due to be
ratified
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
9

10. Criteria/Line of
Enquiry
Minimum Requirements Core
Standards
Approved
Documentatio
n Name
Responsible
Lead
Gaps in Current
Documentation
Actions
Required for
Compliance
Timescale
for
Completion
Progress/Comments Compliance
RAG Rating
practice, as
defined in
nationally agreed
guidance, the
National Service
Frameworks,
National
Confidential
Enquiries and
other High Level
Enquiries that
make
recommendations
for patient safety,
is taken into
account in the
context of the
clinical services
provided by the
organisation.
relevant documents
d. process for conducting an
organisational gap analysis
e. process for ensuring that
recommendations are acted
upon throughout the
organisation
f. process for monitoring
compliance with all of the
above.
finalised and
due to be
ratified
KEY:
RED Meets less than 50% of the minimum requirements for the criterion OR no policy currently on database
AMBER Meets more than 50% (less than 100%) of the minimum requirements for the criterion
GREEN Meets 100% of the minimum requirements for the criterion
NHSLA RM Standards Level 1 Action Plan – Sept 2009
9