D Governance 1 The CEO should review the governance processes including responsibilities for policies and Standard Operating Procedures (SOPs). Specifically, this should include: How policies and SOPs are created, approved, communicated and Review within 1 reviewed. month Replacement of the Whistleblowing Policy using the NHSE guidance for Replace within 1 primary care providers. month (guidance link already sent) Update all out of date policies using best practice. (Prioritise Grievance Within 2 months Policy). How access policies. Currently some are on a public facing website Within 1 month and some on the V drive. E.g. Whistleblowing Policy is on the public facing website and Grievance is on V drive. They are policies that staff may wish to easily access at the same time. Both are out of date and need updating. 2 The CEO should ensure that the Medical Director is supported to continue the improvement work on Quality and Safety. Specifically, this should include: Review of capacity in Continue to develop and extend the coverage of the GP audits. the clinical Review and develop the balanced scorecard with the Operations Director. governance team Continue to develop policies and processes that promote the quality of within 1 care and safety of patients and Ongoing support Theme No Recommendations Suggested Timescale
D Governance 1 The CEO should review the governance processes including responsibilities for policies and Standard Operating Procedures (SOPs). Specifically, this should include: How policies and SOPs are created, approved, communicated and reviewed. Replacement of the Whistleblowing Policy using the NHSE guidance for primary care providers. Update all out of date policies using best practice. (Prioritise Grievance Policy). How access policies. Currently some are on a public facing website and some on the V drive. E.g. Whistleblowing Policy is on the public facing website and Grievance is on V drive. They are policies that staff may wish to easily access at the same time. Both are out of date and need updating. Review within 1 month Replace within 1 month (guidance link already sent) Within 2 months Within 1 month 2 The CEO should ensure that the Medical Director is supported to continue the improvement work on Quality and Safety. Specifically, this should include: Continue to develop and extend the coverage of the GP audits. Review and develop the balanced scorecard with the Operations Director. Continue to develop policies and processes that promote the quality of care and safety of patients and Review of capacity in the clinical governance team within 1 Ongoing support Theme No Recommendations Suggested Timescale
20180806-SELDOC-WB-Final-Report-V11-16.7.18.docx