Follow-up and Assurance Policy

This policy does not cover enforcement in the independent sector.

HIW receives information about healthcare providers in a number of different ways, upon which it might seek to take action.

1. HIW undertakes a large number of inspections, reviews and investigations each year. Most of these inspections generate some kind of improvement action or identify issues requiring action by the healthcare provider.
2. HIW receives concerns directly from patients, families or from whistleblowers.
3. HIW has Relationship Managers who, through their work with a health board, trust or independent provider, can discover information of concern

Given the finite resources at its disposal, HIW cannot in all cases undertake an inspection to establish whether action has been taken to address recommendations and concerns. Furthermore, providers should not be reliant on HIW to undertake an inspection as a catalyst for any action to be delivered. It is the responsibility of those providing and managing healthcare to ensure services are delivered in a safe and effective way.

HIW has developed a range of activities which act as a means of gaining assurance that issues have been addressed, resolved, or actions delivered. This paper sets out the range of activities at HIW’s disposal and the circumstances in which it would use them. A high level summary of our approach is contained within our overarching inspection methodologies for how HIW inspects the NHS and independent services.

HIW will follow-up issues arising from completed inspections in two key ways:

• Annual/Scheduled process

HIW periodically asks Health Boards to provide an update on all outstanding action plans. Health Boards are large entities and this allows HIW not only to establish what progress has been made on individual actions, but also to assess the arrangements in place to ensure that any issues identified are learned from and are not replicated elsewhere within the organisation (e.g. other wards, units or hospitals). HIW assesses all responses received and determines whether there is a need for a specific follow up activity to be delivered.

• Activity following each inspection

Following the completion of an inspection and the receipt of any improvement plan, the inspection manager, or person responsible for an inspection, review or investigation, will consider whether the action proposed by the healthcare provider provides HIW with assurance.

Where a completed improvement plan does not provide HIW with sufficient assurance, this is returned to the healthcare provider with a request for further detail. If, following an inspection, an improvement plan continues to provide insufficient detail to provide HIW with assurance after three attempts, HIW will escalate this.

For NHS services, this escalation could include requiring the Executive leaders from the service to attend a meeting with HIW, and, ultimately, escalation of the matter to the Chief Executive of NHS Wales. Where a health board fails to provide sufficient assurance that improvement action is being taken, this will form part of HIW’s contribution to the NHS Wales Escalation and Intervention meetings with the Welsh Government and the Wales Audit Office.

For Independent services, this escalation will include a meeting with the service provider, and ultimately, cancellation, suspension or conditions placed on registration.

When a completed improvement plan is deemed to provide sufficient assurance, the inspection manager will consider what action is necessary in order to follow-up on issues identified during an inspection.

Options for follow-up activity will include but not be limited to:

• No follow up required
• Request update on implementation of improvement plan
• Drop-in visit to check action undertaken
• Undertake inspection focused on action required*
• Undertake full inspection*
• Refer to other agency (e.g. Audit Wales, Llais).

Further supporting information on the rationale for each approach is supplied in Table 1 (Annex 1). 

*There are two ways that a focused or full inspection can be conducted, depending on the primary areas of focus. This can be within:

• The same service area and location as the original inspection
• A different service area or location to the original inspection e.g. looking at issues raised during inspection of ward X at ward Y to check if lessons have been shared.

• Special Review and Thematics

Following the completion of any special review or thematic, we expect the relevant health organisations / stakeholders to produce improvement plans.

We usually request updated improvement plans 12 months following the report’s publication. We follow up other specific recommendations from thematic reviews in an appropriate way for the topic and the type of recommendations we make, for example through ongoing engagement with stakeholders.

    a. Concerns notified to HIW directly

HIW does not routinely investigate the particular circumstances of an individual patient’s treatment or concerns raised by individuals. While it is not our role to routinely investigate individual concerns, we do consider all information we receive and use it to inform any future work that we carry out: in particular where there is a pattern of concerns about a hospital or service.

When we receive concerns we will them assess in terms of risk. The highest risk concerns which relate to significant matters of patient safety are responded to within 2 working days. Concerns assessed as this level usually involve:

• a clear current or imminent threat to patient safety (for example a potential safeguarding concern about a current patient in a hospital/setting)
• allegations of criminal behaviour that require HIW to immediately contact the police
• concerns regarding patients detained under the Mental Health Act

Typically, concerns falling into the above categories will be immediately raised at a senior level within a health body or an independent provider for immediate action and response.

In general, most of our concerns are dealt with by means of signposting the individual to the relevant organisation/body in order to pursue their concern. There may be a need to request further information in order that the intelligence that we gather can be used more effectively. For instance, intelligence about specific wards as opposed to a general concern about a hospital can assist us in focusing our inspection visits accordingly.

All of our concerns are logged onto our Organisational Records and Relationship Managers have a responsibility to ensure that they are aware of concerns raised about their organisations in order to inform the yearly planning process, and the monthly Risk and Escalation meeting.

     b. Information obtained by Relationship Managers

HIW has Relationship Managers for each health board and for the independent sector. Relationship Managers are a single point of contact for a health board/trust/independent provider with HIW. Relationship Managers attend health board meetings, such as the Quality and Safety/Patient Safety Committee to gain assurance about how the health board seeks its own assurance that services are safe and effective.

HIW Relationship Managers also regularly engage with partner organisations for example Audit Wales, Llais and Public Services Ombudsman for Wales to share views and intelligence about the health board or trust.

On an annual basis HIW Relationship Managers attend full health board/trust meetings to present HIW’s annual report findings. This ensures that any themes or trends identified during the year are highlighted directly to the Board.

Relationship Managers summarise all themes and concerns about the health board/trust known to HIW from all sources (including from inspections) on a monthly basis and feed this into HIW’s Risk and Escalation Committee. They also summarise themes and concerns about the organisation that contribute to HIW’s view of the escalation status for the organisation ahead of the Escalation and Intervention meetings.

Any proposed follow-up activity will be added to HIW’s ‘tracker database’. Before any activity is undertaken, HIW will assess whether it can be justified in relation to other programmes of work and known risks across Wales. This assessment will take place in one of two ways:

• If a proposed follow up activity falls in the next inspection year, its benefit will be assessed as part of the planning processes for that year. Relationship Managers will play a role in assessing relative priorities for work programmes in each healthcare setting.
• Follow up activity proposed in the same year as the original inspection will be authorised by HIW’s Risk and Escalation Committee (REC). The REC will consider the in-year follow up programme on a monthly basis, receiving information from HIW’s tracker database on activities proposed by inspection managers.

1) This guidance sets out a number of common activity types. It is not intended to be wholly prescriptive. HIW reserves the right to undertake different follow up activity where this is deemed necessary.