1. Premises Assurance Model SAQ P1: To ensure engagement and involvement on estates an facilities services from people who use the services, public and staff can you organisation evidence the following? 10/08/16

2. Guidance • Data Protection Act 1998 • Freedom of Information Act 2000 • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: and CQC Guidance for providers on meeting the regulations: 16: Receiving and acting on complaints (FS) 17(2)(e) seek and act on feedback from relevant persons and other persons on the services provided In the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services; 17(2)(f) evaluate and improve their practice in respect of the processing of the information referred to in sub-paragraphs (a) to (e). • CQC Provider Handbooks R1.1. Is information about the needs of the local population used to inform how services are planned and delivered? R1.2. How are commissioners, other providers and relevant stakeholders involved in planning services? R1.3. Do the services provided reflect the needs of the population served and do they ensure flexibility, choice and continuity of care? R1.4. Where people’s needs are not being met, is this identified and used to inform how services are planned and developed? • NHS England Transforming Participation in Health and Care -September 2013 • The Kings Fund Research Paper; Patient Engagement and Involvement • The Kings Fund Research Paper; The Quality of Patient Engagement and Involvement in Primary Care 2010 Enter the presentation's title using the menu option View > Header and Footer

3. Patient experience - evidence source • Documentary evidence relevant to the prompt questions e.g. evidence of patient involvement. • Engagement process and methodology • Surveys and questionnaires • Focus Groups • Engagement feedback influencing services developments and improvements • Governance and process for dealing with feedback • Adherence to confidentiality policy • Feedback to stakeholders and patients • Friends and Family Test • Patient Advice and Liaison Service (PALS) Enter the presentation's title using the menu option View > Header and Footer

4. P1. Views and experiences Comments Are people’s views and experiences gathered and acted on to shape and improve the services and culture? • Evidence • Patient satisfaction surveys - Reports • Staff survey • Infox • FoI • Inpatient survey • Estates & Facilities Governance Steering Group • Patient listening and learning events • Monthly walk around - quality improvement visits • Freedom to speak up • Post project evaluation • Duty of candour Enter the presentation's title using the menu option View > Header and Footer

5. P2. Engagement Comments Are people who use services, those close to them and their representatives actively engaged and involved in decision making? • Evidence • Patient and Carer Experience Group • Patient Listening and Learning Event findings, August 2014 • Monthly walk around - quality improvement visits • Patient Environment Action Group environmental action plan • User consultation on designs and signage Enter the presentation's title using the menu option View > Header and Footer

6. P3. Staff engagement Comments Do staff feel actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? • Evidence • Strategic framework - our patients, our hospital, our future, together • EFM questionnaire • General service questionnaires • Staff survey results • MDT prioritisation assessment of capital investment for backlog and developments • Staff involvement in the development of service strategies • Stakeholder consultation, master plan, planning applications • Governor consultation meetings • Patient Environment Action Group • Staff conversation Enter the presentation's title using the menu option View > Header and Footer

7. P4. Prioritisation Comments Do staff feel actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? • Evidence • Staff consultation for strategic framework - our patients, our hospital, our future, together • MDT prioritisation assessment of capital investment for backlog and developments • Staff involvement in the development of service strategies • PAM action plan • Staff conversation • 10 behaviour standards • Trust values • Staff survey Enter the presentation's title using the menu option View > Header and Footer

8. P5. Value • Evidence • Whistle blowing policy • Freedom to speak up • Infox • Weekly news letter • Fraud display Comments Do both leaders and staff understand the value of staff raising concerns? Is appropriate action taken as a result of concerns raised? Enter the presentation's title using the menu option View > Header and Footer

9. P6. Costed action plans Comments If any ratings in this SAQ are 'inadequate' or 'requires moderate or minor improvement' are there risk assessed costed action plans in place to achieve compliance? • Evidence • Business planning documentation • PAM action plan • Datix risk assessments • EFM top 10 risk register • EFM Governance report Enter the presentation's title using the menu option View > Header and Footer

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