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Version: V7

Ratified By: Quality & Safety Committee

Date ratified: 25/03/2025

Job Title of Author: Head of Quality and Safety

Reviewed by Subgroup or Expert Group: Sent out to quality and safety membership Expert Stakeholders: Head of Safety & Resilience Assistant Director of Finance Assistant Director of Estates & Facilities

Equality Impact Assessed by: Head of Quality and Safety

Related Procedural Documents: HSPOL02 VIP Management

Review Date: 25 March 2028

It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet.

In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.

Version Control Sheet

Version Date

Author Status Comment

V1 Nov 2009 Senior Governance Manager Approved by PCT Board

V2 March 2011 As above Approved IGC Reviewed in line with Provide CIC transition

V3 March 2013 Senior Quality and Safety Manager Approved Reviewed as expired

V4 March 2016 Head of Quality and Safety Approved

V5 April 2018 Quality Performance Analyst Approved Routine review

V6 March 2021 Head of Quality and Safety Review

V7 February 2025 Head of Quality and Safety Review

1. Introduction

This Policy describes the systems in place to provide co-ordination and evaluation of the work of external agency visits, inspections and accreditations, which will bring increased benefits to both the Provide Group and the review bodies. It will help minimise the burden on the Provide Group by reducing overlap and allow potential gaps in assurance to be identified and addressed. It is seen as part of the Provide Groups internal control system and provides assurance to the Board, who need, wherever possible, to make use of the work of the many external reviewers and ensure the whole process is efficient.

2. Purpose

The Chief Executive Officers are the key contact points for all external visits, inspections, and accreditations. The work of managing and responding to resulting recommendations will be co-ordinated by the appropriate committee and corporate work stream. This committee will ensure that there is a centrally held, internally audited, record of all external agency visits, inspections and accreditations together with their reports and action plans, which are updated and monitored within specified timescales

3. Definitions

External agency: An authoritative body that has been given a role by the NHS Executive or Social Care equivalent in regulating the corporate and professional activities of all NHS and social care organisations.

Accreditation: Provides independent assurance from a third party that the organisation has achieved a level of compliance with an agreed set of criteria/standards.

Inspection: An organised examination or evaluation comparing results to specific requirements or standards.

Internal control: Systems, procedures and behaviours by which the organisation controls its functions in order to achieve organisational objectives, safety and quality of services.

Assurance Framework: The Board Assurance Framework provides a structure and process that enables the organisation to be sensitive to the risks to achieving its most important (corporate) annual objectives and be assured that adequate controls are operating to reduce these risks to acceptable levels.

Scope: This policy applies to all external agency visits, inspections and accreditations undertaken for Provide Group

4. Duties

The appropriate Chief Executive Officer will nominate/appoint an individual or individuals to coordinate and report on any reviews carried out by external agencies (see section 5). This process will be managed centrally by the Quality and Safety team and reported to the Quality and Safety Committee, Finance and Investment Committee, Quality Reference Group and Audit Committee.

Duties within the Organisation

Where a member of staff is informed that a visit, inspection or accreditation is scheduled to occur, they must immediately inform the Director of Operations and Registered Manager

Provide Group Board: will receive summary reports of results and actions to be taken in response to all external agency visits, inspections and accreditations in order to be assured that the system is working effectively.

The Chief Executive of Provide Group is ultimately responsible for the process of managing and responding to external agency visits, inspections and accreditations effectively and efficiently and for how this responsibility is delegated.

There are several key regulators with the rights to visit the organisation for the purposes of inspection, audit or accreditation. The entry point into the organisation may differ, dependant on regulator visiting. Dependant on the regulator visiting the following actions are essential and should be carried out by the Directorate where the regulators main focus will sit:

• Confirm the accountable and relevant committee/group for specific visits.

• Evidence summary reports of all visits and approve the action plans to address the recommendations.

• Report to the Quality and Safety Committee, Finance and Investment Committee, Audit Committee or the Board highlighting any areas of concern.

• Ensure, through the relevant committee team and Chief Executive Officer that any lessons to be learnt are identified and shared.

• All action plans arising from external visits are presented at the relevant committee at closure for assurance of evidence that requirements and learning have been implemented.

Accountable committee/group for specific external agency visits, inspections and accreditations:

Once identified, the responsible committee/group/individual for specific visits, inspections and accreditations, the committee/group will:

• Identify or confirm an appropriate lead for each specific external review to coordinate the process of review/inspection – See section 5.

• Review summary reports and consider if the identified action is adequate and appropriate to address the recommendations.

Nominated/appointed lead for coordinating and reporting on all external agency visits, inspections and accreditations:

The appropriate Chief Executive Officer will lead for coordinating and reporting on all external agency visits, inspections and accreditations. This is a coordination role to ensure

the specific external agency visits, inspections and accreditations lead is fulfilling their duty regarding specific external agency requirements.

Duties:

• Maintain a schedule of review dates (external agency visits, inspections and accreditations)

• Maintain action plans to implement any recommendations made as a result of reviews

• Ensure action plans are reviewed regularly and evaluated by the nominated committee/group until closed and actions completed

• Liaise with the nominated/appointed lead for each specific external agency visit, inspection or accreditation

• Ensure that the organisation-wide risk register is populated with risks identified from external agency visits, inspections and accreditations

Nominated/appointed lead to coordinate the process for specific external agency visits, inspections and accreditations:

This individual may be nominated/appointed by virtue of their position e.g. Director of Operations for the service being reviewed / inspected. Examples of identified leads for specific external agency visits, inspections and accreditations are shown in Section 5.

The post holder’s duties include:

• Provide a summary briefing of the initial findings of the specific external agency visit to the identified committee/group, highlighting any areas identified as being high risk or of media interest

• On receipt of the report following the specific external agency visit, inspection or accreditation, ensure that all the information included in the report is accurate

• Carry out risk assessments for activities identified in the report recommendations and, as appropriate, enter on the risk register

• Ensure the action plan is implemented

• All action plans arising from external visits are presented at the relevant committee at closure for assurance of evidence that requirements and learning have been implemented.

All Staff

• Represent the organisation in a polite and professional manner

• Will request identification of anyone presenting as an inspector and notify their manager and the Clinical Quality Team immediately

• Will not allow access to clinical or corporate data until visitor identity has been verified

• Will be mindful of Provide Group policies and procedures with particular note to information governance policies

• Consult organisational guidance relevant to the external agency visit, e.g. CQC Toolkit.

5. Identification of External Organisations and the Related Leads

External Agency

CQC

Audit Commission

PLACE

Health and Safety

Executive (HSE)

Executive Committee

Provide Group Board Quality and Safety Committee

Provide Board/ Audit Committee

Finance and Investment Committee with links to Quality and Safety committee

Health and Safety Committee/ Board

Royal Colleges Quality and Safety Committee

Information Commissioners Office (ICO)

Finance and Investment Committee with links to Quality and Safety Committee

Internal Audit Finance and Investment Committee

External Audit

County Council /Local Authority

Finance and Investment Committee

Provide Group Board Quality and Safety Committee

6. Scheduling Visits

Nominated Lead

Chief Executive Officer and Registered Manager

Chief Finance Officer

Chief Finance Officer and/or

Chief People Officer

Chief Executive Officer/Chief Nurse

Chief Finance Officer

Chief Executive Officer and Registered Manager

The nominated lead or an appointed deputy in the table above is responsible for coordinating and scheduling the relevant visits. This will include:

• Any and all communication, both internally and externally, to ensure the smooth and effective running of the visit

• Housekeeping arrangements: venue, equipment, catering/ refreshments, etc

• The provision of the required evidence.

• Ensuring that the staff required for the assessment, for example, staff that are being interviewed as part of the assessment, are available at the required time and venue

7. Post Inspection/Accreditation

The nominated lead for the inspection is responsible for managing the process following inspection. This will include:

• Formally reporting the findings, recommendations and actions to the relevant stakeholders and staffing groups

• Ensuring that the report is presented to and discussed at the relevant executive committee

• Ensuring that any and all risks that require inclusion on the risk register are discussed accordingly and the mitigation/management plans are agreed

The responsible executive committee must ensure that the post inspection/accreditation report and related action plans are implemented as required. This will differ depending on the respective process and implications. This will include:

• On-going oversights until all of the actions/recommendations are implemented

• Strategic decision-making as required relating to the reports / actions / recommendations

8. Counter Fraud and Bribery

Fraud is where any person who dishonestly makes a false representation to make a gain for themself or another or dishonestly fails to disclose to another person, information which they are under a legal duty to disclose, or commits fraud by abuse of position, including any offence as defined in the Fraud Act 2006.

Bribery is the giving or receiving a financial or other advantage in connection with the ‘improper performance’ of trust or a function that is expected to be performed impartially or in good faith. Where the Provide Group is engaged in commercial activity it could be considered guilty of a corporate bribery offence if an employee, agent, subsidiary or any other person acting on its behalf bribes another person intending to obtain or retain business or an advantage in the conduct of business for the Provide Group and it cannot demonstrate that it has adequate procedures in place to prevent such. The adequate procedures that the Provide Group is required to have in place to prevent bribery being committed on their behalf are performed by six principles – proportionate procedures, toplevel commitment, risk assessment, communication (including training), monitoring and review. The Provide Group does not tolerate any bribery on its behalf, even if this might result in a loss of business for it. Criminal liability must be prevented at all times.

Staff must declare any potential conflicts of interest prior to participating in external agency visits or inspections.

Counter Fraud

If any member of staff has good reason to suspect a colleague, patient or other person of fraud, bribery and / or corruption, involving the Provide Group, they should report their genuine concerns to the Local Counter Fraud Specialist (LCFS) or Executive Finance Director immediately. The LCFS will then decide on the next course of action and advise

the member of staff accordingly. All calls are dealt with in the strictest of confidence and callers may remain anonymous.

Suspicions of fraud, bribery or corruption should be reported to the Local Counter Fraud Specialists on telephone 01473 945843, Provide’s Chief Executive Officer or NHS Counter Fraud Authority (NHSCFA) via an online reporting form: https://cfa.nhs.uk/reportfraud: or NHSCFA Freephone: 0800 028 4060. Further details including email addresses for those responsible can be found on Provide’s Intranet.

Individuals suspected of committing an offence of fraud, bribery or corruption may be subject to criminal and/or disciplinary investigation, which could result in criminal and/or disciplinary action being taken, including prosecution and/or dismissal. For more information, please refer to the Local Anti-Fraud, Bribery and Corruption Policy or to Provide’s Counter Fraud intranet pages.

This policy aligns with NHSCFA Functional Standards and is subject to regular review to ensure compliance with national guidance. All staff involved in external agency visits will receive regular training on fraud awareness, bribery prevention, and reporting procedures.

9. Monitoring of this Policy

The monitoring and audit of policies and procedures is a requirement of corporate and clinical governance.

The Quality and Safety Committee and Finance and Investment Committee will be responsible for ensuring that all of the requirements as set out in this document are met and monitored.

This policy will be reviewed three-yearly and also whenever national reporting guidelines change.

10.Breach of this Policy

A breach of this policy could lead to confusion regarding the management of external agency visits, inspections and accreditations and could compromise the effective governance arrangements in place at the organisation.

11.References

• Care Quality Commission: March 2024 Single Assessment Framework

• Department of Health 2018 Audit Committee Handbook

• Department of Health 2003 Building the Assurance Framework

• Department of Health 2002 Assurance: The Board Agenda

• National Health Service Litigation Authority 2013- 2014 Risk Management Standards

• Department of Health 2011 Board Governance Assurance Framework for Aspirant Foundation Trusts

• NHS Improvement 2017 Developmental reviews of leadership and governance using the well-led framework: guidance for NHS trusts and NHS foundation trusts

EQUALITY IMPACT ASSESSMENT

TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Management of External Agency Visits Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Project/Policy Manager: Head of Quality and Safety 18/02/2025

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

This policy is neutral and will not have a specific impact on a particular group. Any arising issues will be managed and reviewed in real-time.

Guidelines: Things to consider

• Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

• The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

• Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

• Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

• Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

• It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

• It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

• An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

• It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

• The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

• If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.efa.org.uk – Employers forum on age

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’