department of health third sector partnership team third sector baseline entry standards (tsbes)...

Department of Health

THIRD SECTOR PARTNERSHIP TEAM

THIRD SECTOR BASELINE ENTRY STANDARDS (TSBES)

PHASE 2 PILOT



PHASE 2 PILOT

Why is this work being undertaken?

Many small organisations are not subject to any standards and do not fall within the remit currently

covered by health and social care regulators.



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An organisation may have very good outcomes but there may be hidden problems around organisational

structures and governance

The majority of small businesses fail because they do not manage their business as well as they deliver their services.



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What is Governance?

Governance is concerned with the way in which your organisation’s governing body carries out its responsibilities.

Governance encompasses the values, processes, controls and rules of accountability at the heart of your organisation - the means through which your organisation makes decisions and exercises power to achieve its objectives



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There is no accepted measure that enables commissioners to assess the safety of TSOs.



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Aim of TSBES

To develop a set of baseline standards that commissioners will recognise as evidence of

competency and ‘fitness for purpose'



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TSBES Objectives are to:

Develop a set of ‘field tested’ standards that will present an opportunity for the Third Sector to demonstrate existing skills and professionalism and an evidence

base to platform the Third Sector’s particular strengths.



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How is the work being undertaken?

Field testing the standards with Third Sector organisations, service users and commissioners.



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How TSBES Relates to Sustainability

Provides a baseline measure of competency that will:

• Support local commissioners in assessing organisations that fall outside the scope of CQC (and other regulators) and who are new entrants into the commissioning process



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How TSBES Relates to Sustainability

Provides a baseline measure of competency that will:

• Facilitate ongoing assurance with regard to contract (and grant) management of Third and independent sector service provision.



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Standards Categories (Phase 2 Pilot)

1. Management of Risk

2. Governance

3. Equality, Diversity and Anti-Stigma

4. Partnership Working

5. Service User Focus



PHASE 2 PILOT

STAGE 3

TSBES EVALUATOR TO EMAIL:

TSBE STANDARDS (including best practice reference sources and web based toolkit links)

QUESTIONNAIRE TO RATE TSBES COMPLIANCE

ORGANISATIONAL PROFILETaking a profile of each organisation enables us to identify commonalities from like to like organisations when we evaluate and compare results. It will not be possible to identify organisations from information provided in the final report.

STAGE 5

COMPLETE PILOT SESSION WITH PARTICIPATING ORGANISATION

Compliance rating and evaluation session with the evaluator on site

(approx 3 hours)Local infrastructure organisation to be present (where possible) to support the development and requirements of an action plan

STAGE 6

POST PILOT EVALUATIONof TSBES process

Two weeks following pilot

STAGE 1

PARTICIPATION IN TSBES AGREED BY ORGANISATION THROUGH SELF

SELECTION PROCESS

STAGE 2

ENGAGE LOCAL INFRASTRUCTURE SUPPORT ORGANISATION (WHERE AVAILABLE) IN THE PILOT PROCESS.

This will be of particular help where an action plan is to be developed.

STAGE 4

ORGANISATIONAL PROFILE RETURNED

SET DATES FOR PILOT EVALUATION(on site session)



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1. Management of RiskWorking practices and procedures are in place to prevent or reduce the risk of harm to service users, staff and others.

Standards Evidences MET PARTMET

UNMET

P I P I P I

STANDARD C3Organisations should demonstrate:a) That staff (employees and

volunteers, temporary and permanent) have a knowledge of and adhere to Vulnerable Adults and Child Protection policy and

Procedures

E12 Staff members have received training to ensure practice complies with Vulnerable Adults and Child Protection policies and this is recorded

E13 Systems are in place to:a) identify incidents and circumstances where the welfare of children and

vulnerable adults may be at risk and this is recorded

a) Ensure that the procedures to protect children and vulnerable adults are carried out in a timely and co-ordinated manner and are in line with Local Authority guidance.

a) A knowledge and understanding of information sharing arrangements around child protection and vulnerable adults

E14 Information sharing policies and procedures are in line with Local Authority child protection and vulnerable adults policies



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Evaluating the Standards

1) The Standard and the evidences are clear and easy to understand:

Yes Not at all

0 1 2 3 4 5 6 7 8 9 10

I---------------------------------------------------------------------I----------------------------------------------------------------------I

1 a) If Q1 is rated 4 - 10 please say why:



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3) The organisation will be able to meet the standard in the future:

3 a) Please say why:

Easily Reasonablyeasily

With difficultyWith great difficulty

Not at all



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2) The information required to provide evidence for the standard will be:

2 a) Please say why:

Easy to collectReasonably

easy to collect

Quite difficult

to collect

Very difficult to collect

Not possible to collect



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0

10

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100

P I P I P I P I P I P I P I

% MET % MET % MET % MET % UNMET % MET % PARTLY

NATIONAL MEDIUM REGIONAL LARGE LOCAL LARGE LOCAL MEDIUM LOCAL Small

Organisation 3 Organisation 1 & 2 Organisation 4 Organisations 5 & 6 Organisation 7

CATEGORY 3: EQUALITY AND DIVERSITYStandards C9 & Developmental Standard D3



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P I P I P I P I P I P I P I P I P I

% MET % MET % MET % PARTLY MET % MET % PARTLY MET % UNMET % PARTLY MET % UNMET

NATIONALMEDIUM

REGIONALLARGE

LOCAL LARGE LOCAL MEDIUM Organisation 7

Organisation 3 Organisation 1 &2

Organisation 4 Organisations 5 & 6 LOCAL Small

CATEGORY 2: GOVERNANCE - SUMMARY OF RESULTS Standards C5 to C8 & Developmental Standard D2



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Opportunities and Challenges

• Trustee involvement • Support to develop compliance • Strengthening the sector – evidence of achievement • Commissioner confidence• Extending the assurance and accreditation framework• Securing the provision of local services• Standardisation of commissioning and reporting processes



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The Revised Standards

1. Working Safely and Protecting Others

2. Effective Management and Accountability

3. Valuing Workers and People Within The Service

4. Partnership Working

5. Focussing on People That Use The Service



PHASE 2 PILOT

Standard 2.1 Governance structures are open, accountable and directed to achieving the aims of the organisation in the best possible way

PROCESSPOINT

Process Description Examples of Evidences (Evidences highlighted in bold are mandatory) MET UNMET

E2.1.3 There are clear lines of accountability to the Board and Chief Executive Officer / senior manager or other accountable person

Organisational chartAND

Job descriptions for chair, secretary , treasurer and trustees, officers and paid staff

E2.1.4 There is a clear management structure for all workers outlining roles and responsibilities. This is communicated to all workers at induction and changes are circulated as they arise.

Organisational chartAND

Induction recordsAND

Workers (paid and unpaid) updates

E2.1.5 A mission or vision statement has been developed with people that use the service, trustees, workers (paid and unpaid) and other key stakeholders

A mission / vision statement is included on all publicity and documents

AND Records of consultation meetings

E2.1.6 The organisation’s aims, objectives, policies and procedure of are consistent with the mission / vision statement.In responding to the day-to-day management of an organisation, it is easy to make revisions to policy and procedure that can conflict with the stated mission or vision.

• Service information and publicityAND

Service development plansAND

Records of planning meetingsAND

Records that aims, objectives, policy and procedure has been mapped against the mission / vision statement.



PHASE 2 PILOT

Standard 5.1 People that use the organisation are informed and consulted about the service. Their views are listened to and acted upon.

PROCESSPOINT

Process Description Examples of Evidences (Evidences highlighted in bold are mandatory) MET UNMET

E5.1.1 People using services receive information about the organisation in a form they can easily understand, to include:1.The aims and ethos of the service2.What they can expect to receive from the service3.How and where this will be delivered

Advertising material – posters, leaflets etc is suitable for all potential service users.

AND Literature provided to people using services with:- clear description of services offered and- what people using the service can expect at all stages of care / support

AND List of places and resources where such information is available.

E5.1.2 People using services are consulted and fully involved in decisions about all aspects of their care and the services they receive and this is noted in all documents that record the planning; delivery and co-ordination of care.

Literature provided to people using servicesAND

Service user case filesAND

Care plans / action plans

E5.1.3 People using services, relatives and carers and significant others (in the view of the service user) are encouraged to express their preferences, and supported to make choices and shared decisions about their own care/ support.

Literature provided to people using servicesAND

Service user case filesAND

Care plans / action plans



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Rating compliance with the TSBE Standards provides

a health check for your organisation.

Low compliance does not signify a lack of commitment amongst workers, nor does it mean that outcomes for people using your organisation are less than high.



PHASE 2 PILOT

Rating compliance with the TSBE Standards provides

a health check for your organisation.

However, it may show areas where your organisation’s structures and systems are unsafe. And in the face of a challenging situation or circumstance, you may not have the policies and procedures in place to provide a timely and appropriate response.



PHASE 2 PILOT

Developing an Action Plan.

The results of your standards health check will give you a ‘to do’ list which can be prioritised to give you an action plan. The actions you need to take to reach compliance are often relatively straightforward to put in place. There is no area covered by the standards where ‘the wheel has not already been invented’.

department of health third sector partnership team third sector baseline entry standards (tsbes)...

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