The pre-award audits for HealthTrust Europe TWSIII are finally over and now it’s all about implementing the new contract to turn all that hard work into some well-earned business. Naturally focus is now on bauilding relationships with Participating Authorities to achieve direct supply agreements and win mini competitions.
But all that said, don’t take your eye off the compliance ball! Remember, you will be subject to annual audits for both the HealthTrust Europe and Workforce Alliance Frameworks, and these come round quickly! In fact, the Workforce Alliance audits are already in full swing, and we’ve had feedback from agencies who have been supplying under this framework for years that these audits are tough!
So what can you do to prepare?
ACI Training & Consultancy have just completed literally hundreds of pre-award audits for HTE and we have found a number of common issues across many of the agencies they audited (and not just those that are new to supplying the NHS)! We are sharing our experience to help you navigate the minefield of regulation and requirements in this blog. What is also important to note is that post-award audits will have more criteria to meet and a different scoring system.
What is the purpose of an audit?
Contrary to popular belief, the auditors are not trying to catch you out! Annual compliance audits (and indeed your internal audit procedures) are a genuine measure to reduce the risks associated with supplying medical and clinical staff to the NHS. Implications of compliance failures for patients can be significant, so auditors take their job seriously and will probe deeply into your policies, procedures and candidate files to ensure every element is present and correct.
Audits are designed to:
- Ensure adherence to regulations: they verify that you are following relevant laws and regulations, which vary by discipline and jurisdiction.
- Identify gaps and risks: they identify where you may be falling short, allowing for corrective actions to mitigate risks and maximising patient safety.
- Allow you to demonstrate compliance: you can use audits to enhance your reputation, build trust with Participating Authorities and secure business.
- Improve internal controls: insights from audits can help you identify weaknesses and develop processes to prevent recurrence of issues.
- Prevent legal penalties and fines: these can arise from persistent non-compliance.
What are our top 10 audit recommendations?
Platinum audit status is a great selling tool, and whilst there are many potential areas for non-compliances, we have identified 10 key areas you can focus on to ensure you avoid the most common pitfalls that can lead to repetitive fails on audits.
1. Application form issues
- Application forms must align to best practice standards (they need to be signed and dated by the worker – and if they have been sent electronically the source from which they have been sent and received must be evidence and/or the electronic signature verified by a 3rd party (e.g. Adobe).
- Application forms must also include legal and regulatory declarations including permission to perform DBS update checks, NMC/GMC/HCPC checks, consent to share information etc.
2. CV formatting issues
- CVs not dated. They have to be updated annually so it’s critical that they are dated to show when the candidate first registered and when they were last updated.
- Date of employment on CVs not being in the correct format. These must be in month/year format, e.g. 12/2021-08/2023 and not just year e.g. 2021-2023. This enables gaps in employment to be identified and explored thoroughly and documented.
3. Referencing issues
- References not matching the dates on the CV (all dates must align).
- References not being received from a professional/business email address (references cannot be sent from a personal email address such as BTInternet or Gmail) – see the NHSE standard for more details.
4. Interview issues
- Interviews not being conducted by interviewers with the required training and experience (interviewers have a background that aligns with the grade/band of the worker, e.g. if the worker is a registered nurse, the interviewer must be a more senior registered nurse from the same speciality.
- Interview records must be documented correctly (i.e. written clinical questions asked and answers given).
- Interview forms not signed (they must be signed by both the candidate and the interviewer).
5. Skills check assessment issues
- No evidence of skills checks (all staff assigned to the NHS need to demonstrate their skills and abilities through completion of a skills checklist appropriate to the speciality area that they will be assigned to work in. This must be completed and assessed to ensure they are appropriate to work in that area of specialism).
6. Mandatory training issues
- Certificates presented from multiple training companies for each worker. Every training certificate must be verified as authentic and evidence to show that the training is aligned to UKCSTF. Ideally there will be a copy of the declaration of alignment from each training company. The best way is to use an established training company that is mapped and aligned to UKCSTF.
7. Performance checks and appraisal issues
- Performance needs to be checked formally within the first 6 months and thereafter annually (a documented performance and welfare check must be present in candidate’s file and be dated to show it took place within the first 6 months).
- After the 6 month performance check, appraisals must be conducted annually (evidence that an appraisal has been conducted by a trained and experienced appraiser with relevant qualifications and seniority must be included e.g. an appraisal for a registered nurse must be undertaken by a registered nurse who is senior to the candidate).
- The employing authority must be informed of the date of the last appraisal and the date that has been scheduled for the next appraisal (this must be evidenced in writing in the candidate file).
8. Induction, placement and end of placement checklists issues
- There should be a checklist that is completed and sent to the participating authority before the start of each assignment (the date that this was sent and evidence that it was received must be present in the candidate’s file unless the participating authority does not require a pre-placement checklist in which case you must be able to evidence this in writing).
- In all cases, an end of placement checklist is required once the assignment is completed.
- Evidence to show that induction was completed for all workers (this must be dated within 2 weeks of the assignment start date).
- Each candidate must have been issued with Key Information Document (KID) for each assignment (and the agency must be able to provide evidence that this has been shared with the candidate).
- Evidence that the candidate has been provided with an ID badge must be kept on file (including a dated declaration from the worker that they have received this).
9. Original document issues
- All original documents (e.g. ID documents, proof of address, proof of right to work in the UK, qualification certificates, DBS by 3rd party etc) must be checked as part of the compliance process (each one must be copied, time/date stamped and signed to confirm “original seen” by the person who conducted the check).
- Original documents obtained to prove the candidate’s identity must be verified using an electronic scanner.
- Each candidate’s identity must be checked using a certified IDSP (identity service provider) and evidence of this check must be available for audit.
10. Occupational health screening issues
- All agencies must use a SEQOHS accredited occupational health provider to conduct work health assessments and provide a fitness to work certificate (which must evidence the results of serology/immunisation reports).
If you feel that you could benefit from help with your compliance, ACI provides an ethical and tailored service at affordable prices. They’re not only independent auditors – they are specialists in the field of healthcare compliance and training, and provide a consultative service to help you get it right with minimal pain and drama!
Why not call Kate or Darren on 01291 624451, or email [email protected] and we will be pleased to discuss how we can support you.
