Michael Robinson, Associate Director Integrated Governance & Policy. Dr Colin Mercer, Clinical Director Clinical Governance and Safety

Transcription

1 NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 15(ii) Date of Meeting: 27 th May 2016 TITLE OF REPORT: AUTHOR: PRESENTED : PURPOSE OF PAPER: (Linking to Strategic Objectives) RECOMMENDATION TO THE BOARD: (Please be clear if decision required, or for noting) COMMITTEES/GROUPS PREVIOUSLY CONSULTED: Quality & Safety Committee Minutes Michael Robinson, Associate Director Integrated Governance & Policy Dr Colin Mercer, Clinical Director Clinical Governance and Safety For the Board to receive and review the minutes of the Quality and Safety Committee meeting held on 13 th April The Board is asked to approve the Minutes. Quality & Safety Committee REVIEW OF CONFLICTS OF INTEREST: VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT: Conflicts of Interest are reviewed at every meeting. Patient views are not specifically sought as part of this report. EQUALITY IMPACT ASSESSMENT (EIA) COMPLETED & OUTCOME OF ASSESSMENT: EIA and an assessment is not considered necessary for the report. 1

2 QUALITY & SAFETY COMMITTEE Wednesday 13 th April am 11am Present: Colin Mercer Clinical Director, Governance & Safety(Chair)(CM) Michael Robinson Associate Director, Governance & Policy(MR) Jen Riley Senior Commissioning Manager(JR) Grace Birch Head of Informatics(GB) Nicola Onley Communication & Engagement Manager(NO) Lynda Helsby Associate Director of Primary Care & Health Improvement(LHe) Bob Hunt GP Clinical lead for Mental Health In attendance: Joanne Meaney, Corporate support (JM) Diane Sankey, Governance, Risk & Complaints Manager (DS) Kaleel Khan, Designated Adults Safeguarding Manager (KK) Pam Jones. Associate Director Designated Nurse (PJ) Louise Coulson, Quality & Safety Support Officer (LC) 1 Apologies for Absence/Introductions Apologies for absence were received from Ben Woodhouse, Gerry Donnellan, Steven Greenhalgh, John Tabor, Mary Moore, Suzanne Mackie Chair informed the Committee that Gerry Donnellan would be stepping down from his lay member position and wished to thank him for a great contribution to patient focus. Chair introduced and welcomed Bob Hunt who is newly appointed as the Clinical lead for mental health. The CCG are now the lead commissioner for mental health and Bob will be able to provide parity of physical and mental health and maintain focus on mental health quality issues and serious incidents. Chair introduced and welcomed Louise Coulson who has recently taken up post as Quality and Safety Support Officer within the Clinical Governance directorate. 2 Agenda papers Chair made a plea to members to provide agenda papers by the requested timescale in order that the final agenda papers can be produced and circulated one week in advance of the meeting. 3 Declarations of Interest None declared 4 Minutes of the previous meeting The minutes of 10 th March 2106 were approved as a correct record 1

3 5 Matters Arising /Actions (refer to action sheet) - NEWT LHe reported that primary care do not purchase this booklet for practices and recognised that the issue raised was an isolated issue and that practices and nursing/care homes are able to contact the medicines optimisation team. The team access the NEWT online to give advice to practices. The CCG support practices by identifying special products through quarterly reviews of specials and offer alternatives - messages added to scriptswitch highlighting alternative options to unlicensed products - encouraging practices to contact the team for advice (often patients with swallowing issues require more than just a drug change, the review includes challenging prescribers if the product is required, risk and benefits of the medication and the combinations the practice prescribes e.g. BP medication without BP review, medication prescribed without knowledge of indication, lack of need (urinary urgency medication for incontinent patients). - Bolton FT Quality Assurance Governance report MR reported that the report key lines of enquiry now include an explanation against the categorised colours; - Infection Prevention MR confirmed that this has been added to the agenda for the next IPCC meeting and that he will also add CQUIN antimicrobial prescribing; - Gathering data from high risk providers and a full report at the May meeting and Board, triangulate with risk register MR 6 Terms of Reference Members received a copy of the updated Terms of Reference highlighting the amended items In relation to medicines safety it was agreed that this should be added and LHe would discuss this with the team. Research and Innovation - the Committee acknowledged that this requires review as there has not been any focus. Chair requested that assurance of the ethics approval process within providers should be part of this. Action Members approved the updated Terms of Reference Annual Report This draft document is a reflection of the work undertaken during the last 12 months and gives the Committee an ability to set its agenda and work plan going forward. The final Annual Report will be presented to the CCG Board in July. Action members are requested to feedback any comments to MR Minutes of Other Meetings to Note and Associated Actions Bolton Integrated Safeguarding Committee PJ reported that the Committee are widening representation from providers. All 2

4 7.2 BFT Quality Assurance Committee Divisional report Extensive report received for information In relation to the Community report, CQC lines of enquiry red rating, MR reported that the Trust were not able to provide timely evidence to CQC and this is the reason for the red rating GMW Quality Monitoring notes Received for information. MR reported now that Bolton are lead commissioner for mental health services, a Quality and Performance Group with GMW will be established. The CCG will be responsible for reviewing and performance managing serious incidents and will seek assurance in respect of evidence against 28 day prescribing. NWAS Commissioning Quality Group Received for information. The main issues discussed were workforce and training. The training and sickness issues have been addressed and staffing is being mitigated with overseas recruitment. NWAS is due to have a CQC inspection and the CCG was asked for input. Personalised Care 8 Patient Experience/Engagement update NO reported that the new website and intranet had been launched and the feedback had been good and she will be attending a number of key meetings to promote this. NO stated that this is not a finished product but will require further content. The communication team are working up campaign material in relation to A&E and are looking to display signage at both entrances to hospital which has CCG and Trust Executive approval. The next major campaign with be focussed on health checks with Dave Spikey, local Bolton Comedian fronting the campaign through radio and poster material. Committee highlighted the readiness of primary care in managing this workload. JR informed members that has not been any adverse reaction to the recent podiatry consultation. 9 Healthwatch update In SG s absence MR updated some issues in behalf of Healthwatch : 3

5 - GP services not wanting to register as a result of boundary issues it was agreed that this issue be raised with Kath Oddi in the primary care directorate - Service user deaths in mental health and if the deceased had any relationship with mental health services MR to action and understand the issue in more detail LHe MR 10 Complaints Policy The final draft Complaints Policy was received following consultation with Healthwatch Members approved the final draft Safety 11 Safeguarding update Update paper received for information. MIAA action plan - PJ reported that assurance that provider organisations are compliant is required by providing evidence against standards and she will be seeking this evidence from Bolton FT. Service specification PJ reported that Bolton FT wish to have their own specification and not be included in the health economy wide service specification PJ reported that she had met with Bridgewater, the provider of 5-19 year old service, which is commissioned by public health and had agreed a pragmatic approach. GMW PJ reported that audit against safeguarding issues will be undertaken. 12 Four Seasons NH update The report detailed the current position. There is a slow improving picture and a strategy group meetings are considering sustainability of improvements. Committee were concerned in relation to sustainability and the timelines to improve. 13 Update on Serious Incidents and Never events The report provided information in relation to on-going serious incidents. There has been a recent reported never event in ophthalmology in relation to anaesthetic block into the wrong eye. It was highlighted that the management of pressure ulcer incidents has lapsed recently and the CCG will continue to work with Trust to resolve this. The harm free care panels are functioning well within the FT but the RCAs being forwarded to the CCG is inconsistent. Committee discussed and agreed to write to the Ophthalmology clinical lead regarding the recent never event and request to meet to discuss further and seek assurance and CM/MR to raise with the Trust Medical MR/CM 4

6 Director when they next meet. 14 Risk register Quality Risks DS tabled the report and stated that there are no new quality risks. The 18 week MSA breach risks have been increased Members requested to comment on the report outside of the meeting All Effectiveness 15 Staffing update Gathering data from high risk providers and a full report will be provided at the May meeting MM 16 Quality Matrix Infection control the Trust have not met the target of 19, currently at 25 for the year Infection Prevention Committee have acknowledged the achievement and work done as a health economy. Target remains the same for next year. MRSA there have been a number of reported cases against a zero tolerance target and initiatives implemented to address this. Serious incident process reporting better, inclusive of pressure ulcers, but the CCG is keen to see a reduction of pressure ulcer prevalence. Mixed Sex Accommodation Bolton FT are an outlier in this area, breaches occur in HDU and this has been identified as an estate issue. MR confirmed that he was to discuss further with Deputy Director of Nursing. Hyper acute stroke service propose that this is now removed from the matrix. Members approved PJ reported that the safeguarding issues in relation to issues on the quality matrix will be addressed with the Trust and included in the report. 17 Nurse revalidation update All on track, first candidate to revalidate in July and future reports by exception. 18 Quality Strategy A final copy of the 3 year strategy was received for information which will be presented to the April CCG Board. The communication team will prepare a one page summary for circulation throughout the health economy. Committee noted the strategy document 19 CQUIN update 2016/17 The report detailed the final CQUINs for 2016/17 and the CCG will maintain a 5

7 focus on delivery of outcomes and KPIs. It was recognised that there had been better clinical engagement during this process. Members noted the report and acknowledged the level of detail and work presented by Sam Ball. 20 Feedback from Education event LHe reported that the overall event feedback and prescribing safety audit is being collated. Sign up to safety practices are being encouraged to sign up and the CCG have been visited by Sheffield and Derbyshire CCG to share knowledge. 10 people have been nominated to attend Patient Safety congress in July and the CCG will be sponsoring representing from GMW, Local Authority and Trust to join them. 21 Any Other Business There was no other business 22 Chairs reflection on significant decisions, actions and issues to be reported to the Governing Body - 23 Date and Time of Next Meeting Next meeting would take place on 11 th May 2016 at 9am PJ apols 6