Apologies for absence were received from Mrs P Murray; Cllr I Whyte; Mr R Burley; Dr I Mckay; Ms L Campbell; Mr D Bolton; Mr J Forrest
|
|
- Buddy McBride
- 6 years ago
- Views:
Transcription
1 LOTHIAN NHS BOARD PAPER 17 HEALTHCARE GOVERNANCE & RISK MANAGEMENT COMMITTEE Minutes of the Meeting of the Healthcare Governance and Risk Management Committee held at 9.00am on Tuesday 17 th April 2007 in the Board Room, Deaconess House, 148 Pleasance, Edinburgh. Present: Mr S Smith (in the Chair); Dr C P Swainson; Mr R Y Anderson; Dr A McCallum; Mr E Egan; Ms P Dawson; Ms R Strachan; Ms T Douglas; Dr M Winter; Ms S Gibbs; Mr J McCaffery; Ms H Tierney-Moore; Dr B Montgomery; Dr J Jenkins; Mr M Mehdi; Mr D Forbes; Ms S Lloyd; Ms J Stirton; Ms V Baker; Mrs M Anderson; Ms S Lee In Attendance: Dr C Kalman; Mr C Graham Apologies for absence were received from Mrs P Murray; Cllr I Whyte; Mr R Burley; Dr I Mckay; Ms L Campbell; Mr D Bolton; Mr J Forrest 107. Minutes of Previous Meeting The minutes of the meetings of 20 February 2007 were accepted as a correct record of the meeting subject to the following amendments:- Page 3, third paragraph under 95.4, last line should read SNOMED not SNOWMED Page 8, third line should read UNICEF not UNIFEC Page 10, final paragraph re hip fracture performance needs to be reworded Page 15, third paragraph should read children s nursing and not children nurseries The Committee also noted that in future the Information Meeting minutes/action note would be submitted to the formal committee meetings for approval Matters Arising Update on Clinical Coding (Item 95.4 from 20/02/07 minute) The Committee were informed that the six week target for discharge summary coding is currently around 60%, there were still remaining issues. There was a local backlog which was being reduced through the use of an action plan and there was a merge team addressing coding. The backlog was reducing slowly however the information was highly accurate. It was suggested that more action on wards may be required with nurses/clerical staff coding themselves. Bed statements may also be reinstated. Use of the TrakHealth system may also be made mandatory. It was also hoped that there would be a single discharge summary revised data template for documentation of discharge. There were concerns expressed about the potential for additional workload being placed onto Nurses by non-nursing duties. The Committee noted that
2 as yet there had been no proposals submitted to the partnership forum or divisional management team. It was reported that there was still teams of Clinical Coders and that they had not been disbanded. There were currently 3 teams of Coders, at the Western General Hospital, the Royal Edinburgh Hospital and St John s Hospital in Livingston. However the mechanisms used by each team were varied. It was hoped to encourage accurate local data entry. The Committee noted that there was no agreement with nurses to do this and that staff cannot be forced to do it. Committee members were informed that as an organisation it was important to know where patients are and why they are there. There needs to be agreement at ward level for this. Accountability for this is with the Director of Finance. The Committee agreed that the processes of the transition to electronic records need to be looked at again and that a written report should go to the Audit Committee, Finance and Performance Review Committee and to the next meeting of this Committee. HTM/VB 109. Other Minutes Minutes of the Primary Care Organisation Clinical Governance Operational Group held on Thursday 18 th January 2007 The Minutes were noted. There was discussion on the new CHPs/CHCPs terms of reference. The Committee felt that it was important that the meeting agendas for each CHP followed a template which could be shared consistently across Lothian including topics such as child protection, adult protection, complaints analysis and trends (quarterly), critical incidents and trends (serious ad hoc, otherwise quarterly), review of risk register (CHP/CHCP one at each meeting), effective clinical care, NHS QIS reviews and action plans, monitoring of clinical governance strategy & clinical effectiveness plans and quality assurance. The Committee were informed that there is currently a paper with the CHP subcommittee looking at standardising guidelines and agendas. It was also pointed out that representation from each CHP was expected at all future Healthcare Governance and Risk Management Committee meetings. There was discussion on the Quality Assessment Visits. The Committee were reassured that key risk issues for NHS Lothian were being identified and addressed, specifically the issue of vaccine fridges. At present it was felt that this issue was being addressed and a recall was not required. It was reported that in Lothian there has always been a good return of vaccine logging and there had been two incidents over the past year where out of date vaccines had been given. One incident was actually a transcription error. 2
3 The Committee noted that current practice is more than meets the requirements under the SEHD paper and agreed that a paper expanding on this should come to the next meeting. AKM The Committee also agreed the CHP General Managers would be written to regarding standardisation of agendas. CPS The Committee also discussed the issues around diary pressure of CHP representatives, how CHPs could be better supported and how statutory subcommittees could best be approached. There were also concerns raised about the importance of health and safety in the CHPs, this was especially concerning as it was likely that there would be a Health and Safety Executive (HSE) review of NHS Lothian shortly. The Committee were informed that the Edinburgh CHP would be looking at risk management and managing health and safety at their next half away day. The Committee agreed that this issue should be taken back to the Partnership Forum. EE Minutes of the University Hospitals Division Clinical Governance & Risk Management Committee held on Friday 9th February 2007 The Minutes were noted. The Committee acknowledged the continuing rollout of the HELICS method in critical care and also the cleaning schedules in particular for curtain changing. It was also noted that these Committee meetings were being used to pull out problems which remain on the agenda until they are dealt with. There was discussion around end of life care and appropriate support. The Committee noted that support from the palliative care team was not always asked for Minutes of the Health & Safety Committee held on Thursday 11 th January 2007 The Minutes of the Committee s second meeting were noted. The importance of attendance at the health and safety meetings was emphasised. There was discussion on incidents of violence and aggression, the Committee noted concerns that although there was a zero tolerance approach to violence and aggression towards staff, staff still felt threatened by it. There were also concerns expressed about the lack of staff training in the management of aggression. It was noted that there were also concerns coming from staff trainers at the number of courses that were having to be cancelled due to lack of numbers attending sessions. It was suggested that perhaps better use of bank and agency staff was required to avoid staff missing training. There was discussion on the potential of e-learning which 3
4 was currently being used, as a short term interim policy until the end of 2008, to provide manual handling training. The Committee felt that the protocols for the training budget may need to be looked at to establish how best to use the funding. There was discussion on recording of incidents. It was agreed that a one streamlined reporting system would be useful and the Committee asked if it would be possible to establish why incidents took place or a top 10 list of incidents and hotspot areas. The Committee also suggested that it may be worthwhile looking into training on a larger scale (scotland wide) perhaps in conjunction with other health boards and the SEHD. JTM 110. Workplan Revised Terms of Reference The Committee noted the changes to the terms of reference to include attendance of representatives from CHPs and CHCPs. It was noted that Information Governance had been omitted and that this should be added in under the functions of the committee section. CPS Committee Annual Report to the Board The Committee noted this end of term report to the parent Board. The report has been drawn from the Committee minutes for the previous year. Expansion of Risk Management was required and showing learning from complaints may be useful. It was noted that this report was to go to the May Board meeting and that any changes or improvements should be ed directly to the Medical Director by the 11 th May CPS 111. Clinical Effectiveness Occupational Health Annual Clinical Governance Plan & Report The Chairman welcomed Dr C Kalman to the meeting. The Committee were informed that before 2005 there was no clinical governance occupational health in NHS Lothian and that physiotherapy was now recognised by the Health and Safety Executive (HSE). The current service is under resourced and there is no physiotherapy currently at St John s Hospital. The Committee noted that the proposed service would be run on a spend to save basis with every pound spent return one to six pounds back. It was also stated that the agreed actions for the programme were now complete. 4
5 There were concerns raised about attendance at work and the time spent waiting for occupational health referrals. It was noted that this would hopefully reduce once a single system was established but ultimately delays came back to resource issues. The Committee noted that there was funding agreed for one staff grade starting from June The amount of funding secured for the programme for was 250k. With the funding secured it was hoped to enhance nurse referring and run a four year programme instead of the initially proposed three years. It was suggested that a NHS Lothian risk register be developed and it was agreed that the spend to save financial model was correct. There was discussion on the Monitoring of Complaints and Review of Critical Incidents (Section 8 of the report) The Committee found this an interesting area but it was unclear who would take this forward and monitor it. The Committee were reminded that the NHS Lothian occupational health service chose not to be aligned with fife or Lanarkshire but does provide some services to other health boards and the Scottish Executive. There was discussion on workplace assessments and staff counseling services The Committee suggested that Dr Kalman should submit future reports to the Finance and Performance Review Committee with clear recommendations and emphasising the spend to save approach. It was agreed that a copy of this section of the minute be forwarded to the Chair of Finance and Performance Review Committee and the Director of Finance. CG Health & Inequality Update The report updating the Committee on actions taken to address health inequalities in the past year was noted. There was discussion about the effectiveness of health impact assessments and quality improvement. The Committee noted that the impact assessments had been used to pick up changes for 1 year now and that a random sample of questions asked had been viewed. Concerns were then raised over child protection in the traveling communities and the difficulties with processing and keeping of records. Concerns were also expressed about current child dietician waiting times and GP child referrals to Weight Watchers. The Committee noted that the childhood obesity framework would be going to the Board in May or July. There was also discussion about risk management for staff working with traveling communities. The Committee asked for an additional column to be added to the report for recording of evidence based outcomes and clear evidence of money equaling results. Also it was noted that there was no mention of deaf/hard of hearing in the action plan. AKM 5
6 111.3 Clinical Documentation Group - Final draft action plan The Committee were informed that this was still to be seen as a work in progress as the Clinical Documentation Group had not met since the last meeting of this Committee. The Committee agreed that this should come back to the Committee when finalised. BM 112. Quality Assurance Progress Towards Staff Governance Standard The Committee noted that the report showed very well the progress being made in Lothian. It was also noted that NHS Lothian was the only board in Scotland where the Partnership Forum has the Board s authority to approve employment policies. There was discussion on staff personal development plans (PDPs) The current level of staff with PDPs is around 70% The Committee were informed that currently there was no agreed general policy on alcohol testing of staff. However some staff were taking up alcohol counselling as an alternative to disciplinary action. The policy on MHRA was nearly agreed. The Committee discussed sickness, absence and staff morale. It was noted that an independent survey or examination of sickness/absence would be useful. The Committee agreed that this should be taken to the Staff Governance Committee (SGC). EE Update on Radiation Protection Committee The Committee noted that the Radiation Protection Committee was now up and running it has met three times and continues to operate satisfactorily. It was noted that there was concern about the continuing absence of an RSAC certificate holder at the Royal Hospital for Sick Children (RHSC). This was a breach of statutory requirement but there was an action plan in place. However an inspection would pick this up as non statutory compliance Cervical Screening Programme Annual Report The Committee found the report self explanatory and it was noted. 6
7 112.4 NHS Boards' Overall Strategy for Preparedness and Response to Pandemic Influenza Report The Committee discussed the report. There were concerns over the preparedness and staff training. The Committee asked for a formal response to the training issues. JTM 113. Risk Management Clinical Governance Register The Committee noted that there were several incomplete items in the report and asked that these items were addressed by the responsible Directors. AKM/JM Healthcare Associated Infection (HAIs) The Committee noted the report. There was discussion about recent presentations on decontamination of endoscopy and dental instruments. The Committee discussed how communication and risk assessment could be improved. The Committee were concerned that this topic was again back at the table. The Committee needs to see evidence of things being done, actions taken and improvements implemented. AKM was requested to submit an action plan to the next HG&RM Committee. AKM There was further discussion on the process with the decontamination group and the non-compliance situation in NHS dentistry. The Committee were informed that HAIs would be discussed at the nonexecutive board members education session scheduled for 25 th April The session would be looking at what HAIs are, the key issues for Lothian and how they are being addressed. THE CHAIRMAN LEFT THE MEETING AT THIS POINT. MR E EGAN AGREED TO CHAIR THE REST OF THE MEETING. 7
8 113.3 Update of Jarvie Report The Report was noted. The Committee expressed appreciation to Ann Jarvie for her input to the report. The Committee were informed that the Liberton incident was now complete. A person sensitive approach to care was now being developed. There was discussion about the potential for a non-executive director to take on a older peoples champion role. Chair to raise this with non-executives. SHS The Committee were informed that at a recent Protection Of Vulnerable Adults (POVA) Training session there had been a poor turnout from staff that would have probably benefited most from the training Clinical Governance with Scottish Ambulance Service The Committee agreed to defer this paper to a future meeting Quarterly Report of Critical Incidents and Trends The Committee noted the reports showing incident statistics from July September 2006 and October to December The Committee were advised that the statistics were currently being compiled using two incident reporting systems, SAFECODE and DATIX. There was discussion on the reports, the incident reporting schedule and template (appendix 3), the not stated incidents and their follow up and how better completion of forms could be encouraged. The Committee were also informed of the recent Health Department Letter (HDL)(2007)13, which deals with prevention of falls in older people. The Committee would like to see incidents of HAIs and medication related incidents being included in the report. The Committee also asked for a report on the recent work done and whether this fits in with the recent HDL. SG Analysis of Litigation and Claims The report was noted. The Committee discussed the timescale for settling on non clinical claims and there was discussion on the legal standing of negligence in relation to MHRA claims. The Committee noted that the claim levels in England were much greater than in Scotland Child Protection - Joint Inspection of Child Protection Arrangements The Committee noted the Action Plans. 8
9 The Committee were informed that there was now updated version of the East Lothian Action Plan and both the Midlothian Action Plans. These updated Action Plans would be circulated via for comments. HTM The Committee noted that the Inspectorate for Midlothian having asked for the Action Plan seemed now not to want it. It was noted that a number of areas in the Midlothian Action Plan required rewriting and a number of costs needs to be quantified. The Committee were informed that currently there was no enough child protection advisers in place and only 5 had been appointed. There was discussion on information for children on the Children Charter information for practitioners on children s rights. The Committee felt that it was important that GPs were being engaged. There was discussion about nursing in the community and how health visitors in certain parts of Lothian were under more pressure than others. Perception of risk was also mentioned. It was felt that a consistent approach to risk assessing according to health was needed. CHP and pharmacist responsibility in identifying risk was also raised Items for Information Update on dates for Business Continuity and Training Meetings It was noted that this would be an item for discussion at the Board Away Day on 25 th April The Scottish Patient Safety Alliance The Committee agreed to defer this paper to a future meeting Maternity Services Liaison Committee Annual Report 06/07 The Annual Report was noted Education for Scotland Themes and Issues The circulated document was noted Any Other Competent Business Topics of Future Information Meetings The Committee were informed of the suggested core topics for future information meetings, these were Child Protection, NHS QIS Reviews, Business Continuity and Health & Safety Reports. The Committee also agreed not to cancel the July Information Meeting. Other topics to be covered at future meetings included patient safety alliance, modernising medical careers and inequalities in health. The Committee also suggested talks on finance, other aspects of child health community paediatrics, how CHPs hosting services pan Lothian carry out Risk Governance and the Clinical Governance and Risk Management of the transfer of patients from the State 9
10 Hospital to NHS Lothian. The Committee noted that there would be a suggested plan for 2008 meetings outlined at the November 2007 information meeting. PD 116. Date of Next Meetings Tuesday 15 th May 2007 from 9.00 to Full Day Quality Improvement conference at Our Dynamic Earth Tuesday 19 th June 2007, 9.30am, Board Room, Deaconess House 10
ST ROQUE BOARD ROOM, ASTLEY AINSLIE HOSPITAL
PAPER 5.1 NHS LOTHIAN HEALTHCARE GOVERNANCE AND RISK MANAGEMENT COMMITTEE DRAFT v2 MINUTES OF MEETING of PRIMARY AND COMMUNITY SERVICES HEALTHCARE GOVERNANCE and RISK MANAGEMENT OPERATIONAL GROUP DATE:
More informationInternal Audit. Health and Safety Governance. November Report Assessment
November 2015 Report Assessment G G G A G This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted
More informationNOTES OF THE MEETING HELD ON TUESDAY 23 rd MARCH 2010 AT 10AM IN THE BOARD ROOM, BECKFORD STREET, HAMILTON
DRAFT NHS LANARKSHIRE EQUALITY, DIVERSITY AND SPIRITUALITY GOVERNANCE COMMITTEE NOTES OF THE MEETING HELD ON TUESDAY 23 rd MARCH 2010 AT 10AM IN THE BOARD ROOM, BECKFORD STREET, HAMILTON Present: In Attendance:
More informationEDINBURGH CHP HEALTH & SAFETY COMMITTEE Paper
EDINBURGH CHP HEALTH & SAFETY COMMITTEE Paper 5.2.3. Minutes of the meeting held on Wednesday 14 September 2011 in the Boardroom, St Roque, Astley Ainslie Hospital. Present: Robert Aitken Acting General
More informationLOCAL SUPERVISING AUTHORITY ANNUAL REPORT
LOCAL SUPERVISING AUTHORITY ANNUAL REPORT 2006 Table of Contents 1.0 PURPOSE OF REPORT...1 2.0 ORGANISATION OF SUPERVISION OF MIDWIVES...1 2.1 Appointment of Supervisor of Midwives...1 2.2 Resignation/De-Selection
More informationIntensive Psychiatric Care Units
NHS Lothian St John s Hospital, Livingston Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We
More informationWELSH AMBULANCE SERVICES NHS TRUST
APPENDIX DRAFT WELSH AMBULANCE SERVICES NHS TRUST MINUTES OF THE OPEN MEETING OF THE QUALITY, SAFETY AND GOVERNANCE COMMITTEE HELD ON TUESDAY 10 MAY 2011 AT VANTAGE POINT HOUSE, BOARD ROOM, HQ, ST ASAPH
More informationPATIENT SAFETY, QUALITY & RISK COMMITTEE
PATIENT SAFETY, QUALITY & RISK COMMITTEE Minutes of the Patient Safety, Quality & Risk Committee Thursday, 6 th March 2014 West Herts Meeting Room, Willow House Watford General Hospital Chair: Mahdi Hasan
More informationWELSH AMBULANCE SERVICES NHS TRUST
APPENDIX 1 DRAFT WELSH AMBULANCE SERVICES NHS TRUST MINUTES OF THE OPEN MEETING OF THE QUALITY, SAFETY AND GOVERNANCE COMMITTEE HELD ON TUESDAY 28 JUNE 2011 AT VANTAGE POINT HOUSE, HQ, ST ASAPH AND CONWY
More informationGP and Lead Clinician, Respiratory MCN (chair) Respiratory Care Facilitator, WL CHCP
LOTHIAN RESPIRATORY MCN CORE GROUP Minutes of the meeting of Tuesday, 14 May 2013, 2.00pm to 3.30pm, Seminar Room 3, Chancellor s Building, Royal Infirmary of Edinburgh Present Dr Ninian Hewitt Ms Shena
More informationIndependent Living Services - ILS Ayrshire Housing Support Service Cumbrae House 15A Skye Road Prestwick KA9 2TA
Independent Living Services - ILS Ayrshire Housing Support Service Cumbrae House 15A Skye Road Prestwick KA9 2TA Inspected by: Michelle Deans Type of inspection: Announced (Short Notice) Inspection completed
More informationSample CHO Primary Care Division Quality and Safety Committee. Terms of Reference
DRAFT TITLE: Sample CHO Primary Care Division Quality and Safety Committee Terms of Reference AUTHOR: [insert details] APPROVED BY: [insert details] REFERENCE NO: [insert details] REVISION NO: [insert
More informationLincolnshire County Council Officers: Professor Derek Ward (Director of Public Health) and Sally Savage (Chief Commissioning Officer)
Agenda Item 5 1 LINCOLNSHIRE HEALTH AND WELLBEING BOARD PRESENT: COUNCILLOR MRS S WOOLLEY (CHAIRMAN) Lincolnshire County Council: Councillors C N Worth (Executive Councillor Culture and Emergency Services),
More informationGREATER GLASGOW AND CLYDE NHS BOARD
ACF(M)10/02 Minutes: 11-20 GREATER GLASGOW AND CLYDE NHS BOARD Minutes of a Meeting of the Area Clinical Forum held in the Conference Room, Dalian House 350 St Vincent Street, Glasgow on Thursday 1 April
More informationWorking with you to make Highland the healthy place to be
HIGHLAND NHS BOARD Assynt House Beechwood Park Inverness IV2 3HG Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.nhshighland.scot.nhs.uk Highland NHS
More informationJob Description NHS Dumfries and Galloway Occupational Health and Safety Services
Job Description NHS Dumfries and Galloway Occupational Health and Safety Services Part Time Occupational Health Physician 2 sessions (0.2wte) 8 hours per week 1. JOB IDENTIFICATION Job Title: Part time
More informationHomecare Support Support Service Care at Home 152a Lower Granton Road Edinburgh EH5 1EY
Homecare Support Support Service Care at Home 152a Lower Granton Road Edinburgh EH5 1EY Type of inspection: Unannounced Inspection completed on: 19 December 2014 Contents Page No Summary 3 1 About the
More informationInspection Report. Royal Infirmary of Edinburgh. NHS Lothian 18 and 19 January February 2010
Inspection Report Royal Infirmary of Edinburgh NHS Lothian 18 and 19 January 2010 2 February 2010 qüé=eé~äíüå~êé=båîáêçåãéåí=fåëééåíçê~íé=áë=~=é~êí=çñ=kep=nì~äáíó=fãéêçîéãéåí=påçíä~åç= The Healthcare Environment
More informationCLINICAL GOVERNANCE STRATEGY
CLINICAL GOVERNANCE STRATEGY Clinical is the corporate responsibility for the quality of care Date: November 2014 2017 Last review date: November 2014 Next Formal Review: November 2017 Implementation Date:
More informationLearning from adverse events. Learning and improvement summary
Learning from adverse events Learning and improvement summary November 2014 Healthcare Improvement Scotland 2014 Published November 2014 You can copy or reproduce the information in this document for use
More informationNHS Borders. Intensive Psychiatric Care Units
NHS Borders Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009 NHS Quality Improvement Scotland (NHS QIS) is committed to equality and diversity. We have assessed the performance
More informationHealthcare Governance Committee Monday 5 June 2017 at 9.30am Room 2, Training Centre, Ayrshire Central Hospital
Healthcare Governance Committee Monday 5 June 2017 at 9.30am Room 2, Training Centre, Ayrshire Central Hospital Present: Ms Claire Gilmore (Chair) Non-Executives: Mrs Margaret Anderson Dr Janet McKay Miss
More informationNHS LANARKSHIRE & NHS GREATER GLASGOW & CLYDE Paper No 06/67 CHP SOUTH OPERATING MANAGEMENT (PERFORMANCE MANAGEMENT) COMMITTEE
NHS LANARKSHIRE & NHS GREATER GLASGOW & CLYDE Paper No 06/67 CHP SOUTH OPERATING MANAGEMENT (PERFORMANCE MANAGEMENT) COMMITTEE Note of a meeting held on Monday 10 th July 2006 at 9.30 am in the Committee
More informationNon Executive Director. Named Professional for Safeguarding and Welfare of Children. Interim Chief Executive Officer
WELSH AMBULANCE SERVICES NHS TRUST Minutes of a meeting of the Clinical Governance Committee of the Welsh Ambulance Services NHS Trust held on 13 May 2010 at HQ, St Asaph, Vantage Point House, Cwmbran
More informationSOUTH EAST CHCP PROFESSIONAL EXECUTIVE GROUP MINUTE OF MEETING HELD ON 21 ST JANUARY 2010 AT SAMARITAN HOUSE
South East Community Health & Care Partnership (SE CHCP) 29 March 2010 Author Kevin Fellows/Sheena Morrison Paper No. 10/17 SOUTH EAST CHCP PROFESSIONAL EXECUTIVE GROUP MINUTE OF MEETING HELD ON 21 ST
More informationNHS Lothian. Local Report ~ June Out-of-Hours Emergency Dental Services
NHS Lothian Local Report ~ June 2009 Out-of-Hours Emergency Dental Services NHS Lothian Local Report ~ June 2009 Out-of-Hours Emergency Dental Services NHS Quality Improvement Scotland (NHS QIS) is committed
More informationNURSING & MIDWIFERY WORKLOAD & WORKFORCE PLANNING PROJECT RECOMMENDATIONS AND ACTION PLAN NOVEMBER 2006 UPDATE
Forma cm NHS HIGHLAND WORKLOAD AND WORKFORCE PLANNING PROJECT RECOMMENDATIONS AND ACTION PLAN NURSING & MIDWIFERY WORKLOAD & WORKFORCE PLANNING PROJECT RECOMMENDATIONS AND ACTION PLAN NHS HIGHLAND NOVEMBER
More informationIntensive Psychiatric Care Units
NHS Greater Glasgow and Clyde Leverndale Hospital, Glasgow Intensive Psychiatric Care Units Service Profile Exercise ~ November 2009 NHS Quality Improvement Scotland (NHS QIS) is committed to equality
More informationabcdefghijklm abcde abc a Health Department NHS HDL (2002)70 3 October 2002 Dear Colleague, THE MANAGEMENT OF WAITING LISTS IN NHSSCOTLAND Summary
NHS HDL (2002)70 abcdefghijklm Health Department St Andrew s House Regent Road Edinburgh EH1 3DG Dear Colleague, THE MANAGEMENT OF WAITING LISTS IN NHSSCOTLAND Summary 1. This HDL sets out an action plan
More informationReport by Mirian Morrison, Clinical Governance Development Manager
Highland NHS Board June 2011 Item 3.7 CLINICAL GOVERNANCE COMMITTEE Report by Mirian Morrison, Clinical Governance Development Manager The Board is asked to: Note that the Clinical Governance Committee
More informationNational Minimum Standards Care Homes for Older People. Sept 2016
National Minimum Standards Care Homes for Older People Sept 2016 Page 1 of 5 Contents Page Content Page No. National Minimum Standards Care Homes for Older People 3 Regulatory Context 3 Structure and Approach
More informationNORTH LANARKSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP SHADOW INTEGRATION BOARD - 7 July Kirklands Hospital, Bothwell, 7 July 2015 at 1.30 pm.
Kirklands Hospital, Bothwell, 7 July 2015 at 1.30 pm. Note of Meeting of the NORTH LANARKSHIRE HEALTH AND SOCIAL CARE PARTNERSHIP SHADOW INTEGRATION BOARD PRESENT Councillor Smith (Chair) and Councillors
More informationBOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013
Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health
More informationInternal Audit. Public Dental Service Accounts Receivable. December 2015
December 2015 Report Assessment A A A A A This report has been prepared solely for internal use as part of NHS Lothian s internal audit service. No part of this report should be made available, quoted
More informationCLINICAL GOVERNANCE STRATEGY
CLINICAL GOVERNANCE STRATEGY Clinical Governance is the corporate responsibility for the quality of care Date: March 2009-2012 Last review date: March 2011 Next Formal Review: January 2012 Implementation
More informationContract Management Framework:
Glasgow City Council Social Work Services Contract Management Framework: Overview Document April 2015 For copies or more information contact: Social Work Service Modernisation SW_ContractManagement@sw.glasgow.gov.uk
More informationHealthy lives, healthy people: consultation on the funding and commissioning routes for public health
Healthy lives, healthy people: consultation on the funding and commissioning routes for public health December 2010 The coalition Government published Healthy Lives, Health people: consultation on the
More informationStrategic Leadership Team
Strategic Leadership Team Who s Who 2015 The Strategic Leadership Team The Strategic Leadership Team (SLT) came together in April 2015 and now meets monthly, bringing together leaders from across North
More informationBorders NHS Board Clinical Governance
Borders NHS Board Clinical Governance Minutes of a meeting of the Borders NHS Board s Clinical Governance Committee held at 2.30 pm. on Wednesday 8 th September 2010 in the Boardroom, Newstead Present
More informationNHS Borders. Local Report ~ November Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services
NHS Borders Local Report ~ November 2009 Clinical Governance & Risk Management: Achieving safe, effective, patient-focused care and services NHS Borders Local Report ~ November 2009 Clinical Governance
More informationCONTROLLED DOCUMENT. All Managers. All Employees. Page 1 of 30. Health and Safety Policy Issued: 26/01/2017
CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Health and Safety Policy Policy Health and Safety Policy covering scope and responsibilities for health and safety in UHB
More informationShaw Community Services - Edinburgh Support Service Care at Home Unit 5 Newington Business Centre Dalkeith Road Mews Edinburgh EH16 5DU Telephone:
Shaw Community Services - Edinburgh Support Service Care at Home Unit 5 Newington Business Centre Dalkeith Road Mews Edinburgh EH16 5DU Telephone: 01316629226 Inspected by: David Todd Type of inspection:
More informationApologies were received from Linda Boyd, Lesley Cantell, Dan Doherty, Elaine McFadden, Linda Mair, Sinclair Molloy and Marlene Murty.
HEALTH, SAFETY & WELLBEING COMMITTEE Friday 18 March 2011 Board Room, Biggart Hospital, Prestwick Present: Dr Wai-yin Hatton, (Co-Chair) (In the Chair) Mr S Donnelly, Partnership Facilitator (Co-Chair)
More informationSWAG Scottish Workforce & Staff Governance Committee
Scottish Workforce & Staff Governance Committee Friday 26 June 2009 Conference Room C, D & E, St Andrew s House Present: In attendance: Apologies: Ingrid Clayden SGHD (Chair) Michael Fuller Unite John
More informationSCOTTISH BORDERS HEALTH & SOCIAL CARE INTEGRATED JOINT BOARD UPDATE ON THE DRAFT COMMISSIONING & IMPLEMENTATION PLAN
Appendix-2016-59 Borders NHS Board SCOTTISH BORDERS HEALTH & SOCIAL CARE INTEGRATED JOINT BOARD UPDATE ON THE DRAFT COMMISSIONING & IMPLEMENTATION PLAN Aim To bring to the Board s attention the Scottish
More informationGREATER GLASGOW NHS BOARD
ACF(M)02/04 Minutes: 25-35 GREATER GLASGOW NHS BOARD Minutes of a Meeting of the Area Clinical Forum held in Board Room 2, Dalian House 350 St Vincent Street, Glasgow on Monday 11 November 2002 at 2.00
More informationApologies for absence were noted from Ms Claire Dobson, Dr I Gourley, Dr J Kennedy, Professor S McLean, Mr I Mohammed.
CONFIRMED MINUTES OF THE MEETING OF THE FIFE DRUGS AND THERAPEUTICS COMMITTEE HELD AT 12.30PM ON WEDNESDAY 4 OCTOBER 2017 IN MEETING ROOM 2, WARD 6, VICTORIA HOSPITAL, KIRKCALDY. Present: Dr Frances Elliot
More informationEMPLOYEE HEALTH AND WELLBEING STRATEGY
EMPLOYEE HEALTH AND WELLBEING STRATEGY 2015-2018 Our community, we care, you matter... Document prepared by: Head of HR Services Version Number: Review Date: September 2018 Employee Health and Wellbeing
More informationThe Royal Wolverhampton NHS Trust
The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 25th July 2016 Title: Executive Summary: Action Requested: Author: Contact Details: Resource Implications: Equality and Diversity Assessment
More informationLothian RESPIRATORY MCN CORE GROUP Wednesday, 17 th September 2.00pm to 3.30pm The Chancellor s Building Seminar room 6, RIE
Lothian RESPIRATORY MCN CORE GROUP Wednesday, 17 th September 2.00pm to 3.30pm The Chancellor s Building Seminar room 6, RIE 1. Introduction and apologies for absence Present: Dr Ninian Hewitt - GP and
More informationUnannounced Follow-up Inspection Report: Independent Healthcare
Unannounced Follow-up Inspection Report: Independent Healthcare St Vincent s Hospice St Vincent s Hospice Limited 28 www.healthcareimprovementscotland.org Healthcare Improvement Scotland is committed to
More informationMr P K Corsar, Non Executive Director
Lanarkshire NHS Board 14 Beckford Street Hamilton ML3 0TA Telephone 01698 281313 Fax 01698 423134 www.nhslanarkshire.org.uk Meeting of Lanarkshire NHS Board, Wednesday 27 May 2009, at 9.30 am in the Board
More informationGP and Lead Clinician, Respiratory MCN (chair) Respiratory Care Facilitator, WL CHCP
LOTHIAN RESPIRATORY MCN CORE GROUP Minutes of the meeting of Wednesday 18 December 2013 in Seminar Room 6, Chancellor s Building, Royal Infirmary of Edinburgh Present Dr Ninian Hewitt Ms Shena Brown Ms
More information[The section is subject to the publication of Scottish Government Guidance and ongoing discussions between the Parties]
7 Clinical and Care Governance [The section is subject to the publication of Scottish Government Guidance and ongoing discussions between the Parties] 7.1 Introduction NHS Lothian and the Council have
More informationNHS Clinical Governance Annual Report 2010/2011
NHS Board Meeting 22 June 2011 Paper 3 NHS Board Meeting Wednesday 22 June 2011 Subject: Purpose: Recommendation: NHS Clinical Governance Annual Report 2010/2011 To provide a report containing the key
More informationHealthwatch Dudley Board Meeting in Public Tuesday, 24 January 2017 at 6.00 pm Savoy Centre, Northfield Rd, Netherton, DY2 9ES
Attendees Healthwatch Dudley Board Meeting in Public Tuesday, 24 January 2017 at 6.00 pm Savoy Centre, Northfield Rd, Netherton, DY2 9ES Name Pam Bradbury PB (Chair) Jayne Emery JE (Chief Officer) Sally
More informationNHS GRAMPIAN Infection Control Committee. Minutes from meeting held on 10 July 2014 The Conference Room, Aberdeen Maternity Hospital
NHS GRAMPIAN Infection Control Committee Minutes from meeting held on 10 July 2014 The Conference Room, Aberdeen Maternity Hospital 11.00 13.00 Present: Pamela Harrison, Infection Prevention & Control
More informationHead of Nursing, Emergency Care Directorate. PA to Associate Medical Director, Acute Services Division
IT 6F A NOTE OF THE ACUTE SERVICES DIVISION CLINICAL GOVERNANCE COMMITTEE HELD ON WEDNESDAY 2 nd April 2014 AT 10AM WITHIN THE BOARD ROOM, HAYFIELD CLINIC, VICTORIA HOSPITAL Present Mr Nick Barber Ms Lynn
More informationSafeguarding Children Annual Report April March 2016
Safeguarding Children Annual Report April 2015 - March 2016 Report Author: Andrea Anniwell, Interim Named Nurse for Safeguarding Children Date: April 2016 1 CONTENTS SECTION PAGE 1 Introduction 3 2 Overview
More informationWorking with you to make Highland the healthy place to be
Assynt House Beechwood Park Inverness IV2 3HG Tel: 01463 717123 Fax: 01463 235189 Textphone users can contact us via Typetalk: Tel 0800 959598 www.show.scot.nhs.uk/nhshighland/ MINUTE of MEETING of the
More informationScottish Ambulance Service. Our Future Strategy. Discussion with partners
Discussion with partners Our values Glossary of terms We will: put the patient at the heart of everything we do. treat each and every person well, with respect and dignity. always be open, honest and fair.
More informationPlease indicate: For Decision For Information For Discussion X Executive Summary Summary
Governing Body 22 March 2017 Details Part 1 X Part 2 Agenda Item No. 10 Title of Paper: Board Member: Author: Presenter: PAHT Quality Improvement Plan Catherine Jackson, Executive Nurse Catherine Jackson,
More informationCLINICAL AND CARE GOVERNANCE STRATEGY
CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016
More informationNHS Equality Delivery System for Isle of Wight NHS Trust. Interim baseline assessment against the
Interim baseline assessment against the NHS Equality Delivery System for Isle of Wight NHS Trust The NHS Isle of Wight has adopted the NHS Equality Delivery System as the framework to achieve compliance
More informationInternal Audit. Complaints. June Report Rating. Contents. Executive summary. Background, objective & scope. Audit issues & recommendations
June 2014 Report Rating RED Contents Page 1 Page 2 Page 3 Page 9 Executive summary Background, objective & scope Audit issues & recommendations Definition of ratings & distribution list Executive Summary
More informationNLG(13)250. DATE 30 July Trust Board of Directors Part A. Dr Liz Scott, Medical Director REPORT FROM
NLG(13)250 DATE 30 July 2013 REPORT FOR Trust Board of Directors Part A REPORT FROM Dr Liz Scott, Medical Director CONTACT OFFICER Dr Liz Scott, Medical Director SUBJECT Infection Control Committee Minutes
More informationWOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE
Wolverhampton Clinical Commissioning Group WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE Minutes of the Quality and Safety Committee Meeting held on Tuesday 12 th May 2015 Commencing
More informationPaper North Edinburgh Public Partnership Forum Steering Group
Paper 5.2.7. North Edinburgh Public Partnership Forum Steering Group Draft Notes of Meeting Wednesday 30 March 2011 : 2.00pm to 4.00pm The Leith Community Treatment Centre Present: Irene Garden Stewart
More informationACF(M)15/03 Minutes: GREATER GLASGOW AND CLYDE NHS BOARD
ACF(M)15/03 Minutes: 22-33 GREATER GLASGOW AND CLYDE NHS BOARD Minutes of a Meeting of the Area Clinical Forum held in Meeting Room A, J B Russell House, Corporate Headquarters, Gartnavel Royal Hospital,
More informationSUBJECT: NHSL CORPORATE RISK REGISTER. For approval For endorsement X To note. Prepared Reviewed X Endorsed
Meeting of Lanarkshire NHS Board 31st August 2016 Lanarkshire NHS Board Kirklands Fallside Road Bothwell G71 8BB Telephone: 01698 855500 www.nhslanarkshire.org.uk 1. PURPOSE SUBJECT: NHSL CORPORATE RISK
More informationVersion: 3.0. Effective from: 29/08/2012
Policy No: RM51 Version: 3.0 Name of policy: Learning from Experience Policy A systematic approach to incident, complaint and clai management, analysis and sharing safety lessons Effective from: 29/08/2012
More informationWEST HERTFORDSHIRE HOSPITALS NHS TRUST TRUST LEADERSHIP EXECUTIVE COMMITTEE
Trust Board 25 July 2013 Part 1 Item 46.5c/13 WEST HERTFORDSHIRE HOSPITALS NHS TRUST TRUST LEADERSHIP EXECUTIVE COMMITTEE Minutes of the TLEC Meeting held on Thursday 4 July 2013 Lecture Room 2, Medical
More information(a) check that GP practices were acting in accordance with the relevant regulations (see below)
REPORT ON VACCINE STORAGE IN GP PRACTICES Scope and Purpose 1. This report sets out the findings of a two part survey, carried out in 2006 and 2007, of all GP practices in Scotland concerning the proper
More informationThe Prevention and Control of Violence & Aggression Policy CONTROLLED DOCUMENT
CONTROLLED DOCUMENT The Prevention and Control of Violence & Aggression Policy CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document
More informationUnannounced Inspection Report: Independent Healthcare
Unannounced Inspection Report: Independent Healthcare Marie Curie Hospice - Edinburgh Marie Curie Cancer Care Edinburgh 22 May 2013 Healthcare Improvement Scotland is committed to equality. We have assessed
More informationApproval Discussion Assurance ( )
TRUST BOARD IN PUBLIC Date: 27 th July 2017 Agenda Item: 6.2 REPORT TITLE: 2016 National Staff Survey Update SASH Action Plans Mark Preston EXECUTIVE SPONSOR: Director of Organisational Development & People
More informationHealth priorities for the next UK government a manifesto from the Royal College of Nursing
Health priorities for the next UK government a manifesto from the Royal College of Nursing HEALTH PRIORITIES FOR THE NEXT UK GOVERNMENT Health priorities for the next UK government With over 370,000 members,
More informationNHS SHETLAND CLINICAL GOVERNANCE STRATEGY
NHS SHETLAND CLINICAL GOVERNANCE STRATEGY 2010-13 Clinical governance is the defining heart and inspiration of quality in the NHS Aidan Halligan 2006 Last version date: March 2007 Next Formal Review January
More informationHealth and Safety Policy
Document reference: 210A2015 Date: March 2015 Health and Safety Policy Index 1.0 Introduction 2 2.0 Health and safety policy statement 2 3.0 Health and safety responsibilities 3 4.0 Health and safety risks
More informationThe impact of a flu or norovirus outbreak could have a significant impact on health and social services and could involve:
NHS National Waiting Times Centre Winter Plan 2010/11 Introduction This plan outlines the proposed action that would be taken to deliver our key business objectives supported by contingency planning. This
More informationMinute of the above meeting held at 2:00 pm on Tuesday 14 March 2017 in the Board Room, Kings Cross, Hospital.
Item 3.1 Please note any items relating to Board business are embargoed and should not be made public until after the meeting STAFF GOVERNANCE COMMITTEE Minute of the above meeting held at 2:00 pm on Tuesday
More informationQuality Assurance Committee (QAC)
Quality Assurance Committee (QAC) Minutes of the meeting of the Quality Assurance Committee of the Sheffield Health and Social Care NHS Foundation Trust, held on Monday 25 TH April 2016 at 1pm in Rivelin
More informationLIVING & DYING WELL AN ACTION PLAN FOR PALLIATIVE AND END OF LIFE CARE IN HIGHLAND PROGRESS REPORT
Highland NHS Board 4 October 2011 Item 5.3 LIVING & DYING WELL AN ACTION PLAN FOR PALLIATIVE AND END OF LIFE CARE IN HIGHLAND PROGRESS REPORT Report by Chrissie Lane, Cancer Nurse Consultant/Project Lead
More informationQuality and Safety Committee Terms of Reference
Approved May 2016 Quality and Safety Committee Terms of Reference 1. Constitution The Quality and Safety Committee is established as a sub-committee of The Hillingdon Hospitals NHS Foundation Trust (THH)
More informationUNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST TRUST BOARD
UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST TRUST BOARD Date of meeting: 25 July 2012 Title / Subject: Status Internal Purpose: The attached paper provides an update of progess made in UHMB
More informationNorthumberland, Tyne and Wear NHS Foundation Trust. Board of Directors Meeting. Meeting Date: 25 October Executive Lead: Rajesh Nadkarni
Agenda item 9 ii) Northumberland, Tyne and Wear NHS Foundation Trust Board of Directors Meeting Meeting Date: 25 October 2017 Title and Author of Paper: Clinical Effectiveness (CE) Strategy update Simon
More informationVisit Report on NHS Grampian
National Review of Scotland 2017 Visit Report on NHS Grampian This visit is part of our national review of undergraduate and postgraduate medical education and training in Scotland. Our visits check that
More informationSupport Work - Inverness Community Mental Health Service Housing Support Service Inverness Community Mental Health Service The Corbett Centre
Support Work - Inverness Community Mental Health Service Housing Support Service Inverness Community Mental Health Service The Corbett Centre Coronation Park Inverness IV3 8AD Inspected by: Lindsey McWhirter
More informationPerformance and Delivery/ Chief Nurse
Governing Body 26th May 2017 Quality and Performance Report 22nd May 2017 Author: Other contributors: Executive Lead Audience Eileen Clark - Acting Director of Clinical Performance and Delivery/ Chief
More informationCatherine Hughson Kathryn Kearney Number of supervisors relinquishing role since last report:
Name of Local Supervising Authority: Western Isles Health Board Period of report: 2005/2006 Date: September 2006 1. Supervision of Midwives and Midwifery Practice 1.1 Designated Local Supervising Authority
More informationMENTAL HEALTH AND WELL BEING SUPPORT GROUP. REPORT OF VISIT TO BORDERS 26 June Report of Visit to Borders 26 June 2001 (Pages 1 to 4)
MENTAL HEALTH AND WELL BEING SUPPORT GROUP REPORT OF VISIT TO BORDERS 26 June 2001 Report of Visit to Borders 26 June 2001 (Pages 1 to 4) The 6 Month Progress Report - December 2001 (Pages 5 to 9) 1 MENTAL
More informationCLINICAL GOVERNANCE STRATEGY. For West Sussex PCT
CLINICAL GOVERNANCE STRATEGY For West Sussex PCT 2006 2009 Agreed by the Clinical Governance Committee: 31/01/07 Effective from: 31/01/07 Review: 31/07/07 Page 1 of 8 Contents Page Introduction 3 Principles
More informationBARTS AND THE LONDON NHS TRUST TRUST BOARD MEETING
BARTS AND THE LONDON NHS TRUST TRUST BOARD MEETING Minutes of the open meeting of the Trust Board held on Wednesday 26 January 2005 at 11.30am in the Old Library, School of Medicine and Dentistry, Turner
More informationCARERS POLICY. All Associate Director of Patient Experience. Patient & Carers Experience Committee & Trust Management Committee
CARERS POLICY Department / Service: Originator: All Associate Director of Patient Experience Accountable Director: Chief Nursing Officer Approved by: Patient & Carers Experience Committee & Trust Management
More informationLevel 2: Exceptional LEP Review Visit by School Level 3: Exceptional LEP Trigger Visit by Deanery with Externality... 18
Postgraduate Training Ongoing Quality Review and Enhancement Framework Version 1: 2010 Contents Contents... 2 PMET Quality Review Framework Introduction... 3 Introduction... 3 Postgraduate Training Quality
More informationAgenda Item: REPORT TO PUBLIC BOARD MEETING 31 May 2012
Agenda Item: 5.1.1 REPORT TO PUBLIC BOARD MEETING 31 May 2012 Title Lead Director Author(s) Purpose Previously considered by Ratification of the Strategy for the Care of Older People Siobhan Jordan, Director
More informationAnnounced Inspection Report
Announced Inspection Report Udston Hospital NHS Lanarkshire 20 21 September 2017 www.healthcareimprovementscotland.org The Healthcare Environment Inspectorate was established in April 2009 and is part
More informationSafeguarding Committee. Held on Tuesday, 10 th January pm at Hawthorn House, Ransom wood Business Park, Mansfield
Working on behalf of NHS Newark and Sherwood CCG, NHS Mansfield and Ashfield CCG, NHS Rushcliffe CCG, Nottingham North and East CCG, NHS Nottingham West CCG, NHS Bassetlaw CCG Safeguarding Committee Held
More informationREVIEW AND UPDATE OF THE COMMITTEE WORK PROGRAMME
AGENDA ITEM 3.1 14 June 2013 REVIEW AND UPDATE OF THE COMMITTEE WORK PROGRAMME Executive Lead: Committee Chair Author: Assistant Director of Patient Safety & Quality Contact Details for further information:
More informationSafeguarding of Vulnerable Adults. Annual Report
of Vulnerable Adults Annual Report 2011-2012 April 2012 DOCUMENT CONTROL Version Author Date Change V0.1 Veronica Flood 20 April 2012 First draft V0.2 Mary Sexton 24 April 2012 Second Draft V0.3 Mary Sexton
More information