Present. In attendance

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1 Minutes of NHS Shetland Clinical Care and Professional Governance Committee (CCPGC) Held on Tuesday 17 th May 2016, Board Headquarters Bressay Room Montfield Present Malcolm Bell Keith Massey Billy Fox Vaila Wishart Ian Sandilands In attendance Ralph Roberts Simon Bokor Ingram Emma Garside Chris Nicolson Roger Diggle Edna Mary Watson Mary Marsland Colin Marsland Ray Cross Janice McMahon Chair, IJB Audit Chair & non Executive Member of the Health Board SIC Councillor and Member of the IJB SIC Councillor and Chair of SIC Education & Families Committee Employee Director of the Health Board NHS Shetland Chief Executive NHS Shetland Director of Community Health & Social Care NHS Shetland Clinical Governance & Risk Lead NHS Shetland Director of Pharmacy NHS Shetland Medical Director NHS Shetland Chair of Area Clinical Forum NHS Shetland Corporate Services Supervisor (minute taker) NHS Shetland Director of Finance (agenda Item 10 only) NHS Shetland Clinical Director of Dental Services (agenda item 11 only) NHS Shetland Assistant Director of Nursing (agenda item 17 only) Dr Catriona Waddington, non executive member of the Health Board and member of the IJB attempted to link into the meeting via video conference and teleconference but was unable to do so due to technical difficulties The meeting was noted as being quorate. 1 Apologies for absence Apologies for absence were received on behalf of Allison Duncan, SIC Audit Chair, Susanne Gens, SIC Staff Representative, Martha Nicolson, SIC Chief Social Work Officer, Kathleen Carolan, NHS Shetland Director of Nursing & Acute Services and Susan Webb, NHS Shetland Director of Public Health 2 Declaration(s) of Interest There were no declarations of interest to note. Page 1 of 10

2 3 Minutes of the meeting held on 27 th October 2015 Roger Diggle (RD) noted, top of page 4, last paragraph under CG 15/40 Update on DNACPR review June 2015 that he would have discussions with Aberdeen and not the Medical School. The minutes were approved as a true and accurate record. 4 Matters arising from the minutes of 27 th October 2015 Simon Bokor Ingram (SBI) noted on page 7 of 11 around the actions of Mental Health that the Mental Health Team do have a governance process that has been put in place, however this does need more discussion with the Mental Health Team. SBI reported himself and Ralph Roberts will be meeting with the team imminently. In terms of how much they are looking into the wider Grampian network for the individual professional groups within Mental Health, whilst there is a strong link to Grampian it needs more exploration with them around links to Community Psychiatric Nurses (CPN s) for instance who are a small group of staff within the Mental Health Team and how they get support from a wider and larger group. There is a governance process in place however it was thought it was early days so they haven t seen a full output as yet. Keith Massey (KM) indicated the Mental Health Action Plan had been presented to the Integrated Joint Board (IJB) and enquired if it should come to this committee for greater scrutiny. The committee noted the action plan should come to CCPGC in the first instance and that it will be presented at the next meeting - ACTION. RD informed the committee that the Royal College of Psychiatrists have been asked to conduct a review of the management of particular group of patients within Mental Health. Once undertaken, the report from the review will be presented to this committee ACTION. 5 Action Tracker Roger Diggle (RD) informed the committee most actions were within green, however the Information Security Policy which is the responsibility of Craig Chapman will now report to the Information Governance Committee. It was reported limited work has been undertaken within Neurological Pathways. Discussions have taken place with Dr Unsworth who currently deals with the Shetland aspect as to how this will be dispersed over time to either his successor or to an off island system, this action is in hand. The intention is there will be a clear timetable and plan in place by the end of the year 6 CCPGC Key Performance Indicators (KPI s) Roger Diggle (RD) presented paper number 07/2016 and informed the committee that this was a brief report for discussion and to note this committee has three KPI s which need to be agreed upon. It was reported at every committee meeting there would be a report on a particular key specialty which would be from either NHS or Care that sets out what the current governance arrangements are and any action plans associated with that. Much discussion took place and the committee agreed and approved the three KPI s associated with the CCPGC. 7 Draft Clinical, Care & Professional Governance Framework Roger Diggle (RD) presented paper number 08/2016 and informed the committee that this was the framework NHS Shetland are intending to work to. It describes how to ensure systems are in place to evidence best care across the level of services provided. Page 2 of 10

3 The report has been drafted by Kathleen Carolan, Martha Nicolson and Roger Diggle. It was felt the important thing for the IJB members present to note is Martha Nicolson was keen to have the whole of Social Services involved in this rather than it just being adults as there is a linkage between children s care provided by Social Services and children s care provided by Health so there is an overlap. It was reported this does not take away the remit of the Families and Education Committee which has an overall responsibility for Children s Services within the Council and that it was a more holistic approach of how the services connect together. The committee were invited to raise any comments, questions or reservations around the report, the following points were raised: SBI indicated this highlights the importance of a Joint Governance Group from the participation from Health, Social Work and Social Care in order to ensure the right business is being brought forward to the committee. This committee needs to be supportive and encourage the participation at a joint governance group level otherwise this committee would not function properly. KM questioned how it could be made more robust in terms of the involvement of the joint governance group as to receive an update as part of the standing item on this agenda. It was noted the Clinical Care Co-ordinating Group (CGCG) is the predecessor on the Health side which had mixed fortunes in terms of its participation, so it s about making sure we have that link. It was suggested that a regular standing item of agendas and key actions from that group be brought to future CCPGC meetings. RD conveyed the purpose and process of the CCPGC and confirmed future agendas and key actions from the Joint Governance Group (JGG) would be a standing item agenda on future CCPGC meetings ACTION. RD informed the committee the only other area for consideration at this committee would be if an area was considered as high risk that necessitated a more senior input. This could be if there had been a category 1 incident or a never event, an example of which was given. Catriona Waddington (CW) noted on page 10 of the report each committee reviewed their terms of reference on an annual basis. She wondered if it was possible to make this more active rather than just a purpose review, adding in more pro active questions and for the CCPGC to challenge each group around these, every two years. Discussion took place and it was noted this is reviewed within the controlled assurance process, however adding more controlled questions would be an idea. RD indicated this was a possibility and he would review this with Emma Garside and Kathleen Carolan to think about how this could be put into practice ACTION RD 8 Systematic Anti-Cancer Therapy Self Assessment 2016 (SACT) Ralph Roberts (RR) presented paper number 09/2016 and informed the committee that NHS Shetland participated in the review of SACT standards which is happening across Scotland. These standards are being reviewed as the North of Scotland is not in as good a place as some of the other regions and so reflects the complexity of providing services consistently across an area like the North of Scotland. As a result they have asked all Boards within the North of Scotland to provide a self assessment which will link in on a regional level. NHS Shetland had a visit a week ago from a team from the North of Scotland who are going around and looking at where Boards are up to with this. It was very complementary about what is being done locally but also flags that there are Page 3 of 10

4 issues around the interaction between ourselves and the centre and particularly what s happening at a regional level to make sure that the North of Scotland complies with all of these standards, this work is being taken forward by North of Scotland Cancer Network. It was reported NHS Shetland are doing what they can locally; however there is still more work to do regionally. Edna Mary Watson (EMW) speculated, looking at the report it seems to have been around a little while and it suggests post visit we have actually had to down grade where we thought we were at as opposed to upgrade, do we have an overly optimistic view of where we were at before or whether time has actually moved on and we have slipped back a bit? She fully understands things are not as good in the cancer world within the North of Scotland as they are within other areas but the report makes it look as though we are a little worse locally than we thought we were. KC stated the reason that the standards either shifted up or down were because they took out the partially met category in the middle of the review process so they said we were either fully compliant or not compliant. RR indicated, within the Governance Framework and Audit Tool (2a), protocols and guidelines, this is an issue across the North of Scotland. The report signifies how NHS Shetland can make sure staff are fully engaged. RD specified, NHS Shetland has got as many procedures, protocols and processes in place locally as it can, given that most of the treatment is directed from Aberdeen. NHS Shetland is working as effectively as it can given the information being supplied from outside. Chris Nicolson (CN) indicated it was important to recognise more patients were being treated within Shetland for Chemotherapy with some of the regimes being more complex. It is very important we continue to build the links with the pharmacy service within Aberdeen to make sure that we always have the necessary treatments in place. Although Aberdeen is taking responsibility for the dispensing of medicines, increasingly we are moving towards rural therapies within medicines and there is no reason why we wouldn t hold some of these medicines in stock within Shetland and dispense them from here so again there is a need for robust protocols. RD noted Shetland does a lot more cancer work than a lot of other rural general hospitals which poses a risk as a consequence. We have a robust governance and clinical system within Shetland which does ensure we have effective safe care.. 9 Care Supervision Policy for Health Visitors, Public Health Nurses, School and Children s Nurses Edna Mary Watson (EMW) presented paper number 10/2016 and informed the committee that this policy provides a framework case supervision for nurses working within Child Health Team. Case supervision is the regular review of identified vulnerable children within an individual practitioner s caseload in order to ensure that best practice is used in the management of each case and that both these children and the practitioners are kept safe from harm. Vaila Wishart (VW) indicated the communication between the two services was really important. Discussion took place around the different policies nurses and APN s adhere to. It was reported the Governance Framework around ANP s was written by Kathleen Carolan and is used as a model across Scotland making it the most robust governance process for any ANP within Scotland The committee approved the policy. Page 4 of 10

5 10 Internal Audit Report Ralph Roberts (RR) presented paper number 11/2016 and informed the committee that this report has been through the internal audit committee. It covers information governance but particularly Public Record (Scotland) Act. It has highlighted an issue in which the Health Board has not developed its Public Records Management Plan. The Keeper has been informed NHS Shetland will not meet the August 2016 deadline however confirmation from the Keeper indicates a revised date of May 2017 which will be confirmed this week. A Project Management post is in the process of being put in place. The chosen candidate will address this issue along with other works that need to be undertaken. Discussion took place around records management. 11 Dental Service Update Report Ray Cross (RC) presented paper number 12/2016 and informed the committee that this was a brief report around business within the last three months with some keys issues which have been taken into the framework, shown within appendix 1 of the report. This has gone through the Dental Senior Management Team in order to streamline services and to focus on quality, the outcomes of which are just now coming through. Five significant steps have been taken forward within the framework, these are: A new dental quality improvement group A new shared drive for Clinical Governance (CG) in the Public Dental Service (PDS) Introduction of digital x-ray development The PDS response to recommendations from SPSO Consideration of a system to include quality monitoring with independent NHS dental practice/s It was reported the Oral Health Strategy is near to completion for final submission however, the final chapter of the strategy is posing a problem, the reasons for these problems were explained. Much discussion took place around the new Lerwick Dental Practice which is both Private and NHS and the registering of patients as it may well be patients formally with NHS Montfield are also registering with the new practice therefore registering with both practices before making up their minds as to which practice they wish to stay with. It was thought it was a mixed picture at the minute. RC reported Montfield Dental Practice needs to shed at least patients and concentrate on a quality service. RR ascertained one of the challenges with deregistering people from the Montfield Services is doing this in an ethical and fair way and in a way that sustains the financial liability of the new premises. We need to be more assertive with people in a way in which they register somewhere; this would need to be managed carefully. SBI reiterated the issues around funding with the government allocations for community and public dental services having been cut again for this financial year and the likely hood they will continue to scrutinise each area within Scotland in a way that does push a move to NHS Independent Practices. We need to be more assertive around how we direct people to the most appropriate services. We need to decrease the numbers in order to maintain the standards we have within the dental services. Page 5 of 10

6 It was noted this would be Ray s last ever meeting as he is to retire at the end of June 2016 after a long NHS career. It was noted Ray had accomplished sterling work within Shetland and had created a much stronger service. Ray was thanked on behalf of the committee for all he had contributed to the service over the years. 12 Clinical Governance Quarterly Report 01 January 31 st March 2016 Emma Garside (EG) presented paper number 13/2016 to the committee and provided an update on Clinical Effectiveness undertaken from January to March It was noted the report is consistent with how it has been at previous committees. It was noted the Scottish Ombudsmen provide summaries and lessons learnt. We then send these summaries out directly to the relevant services and departments so they go to the right people for areas of review. There is then a requirement for them to review at their governance groups and to identify if it is relevant learning for their particular area /service. It was noted at the last meeting Catriona Waddington had requested the grid be attached to the report. This is now attached and included within the report as an appendix. The Clinical Governance Team are in the process of updating the report however for this year it will stay as it is. One of the key priorities is to review and update the Clinical Audit Procedure. Updates will be brought to the committee as part of this report and also via the Joint Governance Group. RD asked if there was any way to get something similar for Social Care in terms of the Grid, as he is unsure how the governance process procedures work. SBI indicated there is improvement work that goes on however it would be valuable in a consistent approach. EMW indicated within page 9 of the report under Pressure Ulcers herself and Social Work Colleagues did put forward a bid to the National Scottish Safety Programme to be part of the programme, however they were not successful. A response was received with an offer to join their network and learning event which we will try to participate in. KM informed EG this was an important piece of work she could do for this committee, mapping out the whole area with what is being looked at externally & internally as we are inspected from every possible angle. A real important piece of work that will be beneficial long term by putting the effort within the right place and he wished her luck with this. KM noted Infection Control within the grid had a lot of unknown at present against it and was this a case of updated information not being received? EG informed KM a request had been made for updated information, however this had not been received in time for this committee. It will be presented at the next committee meeting with all requested updated information included within ACTION EG. 13 Ambulance Liaison Group Update Ralph Roberts (RR) presented paper number 14/2016 and updated the committee on works undertaken by the Scottish Ambulance Service (SAS) It was noted an Ambulance liaison Group is in place which allows us to deal with joint issues with the ambulance service. Within the last year there have been two main issues, these are: Ongoing provision of the air ambulance linked around the change of the Bond Helicopter Page 6 of 10

7 Land ambulances and their sustainability within the provision of service 24/7. The Liaison group is continuing to deal with these two issues however it was reported Scottish Ambulance are developing their staffing in order to address the issue around sustainability within the provision of service 24/7. The air ambulance work is ongoing. Each incident is monitored reviewed. It was noted over the last year each incident reviewed seemed to have operated well which was positive. The reality of the provision is that the vast majority of the air ambulance retrievals are being done via the Coastguard ambulance which has always been the case much more than Bond ever did. The next significant change is Scottish Ambulance Service are changing their central control network to co-locate. The expectation is that the creation of a more functioning service desk will improve communication. It was noted the Coastguard was represented at the last Ambulance Liaison Group which was a significant step forward. 14 Quality Score Card Emma Garside (EG) presented paper number 15/2016 and informed the committee the report had been submitted to the April Board where it was agreed to bring the Quality Score Card to this committee. Updates of the report were reported as: Page five of nine of the report SPSPPU1 which relates to pressure ulcers, a Grade 2 was reported to have been developed on the ward however the patient actually came into hospital with a pressure ulcer as opposed to them developing it on the ward, this measure should be green. The measure below SPSPPU2 should indicate a one instead of a zero which should measure red. Measure SPSPPU3, how many days between pressure ulcers developed on the ward should now go back to green as it wasn t developed on the ward. It was noted this will be updated within the next Board report RD indicated the purpose of this committee is not to look at the detail but to look at the overall colour. If it was all red then the committee should be worried. Ian Sandilands (IS) reported feedback from staff around the usage of Datix is It s not user friendly and error can come into the system as you can t search the system if you are going to report a new pressure ulcer if it s been reported elsewhere you can t search things with the Community Health Index Number. EG indicated a report may be able to be set up in order for this to be achieved ACTION EG to explore if this is a possibility. 15 Adverse Event Report 01 January 31 st March 2016 Emma Garside (EG) presented paper number 16/2016 to the committee and reported this was the quarterly adverse event report January March There are a few key issues to note, these are: Progress is being made with reducing numbers within the holding area. The committee has expressed concerns at an earlier meeting the number of adverse events that were sat in the holding area which meant no one was looking at these therefore they were just sitting there. A weekly meeting now takes place within the Clinical Governance Team to review all the new incidents that come Page 7 of 10

8 in and to look at those events within the holding area. They have a plan of action which they work through with the managers to review. Within the yearly graph there are still outstanding events from Work is underway to make sure that these incidents are closed off. It is thought a lot can be closed off, they just haven t been confirmed through the system. A significant amount of work is going on around making the system more functional and user friendly and how to align with other systems and processes through joint reporting. Safety Notice Alerts have been added in to provide assurance that we are reviewing these notice safety alerts which are sent through external agencies. The full report around this is received by the Health and Safety Committee. KM asked within page one of the report the reporting of adverse events by the Mental Health Department January 2016 why were the cases not allocated in to the report in the month they occurred so a better more accurate picture of when they occurred could be had. SBI gave some background. It was noted a member of the counselling staff had been off work unwell. Other colleagues when patients were returning realised on the electronic patient records system there wasn t a note of the previous consultation setting alarm bells for the lack of information being recorded. Permission was sought to break open the draws that belonged to the member of staff who was off unwell within the department. SBI gave the permission to gain access in whatever way they could, which they did. Although not helpful it was reported this had minimal effect on patients and clients. The reasons why systems and processes that had been put in place were not being followed was explained. RD enquired if integration of Social Care incidents could be combined into the report which would be helpful. He understands this could be difficult as it is a completely different system when looking at joining up services within the Integrated Joint Board (IJB) it was decided to use one system which would work for all but it would seem this is one area which has defied merger at this moment in time. SBI indicated there was a clear structure within the Council around Risk Management reporting and it should be straight forward to get the number and descriptor of incidents translated across. Effectively aggregate numbers can be collected along with descriptors of incidents and transfer it into a report template. It was reported EG is already in discussion with colleagues around this KM reported this current report was far better than any report previously submitted in terms of the work and output from Datix. Congratulations were conveyed to Andrew and his team on this comprehensive and meaningful report.. 16 Approved minutes of Patient Focus Public Involvement Committee The committee noted the minutes of the Patient Focus Public Involvement Committee held on 07 th March Older People in Acute Hospitals Self Evaluation 2016 and Updated OPAH 16 week post inspection action plan Janice McMahon (JM) presented paper number 17/2016 to the committee and reported in October 2015, Inspectors from the Healthcare Environment Inspectorate (HIS) undertook an unannounced inspection of care of older people s services at the Gilbert Bain Hospital. The inspections have been put in place to ensure that older people are Page 8 of 10

9 being treated with compassion, dignity and respect while they are in an acute hospital. The focus of the inspection was on assessing the care provided in relation to national standards for nutrition, pressure acre, cognitive impairment and falls management. The inspection was carried out on Ronas Ward, Ward 1 and Ward 3 and highlighted a number of areas of strengths and areas for improvement. The inspectors observed many positive interactions with patients and high standards of patient care including: Good communication between patients and staff Positive feedback from patients around the care they received whilst in hospital Effective leadership on the wards from the nurses in charge, creating a calm environment and well co-ordinated care Evidence that patients were well cared for whilst in hospital Mealtimes were protected and evidence that patients received appropriate support with their meals and given a good range of choices to suit their nutritional requirements Evidence that patients had appropriate care plans for nutritional care. Pressure care, falls and cognitive impairment and documentation was generally well completed There was evidence that good systems for team work are in place, including the multi-disciplinary meeting held every morning to plan care across the whole hospital. These are in the form of the hospital huddle. A number of areas for improvement were also highlighted in the report about ensuring consistency in completing record keeping, clinical assessments and discharge planning. Since the inspection we have continued to progress our improvement plans and have made changes to our documentation, progressed work on streamlining the way we organise patient discharge, provide more training for staff undertaking key assessments in nutrition, wound care and assessing patients capacity to make decisions about their treatment. The most recent action plan is attached as appendix A and this was submitted to HIS in February The self evaluation includes an additional theme on organisational communication and leadership whilst the other themes are consistent with the last submission in March Key areas of improvement work in respect of older peoples care standards were summarised. The committee were asked to note actions and update of the current action plan along with the self assessment. RD reported one of the key areas of weakness is record keeping. The care is being provided however was not being documented and that is why the record keeping audits for all departments was an issue. It was noted, this committee needs to make sure every department completes its record keeping audits on a regular basis. JM commented the National Record Keeping Audit is a national document that isn t necessarily bespoke to our documentation. The quality assurance work being done is trying to create a method that can match our documentation to make it easier to follow. KM enquired if we are on course in terms of the capacity and priorities. JM reported this was the case. The committee noted the action plan, priorities and the self evaluation report. Page 9 of 10

10 It was at this stage Vaila Wishart left, therefore making the meeting to be no longer quorate however it was noted remaining items were for information only. 18 Freedom of Information Model Colin Marsland (CM) presented paper number 18/2016 to the committee and reported the Model Publication Scheme 2014 was originally approved by the Freedom of Information (FOI) Scotland Keeper. The report submitted today updates the 2014 version to reflect current information and website links for documents that are publicly available. This fits with the Boards organisational priorities and aims to ensure that NHS Shetland is open and transparent to the public scrutiny in-line with national obligations. RD indicated the only issue which creates major problems for the General Practitioners (GP s) is were the first 100 s of FOI information is free of charge. The solicitors are asking for notes under FOI as opposed to asking for a medical report which is causing difficulty. CM reported you can refuse to give it to them under an FOI. An FOI is not about patient individual exclusivity, they can exempt it under the grounds that the FOI does not cover patient specific information. Discussion took place around FOI s. 19 Internal Audit Complaint Report Paper number 19/2016 was noted by the committee. The committee remarked the report was self explanatory and well written. SBI indicated minor improvements had been made. RD indicated the report fits with the Ombudsman review around a case where an individual was unhappy around the way the Board had reviewed his case, this complaint was not upheld. The Ombudsman commented on the high quality of the record keeping around the particular complaint completed by Barbara Foran and Carolyn Hand. AOCB It was noted there was no other competent business. The committee were informed this was to be Keith Massey s final meeting. Keith was thanked for all his input over the years for this particular committee. The date of the next Clinical Care and Provision Governance Committee is to be held on 26 th July Page 10 of 10