NLG(15)397. Trust Board of Directors Part A. Tara Filby, Acting Chief Nurse N/A N/A

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1 NLG(15)397 DATE OF MEETING 29 th September 2015 REPORT FOR Trust Board of Directors Part A REPORT FROM Tara Filby, Acting Chief Nurse CONTACT OFFICER Tara Filby, Acting Chief Nurse SUBJECT QPEC minutes from September 2015 BACKGROUND DOCUMENT (IF ANY) REPORT PREVIOUSLY CONSIDERED BY & DATE(S) EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN AND / OR NED CHALLENGE THAT THE BOARD NEED TO BE MADE AWARE OF) These are the minutes from QPEC September s meeting for information purposes. HAVE THE STAFF SIDE BEEN CONSULTED ON THE PROPOSALS? HAVE THE RELEVANT SERVICE USERS/CARERS BEEN CONSULTED ON THE PROPOSALS? ARE THERE ANY FINANCIAL CONSEQUENCES ARISING FROM THE RECOMMENDATIONS? IF YES, HAVE THESE BEEN AGREED WITH THE RELEVANT BUDGET HOLDER AND DIRECTOR OF FINANCE, AND HAVE ANY FUNDING ISSUES BEEN RESOLVED? ARE THERE ANY LEGAL IMPLICATIONS ARISING FROM THIS PAPER THAT THE BOARD NEED TO BE MADE AWARE OF? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO THE NHS CONSTITUTION IN ANY DECISIONS OR ACTIONS PROPOSED? WHERE RELEVANT, HAS PROPER CONSIDERATION BEEN GIVEN TO SUSTAINABILITY IMPLICATIONS (QUALITY & FINANCIAL) & CLIMATE CHANGE? THE PROPOSAL OR ARRANGEMENTS OUTLINED IN THIS PAPER SUPPORT THE ACHIEVEMENT OF THE TRUST OBJECTIVE(S) AND COMPLIANCE WITH THE REGULATORY STANDARDS LISTED ACTION REQUIRED BY THE BOARD To note Page 1 of 4

2 Meeting: QUALITY & PATIENT EXPERIENCE COMMITTEE Date: Wednesday, 9 th September 2015 Time: 10:00am 12:30pm Venue: Main Boardroom, Grimsby Hospital MINUTES OF THE MEETING Alan W Bell Karen Dunderdale Tara Filby Kathryn Helley Claire Jenkinson Rachel Greenbeck Keith Fowler Karen Griffiths Anne Shaw Lawrence Roberts Non-Executive Director (chair of the meeting) Deputy Chief Executive Acting Chief Nurse Deputy Director of Performance Assurance & Ass. Trust Secretary Head of Performance Quality Matron Head of Facilities Services Chief Operating Officer Non- Executive Director Medical Director In attendance Karl Robert (for item 233/15) Clinical Quality, Patient Experience & Safety Lead Pam Clipson (for item 244/15) Director of Strategy & Planning Craig Ferris (for item 241/15) Head of Safeguarding Karen Wilson ((for item 251&6/15) General Manager Medicine Joanna Loughborough Patient Experience Practitioner Rachel Pollard PA to the Chief Nurse (for the minutes) 228/15 Apologies for Absence: Jim Whittingham, Wendy Booth, Jeremy Daws and Jane Heaton. 229/15 Minutes of the Previous Meeting held on 12 th August 2015: Item 205/15 Stroke Action Plan Update Karen Griffiths confirmed the accurate position also confirming the stroke action plan programme will be monitored via the Mortality Performance Meetings, which was not accurately reflected in the highlight report to the Board. There were no amendments to the minutes required and they were accepted as a true and accurate record. 230/15 Matters Arising: 231/15 Update from Monitor statement C. diff explanation (Action 194/15 from Augusts meeting) All new c.diff cases, including investigation processes will continue to be monitored via existing processes and reported within the Monthly Quality Report. Monitor has confirmed that the target set relates to lapses in care identified. The Chief Nurse, Medical Director and Deputy Chief Executive will continue to attend root cause analysis meetings. 232/15 Confirmation of clinical time for Dr Kamath (Action 202/15 from August s meeting) Karen Griffiths advised that Dr Kamath is not an appointed Clinical Lead and therefore has not currently got dedicated job plan time but has been leading the work in terms of medical input. Karen Griffiths had confirmed with Rachel Greenbeck that Dr Kamath had supported this work to date. Lawrence Roberts contributed to the discussion and advised that many medical staff have special interests and take a lead for work but are not an appointed clinical lead. Spa time in job plans is often used to recognise and support this work. Anne Shaw commented that she did not find this acceptable and LR and KG agreed to pick this up outside the meeting. Action Karen Griffiths/Lawrence Roberts to identify the requirements of a Clinical Leader for dementia and feedback to the next committee. 233/15 Detailed PLACE update report including outcomes (Action 220/15 from Augusts meeting) An update report was attached to the agenda in which the Trust appears within the bottom 6 in England for dementia friendly environments. A core group has been formed to develop a specification and in October there Page 1 of 4

3 will be proposal following conversations with stakeholders, future mini-place visits are being planned for December 2015 in which Karl Roberts will lead. Further training for patient and staff assessors will be planned. The committee noted the dementia position, with Tara Filby confirming that work is ongoing with support needed to inject pace with regards to environment issues. Improvements were seen regarding cleanliness, privacy and dignity and food scores however the condition of the fabric of building had seen deterioration. Alan confirmed that a refurbishment plan is in place and will be tabled at future QPEC meetings monthly. Pam advised that this needs to also have the approval of Strategy & Planning to ensure the programme is funded. The committee were concerned that the planning, cost and priorities could become disjointed and therefore asked for an update each month. However, the committee noted that year on year the Trust has seen improvements in the overall PLACE scores. Action Tara to provide a verbal update (by exception) at each committee meeting. Post meeting note Rachel added the action into the report schedule Action The committee asked Karl Roberts to change the word worse to better within page 2 of the attached report. Although only a snap shot, the committee noted the difference between NLaG and other Trusts in overall food scores and the noticeable gap between Grimsby and Scunthorpe Hospital. Tara confirmed the information would continue to be triangulated via the Patient Staff Experience Group. Although Keith Fowler had concerns over the feedback received regarding food scores, Alan Bell asked that he provide reasoning for the clear differences at the next meeting. Work on cleanliness and condition of the buildings will continue to be linked into the Matrons Environmental report with priority areas identified. Action Keith Fowler to take view of the different food models between DPoW and SGH to understand the difference as previous years the scores are so different. 234/15 Patient story Joanna Loughborough presented a verbal story regarding a patient with Motor Neurone Disease (MND). 235/15 Patient Safety 236/15 Action plan summary Morale in A&E / retirement figures Karen Griffiths updated the committee following Neil Pease s update given in June. The report incorporated the use of actions contained within existing action plans used within A&E. Progress has been made via the business meetings, with positive changes to A&E leadership. Red areas within the report relate to a possible over spend to contract overspend with regards out of hours work for SPA with work continuing with commissioners to resolve this. Signage was also shown as an issue, with Karl Roberts s leading ongoing work to resolve the mixture of signage within the Emergency Care Centre (ECC). Kathryn confirmed that ECC and A&E are a priority area for improvement. Although there is a large gap in relation to the medical workforce it was reported that staff feel that the Trust are recognising their individual qualities. A review will be completed in December 2015 and reported to this committee in January and will continue to be monitored through the sustainability work. 237/15 Critical Care CQC Action plan monthly update by exception The business case was taken to the Strategy and Planning committee in September containing 3 options for relocation including ward 25, HDU (within the anaesthetic offices) or relocation to HSDU. Once a decision is made the feasibility study will be processed and seen at Trust Board for a final decision. Karen Griffiths was unsure of timescales but a workforce group will be arranged and will continue to be monitored. The committee agreed that an immense amount of work had been completed and were confident with the robust plan moving forward. 238/15 Director visit report (Q1) The report showed 4 ambers that all related to fabric of building which would be monitored via a future monthly report from facilities. Following concerns from the wards it was agreed that protected mealtimes would be avoided where possible however, if necessary the ward will be notified that the visit has been arranged deliberately. Keith Fowler confirmed that all hydration trolleys have been delivered and are in use within every area Trust wide. 239/15 Quarterly Discharge and Transfer Group update Karen Fanthorpe continues to lead this work, with meetings taking place regularly. Early work is underway to ensure the data is received and understood with unit/ward discharges considered important as they sit alongside the Department of Health standards. It was reported that the pharmacy process have improved since the introduction of the 7 day working although there was no evidence to confirm this. Work continues with regards to the prompt completion of the discharge letters and it was understood that the tough books due to their limited use, were hindering this process and therefore discharge summaries are inputted after the completion of the individual ward rounds. Voice translators have been trialled but not been widely implemented however, WebV are looking to devise a system to make the production of the discharge summaries faster. It was agreed that there is a need to understand why the Trust appears worse than other Trusts and to understand what process they follow. This committee will continue to receive quarterly updates to provide assurance. Action Lawrence Roberts to discuss issues regarding the discharge summary process with Clinicians Page 2 of 4

4 and verbally feedback to the next committee. 240/15 NED challenge highlight report Extra falls training continues to be arranged for some wards. The displaying of pressure ulcer and falls data is now seen on the wards allowing Sisters/Charge Nurses to keep up to date. Dawn Garrod, Nursing Professional Lead for Older People and Dementia from the Royal College of Nursing will work with the Trust for one day a month to help drive dementia work forward, including looking at overall quality and the action plan. The Trust has not achieved the target for dementia screening for May, June and July 2015 as staff have not been completing the screening within the required first 72 hours of admission. Work will be targeted on three wards at Grimsby to ensure they understand the importance of the process. Action Karen Wilson agreed to discuss the importance of dementia screening with the wards concerned. An observational audit of patient mealtimes will be undertaken by Matrons in September. This will look at nursing practices during patient mealtimes to provide assurance with regards to nursing and catering practices. Sponsorship is being sought with regards to the mobile freezers initiative. 241/15 Female Genital Mutilation (FGM) Following receipt of a letter from NHS England, data required was collected and sent in relation to FGM and will continue to be sent quarterly as requested. A Trust wide policy with separate procedure is in place (separate policy for maternity use) and is to be used in conjunction with the safeguarding training. The committee were advised that training would promote conversations and understanding and awareness. Craig Ferris explained the stages of the sensitive process and the requirement of staff and assured the committee that the policy will be monitored via the safeguarding forum. 242/15 Nurse retention and recruitment update Karen Dunderdale updated the meeting advising of a summit scheduled to understand the gaps and what is required, the findings of which will be reported to the next Resources Committee and also Executive Team on the 22 nd September. Weekly nurse staffing control meetings continue to look at usage which also continues to feed into the Resources Committee. Although there were concerns over the nursing vacancy position it was evident that there was a clear robust profile relating to each ward that highlights a list of 8 wards across the Trust that is classed as a risk in relation to their recruitment position, this profile is in addition to monitoring via nurse quality indicators. However, it was made clear that although there were areas of risk, the existing staff numbers have not put any risk to patient safety and a review will continue ward by ward. We continue to work with Allocate in relation to software that will allow us to provide the safe care live monitoring tool. From our existing information there are benefits being seen from the correct usage of bank and agency staff with a balanced mixture of staff on each shift. Figures will be inputted into a competency framework to build into the e-rostering system with risk ratings easily identified allowing the Associate Chief Nurses to make the decision where staff are required to be deployed. 243/15 Clinical Effectiveness 244/15 Strategy and Planning Highlight report: Future Construct A proposal was heard at the Trust Board in July which gave a position with regards to the Healthy Lives, Health Future. A number of work streams were generated split into in and out of hospital work. Work has been ongoing within Clinical teams to ensure the Trust continues to deliver all quality aspects as a 7 days service. General Practitioners, Care Plus Group and Commissioners have been looking at start to impact on demand to organise what would be required to support patients not to be admitted to hospital if not required. Work continues with regard to medical models in particular to reduce the length of stay for dementia patients. Positive feedback has been received in terms of patient experience in the media. Representatives will sit on the future board meetings to discuss a way forward with regards to performance and nursing dashboards and to ensure quality and key measures to ensure improvement / maintenance. It was confirmed that the robust quarterly Quality Impact Assessment process will adequately measure all requirements and that the information will be fed back into the Strategy and Planning work streams. Further work is to be done to monitor quality benefits to ensure patients are provided with adequate caring experience with an independent review being completed (arranged via NAViGO). It was agreed that Tara Filby and Lawrence Roberts will continue to assess this process via Quality Impact Assessment route. Further discussions were agreed between Tara Filby and Angie Davies regarding quality with support from Kathryn Helley and Jeremy Daws. Action Pam Clipson to ensure information from the independent review is seen at a future committee. 245/15 Quality report Kathryn Helley updated the committee with the highlights. The latest SHMI figures were as expected. 3 cases of c.diff have been confirmed. The community safety thermometer figures showed a drop below target with comments noted that due to a change in staff there was a need for further training. Tara Filby advised that the Quality Matrons will increase their oversight with regards to community. Action Tara to liaise with Operational Matrons to understand the dip in community safety thermometer figures. Action Kathryn Helley to ensure the information on page 24 of the report showing the number of bed days per thousand matches the bar chart information. Page 3 of 4

5 The information submitted with the agenda had already been discussed within the previous committee in August therefore Kathryn agreed to send the full report once Jeremy Daws had returned from annual leave. Action Kathryn Helley to ensure a full report is circulated to the committee on Jeremy s return. 246/15 Mortality Performance Assurance Committee Exception Report and Monthly Mortality Report Alan Bell suggested that the out of hospital moving annual total is showing signs of turning downwards and looked forward to seeing benefits from the ongoing work of the Mortality Performance Assurance Committee. The Committee noted that although work was ongoing with regards to crude mortality, the trend was concerning and asked that the figures be shown linear rather than up or down and to include the actual numbers involved. In addition, it was agreed text could be added alongside graphs showing the output of all work undertaken. Tara Filby confirmed that to encourage documented evidence of the last offices, a refresh of the policy with the addition of a printed checklist has been approved by the Nursing Midwifery Advisory Forum (NMAF) and will continue to be monitored via this report. 247/15 Quality Development Plan (QDP) & KPI's (by exception) Although the report shows a lot of completed actions in green it was considered inappropriate to archive these until after the impending CQC visit. Claire Jenkinson will continue to work with the groups to ensure that the actions are embedded and that changes are permanent. Action Kathryn Helley to ensure the KPI s are to appear first on the report to ensure focus on the red areas. 248/15 PROMS Quarterly Report ( annual report) The report referred to 4 procedures, however there was no data relating to varicose veins due to the insufficient number of procedures undertaken. Kathryn Helley highlighted the creditable response rate being 98% (national average is 75%). Action The committee agreed that the response rate was commendable and asked Kathryn Helley to formally publish this information via PR and Comms team. Action Tara Filby to ensure this rate was inputted within the highlight report to Trust Board. 249/15 Mock CQC visits The item was deferred until October s meeting 250/15 Quality Dashboard report The committee noted the exceptional improvements made within both Wards 19 and 24. Angie Davies continues to refine the quality indicators. Discussions will continue between Tara Filby, Wendy Booth, Kathryn Helley and Angie Davies regarding ward accreditation. Tara Filby confirmed that nursing Trust wide issues are picked up at NMAF that the Associate Chief Nurses attend; in addition, the nursing dashboard information is seen within the capability and capacity monthly report seen at Trust Board and in the future will have the addition of the overall figures including pressure ulcers and falls. 251/15 Electronic Patient Record Project Report Karen Wilson updated the meeting. Dementia screening has fallen below target. All discharge summaries are now electronic but work is in progress to improve this to ensure it is easy to use for the doctors completing. A few breaches have been identified where patient identifiable information on handover sheets has been found outside the hospital grounds and have been dealt with under breach of confidently with zero tolerance. A new indicator flag within the Web V system has been introduced to display do not resuscitate following a recommendation via MPAC on Web V. The electronic version of the majority of nursing documentation is now ready, that will change the way the Trust delivers the individual care plans to patients. The committee felt it important that the nurses are felt empowered to apply their professional judgement. Dermatology has been identified to be the first full specialty to be fully electronic which is anticipated to occur once the generation two project has been developed Karen Wilson was pleased to announce that NLaG has been shortlisted as a finalist in the E-Health Insider Awards digital Trust of the year for the WebV solution. 252/15 Evaluation of QPEC and Terms of Reference Review Alan Bell and Tara Filby were disappointed with the number of responses which does however suggest a broad level of contentment with the functioning of the committee. The only suggested change was to allow more time for the meetings but this was discussed and rejected at this time. It was also agreed to update the terms of reference with regards to job titles with the addition of Jeremy Daws. Action Alan Bell, in his capacity of chair and Tara Filby as the Executive Lead for Quality to discuss outside the meeting and feedback to the next committee. 253/15 Reflection on Patient Story It appeared that the care for patients with complex needs was not consistent and this is exacerbated with the lack of Page 4 of 4

6 a nurse specialist lead. Paul Kirton-Watson will lead meetings including service users, their relatives and staff within the medicine group who actively care for patients with MND. The committee agreed that adequate care of patients with complex needs must start at the very point of referral from the GP and considered prior to admission. It was not considered acceptable to not have drinking straws readily available. The committee discussed the inclusion of a paragraph within admission letters or admission booklets advising the patient and/or relatives to contact the hospital if any complex, individual care is required. It was agreed that Joanne Loughborough feedback information following the meetings and keep the committee informed. Patient Experience 254/15 Complaints Report The numbers of open complaints have reduced with the data collected feeding into the learning lessons process. A high number of PALS complaints continue. The location of the PALS area at DPoW appears to be used as a receptionist area with all minor queries being registered however, with processes underway to organise front of house organisation to resolve any issues. The committee confirmed that all the staff involved with staff attitude continues to be spoken to and a file note recorded for the personal file and will also feed into the revalidation process and continue to be monitored. 255/15 End of Life Quarterly Report Following the replacement of the Liverpool Care Pathway the Trust piloted a new document, with no major issues fedback and will therefore be rolled out across the Trust. An Educators post has been approved for 1 Year to embed the process. It was noted that the action plan attached to the report was not the up to date version. Action Tara Filby to ensure the up to date action plan be circulated via 256/15 Eliminating Mix Sex Accommodation Progress Report There have been no breaches since October An update to the HOBS administration and dashboard protocol has been completed and Web V is utilised to identify possible live breaches. Mix sex occurrences continue to be appropriate within HOBS, CCU and ITU until they are clinically suitable for a ward, in which the Trust has 24 hours to move the patient. Timings will eventually be monitored via the Web V system with s generated to Matrons. 257/15 National Inpatient Survey 2014 (full report) and action plan response to outstanding actions The 2014 data was seen at last month s meeting with the outstanding actions from 2013, it was questioned why there were 3 ambers relating to:- - Electronic care plans - These plans are now in place and are awaiting Web V to roll out. - How do doctors keep patients involved in treatment - A checklist has been produced to be used during ward rounds. Work is ongoing to develop additional patient information leaflets. In addition, support via Macmillan to train facilitators in better communication training is being explored. - Pain management audit tool -This has been reviewed at NMAF with pain tools standardised across the Trust. The dashboard has also been amended. Anne Shaw asked if nurses could improve communication in relation to empowering patients to ask about pain management. Tara Filby advised that embedded in the care round chart and the pain assessment tool. It could be introduced within the bedside care folder. Action Tara Filby to ensure information relating to pain management is included in the bedside folder. Post meeting note Tara ed Hazel Moore (15 th Sept) to request a piece of work to be included in the bedside folder. 258/15 Items for Information These items were noted for information purposes only. 259/15 Items for Approval No items for approval were discussed. 260/15 Items to highlight to Trust Board / Mortality Performance Committee Action - Alan Bell and Tara Filby to write the highlight report to the Board following the meeting. 261/15 Any Other Urgent Business No items of urgent business were discussed 262/15 Review of Action Log Action Tara Filby and Alan Bell to discuss outside the meeting. 263/15 Date and Time of Next Meeting: Page 5 of 4

7 The next meeting will take place on Wednesday, 14th October 2015, am pm, in Boardroom, Scunthorpe General Hospital Page 6 of 4