Minutes. Cardiff and Vale University Health Board Primary Community and Intermediate Care Clinical Board Quality and Safety Group

Transcription

1 Minutes AGENDA ITEM 2.3e Cardiff and Vale University Health Board Primary Community and Intermediate Care Clinical Board Quality and Safety Group Present: Vicky Warner Brendan Boylan Sue Morgan Nicky Hughes Kay Jeynes Anna Mogie Gareth Hayes Clare Evans Rhian Floyd Karen May Denise Shanahan Claire Watson Tuesday, 13 th January 2015 CRI Meeting Room 1 Clinical Board Nurse (Chair) Clinical Board Director Head of Operations & Delivery Locality Lead Nurse, Cardiff South & South East Locality Lead Nurse, Vale of Glamorgan Locality Lead Nurse, Cardiff North, West & South West Clinical Director of Clinical Governance Head of Primary Care Services, Operations & Delivery Head of Primary Care Service Delivery Unit Head of Medicine Management, PC Community CB. Consultant Nurse Older Vulnerable Adults Clinical Governance Officer (Minutes) 1 Welcome, Introduction and Apologies for Absence Vicky Warner welcomed everyone to the meeting. ACTION Apologies were received from: Lynne Aston, Carol Evans, Rachel Thomas, Dawn Ward, Rosemarie Marnell, Hayley Lewis, Chris Darling and Lynne Topham. 2 Minutes of the Previous Meeting and Matters Arising The Minutes of the previous meeting held on Tuesday, 11 th November 2014 were agreed as an accurate record. Matters Arising from 11 November 2014 Meeting: Matters arising will be picked up as part of the action log. 3 To Review Clinical Board Quality & Safety Group Action Log The Clinical Board Quality and Safety Group action log was reviewed. Members noted the content and were asked to send any outstanding updates to Claire Watson prior to the next meeting. Actions requiring further work: 251: Western Vale Concerns Process on reporting centrally to be confirmed with Sian Rowlands. 1

2 Gareth Hayes asked that the GP Cluster be informed of the reporting mechanism once organised. Kay Jeynes advised of the ongoing concerns with Bridgend registered patients residing in the Western Vale (approx 3000 patients). If the individual is registered with Bridgend, then their GP and District Nursing services are in Bridgend, but their OOH Service or Continuing Healthcare commissioning is in C&V. This situation is causing governance concerns for example, as ABMUHB configure their syringe drivers differently, they have different medical charts, and C&V are having problems trying to access the patients GPs in relation to medication. It was noted that the majority of these patients were the situations become problematic require palliative care. There has been no further discussion between the two Health Boards to resolve this, and details have been escalated to the executive team but no further advice has been received. Members agreed to include this action on the action log and details would be taken through PCIC Senior Team Meeting. 248: LIPS This is a long term piece of work. Still waiting PARIS to draft a rebuild of the nursing assessment document. Next update will be provided in May /KJ KJ 243: District Nursing Improving the Recruitment System Comments have been sent to Helen Earland. There is a workshop on sickness being held Friday. Members requested that any gaps or concerns regarding the new recruitment service should be reported to Sue Morgan and Vicky Warner as soon as possible. 239: Interface Incidents Clarity to be sought on the transfer of processes in relation to interface incidents. It was agreed that incidents would continue to be sent to Sian Rowlands for review and dissemination to the correct Clinical Board for investigation/response. It was noted that practices have reported poor feedback/response from Secondary Care. Sian Rowlands will be advised of this issue. 238: CMHT Action Plan Discussions have been held with Ruth Walker, who confirmed sign-off and felt assured that actions had been taken to close the incident down. 236: 5 Priority Actions Link for IPC: Discussions ongoing with IPC Team about a designated link. 202: Art Governance Q&S Framework Details were raised at triumvirate and comments invited from all Clinical Boards. No comments have been received. Members agreed that comments will be requested again and a deadline date will be given. 4 Any Other Business There was no Any Other Business 2

3 5 Patient Story It was agreed that the patient story would be deferred until the next meeting. It was also agreed that Claire Watson would issue a schedule for business units to help them to plan ahead for patient stories to the group. 6 Risk Management CW Review risk log using the 4 T s Risks that were highlighted in the meeting for further discussion were: QS&E : Delivering the Integrated Sexual Health Service Nicky Hughes advised on progress around service improvements which is focusing on results and waiting times. The LIPS programme has been undertaken to support streamlining the service / patient flow. The risk continues to be Treated and will remain on the PCIC risk register. QS&E : Healthcare at Home Nicky Hughes was of the understanding that this risk had improved significantly. It is now being managed outside of the S/E Cardiff Team, and details have been escalated to pharmacy. Brendan Boylan advised that Rachel Thomas had been involved in this work. Members agreed that Rachel would be asked to review the risk / score. NH / RT QS&E : GP Out of Hours Clare Evans advised that the risk remains the same due to ongoing demand and pressures on the service. Improvements were seen at the weekend, but the service is still unpredictable due to the flu outbreak. Forward planning is taking place focusing on the next bank holiday and Easter. This risk remains high, and continues to be Treated and Transferred. QS&E : Interface This risk will be updated inline with earlier discussions (Agenda item: 3) QS&E : Independent Sector The position remains the same. Anna Mogie advised that having adequate nurse assessor resource would minimise this risk significantly. A business case is being submitted to the Investment Priority Committee, and interviews are being held to fill a vacancy in South East Cardiff. QS&E: Prison Rhian Floyd reminded members of the update at the last meeting where it was noted that there had been a drop in the risk score, and a Primary MH Team had been established. It was noted that the individual who was put forward from the In-Reach Team for one of the vacancies has taken up another position, this means the vacancy still needs progressing as there is only one other individual in post from the prison healthcare team. The review of the MH pathway within the prison still needs significant progression, this is a key priority for this year to ensure the right pathway and measures are in place inline with Welsh Government guidance. Vicky Warner agreed to contact the Clinical Board Nurse regarding recruitment. 3

4 QS&E : CHC Arrangements for POC Transferring Anna Mogie advised that all patients have now been transitioned. Members agreed for the removal of this risk. QS&E : CHAPS Rhian Floyd reminded members of the pressures and demand on the service. Rhian met with the management team last week where they agreed a number of actions. It was noted that there are operational fractures within the service which have been highlighted within the report. Actions are being agreed to address these issues. The score of this risk remains the same, with the Approach to Managing Risk 4 Ts, requiring to be altered to: treat, tolerate, transfer and terminate. Members agreed to the changes and requested a brief explanation be added against each of the 4 Ts. AM RF QS&E : Patient flow Vicky Warner advised that this risk remains significant and has been heightened in recent weeks because of the unscheduled care pressures experienced. Silver meetings are being held to address the issues, and specific extraordinary measures have been submitted to Alice Casey s Team to set out the additional work that is being undertaken. QS&E : Equipment Vicky Warner advised that the feedback from the service improvement workshops would aid discussions around next steps. It was agreed that feedback would be chased up from Ann. This risk is having an effect on patient flow and respite in the community. Kay Jeynes advised that no concerns have been escalated recently, however monitoring continues. QS&E N/W : Complex packages of care: Vicky Warner advised this risk remains a significant concern. However there has been some positive news, with MPS (nursing agency) now having a team of trained care support workers who will be able to support the packages of care. QS&E Primary Care Estates: Clare Evans advised of the work that is being progressed on Estates Development. Meetings are held with the Director of Strategy & Planning, and GP Contract & Development Manager is linking in with other Health Boards to establish their level of progression. Currently Aneurin Bevan is the only Health Board that has progressed, however they have invested money. Sue Toner is leading from a Public Health perspective on the LDP and is coordinating the planning applications responses received. PCIC CB are feeding into this work, and involving pharmacy, contractor professions and Locality Managers. Finance are also involved, advising on the possible long term financial implications. Rob Mahoney, Finance Manager, is supporting the financial modelling on impact, not only for PCIC and contractors, but for the wider organisation and community services. PCIC attend financial modelling meetings and provide comment on applications, however PCIC lack planning and leadership knowledge to advice on next steps. To address this issue PCIC will be meeting with the Asst. Director of Planning. Presently PCIC are instigating mitigating actions such as; progression towards the development of a large surgery within N/W Cardiff, supporting both contractor professions and community services. PCIC will be working with Local Authority and Third 4

5 Sector to look at developing different models to make this happen. Clare Evans advised of an issue with estates development, which can only be addressed through capital planning. PCIC have both the Whitchurch Hospital and Llanederyn sites to consider. PCIC are working with the Director of Strategy & Planning and the Asst. Director of Planning to try and progress with developments before the sites are sold. The plan is to build alternative treatment centres, supporting both GP surgeries and other contractor professions, however PCIC will need to negotiate with the development contractor buying the sites to ensure they retain land to allow PCIC to put forward a capital bids. QS&E District Nursing Anna Mogie advised that a paper has been developed for consideration at the Service Delivery Group, or at a separate meeting. The Welsh Audit Office report has been received which has provided useful benchmarking information and provides an idea of C&Vs position across Wales. Nicky Hughes advised on the development of escalation cards for district nurses, these are currently out for comment. It was noted that it is currently difficult to articulate what capacity is required to meet the demand. Discussions were held as to whether the risk needs to remain on the PCIC risk register. Kay advised that given the level of risk that is being managed on a daily basis the risk needed to be formalised in this way. Kay advised that district nursing services are also fragile and struggling to meet demand and that the service is intrinsically linked to GMS. From a professional point of view the service is not meeting their professional standards, which from a nursing perspective is a concern. Members agreed that the risk would remain on the log. QS&E Western Vale DN It was agreed that there is more than one concern contained within this risk. Western Vale would need to be the heading, with each risk separated below. (DN / Boundaries). KJ Discuss any new risks GMS: Member enquired as to why GMS was not on the risk register, especially as it was raised as a fragile service at the development session. Members discussed the risks involved and agreed that GMS would be included. CE 7 Statutory & UHB Compliance IRIS Rhian Floyd advised members on the Identification and Referral to Improve Safety (IRIS) programme, which provides identification, referral and safety advice to practices in support of patient s who they suspect are the victims of domestic violence. IRIS is currently running a project in partnership with South Wales Police and the Crime Commissioner. This is a two year project which commenced in October PCIC have recruited Dr Jackie Gantley as Clinical Lead, and Dr Laura Wasst, from Caerau Lane Surgery as Clinical Champion. 25 practices have been identified to be trained for the pilot and 5

6 training started this month. The practices are a random sample from both, those reporting a high level of domestic violence and those reporting a low level, just to see what impact the project has. This is a tested model which has already been run successfully in England. Nicky Hughes advised that a new D&V framework is soon to be disseminated. Feedback has been requested in terms of our organisational requirements on compliance of our services. Welsh Audit Office DN Report & Action Plan Members received a copy of the DN report & action plan. Kay Jeynes advised that a meeting has been held with WAO following their audit in April C&V were the last HB in Wales to receive feedback. The WAO were complimentary about C&V systems and processes, which PCIC can take assurance from. WAO felt that no other Health Board had the performance frameworks and monitoring in place, or even the understanding of services that was found in C&V. Kay updated members on the recommendations and actions, many of which have already been progressed. Members agreed to sign-off the proposed action plan. It was suggested that it would be good to get engagement from the Community Directors/Community Directors Meeting. Discussions around this will be held with Chris Darling. Vicky Warner advised that the Welsh Audit Office report will be presented at People s Performance & Delivery (PPD) Committee in March. Sue Morgan requested that the relevant people who needed to be party to this information were made aware (PARIS lead, Fundamentals of Care Lead) prior to PDD. Brendan Boylan suggested the report could be used to develop a Service Improvement plan, this would support future audits and reduce any service risks. KJ KJ / KJ / It was noted that the WAO will be providing direct feedback to District Nursing teams on 28 th /29 th January Concerns: Complaints, compliments and incidents Summary of themes and trends arising from concerns In order to gain a picture of both the total number of PCIC complaints outstanding, and the total complaints received/actioned over the last month, the complaints report been separated into 2 reports. It was noted that the Complaints Team are only able to provide limited information, which means that PCIC are spending a significant amount of time sourcing data, extracting lessons learnt and altering the report format to make it fit for purpose. Members noted the content of the reports and were concerned that the Complaints Team are not closing-off or following-up complaints to ensure an accurate, up-to-date picture. It was agreed that a meeting would be held with 6

7 Angela Hughes, Complaints Manager, to raise concerns and to identify leads from the Complaints Team for following-up the complaint/action. In-light of the recent HSMB report, which refers to the transferring of the complaint processes to CBs, members felt PCIC CB does not have the capacity or resource to support this transfer of work. It was suggested that if the complaint processes was to transfer to CBs that funding/resource should also transfer to support the large workload. It was agreed that the current complaints process was not fit for purpose and that change was required. It was agreed that the production of this report had demonstrated the significant amount of time and effort required on just one part of the complaints process. Members agreed that improvements to the complaints process would not be made by delegating the work out to CBs without the associated resource, as this would only increase the risk. It was agreed that concerns would need to be escalated. Members reviewed the contents of the report and it was noted that the description of the complaint did not relate to the lessons learnt. It was agreed that the description and the extracting of lessons learnt would need to be clinically supported to ensure accurate reporting. Members agreed that a process on ensuring the sharing of the lesson learnt and confirming compliance would need to be developed. Clare Evans advised that contractors responding direct on complaints do not have a response letter template that supports the recording of lessons learnt. It was suggested that a C&V template, including headings, would be developed and shared with contractors. / CW Serious Incidents Members reviewed the PCIC SI log: HMP Cardiff SIs Vicky Warner advised that the Prison SIs were taken through the last Prison Partnership Board, where it was agreed that a number of the incidents could be closed. It was noted that the signed-off prison action log had only been received today; therefore updates to the PCIC CB SI log will be made after this meeting. A request has been made to the Prison for a copy of their completed Welsh Government Closure Forms to provide PCIC with final assurance. It was noted that it had been agreed at the Prison Partnership Board that learning from the action log will be taken to the Prison Healthcare Improvement Network, in March, by Rose Marnell and Karen Mills. OOHs: SI has now been closed by Out of Hours. Members agreed to sign-off and close this incident. Members requested that OOHs be advised to share any lessons learnt with all GPs/staff. Where OOHs have identified actions for sharing they need to report back to PCIC once these have been carried out/complete. RF / CE WAST: SI remains open. The Patient Safety Team is managing this incident. It is on the PCIC log for information only, as PCIC had some involvement. The Patient Safety Team are still chasing/awaiting a response from WAST. 7

8 PRUDIC MMR: SI remains open. A PRUDIC meeting was held yesterday. PCIC are awaiting outcome/feedback. Sewer Pipe (CRI): Decontamination has taken place in all areas affected. X-ray is now open and normal service has resumed. There are ongoing conversations between UHB Estates Dept and LANG in relation to the ball-joint equipment in the toilets, which UHB Estates feel are substandard and may cause problems in the long term. A Closure Form has been completed and returned to WG. Members agreed to the closure of this incident. GP: SI remains open. Awaiting the finalised Ombudsman report. This will be chased up. PCIC have developed a draft action plan which has been sent to Corporate Office. GH Mental Health Services MH Services are managing this incident. Details are on the PCIC log for information, as PCIC had actions. PCIC actions have now been completed. Members agreed for this incident to be signed-off and closed from a PCIC perspective. _ DOSH Incident (for information only) Nicky Hughes advised members of a recent incident regarding a patient who had visited DOSH in November 2014, where test results were negative. The patient, who was not carrying any identification, was involved in a fatal rail incident on New Years Eve, and the only paperwork they held was an appointment card for DOSH. Police then visited DOSH to identify the patient. There was nothing to suggest that the patients visit to DOSH in November had anything to do with them taking their life. DOSH have not heard anything since, however it is expected that details will go to the Coroners Court. Vicky Warner advised that a decision has been taken by the UHB not to report this incident. It was noted that the patient was not known by mental health services and had not attended his GP with any concerns. 9 Clinical Effectiveness, Policies and Procedures Paediatric Continence SBAR Kay Jeynes referred members to the Paediatric SBAR. It was noted when paediatric continence issues arise in the community the complaints are often directed to the Health Minister or AM, and then forwarded by default to the adult continence service for resolution, as the adult service oversees the continence pad contract within JES. With an increasing number of complaints, and contact from parents/health professionals being received an SBAR has been developed to highlight both the concerns and pressures this situation is causing within the Adult Services. It seems that paediatric services would like part of the adult service budget, however when adult and paediatric services split in the reorganisation, paediatric services were gifted a whole time equivalent as part of a deal to prevent the adult service providing care to children. It was also agreed that 8

9 paediatric services would not be gifted any of the (JES) budget as this was felt to be too small. With no resolution in sight, relationships between the two services are becoming strained. Members noted the content of the SBAR and agreed that engagement should be made with Child Health Services to jointly resolve these issues. Members requested that an update on progress be brought to a future meeting. KJ Non-Medical Prescribers Policy Karen May advised that, unlike Secondary Care, Primary Care have never had a non-medical prescribing policy. The intention of this document is to set out the governance arrangements for non-medical prescribing within the health community served by C&V UHB. Pharmacy in Secondary Care Kay Jeynes advised members that Helen Earland has been overseeing nonmedical prescribing for PCIC nursing, and that an interim community nonmedical prescribing policy and register are already in place. This process also oversees the issuing of pads to all nurses and community (nursing) IPs. Members agreed that pharmacy and nursing documents would be amalgamated. It was noted that the policy is being submitted to the UHB Q&S Committee and the Nursing & Midwifery Board. Members were asked to provide comments to Vicky Warner prior to these meetings. It was agreed that once the final policy has been approved and launched, that a template of the policy will be shared with practices via the LMC, with the advice that they should adopted this policy. KJ / KM ALL KJ / HE 10 Safeguarding S/E Cardiff Nicky Hughes advised of concerns in relation to a S/E Cardiff nursing home, where three attempts to arrange a meeting have failed. The concerns are in relation to; the management of the home, weight loss of a number of resident s and an ongoing police investigation, instigated by WAST, which is unrelated to the UHB and is not a UHB residents. It was noted that the concerns have not impacted on placements within the home. Nicky Hughes advised of a police investigation in a second S/E Cardiff nursing home, where a carer was sacked immediately. Assurance has been sought on the safety of the residents however there is a need to ensure the carer is not employed within another home. Details are being progressed through the POVA process. N/W Cardiff 9

10 Anna Mogie advised of potential escalating concerns in relation to an independent (LD) hospital. There has been a number of safeguarding concerns raised and an improvement action plan has been issued under the framework contract. Vale of Glamorgan Kay Jeynes advised of a pressure damage (VA1) issue. It was noted that the LIPS programme is currently being utilised in the Vale to reduce the prevalence of preventable pressure injuries, however a Vale patient was admitted to hospital with a pressure injury grade 4. On initial assessment a VA1 was completed by ward staff, but the quality of the information provided was found to be poor. On review it was felt that the pressure damage could have been prevented. It was difficult to identify an individual responsible, as there were more than 8 staff involved in the patients care. The patients risk assessments and care plans were all out of date and documentation was poor. The patient and their partner were non-compliant with treatment; however the patient notes did not articulate information to support this fact. The Locality Authority has lead on the safeguarding process, and a caution letter has been issued by the Vale Locality, outside of the disciplinary policy, to all staff in the team. The letter was handdelivered and all staff were asked to sign to show receipt. Any staff not present, have been asked to sign and return a sheet to confirm they have read the letter. From RCA reviews it is clear that professional standards in the completion of documentation are poor across the service and that is why the LIPS programme has been utilised. The Vale Locality will be re-auditing, and any individual not following the correct procedure will be taken down a disciplinary route. In response to the letter staff have raised concerns about the demand on the service, and issues with Netbooks not being able to pick up access in certain areas. Staff concerns have been taken into consideration however staff were clearly acting outside of their professional responsibility, and there was a need to be assured that improvement would take place. Details will be monitored through the Vale Q&S meeting, and the LIPS programme will support this agenda KJ / CW Members requested that details be included on the PCIC SI log. 11 Information management and governance No items 12 Clinical Audit & Clinical Developments LIPS Department of Sexual Health (DOSH) Nicky Hughes advised that a team from DOSH attended the last LIPS programme (two consultants, Nicky Hughes, Rachel Thomas and members of the Nursing Team). As part of the programme the team looked at concerns raised by service users in relation to contraceptive procedures (coils and implants) provided in CRI and in community clinics. Service users had reported that it was difficult to make an appointment, and were often told the clinics were full and to ring back the following month. As part of the programme DOSH undertook a survey, and a number of recommendations have been made to support the findings. Recommendations include; more dedicated nurse lead clinics, a dedicated phone 10

11 line for appointments and a review of staff in community clinics. Part of the community review will be to try and bring the level of service provided in the community inline with the service provide at CRI. It was noted that another team from DOSH will be attending the next LIPs programme to look at results. Ann to be asked to provide a LIPs update at the next meeting. KJ 13 Business unit reports The update reports from the PCIC Business Units were received for consideration and agreement. Vale of Glamorgan Kay Jeynes advised on the mobile netbooks which are causing major concerns around keeping documentation up to date. Sue Morgan advised of the two main factors contributing to the problem, these being; EE the service provide and the age of the netbooks. It was noted that after signing the EE contract, EE had relocated some of their masts to cover an event taking place elsewhere in the UK (Common Wealth Games), which meant that coverage in our area had been significantly reduced. The contract with EE is due for renewal in June 2015 and EE have been advised to return the masts or the contract will not be renewed. It was noted that changing the service provider may not resolve all the access issues, due to the age of some of the netbooks. Members felt that an interim plan was required. Sue Morgan advised that work is ongoing to look at different types of netbooks, and that funding may be available next year. It was noted that even with new netbooks there may still be some remote areas where there will not be coverage. Palliative Care Kay Jeynes advised of the concerns accessing DN support for End of Life. It was noted that 15 hospice beds have been closed due to staffing issues. CHAP Rhian Floyd advised that the engagement exercise in relation to GMS provision within CHAP was completed in January. A range of stakeholders have responded and information is being collated, which will be presented to SMT. The operational staffing pressures were noted. A band 6 position has gone out to advert this week, along with a GP position, and a new receptionist has started. Rhian advised of the risk in relation to some of the professionals in the service around the demand and pressure on the midwife and health visitor roles. Concerns have been raised with W&C CB yesterday, and a conversation has been held with Sandra Dredge, who was advised to raise any concerns. HMP Cardiff Rhian Floyd advised on the Clinical Director and Senior Nurse nominations for UHB staff leadership awards. North West Cardiff 11

12 Report received for information. South East Cardiff Nicky Hughes advised that the ombudsman has responded regarding the case for DOSH and as upheld the decision relating to the two issues raised. It was agreed that Nicola Lomax would need to report back to Vicky Warner on this case. Members agreed that the recommendations and action plan should be brought to the next meeting. NH OOHs Clare Evans advised that a meeting was held on Friday, which looked at: learning, reflection, service improvement and recruitment. Pharmacy & DRSSW It was agreed that Pharmacy and DRSSW would provide a Business Unit Report. KM / Items for Information: Homicide Review (Mr L) Welsh Government Patient Safety Notices: Nasogastric tube placement devices Button batteries Dexamethasone Members noted the items for information. 16 Date and venue of the next meeting: Tuesday, 10 March 2015, 1.30pm, CRI Meeting Room 1 12