RATIFIED MINUTES OF THE QUALITY & RISK COMMITTEE (QRC) (On behalf of the NNE, NW and Rushcliffe CCGs)

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1 RATIFIED MINUTES OF THE QUALITY & RISK COMMITTEE (QRC) (On behalf of the NNE, NW and Rushcliffe CCGs) Wednesday 03 February :30 4:30pm Clumber meeting room, Easthorpe House, 165 Loughborough Road, Ruddington, Nottingham, NG11 6LQ Membership: 23/04/ /07/ /10/ /02/2016 Susan Bishop (SB) (Chair) Nichola Bramhall () Max Booth (MB) Michael Rich (MR) Lynne Sharp (LS) John Tomlinson (JT) Hazel Buchanan (HB) Becky Stone (BS) Dr Ram Patel (RP) Craig Sharples Dr Paramjit Panesar (PP) Gail Colley- Bontoft Esther Gaskill (EG) In Attendance: Elizabeth Owen (EO) Sue Clarke (SC) Annette Pilkington (AP) Coral Osborn (CO) Lay Member, NW CCG Present Present Present Present Director of Nursing and Quality, NNE, NW and Rushcliffe CCGs Patient Representative, Rushcliffe CCG Lay Member, NW CCG (Joined the meeting approx. 13:40) Head of Governance and Integration, Rushcliffe CCG Deputy Director of Public Health, Nottinghamshire County Council Director of Operations, NNE CCG (joined the meeting approx. 14:00) Assistant Director of Quality and Patient Safety, NNE, NW and Rushcliffe CCGs GP Representative Rushcliffe CCG (Joined the meeting approx. 13:50) Head of Quality, Engagement and Governance, NW CCG (Deputy sent) GP Representative NNE CCG (Left the meeting approx. 15:30) Head of Quality and Adult Safeguarding, NNE, NW and Rushcliffe CCGs Head of Quality, Patient Safety and Experience, NNE, NW and Rushcliffe CCGs Quality & Patient Safety Team Secretary, NNE, NW and Rushcliffe CCGs (minutes) Governance Officer, NW CCG (On behalf of Craig Sharples) Senior QA Advisor, Screening QA Service, Public Health England (Observer) Senior Prescribing (North) and Governance Adviser, Nottinghamshire County CCGs (For item QRC/15/096) Present Present Present Present Apologies Present Present Present Present Present Present Present Apologies Apologies Present Present Present Apologies Apologies Present Present Present Present Present Present Present Apologies Present Present Apologies Present Present Apologies Present Apologies Apologies N/A N/A Present Present N/A N/A Present Apologies N/A N/A Present Present Present Present Present Present N/A N/A N/A Present N/A N/A N/A Present N/A N/A N/A Present Quality and Risk Committee February 2016 Page 1 of 11

2 QRC/15/081 Welcome and Introductions SB welcomed the committee and introductions were made. It was noted that PP would need to leave the meeting by 15:30 and RP had informed the Chair that he may be running late to attend due to surgery and patient visit beforehand. It was noted that despite the late arrival and proposed early departure the committee would remain quorate. QRC/15/082 QRC/15/083 Apologies for Absence Apologies were received from: Gail Colley-Bontoft and Craig Sharples. Declarations of interest None. QRC/15/084 Draft minutes of the previous meeting of 30 July 2015 Noted on page 1 of the attendance list, the last column should now read 03/02/2016 as this meeting had been rearranged from 14/01/2016. At the bottom of page 7 there was a typing error with the word edition, this should have read addition. ACTION: Amend the minutes accordingly. EO Subject to the two amendments being made the minutes were agreed as an accurate record. QRC/15/085 Action log outstanding items QRC/15/058 EIA update to be brought to February meeting. To be discussed under item QRC/15/088. E&D forum role had been discussed through a telephone call, a meeting had not been arranged, this was to be reviewed. Circulate an update on domiciliary A deep dive paper had been produced, this was to be circulated after today s meeting. Noted that there was now movement to joint commissioning for home care, with City, County and Local Authority colleagues and involvement from quality team, finance and contracting. ACTION: Circulate the deep dive paper on domiciliary care. QRC/15/062.3 QIA for urgent care centre. This action was ongoing, it had been ascertained that an EIA had been completed. LS was awaiting confirmation regarding whether a QIA had also been completed. QRC/15/063 MP letter to. This had been actioned. QRC/15/074 Primary care quality sub groups highlight report to be submitted to QRC once groups up and running. The NNE group had been established and had an initial meeting. NW and Rushcliffe groups were still to be established. Therefore dashboards were not yet complete and highlight reports would be generated from these. Quality and Risk Committee February 2016 Page 2 of 11

3 MR raised concern regarding the Primary Care quality sub group for NW in that this had not been established yet. It was noted that there was currently consideration to merge two meetings, so that the now Primary Care Development Group would become the Primary Care Quality Sub Group. All other actions were complete/on the agenda for today. Matters arising not elsewhere on the agenda Highlighted that this committee still required a secondary care consultant on the membership. This was to be included in the highlight report to GB. Request made that all actions be completed and updates sent to EO prior to the meeting in order to save time on this section during meetings. QRC/15/086 Lay Member/Lay Representative feedback on activities relating to the Committee MB had attended the NUH QSP in December 2015 (18 th ). The committee were informed that the following had been discussed: Delays in patients receiving medicines on discharge, it had been found that the problem was not attributable to pharmacy but mainly due to delay in prescriptions being written up and signed by medical staff. Maternity services a presentation was given at the QSP regarding patient experience, the audit had been carried out by Picker, MB raised concern of NUH using an external source to highlight efficiency/inefficiency in this service, questioning that NUH should already be aware themselves. The committee were then informed that Picker was a National survey that NUH had been selected to be part of, 1 of 64 trusts. The audit had shown areas for improvement with regards to post-natal care in the community. Digital imaging delays were still an issue, this was being monitored through the quality and performance meeting. Cancer waits 62 day target being missed. NUH were conducting harm reviews on waits over 100 days. MB found this concerning in that this appeared to suggest NUH were pushing the set targets aside, commenting that targets must obviously be set for a very good reason, assumingly; early diagnosis-early treatment. It was noted that cases were very individualistic to each patient and therefore harm reviews required conducting in a way based on the specific patient. It was pointed out that the harm reviews did not appear to asses possible psychological harm to the patient. The committee were informed that contracting were involved with regards to the 62 day wait breaches and a remedial action plan was in place. The QSP also received a presentation on the NUH response to the National safety standards for invasive procedures. MB noted his concern that NUH were not fully following these standards and rather interpreting them to own use. NUH response had been that their approach was to interpret with integrity. An action from the meeting was for BS to meet further with the relevant member of NUH to ensure full understanding of what changes NUH intended and that each had a legitimate reason for doing so. It was also Quality and Risk Committee February 2016 Page 3 of 11

4 confirmed that NUH would be required to complete a QIA for any variance from national guidance. There was no further feedback from lay members present. QRC/15/087 QRC/15/088 QIA spreadsheet 31 QIAs completed. Training undertaken for all 3 CCGs, approx. 40 staff with another session to be held. Sessions evaluated well. QIAs now being completed more robustly. SB queried if the current process was sufficient to assess risk given the magnitude of savings that needed to be made this year. advised that the current process is robust and that the likely implications of the large QIPP target would be an increase in the risk scores in future QIAs. As a result it was noted that the committee would likely see more QIAs in full in future as any with a score greater than 8 would require QRC review. EIA update No EIAs to escalate. Comment that assurance was required that EIAs were being completed and monitored. Agreed this would be discussed at the QRC development session. Highlighted that environmental impact assessments should also be considered. It was thought this would be covered under the sustainability work. The Committee agreed this required clarification but it was felt that this would not be the role of this Committee. ACTION: Discuss approach to monitoring completion of EIAs at the QRC development session. ACTION: clarify where environmental impact assessments should be considered. All Reports QRC/15/089 CCG Governance Leads Service Development updates 1. NNE Noted this report was for quarter 3 not 2 as stated. Items that went through clinical cabinet were discussed. Discussion held regarding QOF Exception Reporting and the significant variation in reporting. A second audit was due within the next month and another in 6 months, tracking clinical improvement work within that. This would be something the Primary Care Quality Sub Group would pick up. 2. NW Comment regarding the IAPT pilot for long term conditions was to continue into 2016/17 but the QIA had not yet been completed. Query raised regarding joint schemes that the QIA may have been completed by another CCG. Each CCG involved should ascertain and note when QIA completed. 3. Rushcliffe Highlighted HCOP in-reach pathway, QIA was to be sent to as soon as possible. Joint schemes issue noted here again, recognition that a smartening up of the process for these was required. Quality and Risk Committee February 2016 Page 4 of 11

5 There was mention that NNE had devised a Primary Care Strategy, there was a question of whether each CCG was to do this. Noted that the quality assurance framework was across all 3 CCGs. QRC/15/090 Quality Report Quarter /16 Page 4 of the report was highlighted, Rushcliffe and NUH had exceeded trajectory for HCAI limits in quarter 3. NUH were currently at 82 cases for C Diff against an end of year target of 91. Peer comparison now included within the report, which the committee welcomed. NUH were in the middle of the pack against peers and Rushcliffe were the best performing CCG in their peer group. Increase in the amount of Pressure Ulcer SIs (mainly HP), there had been a reduction in falls, maternity and HCAI SIs. Confirm and challenge was being conducted with NUH maternity SIs. There was a question of peer reviews for SIs and never events, this was not carried out as difficult to achieve with too many variances it would not wield a great deal and therefore instead sharing of learning was favoured. Transforming care on page 11 was noted, the CCGs were on trajectory for reduction targets by the end of March. Page 13 gave information on care homes of note, 1 home in NNE was on the radar as this home was making a planning application to extend the care home. CQC warning notice regarding staffing had been issued to Coppice Lodge. Quality monitoring visits continued to Eton Park as this home was still in administration. Skylarks issues ongoing, joint working between LA and CCG to monitor. Retrospective CHC reviews had revised timescales, information on these could be found on page 14 of the report. Local stretch target had been retained. At the end of December 2015 both the new National target and the local stretch target were being achieved. Page 15 gave information on quality visits, those in bold had been undertaken in quarter 3; Circle dermatology, HP leg ulcer clinic, NUH sterile services and orthopaedic theatres. All had been positive visits. There was to be a visit to NUH ED tomorrow. Visits to Ramsay and the Park had commenced. There was a question of whether patient feedback was assessed at the Circle dermatology visit. The friends and family test and Circle s questions asked to patients were reviewed, which gave very positive feedback. With regards to patient experience on page 18 of the report, there was no particular theme or trend. Page 21 gave details of GP practices CQC inspection outcomes. The committee were informed that since the time of report writing there had been good outcomes for Appletree and Castle practices. There was concern raised regarding moving work out into community when HP management of PUs did not appear good with respect to the data showing an upward trend in figures. However, it was noted that HP Quality and Risk Committee February 2016 Page 5 of 11

6 had reduced the number of PUs starting, the work remained around stage 3 PUs. It was felt that HP need to look at human factors, comprehensive RCAs are being completed, but they now need to start effecting sustainable change. Assurance required that HP are learning from PUs and implementing that learning to promote change. Suggested that quality feed into mobilisation work. Comment regarding low number of complaints, it was noted that GP practices dealt with their own complaints. QRC/15/0091 Provider quality dashboard Noted very comprehensive. NUH mortality, HSMR remains an outlier, joint work with TDA has been undertaken. An external review of data by Public Health has also been completed which supports the previous analysis that this is related to coding for palliative care patients. Joint meeting to be held with NUH, South CCGs and Nottingham City CCG to discuss incidental findings of the review relating to quality of record keeping. Question regarding figures for staff appraisals, turnover and mandatory training not being very good. Turnover figures seemed high, noted MB. There was also movement around Nottinghamshire. NUH were struggling to recruit to Paediatrics. Reflective of National shortage of nurses. Community National turnover approx. 9-10%. Reviewed at locality level by HP. Question if there was still a knock on effect from EMAS waiting times at Leicester Royal. It was confirmed that there was, work was being done to try and reduce waits. Harm reviews being carried out, based on clinical professional judgement by EMAS alongside external parties being involved. Red misses reviewed so far, noted need to review all categories. Question asked if EMAS were still at the bottom of the table in comparison with peers. EMAS were not bottom for all indicators, cardiac arrest figures had improved, YTD EMAS were the best performer regarding conveyance times of patients with a certain type of heart attack to hospital. 1. CHP QSP minutes of 12 November 2015 Query of 48 incidents reported for one care home, noted on page 3 of the minutes, was this figure correct. Post meeting note: The report submitted for the QSP meeting of 12 November, on page 8 stated 48 incidents are reported from Sutton Manor Care Home. The number of incidents reported in respect of Sutton Manor Care Home which is a Residential home in Sutton In Ashfield, has been shared with Mid-Nottinghamshire CCG s. Assurances have subsequently been provided that this data has been shared with the Local Authority for further analysis and investigation. 2. CN QSP minutes of 07 January 2016 Minutes submitted for information, no queries or comment. 3. NUH QSP minutes of 18 December 2015 Quality and Risk Committee February 2016 Page 6 of 11

7 Noted shared CQUIN across community, question of whether this was to happen. Felt it would be beneficial, liaising with providers over the next couple of weeks. 4. Provider focus reports: CHP No queries. Noted this is a very comprehensive and helpful report. Feedback from Sub-groups QRC/15/092 Care Homes group 1. Minutes of 10 December 2015 Gail Colley-Bontoft now Chair of this group. Active group, Mid Notts keen to join. Noted patient safety collaborative barometer work regarding continence and PUs, good uptake from care homes. Strengthening reporting processes for care homes to the CCGs. AQP contract being looked at. To request monthly feedback from care homes regarding falls and PUs. Question of 1 st sentence on front sheet, regarding collaborative working with LA. Arrangements being finalised. PP mentioned the review of the community geriatric service, was this being linked in with the care home group. It was felt this should be the case as there were members of the group involved in the review also. QRC/15/093 Health and Safety (H&S) group 1. Minutes of 18 January 2016 Request for policy reviews to be every 2 years rather than Progress report Security management standards; no deadline date as yet. Progress already made on these, therefore to stand down this work until deadline confirmed. NHS Property Services compliance reports not providing meaningful data and not being received in timely fashion. Bridget Meats had left NNE CCG, which meant there was no trained IOSH member for that CCG currently. However, this was not felt to pose a risk to the organisation as could be covered by the council, LS/SC. 3. Quarterly incidents report Q3 2015/16 1 H&S incident at NNE CCG, reported and followed up appropriately. QRC/15/094 South CCGs Equality and Diversity Forum 1. Minutes of 12 October and 07 December 2015 No comments or queries. Approval / ratification 2. Progress report Included E&D criteria in quality schedule, data, EDS system and workforce race equality standard. Quality and Risk Committee February 2016 Page 7 of 11

8 QRC/15/095 Policies and procedures: 1. E&D Policy The policy had been to the last E&D forum meeting and there were some alterations to be made following that meeting. Policy deferred. 2. NUH QSP ToR Updated to reflect new team structure. 3. H&S Policy Now reflected Primary care commissioning responsibilities within section 2. Violence and aggression needed including on page Incident reporting procedure inc. RIDDOR Section 3.4 required updating in relation to primary care incident reporting. Approved subject to wording included regarding primary care. ACTION: Send paragraph to LS on primary care reporting to include in the policy. 5. Expectant mothers policy No comments, submitted due to review date. 6. DSE Policy No comments, submitted due to review date. 7. Lone working policy New policy for approval. Question regarding working from home in terms of CCGs responsibility, covered by DSE policy; own responsibility to ensure work station is fit for purpose. CCG staff are contracted to work from a base, if were contracted to work from home then would be CCGs responsibility to ensure H&S of employee at home. 8. Security management policy New policy for approval. 9. Violence, aggression and harassment policy New policy for approval. The Committee agreed to extend the review period to 2 years for existing H&S policies, with new policies being reviewed after the first year and two years thereafter. 10. QIA policy Policy updated with regards to consultation during training. Quality and Risk Committee February 2016 Page 8 of 11

9 Suggestion of QIA training at PLT events. Clinicians agreed need an awareness of QIAs. There had been an additional amendment to the policy in adding the lead CCG for the scheme. 11. Trans* Equality and gender reassignment policy National guidance included, policy aligned to that. Amend to include all 3 CCG logos in order to adopt the same policy across the 3. Positive implication of having the policy was noted. Highlighted paragraph at the bottom of page 10, section 6.3 regarding long term sickness, could be interpreted in a contradictory way. This was noted to be from the National guidance. Action: Policy to be amended to include all 3 CCGs logos and be adopted across all 3. HB For information QRC/15/096 Medicines Management Team 1. MoU This was for controlled drugs, all 5 CCGs had been asked to sign the MoU. Assurance given that everything covered in MoU was already being carried out. This was a formality to have a written agreement. Well established incident reporting, monitoring, investigating and learning from incidents. Query raised in relation to why this was now being formalised, this was due to the process not being conducted across the country, therefore formal agreements were being put in place. Question if communication circulated that this MoU had been written, had it been sent to GP practices. Confirmation required of how this should be taken to GBs. At present the MoU was sent to prescribing advisors of each CCG. To be included in highlight report from this meeting that the MoU was seen here. Consider at development session. 2. Work programme Q3 2015/16 Noted as useful for the committee. 3. Pharmaceutical advice to social care report Commissioned by NCC, work done in social care team. Question raised regarding the wavy line document (a document which outlines what health related tasks can and cannot be undertaken by social care staff), this had been updated for medications. Jane Cashmore was organising the non-medication side. SB thanked CO for the reports and her time. QRC/15/097 NHS England Area Team quality surveillance group feedback The meeting was held on 18 January SFHT situation was discussed, Derby or NUH to be appointed to support. The group registered concern over this arrangement, if NUH were to be successful and be appointed as the support for SFHT this could impact negatively on NUH itself. Need to be mindful of current difficulties at NUH and the Quality and Risk Committee February 2016 Page 9 of 11

10 potential impact on services already under strain, that a turn of attention to SFHT could have. Outcome expected mid/late February. Revisit risk once outcome known. Noted the bid from NUH for this was with commissioner support. Suggested that QIA be carried out if NUH successful and possibly place on risk register. QRC/15/098 QRC/15/099 CQC reports/action plans NUH still awaited. Circle had made good progress with their action plan. Follow up quality visit completed. Ramsay report due this month. Nottinghamshire children in care final report awaited. EMAS report awaited. It was noted that there were significant delays in reports being issued due to capacity issues at the CQC causing delays to the quality assurance process. Safeguarding Committee Highlight report Deprivation of Liberty Safeguards (DOLs) scoping impact of Cheshire West ruling, paper to come here. Likely to be put on risk register. Now includes CHC patients with package of care at home that is restrictive. Issue of completing best interest assessments for those patients, due to capacity. Change effective from now. Question regarding safeguarding risk register, reviewed at committee, noted in minutes. Request to put in highlight report also for auditing purpose. Action: Future safeguarding committee highlight reports to include commentary regarding changes to the safeguarding risk register. Quality Assurance QRC/15/100 Clinical Risk Registers Summary south CCGs Query regarding risk of quoracy for this committee and if this still needed to be on the risk register. It was felt that this no longer needed to be included on the risk register as the committee had GP representation now and a secondary care consultant, whilst desirable on the membership was not essential for quoracy. Committee agreed to remove this risk. Risk 69 presentations received at GBs regarding LA proposed cuts. Each GB was to submit a formal response. Concerns with CHC funding and reduction in care home monitoring. This risk will be updated once the LA consultation has been concluded and we know which schemes are being taken forward. The decision is expected at the end of February. ACTION: Archive QRC quoracy risk. ACTION: Update risk RR69 once LA consultation concluded. BS 1. Identification of new risks resulting from agenda item discussions Possibilities: DOLs- it was noted that this will be reflected on the safeguarding risk register If NUH are identified as support for SFHT this risk will need to be added. New risk: Mental Health in patient bed capacity- this had recently been added but the score had already reduced as a result of mitigations Quality and Risk Committee February 2016 Page 10 of 11

11 put in place. ACTION: Liaise with Karon Glynn, Assistant Director Mental Health & Learning Disabilities, Newark and Sherwood CCG to update risk RR Items for escalation to the GB assurance framework None. QRC/15/101 QRC/15/102 Items for escalation to the Governing Bodies Discussions regarding E&D and how gain assurance. Where environmental factors for schemes be considered. No secondary care doctor on QRC membership. HCAI position against limits for NUH and Rushcliffe CCG NHS Property Services compliance reports. 2 pending risks; NUH and DoLS. Any other business Suggest set of words be sent to each CCGs audit committee for the selfassessment. ACTION: Send set of words to each audit committee Reminder of development session on 17 th February, being held 12-5pm in the Committee room, Gedling Civic Centre, Arnold, NG5 6LU. Annual report writing, section on quality required updating. Send wording for use in all 3 CCGs annual report. ACTION: Send updated quality section for the annual report to LS, Emma Pearson, NNE CCG and SC. QRC/15/103 QRC/15/104 Learning outcomes of this meeting Medicines management team information was useful to receive. Appropriate to review policies every 2 years rather than 1. Timing for each section at this committee was improved. Date and Time of Next Meeting Wednesday 27 April :30-4:30pm Clumber meeting room, Easthorpe House, 165 Loughborough Road, Ruddington, Nottingham, NG11 6LQ All attendees should be aware that NNE CCG is legally required to comply with the Freedom of Information Act 2000 The minutes and papers from this meeting could be released as part of a request for information Quality and Risk Committee February 2016 Page 11 of 11