Note the views of the Audit Committee on the Annual Reports of the Governance Committees.

Transcription

1 NHS Highland Board 24 July 2018 Item 5.8 GOVERNANCE COMMITTEE ANNUAL REPORTS Report by Ruth Daly, Board Secretary on behalf of Elaine Mead, Chief Executive The Board is asked to: Note the views of the Audit Committee on the Annual Reports of the Governance Committees. 1. Summary and Background As part of the Annual Accounts process a number of Annual Reports relating to NHS Highland Committees are produced, including a specific declaration that the systems of control within their respective areas are considered to be operating adequately and effectively. These Annual Reports form part of the framework of assurance supporting the Statement of Internal Control which is part of the Annual Accounts process. At their meetings held on 8 May and 26 June 2018, the Audit Committee considered and noted the following Annual Reports: Appendix 1 Staff Governance Committee Appendix 2 - Remuneration Sub Committee Appendix 3 - Clinical Governance Committee Appendix 4 - Highland Health & Social Care Committee Appendix 5 - Control of Infection Committee Appendix 6 - Health and Safety Committee Appendix 7 - Pharmacy Practices Committee Appendix 8 - Finance Committee Appendix 9 - Asset Management Group Appendix 10 - Audit Committee 2. Contribution to Board Objectives The above reports form a key part of the statutory requirement for NHS Highland to submit an Internal Statement of Control which is included in the Boards Annual Accounts. 3. Governance Implications The production of these Annual reports forms part of the assurance framework for the Board regarding the way in which its Committees discharge their delegated responsibilities. This encompasses all areas of Governance including: Staff Governance; Patient and Public Involvement; Clinical Governance; and Financial Governance. 4. Planning for Fairness This paper describes the annual reporting process and therefore does not require an equality impact assessment. It is however recommended that Committees of the Board are aware of and understand their responsibilities in terms of challenging inequality and promoting equality and diversity and how this can be embedded within governance and decision making processes. 5. Engagement and Communication These reports have already been approved by their Committees in at least draft format. They are public documents both as part of the Board papers and as part of the Annual Accounts process. Ruth Daly Board Secretary July 2018

2 Annual Report Audit Committee 8 May 2018 Item 8.1(2) NHS Highland Staff Governance Annual Report To: From: NHS Highland Audit Committee Alasdair Lawton, Chair, Staff Governance Committee Subject: Staff Governance Committee Report 2017/18 1 Background In line with sound governance principles, an Annual Report is submitted from the Staff Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts. 2 Activity (April 2017 March 2018) The Staff Governance Committee meets 4 times per year, in the reporting period the Committee met on 16 th May 2017, 29 th August 2017, 14 th November 2017 and 13 th February The minutes from each meeting have been submitted to the appropriate Board meeting. Membership for : Membership changed through the year as Anne Gent (Executive Lead) retired at the end of September Gaye Boyd acted as Executive Lead for the November 2017 meeting prior to the new HR Director (Dawne Bloodworth) commencing in post in January At the end of last financial year we had 2 non executive positions vacant which were filled by the February 2018 meeting James Brander and Sarah Compton Bishop. Attendance 2017/18 Name May 17 Aug 17 Nov 17 Feb 18 A Lawton Y Y Y Y R Creelman Y N N Y A Palmer N N Y Y J Brander n/a n/a n/a Y SCompton -Bishop n/a n/a n/a Y A Gent Y Y n/a n/a D Bloodworth n/a n/a n/a Y G Boyd n/a n/a Y n/a E Mackay Y Y N Y M McCrae Y Y N Y B Nott N N N N This year the areas of focus for the Committee continued to be Statutory and Mandatory Training, the Highland Quality Approach, workforce planning and workforce issues. Within these areas specific key topics were Band 1 review, staff experience and i-matter, Everyone Matters action plan and the knowledge and skills framework.

3 3 Sub Groups The Remuneration Committee is one of the formal sub groups of the Staff Governance Committee. Minutes from this sub group are submitted to the Committee. It also produces its own Annual Report. The Highland Partnership Forum (HPF) acts as the operational group of the Staff Governance Committee and considers the majority of agenda items prior to submission to the Committee. Reporting to HPF are further 3 sub groups: HR, Terms & Conditions and Educational Governance (this group has merged with Learning & Development Sub Group through this year). Human Resources Sub Group Co-chaired by Deputy Director of HR and the Employee Director this sub group meets monthly but alternating between a formal meeting and working group in order to progress its work. The group s remit is to consider new HR policies, the implementation of NHS Scotland PIN policies and review existing policies. In the reporting period the key focus has been on reviewing and implementing the suite of policies for supporting the work life balance, reviewing whistleblowing arrangements and the capability policy and process. Terms and Conditions Sub Group Also co-chaired by the Deputy Director of HR and the Employee Director this sub group meets bi-monthly and has representation from management, payroll, HR and staffside. The remit of this group is to consider interpretation of national terms and conditions and NHS Highland s approach to the implementation of National Terms and Conditions Circulars. As with the HR Sub group the minutes are submitted to the HPF. The key focus areas in the reporting period have been on Paid as if at work and the transfer of Highland Council staff to agenda for change in relation to terms and conditions. Learning and Development Subgroup After due process this subgroup was disbanded and the remit merged with that of the Educational Governance Subgroup. Educational Governance Subgroup Co-chaired by Professional Leadership and Staff Side and has representation from key professional groups and service areas. The remit is to provide assurance that there are systems and standards in place to monitor and control education, and learning and development provision in order to achieve compliance with the Appropriately Trained and Developed component of the Staff Governance Standard. During the key focus was Statutory and Mandatory Training, developing an Evaluation Framework and aligning the Educational Governance Framework with tasks previously undertaken by the Learning and Development Subgroup. 4 External Reviews

4 The Staff Governance Standard National Annual Monitoring Return was submitted to the Scottish Government in May In August 2017 the HPF met with Aileen Campbell, MSP, as part of the Board s Annual Review; topics covered included sickness absence, workforce planning, i- Matter, organisational change and the functioning of the HPF. 5 Any relevant Key Performance Indicators Knowledge and Skills Framework NHS Highland has set a local annual target for all Agenda for Change staff to be reviewed with at least 80% of development reviews carried out and recorded electronically. The percentage figure of reviews which were completed and signed off for (non bank) staff at the end of the reporting period (1 st April 2017 to 31 st January 2018) was 22%. We are aware that review figures have been declining and despite communication to the contrary there still remains a misconception among some managers and staff that KSF is going-away rather than that e-ksf is being replaced. We intend to take advantage of the requirement to communicate the introduction and access procedures to Turas Appraisal to managers and staff to simultaneously provide information, support and guidance around the wider benefits of effectively engaging with PDP&R. Key information provided will focus upon improving staff experience and identifying links between increased engagement through participation with PDP&R, imatter and, Dignity at Work leading to staff feeling Appropriately Trained and Developed. i-matter Implementation/Activity The imatter Continuous Improvement Model was successfully implemented within NHS Highland within the national deadline of October Around 800 teams were created using the on-line system providing an opportunity for around 11,000 health and social care staff to participate in the imatter questionnaire and the supplementary questions contained within the Dignity at Work survey. We are now committed to embedding imatter and will be exploring ways to meet the new actions for NHS Boards identified in the refreshed version of the 2020 Workforce Vision and the associated Implementation Plan Statutory and Mandatory Training In accordance with the 2016/17 NHS Highland Internal Audit Plan, Scott-Moncreiff, in March 2017, reviewed the systems and processes in place for monitoring statutory and mandatory training and compliance with the Statutory and Mandatory Training Prospectus. A report was published in April 2017 summarising the findings of an assessment of the adequacy and effectiveness of the controls in place to meet each of the objectives agreed for the audit. Further details, along with improvement actions, were set out in the Management Action Plan. During the key focus was implementing the recommendations of the Action Plan, agreeing governance structures, key performance indicators and monitoring and reporting arrangements for six core statutory and mandatory training topics all affect all staff groups, including; Fire Safety, Moving and Handling, Violence and Aggression, Equality and Diversity, Information Governance and Infection Control.

5 The learnpro Course Booking System was implemented in December 2017 to improve efficiencies with classroom based training booking processes and to enable line managers to develop online statutory and mandatory training plans and monitor and report process against these at local and service level via the Team Scorecard and Service Scorecard dashboard reports. Work is in progress with statutory and mandatory training providers to review existing training provision to make certain programmes are delivered as efficiently and effectively as possible and determine the required capacity within training teams to meet the required demand for training and refresher training. A key performance indicator has been set at 80% compliance with the six core statutory and mandatory training topics by the 31/08/18. A baseline was set in 2016 with subsequent improvement measured and reported to the relevant committees on a quarterly basis. The table below summarises average % of improvement, i.e. compliance with Moving and Handling and Topic Baseline as at Sept 16 Compliance as at Feb 18 Equality and Diversity 21.0% 46.8% (+25.8%) Fire Safety 55.5% 68.7% (+13.2%) Infection Control 23.9% 24.1% (+0.2%) Information Governance 39.9% 45.5% (+5.6%) Moving and Handling 29.6% 35.3% (+5.7%) Violence and Aggression 29.2% 48.7% (+19.5%) 6 Emerging issues and key issues to address/improve the following year In 2018/19 the key issues will be continuing to improve the completion of statutory and mandatory training; continue to improve the response rates and the engagement index of imatter, workforce planning. 7 Conclusion As the Chair of the Staff Governance Committee, I can confirm that the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively. Alasdair Lawton Chair - Staff Governance Committee April 2018

6 Annual Reports Audit Committee 8 May 2018 Item 8.1(3) NHS Highland Remuneration Sub Committee Annual Report: To: From: NHS Highland Audit Committee David Alston, Chair, Remuneration Sub Committee Subject: Remuneration Sub Committee Report April 2017 March Background In line with sound governance principles, an Annual Report is submitted from the Remuneration Sub Committee to the Staff Governance Committee and from the Staff Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts. The Remuneration Committee is a formal Sub Committee of the Staff Governance Committee. The Role of the Remuneration Committee is: To agree all the terms and conditions of employment of executive directors of the Board and other members of the Senior Leadership Team including: - job descriptions - job evaluation - terms of employment - basic pay - performance related pay - benefits (removal arrangements and cars) - agreeing objectives for executives before the start of the year in which performance is assessed - ensuring that effective arrangements are in place for carrying out the above two functions in respect of all other senior managers - conducting a regular review of the Board s policy for the remuneration and performance assessment of executive directors, other senior managers and medical consultants, in the light of guidance issued by the SGHD and any specific National, External or Internal Audit Report. The Role and Remit of the Sub Committee was updated in November 2011 to include reference to Medical Consultants, in relation to regularly reviewing the Boards Policy for their Remuneration and Performance Assessment. The Remuneration Sub Committee has met on 3 occasions during the year on 16 May, 27 June and 14 November. Abridged minutes of the Remuneration Sub Committee have been submitted to the appropriate Staff Governance Committee Meeting.

7 2 Activity The Remuneration Sub Committee considered the following key items at its meetings throughout the year. 16 May 2017 Executive Cohort End of Year Reviews Proposal for Chief Officer Post to lead Highland Health and Social Care Partnership Remuneration Sub-Committee Annual Report 2015/16 Remuneration Sub-Committee Remit, Membership and Workplan 2016/17 Pay & Conditions of Service Executive and Senior Management Pay Developing Executive Level Leadership in NHS Scotland 27 June 2017 Senior Manager Cohort End of Year Outcomes 2016/17 Executive Cohort Objectives 2017/18 14 November 2017 Executive Cohort Mid Year Reviews Interim Director of Human Resources Executive and Senior Manager Pay Update Membership from 1 April March 2018: Dr David Alston, Chair Ms Melanie Newdick, Board Vice Chair Mr Robin Creelman, Chair, Argyll & Bute Integrated Joint Board Mr Alasdair Lawton, Chair of Staff Governance Committee Mr Adam Palmer, Employee Director In Attendance: Mrs Anne Gent, Director of Human Resources (Lead Executive) until 30 September 2017 Ms Elaine Mead, Chief Executive Ms Gaye Boyd, Deputy Director of Human Resources from 1 October 2017 Attendance from 1 April March 2018: Member 16/05/17 27/06/17 14/11/17 David Alston Melanie Newdick Apols Robin Creelman Apols Alasdair Lawton Apols Apols Adam Palmer Apols Elaine Mead Anne Gent N/A Gaye Boyd 3 Sub Groups The Remuneration Sub Committee does not have any Sub Groups. 2

8 4 External Reviews The outcomes of the End of Year Reviews for the Executive Cohort were submitted to the National Performance Monitoring Committee and approved. The Remuneration Sub Committee has access to the National Remuneration Committee Self Assessment Pack to ensure that the performance of the Remuneration Sub Committee is in line with National Guidance. 5 Any relevant Key Performance Indicators There are no Key Performance Indicators for the Remuneration Sub Committee. Audits were progressed in year. No External 6 Emerging issues and key issues to address/improve the following year The Remuneration Sub Committee is well established with a clearly defined Role and Remit and Work Programme, in the main set by national requirements. Attendance at the Sub Committee has been satisfactory and Non Executive Directors demonstrate the appropriate scrutiny required. 7 Conclusion David Alston, Chair, as Chair of the Remuneration Sub Committee has concluded that the systems of control within the respective areas within the remit of the Remuneration Sub Committee are considered to be operating adequately and effectively. David Alston Chair March

9 Audit Committee 8 May 2018 Item 8.1(4) NHS Highland Clinical Governance Annual Report To: From: NHS Highland Audit Committee Gaener Rodger, Chair, Clinical Governance Committee Subject: Clinical Governance Committee Report April 2017-March Background In line with sound governance principles, an Annual Report is submitted from the Clinical Governance Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts. Clinical representatives attend the Clinical Governance Committee from each operational unit and from all professions along with Executive, Non-Executive Board Member representation and two lay members. Together the members ensure rigorous scrutiny of data and issues that are brought to the Committee s attention. A Non-Executive Board Member chairs the Clinical Governance Committee and there was a change in chairperson in June Internal reporting systems are embedded in the organisation by which significant events; serious complaints and issues considered worthy to report on an exceptional basis are brought to the Committee. An atmosphere of open reporting and mutual trust and respect provides assurance to members that the right issues are being raised and shared with colleagues. The system ensures that learning and opportunities for continuous improvement are taken and shared throughout the operational units through their respective Quality and Patient Safety Groups. This system is supported by a central Clinical Governance Team who collates the relevant data using the Datix reporting system, which enables correlations to be made on an organisational basis, and therefore lends rigour to the assurance provided to the Clinical Governance Committee. This Committee has embedded the use of a Quality and Safety Dashboard. The Dashboard allows the members and operational units to visualise real-time data collected on key Quality and Safety issues such as numbers of falls, pressure ulcers, medication errors, and mortality data. Data on a variety of Quality and Safety measures can be used to give both a snapshot view and a longer-term trend overview of performance and improvement. The Committee continues to use the dashboard to inform its Agenda and discussions. The NHS Highland Risk Management Policy has been previously embedded throughout the organisation, with local responsibility for identifying and managing risks being monitored through the unit Quality & Patient Safety Groups and issues escalated to the Clinical Governance Committee where appropriate. In addition, Clinical Risks on the NHS Highland Strategic Risk Register have been reviewed and updated as appropriate. Governance arrangements for children s health services delivered by The Highland Council on behalf of NHS Highland as part of the integration arrangements have continued to be developed. The Committee has incorporated assurance reporting on these services into its work through exception reporting and emerging issues brought by the Highland Council Children s Service Clinical Governance Group.

10 The Committee continues to consider the patient safety and quality aspects of (i) changes in the way care is delivered/ new models of care e.g. Vaccine Transformation Programme and (ii) changes in policy/ legislation e.g. new GMS contract, Duty of Candour. 2 Activity April March 2017 The committee met on five occasions during 2016/17 on 17 April 2017, 17 June 2017, 17 September 2017, 17 December 2017 and 6 February Its minutes and assurance reports were submitted to NHS Highland Board at its public meetings during this period. A list of members and their attendance at the committee meetings is shown in Appendix A. Significant Event Reviews During the past 12 months continuing support has been provided to the Operational Units in order to support the recording of all SERs within DATIX, ensuring that all actions are entered into the improvement / action planning module in DATIX to allow organisation and operational unit monitoring. Monthly reports on active SAERs and those awaiting ratification have been developed and are provided to the Operational Units and the Board Medical and Nursing Directors to assist with monitoring of investigations and the resulting actions / improvements. On the 11 January 2017 a successful training day was held to provide current and future Chair s of SAER s with the knowledge on running SAER and provide information on current policies and tools. Training In 2017/18 monthly training has continued, available for all staff in NHS Highland on the following: - Reporter training - Reviewer training including improvement / action planning. - SERs in DATIX including improvement / action planning. - Running pre-set reports and accessing DATIX Dashboards. - Searching and building reports in DATIX - Adverse Event Toolkit Awareness Sessions. The Clinical Governance Team have revised and built on their existing investigation support tools and there is now a full Adverse Event Toolkit available on the NHS Highland Intranet. efault.aspx This has been updated to include arrangements for Duty of Candour which came into effect on the 1 st April Adverse Event Figures A total of 1,616 adverse events were reported in 2017/18. breakdown of the severity and operational unit. The following table gives a

11 Argyll and Bute CHP North & West Highland Raigmore (IMFOU) South & Mid Highland (IMFOU) Highland Council - Children's Services Corporate Services Estates Pharmacy Total Negligible - no/minor injury or harm not requiring first aid, no impact/risk to service/standards of care Minor - Injury/harm requiring first aid, minimal impact on service provision/standards of care Moderate - reportable, significant injury/harm req med advice/potential impact service/standards of care Major - major injuries/long term incapacity/disability, signifcant issues of standards/quality of care Extreme - death/major perm incapcity/long-term damage, serious adverse event, substandard care Not yet graded Total Complaints Management The new NHS complaints handing procedure came into effect from 1 April Performance against the 20 working day target has remained a challenge throughout the year with the average of 36% of stage 2 complaints being responded to, within the 20 working day target each month. Stage 1 Complaints

12 Total Number of complaints received 258 Total number of complaints investigated 249 Number responded to within 5 days 151 % responded to within 5 days 60.6% Stage 2 Complaints Total Number of complaints received 531 Total number of complaints investigated 504 Number responded to within 20 days 181 % responded to within 20 days 35.9%. Clinical Effectiveness Activity The Clinical Effectiveness Team continues to support NHS Highland staff with a range of audit and evaluation project work that helps inform improvement within NHS Highland. Examples from 2017/18 include the following To support medical revalidation, a large-scale programme of patient feedback is ongoing, based on the CARE questionnaire. Patient feedback documentation and methodology continues to be reviewed to make best use of limited resources; simplify the process for patients and administrative staff, and improve response rates. Nearly 11,000 questionnaires have now been collated for doctors undergoing revalidation. Findings from the feedback are discussed in individual revalidation and appraisal meetings. The team continues to research different approaches to gathering feedback for revalidation. Another aspect of ongoing medical revalidation support is the provision of incident, complaints and claims reports from DATIX for doctors annual appraisal and five-yearly revalidation meetings. Record Keeping audits continue to be supported on an annual basis by the CGST for nursing and allied health professionals. Completed audit tools are returned to the team for highland wide analysis. Audit profile/compliance reports were sent to assigned leads to use the information and disseminate as required The CGST have developed a Mortality Review Tool that continues to be used in Raigmore and Rural General Hospitals. This provides a standardised approach to collecting a data set on all inpatient deaths with further data collected on a smaller cohort of cases which undergo a more detailed assessment used the Royal College of Physicians Structured Judgement Review tool. This will be subject to further revision throughout 2018/19. Examples of other projects include the following: o Endoscopy Unit patient feedback results are used by the individual units to review the service provided and identify where improvements can be made o Highland Sexual Health Patient Satisfaction Survey o Care at Home South & Mid Operational Unit Quality and Patient Safety Groups Each of the Operational Units has a well established Quality and Patient Safety Group which meet throughout the year. The Terms of Reference for the Groups and sub group have been reviewed to ensure standardisation across the operational units.

13 Each group routinely reviews complaints, incidents, mortality and morbidity reviews, SPSP programme, risk registers and reports by exception to the Clinical Governance Committee through the Clinical Director. All operational units have established adverse event ratification groups to enhance the scrutiny of Significant Adverse Event Reviews. Committees Reporting to the Clinical Governance Committee All reporting committees are expected to submit annual reports and report by exception. Emerging issues and key issues to address/improve the following year The committee will focus on the following areas next financial year Embedding the Clinical Governance Dashboard Clinical Risk Management Duty of Candour Leaning and Improving Conclusion The Chair of the Clinical Governance Committee is confident, through the scrutiny of internal and external reports and minutes, systematic review of the reporting mechanism and regular presentations that the systems of internal control of the delivery of safe clinical care are adequate. However it will continue to focus on assuring that any identified weaknesses in the system are addressed and that a culture of continuous improvement in clinical governance is fostered across the Board area. Gaener Rodgers Chair Clinical Governance Committee April 2018

14 Clinical Governance Committee Attendance Tracker Ann Clark Non-Executive Director Myra Duncan Non-Executive Chair Valerie Barker (Public Member) Elspeth Caithness (staff side rep) Mike Evans Non-Exec Board Member Dr Andrew Evennett Non-Exec Board Member Dr Michael Foxley Non-Exec Board Member Dr Rod Harvey Medical Director Ms Deirdre MacKay Non-Executive Director Fiona MacLean Public Member Ms Heidi May Nurse Director Mr Alex Murray (Public Member) Mr Graham Peach Public Member Dr Gaener Rodger Non-Executive Chair Dr Hugo Van Woerden Dir of PH and HP n/a Yes Yes Apols Yes Yes n/a n/a n/a n/a Yes n/a n/a n/a n/a Yes Yes Apols Apols Apols Apols n/a n/a n/a n/a Yes Yes Yes Yes n/a Apols Apols yes Apols Yes Yes Apols B Peters sub Yes Apols B Peters sub Yes n/a n/a n/a Apols Yes n/a Yes Yes Apols Yes Yes Yes Yes Yes Yes Yes n/a n/a n/a n/a n/a n/a n/a Yes Yes Yes Yes Yes Yes yes Apols Yes Apols Apols Apols

15 Audit Committee 26 June 2018 Item NHS Highland Health and Social Care Committee Annual Report To: From: NHS Highland Audit Committee Melanie Newdick, Chair of Health and Social Care Committee Subject: Committee Report 17/18 1 Background In line with sound governance principles, an Annual Report is submitted from the Health and Social Care Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts. 2 Activity 1 st April st April 2018 In response to changes in the Committee s terms of reference we introduced a year planner to ensure we covered all the aspects of our remit. This planner covers what topics will be looked at in the main meeting as well as the sub committees. We have also appointed a Vice Chair of the committee. An online portal was introduced but committee members have not yet been able to access this information. We carried out development sessions on the role and remit of the committee, understanding performance information and balanced scorecards. At every meeting we have reviewed operational reports, balanced scorecard, social work and children s services reports. We have reviewed financial information in all but one meeting. We have also reviewed/discussed; Care Inspectorate reports Regional planning Advocacy Plan approved Transitions Team approved Palliative Care Sustainability Plan Mental Health High Value Work Streams We have reviewed exception reports through the year. We have also met at Invergordon Hospital and during the year. The performance team have worked really hard to adapt this information for the committee and to help improve understanding of these metrics. They have also introduced a Quid which is a one page quick view of 6 key performance indicators and financial performance for the whole of North Highland. There have been six meetings of Highland Health and Social Care Committee during the year, the Minutes have been submitted to the Board along with reports relating to key items. The Membership and attendance at meetings is as follows: Membership from 1 April March 2018: Mrs Melanie Newdick, Chair Chief Operating Officer Dr Paul Davidson, Chair of Professional Executive Committee

16 Ms Janet Spence, Chair of Adult Social Care Practice Forum Dr Gaener Rodger, Non-Exec (from May 2017) Mrs Ann Pascoe, Non-Exec (from May 2017) Cllr Kate Stephen (from June 2017)(was Bren Gormley) Cllr Nicola Sinclair (from June 2017)(was Margaret Davidson) Cllr Ronald MacDonald (from June 2017)(was Hamish Fraser) Ms Shirley Christie, Staffside Representative Mrs Margaret MacRae, Staffside Representative Donna Mitchell, Patient Representative (from June 2017) Mr Michael Simpson, Patient Representative (from June 2017) Norman Houston, Carer Representative (from June 2017) Adult Services Strategic Planning Group Member Ms Mhairi Wylie, Third Sector Representative Dr Chris Williams, GP Representative Joanna Macdonald, Director of Adult Social Care Mr Quentin Cox, Area Clinical Forum Representative (until 31 January 2018) Mrs Alison Hudson, Area Clinical Forum Representative Mrs Gill McVicar (North and West) Mr David Park (Inner Moray Firth) Georgia Haire (South and Mid) Mr David Garden, Head of Financial Planning (to September 2017)/K Rodgers Attendance from 1 April March 2018 (From Terms of Reference): Member 4/5/2017 6/7/2017 8/9/2017 9/11/ /1/2018 1/3/2018 Melanie Newdick, Sub Chair Chief Op ing Officer n/a n/a n/a n/a n/a n/a Dr Paul Davidson A A A A A A J Spence/I Thomson A A A A A A Andrew Evennett Sub A Sub n/a n/a Ann Pascoe Sub Deidre Mackay n/a n/a n/a n/a James Brander n/a n/a n/a n/a Adam Palmer n/a n/a n/a n/a A A Ann Clark n/a n/a n/a n/a A Joanna Macdonald A Cllr M Davidson/ A A A Cllr N Sinclair Cllr H Fraser/ A A A Cllr R MacDonald Cllr B Gormley/ A Cllr Kate Stephen Ms S Christie A A A A Mrs M MacRae Mr G Hogg/ A A Donna Mitchell Michael Simpson

17 Norman Houston, A A Carer Representative Adult Services A A A A A A Strategic Pl g Group Ms M Wylie A A Sub Sub Sub A Dr C Williams A A A A A Mr Q Cox, ACF A Sub N/A Alison Hudson, ACF A Sub G McVicar (N&W) n/a n/a n/a Mr David Park (IMF) Georgia Haire (S&M) A Sub D Garden/K Rodgers 3 Sub Groups There have been two Finance and Performance Sub Group meetings which have considered the current financial situation, the Balanced Scorecard and Performance Indicators on which assurance has been reported back to the Health and Social Care Committee. There is a Sub Group planned for Clinical Governance and a Local Partnership Forum. It is anticipated that these groups will start to meet imminently. 4 External Reviews No significant external reviews 5 Any relevant Key Performance Indicators We are responsible for managing key performance indicators relating to North Highland including; Finance Balanced Scorecard Health and Wellbeing Scorecard Adult Social Care Children s Services 6 Emerging issues and key issues to address/improve the following year The Committee has now established a Work Plan for 2018 which sets out the reporting sequence for routine reports and issues, as well as specific areas of focus for each meeting. We are planning on having further meetings away from Inverness with one taking place in Wick and another in Fort William. We are working to resolve the access issues for all members of the Committee to the management performance information available on the Intranet. 7 Conclusion As the Chair of the Highland Health and Social Care Committee, I can confirm that the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively. Melanie Newdick Chair Health and Social Care Committee 29 May 2018

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19 NHS Highland Control of Infection Control Committee Annual Report Audit Committee 8 May 2018 Item 8.1(6) To: From: NHS Highland Audit Committee Robin Creelman, Chair, Control of Infection Committee Subject: Control of Infection Committee Report - April 2017 March Background In line with sound governance principles, an Annual Report is submitted from the Control of Infection Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts. 2 Activity April 2017 March 2018 The Control of Infection Committee has met five times during the period April 2017 to March This is in line with the Terms of Reference agreement which specifies that the meeting is held bimonthly. Minutes of the Committee are submitted to the Board. Detailed in the table below is the attendance at Control of Infection Committee meetings over the course of 2017/18 of the members. Meeting Dates 13/07/ /09/ /11/ /01/2018 8/03/2018 Chair, Non-Executive Director Yes Yes Apologies Yes Yes Non-Executive Director Change of role Yes Yes Apologies acknowledged Yes HAI Executive Lead (Nurse Director) Yes Yes Yes Apologies Yes Consultant Microbiologist Yes Yes Yes Yes Yes Antimicrobial Pharmacist Yes Yes Yes Yes Apologies Consultant in Public Health / Health Protection Nurse Specialist Apologies Apologies Apologies Apologies Yes GP Yes Yes Apologies Vacancy Yes Infection Control Manager Yes Yes Yes Yes Yes Occupational Health No No No No No Staffside Representatives Yes Apologies Apologies Apologies No Lay Representative Yes Yes Yes Yes Yes Lead Nurse South and Mid Apologies Yes yes Apologies Yes Lead Nurse North and West Apologies Yes Apologies Apologies Apologies Lead Nurse Argyll and Bute No Yes Yes Yes yes Lead Nurse Raigmore Apologies Apologies Apologies Apologies Apologies Head of Midwifery Apologies Apologies Apologies Apologies Apologies AHP Lead Yes Yes Yes Apologies Apologies Directorate GM / CHP Locality Manager No No No No No Senior Manager - Decontamination No No No No No Head of Estates No No No No No The Committee agenda is formatted around the Infection Prevention and Control Annual Work plan, in order to ensure updates on progress and areas for consideration are discussed at every meeting.

20 3 Sub Groups NHS Highland Antimicrobial Management Team The NHS Highland Antimicrobial Management Team monitors antimicrobial prescribing, and regularly reviews the existing NHS Highland antibiotic guidance to ensure the most up to date evidence is reflected in our local guidance. NHS Highland s progress is measured against two national indicators:- Hospital-based empiric prescribing indicator Since June 2015, the key prescribing indicator for hospitals has focussed on improving the documentation of the duration of therapy. Data for national comparison was expanded in 2017 to cover at least 3 downstream (i.e. non-admission wards). In Raigmore Hospital, data is collected in ward 6C (general medicine, endocrinology and cardiology) ward 7A (respiratory medicine) and ward 4C (general surgery). The latest national report (to the end of December 2017) shows NHS Highland medical wards have achieved all the required standards and the surgical ward is just shy of two standards (indication documented at 88% against 95% and all doses administered at 89% against 95% standard). For the new measure of recording oral duration of therapy, 6 boards in Scotland did not meet this in either medical or surgical wards but it was achieved in NHS Highland. Data is collected every month with collated feedback shared with clinical teams each month for discussion and improvement. Further work will be required to meet the higher compliance standard of 80% for oral duration by the end of March As antibiotic therapy is often commenced in an acute admission ward before the patient is transferred to either ward 7A or 4C, the same audit has been conducted in ward 6A (AMAU). Due to a change in the structure of ward 4C and low patient numbers, the data collection for surgical patients switched to ward 4A in January 2018 but this was not included in the national report. Acute Hospital Antibiotic Prescribing Measures indicator The specific measures to be achieved by each acute hospital are to reduce total and specific antibiotic use by 1% in each individual acute hospital from a baseline position in There is no single target rate as the measurement is a local reduction in each hospital. Hospital Antibiotic Prescribing Measure (per 1000 AOBDs): Total antibiotic use Piperacillin/tazobactam (broad spectrum drug) Carbapenems (very broad spectrum drugs) National position of all 29 acute hospitals 3 achieved target 29 achieved target 15 achieved target Belford Status at 31 st December 2017 (% change from baseline in 2015) Caithness Lorn & General Islands Raigmore (-7%) (+33%) (+8%) (+14%) (-176%) (-153%) (-15%) (-147%) (-153%) (+9%) (-1309%) (+30%) As the first report was shared with Antimicrobial Management Teams at the end of October 2017, there has been little time for sharing and improving. However, the data at 31 st December shows a slightly improved position on total antibiotics measure in Caithness, Lorn and Islands and Raigmore although none of these hospitals met the target reduction of 1%. The data also shows a more significantly improved position in carbapenem use in Caithness (down from + 59% to +9%) and Raigmore (down from +66% to +30%). At the end of December, both Lorn and Islands and Belford Hospital met the target for reducing carbapenem use. Further information is awaited from Scottish Government on the target for 2018 calendar year. Primary care antibiotic use: national quality indicator To meet the quality indicator of total antibiotic prescribing rate per 1000 patient per day, general practices must either achieve an equivalent or lower, prescribing rate than that of the Scottish 25th percentile or achieve an acceptable minimum reduction towards that level. For NHS boards to meet the indicator at least 50% of practices will be at or below the 25th percentile of Scottish practices or will have made the minimum acceptable reduction toward that level with each practice assessed equally. In August 2016 after a review of the third year following introduction of the quality indicator, SAPG agreed to continue with the approach but to reset the baseline to data from January-March 2016 to drive further improvement. The data shown below reflects the position at January to March 2

21 2017 with NHS Highland having the second highest percentage of practices achieving the target measure, above the national average. NHS Health Board % Practices achieving shift % Practices achieving 25 th percentile level % Practices achieving Quality Indicator Achieved Quality Indicator? NHS Ayrshire & Arran 43.6% 9.1% 52.7% Y 8 NHS Borders 30.4% 26.1% 56.5% Y 7 NHS Dumfries & Galloway 21.2% 6.1% 27.3% N 14 NHS Fife 22.8% 43.9% 66.7% Y 4 NHS Forth Valley 18.2% 32.7% 50.9% Y 10 NHS Grampian 23.0% 39.2% 62.2% Y 5 NHS Greater Glasgow & Clyde 31.5% 25.3% 56.8% Y 6 NHS Highland 28.6% 39.8% 68.4% Y 2 NHS Lanarkshire 41.0% 4.8% 45.7% N 12 NHS Lothian 12.3% 54.9% 67.2% Y 3 NHS Orkney 0.0% 42.9% 42.9% N 13 NHS Shetland 30.0% 20.0% 50.0% Y 11 NHS Tayside 23.1% 29.2% 52.3% Y 9 NHS Western Isles 44.4% 44.4% 88.9% Y 1 Scotland 27.5% 29.9% 57.3% 11 This is an improvement on 2016 data where 57% of practices in NHS Highland met the target. In general prescribing terms, dentists have continued the downward antibiotic prescribing trend from last year with prescription numbers now at the lowest level for the past NINE years. In 2016/17, NHS Highland dentists wrote 264 fewer antibiotic prescriptions than the previous year, a 2% reduction. Prescribing is now below that of 2008/9 and has fallen by 26% from the high point of 2012/13. Nationally, dentists wrote 4.8% fewer prescriptions in 2016/17 so dentists in NHS Highland are to be commended on the sustained change in practice. Overall prescribing rates remain low in NHS Highland at two thirds of the national average (10.5 vs items per population). As a percentage of all primary care antibiotic use in NHS Highland, dental prescribing now accounts for 5.8% in 2016/17 (unchanged from 2015/16) and compares favourably with the national figure of 7.6% (reduced by 0.3% from previous year). Management of Infection Guidance Sections of the guideline updated in 2017/18 include meningitis, systemic and other infections, respiratory tract infections, urinary tract infections, viral infections and surgical prophylaxis. In addition, the dosing and monitoring guidance for gentamicin and vancomycin were updated in line with national guidelines from Scottish Antimicrobial prescribing Group. Audits of Antimicrobial Prescribing During May and June, a point prevalence survey of antimicrobial prescribing was completed in Belford and Caithness General hospitals with reports fed back to the clinical teams and discussed at the NHS Highland Antimicrobial Management Team. In addition, local audits have been carried out by prescribers in the general surgery wards in Raigmore and in Lorn and Islands Hospital. European Antibiotic Awareness Day Each year, Antimicrobial Management Teams across Scotland are asked to promote optimal antibiotics use within their board. In 2017, the chair and professional secretary of the group attended the Inverness Science Festival Family Fun day to raise awareness of microbes in everyday life and to highlight the problems they can cause. On 18 th November, European Antibiotic Awareness Day, a stand in the Children s Ward in Raigmore hospital was set up to promote prudent antimicrobial use with staff, parents and carers and children. All visiting the stand were encouraged to sign up to be an Antibiotic Guardian to protect antibiotics. As in previous years, national posters and leaflets were sent to medical practices and hospitals throughout NHS Highland for display over the winter period. The communications team were instrumental in promoting the event via NHS Highland social media using an animation, short videos and brief messages. Rank (1 = best) 3

22 Education Sessions were delivered to a variety of staff including foundation year one and two medical staff, nurse practitioners, non-medical prescribers, general surgical audit afternoons, medical students, podiatrists and undergraduate nursing students. Decontamination Group The Highland wide Decontamination group met quarterly throughout 2017 to monitor progress and establish assurance on the decontamination procedures carried out across NHS Highland. As of January 2018 the group now meets six monthly, to be assured processes are robust. Decontamination facilities. The decontamination facilities in NHS Highland have been designed and equipped in accordance with SHPN 13. The decontamination service has direct management control of centralised services and professional lead for indirect that includes training, assessment and periodic audit of facilities and technique. The central decontamination unit operates in line with the ISO standard for medical devices. The previous standard (ISO 13485:21012) has been updated, and the Decontamination Service will utilise the 2016 version to continuously monitor all aspects of the process and environment. The new version gives much tighter controls for our processes, and work is underway to rewrite and change the system to reflect the new requirement of this new standard. The transition audit for this change will occur in May The same approach is undertaken in endoscope and primary care decontamination. During 2017/2018 there have been no decontamination related outbreaks to report. Water Safety Group The Highland wide Water Safety group meets bi-monthly to monitor progress and establish assurance on the water safety procedures in place across NHS Highland. During 2017/2018 there have been no water safety related outbreaks to report. Infection Control Improvement Group The Highland wide Infection Control Improvement group meets bi-monthly and ensures the operational delivery of Infection Prevention and Control is robust across the Operational units. The Infection Control Manager chairs this group and its membership reflects the key stakeholders within the Highland Health and Social Care Partnerships, for example, Lead Nurses, Estates and Hotel Services, Health Protection, and the Infection Prevention and Control teams. 4 External Reviews Internal Audit In August 2014, Internal Audit carried out a review of the Infection Control processes within NHS Highland, in accordance with the 2014/15 Internal Audit Plan. This specifically related to processes in place to ensure effective operational unit monitoring of GP prescribing of C. Difficile-related antibiotics and the use of proton pump inhibitors; as well as the assessment of what information was recorded and reported; and what processes were in place to influence specific GP practice prescribing. Overall the Internal Audit review acknowledged that a range of controls are in place across NHS Highland for the management of infection control and generally operate effectively. They identified no fundamental weaknesses in controls, but did highlight a number of areas in which existing processes could be strengthened and controls improved. The actions identified have been met, with the exception of the ICNET (Infection Control Software programme utilised in NHS Highland) receiving microbiology data from NHS Greater Glasgow and Clyde. Work is underway to progress this; however progress has been much slower than expected due to issues out with the control of NHS Highland, the situation continues to be monitored through the Control of Infection Committee, and it is hoped this action will be met in March Vale of Leven Report The Vale of Leven report was published on the 24 th November 2014, and made seventy-five recommendations in total; sixty-five recommendations were made to Health Boards, twenty-one of which related to nursing care. NHS Highland completed a self assessment of their progress against the recommendations in January 2015, and reported good compliance against most of the 4

23 recommendations and some areas where improvement could be made. An action plan was then developed and monitoring occurs through the Infection Control Improvement Group and Control of Infection Committee. As of February 2018 two areas of the action plan are being monitored. Firstly the audit of the new nursing documentation is to occur in December 2018 to provide further assurance that this recommendation has been met; and secondly the implementation of the live feed of microbiological data from NHS Greater Glasgow and Clyde into ICNET Argyll and Bute). Healthcare Environment Inspections (HEI) 2017/2018 Raigmore Hospital, theatre follow-up Inspection On the 7 th and 8 th of February 2017 an unannounced follow-up inspection to Raigmore Hospital, theatre department was carried out. The finalised report was published on the 18 th of April 2017, and acknowledged that the original four requirements had been met, and identified two new requirements and one recommendation. The 16 week action plan identified that all requirements/recommendations relating to the inspection were met. MacKinnon Memorial Hospital On the 18 th and 19 th of April 2017, a HEI Inspection team attended the MacKinnon Memorial Hospital site and undertook an unannounced healthcare associated infection inspection visit. Inspections of the ward areas (including Accident and Emergency, main acute ward, maternity department, and physiotherapy department) occurred. The finalised report was published on the 27 th of June 2017, and identified three requirements relating to the ward inspection. The 16 week action plan identified that all requirements were met. In June 2017 NHS Highland were approached to participate in the development of a thematic Healthcare Environment Inspection pertaining to urinary catheter care. Three sites were involved (Belford Hospital, Raigmore Hospital and Lorn and Islands Hospital) in the pilot which lasted till September Cleaning and the Healthcare Environment Compliance with cleaning and estates monitoring is undertaken by Domestic Services through the use of the national monitoring tool. Overall an average compliance of 96% for cleaning and 97% for estates monitoring has been achieved for the year This is above the specified national compliance rates. A well-established programme of local unannounced Healthcare Environment Inspection (HEI) monitoring walk rounds is in place throughout NHS Highland. The annual programmes are coordinated by the Lead Nurses within the Operational units, and provide a framework of assessment which provides assurance against the standards set out in the Healthcare Improvement Scotland HAI Standards (2015), and the critical elements of the standard infection control precautions, as well as other key national policies and standards. NHS Highland also continues to conduct annual peer review inspections of cleanliness and the environment. These monitoring inspections are unannounced, and conducted by a Hotel Service Manager and a public partner. Data from these inspections is shared with the clinical areas for information and actioning, and presented at the local and Highland wide Infection Control meetings. Audit The Infection Prevention and Control Team continue to work in conjunction with the Scottish Patient Safety Programme (SPSP) to improve clinical practice and sustain change around the work streams of preventing vascular device related infections, reducing the incidence of colorectal surgical site infection, and preventing catheter associated urinary tract infections. The Infection Prevention and Control Team continue to support clinical teams in their auditing of compliance with the Standard Infection Control Precautions (SICPs) including hand hygiene. During 2017 the Infection Prevention and Control team have continued to be involved with NHS Scotland National Monitoring Framework group in the review of the methodology for SICPs auditing. 5

24 Surveillance The Infection Prevention and Control Team continue to support the clinical teams in the undertaking of root cause analysis for cases of Staphylococcus aureus bacteraemia and Clostridium difficile infections. Mandatory surveillance of Escherichia coli (E coli) bacteraemia is undertaken and submitted to Health Protection Scotland. Alongside this the above surveillance of alert organisms occurs on a daily basis by the Infection Prevention and Control Team, in order to provide early identification of any control measures required. Data to monitor staffs completion of the Clinical Risk Assessment document continues to be gathered from Raigmore Hospital and the Rural General Hospitals across NHS Highland, and is forwarded to Health Protection Scotland (HPS) for collation. Compliance with completion of the clinical risk assessment document has improved following its inclusion within the Common Admission Document and the delivery of targeted education to areas with poor compliance. The data submitted from NHS Highland, along with all other NHS Scotland Health Boards is published annually by HPS. The Infection Prevention and Control Team continue to work closely with the clinical teams within Orthopaedics, Midwifery/Obstetrics, Colorectal and Vascular in order to perform surgical site infection surveillance. Surveillance data is collated and shared with the clinical teams. Learning identified through root cause analysis of patient cases and the adoption of improvement methodologies continues to demonstrate a reduction in the incidence of deep infections across all disciplines. As of the 1 st April 2017 NHS Highland began surgical site surveillance of vascular surgical cases, in line with the mandate from Health Protection Scotland. Outbreaks Outbreaks associated with NHS Highland Hospitals May 2017, ward 1 Belford Hospital, Influenza B confirmed August 2017, ward 7A Raigmore Hospital, Norovirus confirmed December 2017, ward 2A Raigmore Hospital, Clostridium difficile confirmed January 2018, ward 1 and 2 Royal Northern Infirmary, Influenza A confirmed January 2018, Sutor ward Invergordon, Influenza A confirmed January 2018, acute ward, Mackinnon Memorial Hospital, Influenza A confirmed March 2018, 2A ward Raigmore Hospital, Norovirus confirmed March 2018, 2C ward Raigmore Hospital, Norovirus confirmed March 2018, 6C ward Raigmore Hospital, Norovirus confirmed March 2018, 7A ward Raigmore Hospital, Norovirus confirmed 4 Infection Prevention and Control Team Following the cessation of the 1 year fixed term appointment of a 1 whole time equivalent data support analyst within the Infection Prevention and Control Team 31 st March 2017, work is underway with the E-Health team to generate real-time reports in an automated way via a dashboard system. The Consultant Microbiologist team are undertaking a job plan review due to the acknowledgement of the increasing demands of both the microbiology and infection control service, on the Infection Prevention and Control Doctor provision. 5 Any relevant Key Performance Indicators Staphylococcus Aureus Bacteraemia (SAB) NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2017, Staphylococcus aureus bacteraemia (including MRSA) cases are 24.0 cases or less per 100,000 acute bed days. For NHS Highland this means no more than approximately 60 cases by year ending March Based on our current data we are on trajectory to meet our estimated target, 6

25 although the position remains changeable. The final position will be calculated by Health Protection Scotland and published in June Clostridium difficile Infection NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2017, the rate of Clostridium difficile infections (CDI) in patients aged 15 and over is 32.0 cases or less per 100,000 total occupied bed days. For NHS Highland that means no more than approximately 78 cases by year ending March Based on our current data we are on trajectory to meet our estimated target, although the position remains changeable. The final position will be calculated by Health Protection Scotland and published in June Health Protection Scotland and the Scottish Government are aware of the HEAT positions, and the Infection Prevention and Control team continue to work closely with partner agencies to prevent healthcare associated infections. A specific Board wide Clostridium difficile infection and Staphylococcus aureus bacteraemia action plan is in place and progress is monitored through the Control of Infection Committee. An outbreak of Clostridium difficile was declared on ward 2A Raigmore, on the 19 th December patients were identified with Clostridium difficile toxin, and as a result of active screening a further 2 patients were identified with Clostridium difficile toxin over a period of time. Health Protection Scotland were informed and regular updates occurred. Control measures were adopted, and as of the 3 rd of January 2018 the ward underwent deep cleaning, and hydrogen peroxide fogging prior to reopening on the 6 th of January Emerging issues and key issues to address/improve the following year Delivering the current infection prevention and control service to all disciplines of staff in all settings within NHS Highland Health and Social Care Partnership with a limited infection control resource. Sustaining the infection prevention and control improvements made to date within all settings within NHS Highland Health and Social Care Partnership. Focus will continue to be maintained on; Reducing rates of Staphylococcus aureus and Clostridium difficile. Alert organism surveillance Surgical site surveillance, with the addition of vascular surgery HAI standard compliance Significant progress has been made in embedding the culture of infection prevention and control across all NHS Highland staff, and the Control of Infection Committee continues to monitor infection prevention and control strategies and compliance, and highlight any issues to the Board. 7 Conclusion The Control of Infection Committee is confident, through the scrutiny of internal and external reports and minutes, systematic review of the reporting mechanisms and regular presentations that the systems of internal control for the delivery of safe clinical care are adequate. Therefore the systems of control within the respective areas within the remit of the committee are considered to be operating adequately and effectively. The committee will also ensure that any identified weaknesses are addressed immediately in order to provide a duty of candour and support a culture of continuous improvement in infection prevention and control across the Board area. Robin Creelman Chair Control of Infection Committee March

26 Annual Report Audit Committee 8 May 2018 Item 8.1(7) NHS Highland Health and Safety Committee Annual Report To: NHS Highland Audit Committee From: Melanie Newdick and Elspeth Caithness, Joint Chairs, Health & Safety Committee Subject: Health and Safety Committee Report April 17 March Background In line with sound governance principles, an Annual Report is submitted from the Health and Safety Committee to the Audit Committee. This is undertaken to cover the complete financial year, and allows the Audit Committee to provide the Board of NHS Highland with the assurance it needs to approve the Governance Statement, which forms part of the Annual Accounts. The Health and Safety Committee is a formal Committee of the Board. The role of the Health and Safety Committee is to ensure that: It promotes the leadership, management and ownership of Health and Safety as an employer and as an integral part of the provision of health and social care services. It has a key role in ensuring the organisation meets the Staff Governance Standard that entitles staff to be provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community. NHS Highland and its management are clear and it complies with its regulatory obligations legislative under the Health and Safety legal framework, and the organisational requirements for the effective management of health and safety are met. The Board has a Non-Executive Director appointed, Melanie Newdick, as joint chair of the Committee with Elspeth Caithness, RCN Health and Safety Representative. Dawne Bloodworth, Interim HR Director, is the newly appointed Lead Executive for Health and Safety. The Committee has met on 4 occasions during the year, on 11 May 17, 10 August 17, 02 November 17, and 08 February 18. The minutes of the Committee have been submitted to the appropriate Board meetings. Agendas comprise, Reports from the Operational Units, Staffside Issues, Topic Specific items and Regular Advisor Reports 2. Activity The Health and Safety Committee considered the following key items at its meetings 2.1 Committee Workshop Sessions Leadership Walkrounds 2.2 Review of Governance, and Policy & Procedural Development Review of Role, Remit, Function of Health and Safety Committee Revised & Updated Health and Safety Policy and Document Framework Health and Safety Team Plan Operational Units Health and Safety Plans & Management / Reporting Structure Estates Health and Safety Plan

27 Active Safety Leadership Training Revised Operational Unit monthly & annual reporting template Internal Audit Report on NHS Highlands Health & Safety Management System Review of Health and Safety Statutory and Mandatory Training Compliance Planning & Implementation of HSE Enforcement Activity Establishment of Electrical Safety Sub Group 2.3 Documents for Ratification Revised MP11 General Risk Assessment Revised HBP10 - Lone Working Procedure Revised HBP Procedure Managing Skin at Health 2.4 Documents for Comment Registered Premises Officer Procedure HPB25 Fire Safety Policy MP01 Document Control Procedure Revised Management of Sharps Injuries, Blood and Body Fluid Exposures in Healthcare Policy Home Working Policy 2.5 Significant Adverse Events CSU Electrical Isolation Adverse Event Action Plan 2.6 Health and Safety Improvement Programme Health and Safety Team Plan Assessment of risk and management of patients at risk of self-harm from ligature points HSE Skin Health Action Plan. This was an extensive piece of work and resulted in a revision of existing procedures and training Radon Monitoring Statutory & Mandatory Training Performance Review Fire safety Moving & Handling Violence & Aggression Sharps Safety Medical Gases Inpatient Bed Maintenance Health & Safety Implications of Capital Projects Office Redesign Project Operational Plans Baseline risk assessment Face Fit Testing Appointment of Responsible Persons for Fire Safety Management Needlestick Injury Investigations Moving and Handling Risk Assessments Lone Working Risk Assessments Transport Safety Sharps Training Fire Safety Training

28 2.7 Advisory Reports Clinical Governance and Risk Management Performance RIDDOR trends HSE Activity Infection Prevention & Control Occupational Health Radiation Protection 2.8 Attendance from 1 April March 2018: Elspeth Caithness, Joint Chair and RCN Health & Safety Representative Melanie Newdick, Joint Chair and NHS Board Non-Executive Director Ann Pascoe, Non Executive Director Sally Bassett, UNISON Stephen Don, UNITE Tracy Ligema, Deputy Director of Operations, North and West Operational Unit David Park, Director of Operations, Inner Moray Firth Operational Unit Christina West, Chief Officer, Argyll and Bute Health and Social Care Partnership Katherine Sutton, Deputy Director of Operations, Raigmore Hospital Anne Gent, Director of Human Resources (until 30/9/17) Dawne Bloodworth, Director of Human Resources (Interim) (from 3/1/18) In Attendance: Rosie Brunton, Health and Safety Manager, Raigmore Hospital Fiona Campbell, Clinical Governance Manager, Argyll & Bute CHP Sarah Crawshaw, Moving and Handling Manager Eric Green, Head of Estates Fiona Miller, Health & Safety Manager Anna McInally, Corporate Services B Mitchell, Committee Administrator Alison Moore, Health & Safety Manager Mirian Morrison, Clinical Governance Development Manager Barry O Dowd, Physiotherapist Linda Rawlinson, Occupational Health Nurse Manager Bob Summers, Head of Occupational Health & Safety Karen-Anne Wilson, Health and Safety Manager Morag Forbes, Employment Services Officer Diane Fraser, Violence & Aggression Prevention Manager Paul Maber, Business Support Manager Amanda Glen, Operational Unit Health and Safety Manager, South and Mid Harry MacLean, Deputy Head of Estates Irene Stewart, Health and Safety Administrator Virginia Paul-Ebhohimhen, Consultant Occupational Health Physician Catherine Stokoe, Infection Control Manager Peter Craven, Senior Biomedical Scientist John Burnside, Business Continuity Manager Attendance from 1 April March 2018: Member 11/05/17 10/08/17 02/11/17 08/02/18 Elspeth Caithness Melanie Newdick Sally Bassett Apologies Ann Pascoe (until 30/5/17) Apologies

29 Anne Gent Apologies (until 30/9/17) Christina West Apologies Apologies Tracy Ligema Stephen Don David Park Dawne Bloodworth (from 3/1/18) Katherine Sutton Attendee Rosie Brunton Apologies Apologies Fiona Campbell Amanda Glen Eric Green Fiona Miller Alison Moore Linda Rawlinson Mirian Morrison Apologies Apologies Bob Summers Karen-Anne Wilson Sarah Crawshaw Diane Fraser Peter Craven Brian Mitchell Anna McInally Barry O Dowd Morag Forbes Harry MacLean Irene Stewart Paul Maber Virginia Paul-Ebhohimhen Catherine Stokoe Apologies Peter Craven Apologies John Burnside Apologies 3. Health and Safety Assurance, Management and Planning 3.1 Internal Audit Findings and Recommendations. An internal audit of health and safety was undertaken in November 2017 by Scott Moncrieff. Its purpose was to review and assess the effectiveness of NHS Highlands Health and Safety Management system against the Health and Safety Executives Managing for Safety and Health model. The majority of Boards in NHS Scotland adopt this model because of; its flexibility to wrap around existing Board management systems, the fact that delivery is based on plan-do-check-act and the strong emphasis placed on safety management being an integral part of daily management rather than a nice-to-do add on. The principle conclusion from Internal Audit was that: We have gained assurance that the overall health and safety framework is tailored to NHS Highland and complies with the Health and Safety Executive s HSG65 managing safety model. However, the framework is not fully embedded throughout the organisation and to be fully affective there must be an appropriate balance of effort and engagement by the H&S team and operational management.

30 The findings and risks identified were that: A number of management procedures still require to be reviewed or created. The document control system is not yet full complete or embedded across the operational units Operational Units health and safety governance, engagement, management and plan performance at all levels requires to be strengthened and monitored There is an imbalance of work and capacity within the Health and Safety team between addressing and supporting management with their reactive issues, which are a near constant, and embedding proactive risk control systems which, if implemented, would reduce the reactive workload burden as well as the number of adverse events, injuries and ill health. A separate action plan has been created to address the issues identified in the internal audit. 3.2 Policy.The current policy was ratified in Aug 2016, and it includes a revised documented framework which includes a range of Employer Level 1 Management Procedure controls and a suite of Hazard Based Procedures (HBP), which establish the agreed arrangements for managing common health and social care hazards. The framework also includes Radiation, Fire Safety and Estate structures, policies and procedures. Some minor revisions of the policy will be made this year to take into account; the Chief Officer role in North Highland, as well as the comments made by the Inspector for the Ionising Radiation (Medical Exposure) Regulations and it will integrate the recommendations made by the Internal Audit Report. 3.3 Governance and Assurance. At a corporate level, there have been minimal changes to the governance and assurance structures for managing health and safety and these have functioned reasonably well. Operationally, each unit / division is remitted through the Boards Health and Safety Policy and Committee to establish and maintain a Health, Safety and Fire Group (HSFG). Its purpose is to monitor and implement their plans, oversee and monitor compliance and manage new and upcoming operational risks. The success and effectiveness of these groups over the past year has ranged across the units from consistently good in some areas to poor in other areas. The groups in South and Mid and Argyll & Bute have generally functioned well, whereas in North and West and Raigmore have struggled over the past year to meet regularly, maintain a quorate attendance and work through a meaningful agenda. Both units have reflected on this and they have revised the approach for 2018, the effectiveness of which will be monitored through the committee. 3.4 Health and Safety Improvement Programme Improvement Programme. The Health and Safety Programme was revised and update in early It is split into two plans; a corporate level Health and Safety Plan and the Operational Unit level Health and Safety Management Plan Health and Safety Plan(s). This is split further into a number sub plans including the; Health and Safety Team Plan, the Sharps Safety Plan, the Medical Gases Plan and the Estates Health and Safety Plan. In regards to the latter, this is essentially a summary of the more significant Estates driven property / building compliance based risks / systems that Estates manage and oversee. Some of these systems are complex but the intention of the Estates plan is to ensure that Estates are included in the assurance and governance processes of the Board. The common themes amongst all these plans is that they address gaps in our health and safety management arrangements as well as providing revised, update and improved standards and procedures for managing hazard based issues at a corporate / pan highland level.

31 In terms of progress this year, a number of new procedures have been developed, ratified and promulgated across NHS Highland as well as a range of other improvements, all of which are detailed in paragraph 2.2 and 2.6 above 3.5 Operational Unit Health and Safety Management Plans (HSMP). There are approximately 250 HSMP s held and managed at a middle manager / service manager / team leader level. These plans contain basic statutory outcomes which we should already be complying with and they focus on aspects such as: risk assessment and control, the establishment of safe systems of work or specific hazard based controls. There are no gold plated or desirable outcomes in these plans. The main intention is to provide the Units / Divisions with improved risk control over their diverse structures, activities and premises whilst reducing the level of unnecessary reactive unplanned work. The overall aim is to establish more proactive systems and local procedures to manage key operational safety and health risks. Accountability for performance and monitoring lies with the Chief Officers, Deputy Director of Operations and senior managers. Responsibility for the plan actions rests with plan owners. This is a clear requirement in law and a policy aim and expectation of the Board, through its Health and Safety Policy and Committee. The HSMP s are structured and managed through Smartsheet (a commercial web based planning tool). It provides a one stop shop, excluding DATIX and Statutory Mandatory training data, for all compliance performance data. It also facilities plan owners and upper tier management and governance groups to monitor progress easily through a series of dashboards, providing the plans are populated. Twenty interactive web based training sessions were provided to 179 managers across Highland out of 262 managers invited in Jul 17 for all dashboard viewers and plan owners. In addition local health and safety managers have also provided extensive face to face support for managers on how to use the system and work through their actions The plans were launched in August 2017, and progression with the actions to date has varied between operational units and within Divisions. Some Divisions have responded well and working through the actions and some have not responded and are being followed up. Activity levels within the plans are monitored and shared with the Divisions, Committee and the Operational Health and Safety Groups for action on a quarterly basis. 4. Health and Safety Committee Sub Groups 4.1 Radiation Safety Committee. The purpose of the Radiation Safety Committee is to promote the safe and compliant use of ionising and non-ionising radiation throughout NHS Highland. The committee met twice in 2017 and minutes circulated. In compliance with NHS Highland s Radiation Safety Policy the committee received reports from Service Leads to ensure that the duties of the Employer were being properly implemented. Radiation safety audits were also undertaken and incidents monitored. Appropriate action plans were developed from external inspections SEPA May 2017 and IRMER June In 2017 the committee raised concerns about radiology reporting times which have since shown improvement. Committee members have facilitated the safe introduction of new radiation equipment and services. This includes: new medical laser; Nuclear Medicine radium 223 service; new phototherapy service for Golspie; replacement MRI scanners (ongoing); Radiotherapy CT scanner (ongoing). In 2018 major new radiation legislation is being introduced. The Radiation Safety Committee will focus on promoting the necessary actions to ensure the board is prepared for tighter radiation compliance and a likely increased frequency of inspection. More radiation training will be required for various staff groups.

32 Identified risks include: slippage to Estate s radon monitoring programme (including Argyll and Bute); non replacement of ageing Radiology and Nuclear Medicine equipment; IRMER 2017 implementation; the replacement of Head of Medical Physics and Bio-Engineering post; Identification of funding for disposal of radioactive sources. 4.2 Workplace Hazards Advisory Sub Group (WHaG). This sub group has met once over the last year. Its purpose is to ensure the appropriate management arrangements and systems are in place and compliant with respect to physical (excluding ionizing and non-ionising Radiation), chemical and biological hazards. This year it has focused; COSHH management, Face Fit Testing, skin health, Noise and Hand Arm Vibration as well as occupational hygiene monitoring. 4.3 Sharps Safety Group. This sub group has met once over the last year. Its purpose is to ensure that the appropriate management arrangements and systems, highland wide, are in place and compliant in respect to NHS Highlands sharp policies and the Health and Safety (Sharps Instruments in Healthcare) Regulations The group is represented by: occupational health, infection prevention and control, health and safety, local operational management and procurement. Procurement has a vital role in securing organisational control. A number of improvements have been made this year including; tighter procurement monitoring and control for the continued use of traditional needle systems, development of a Safety Device Selection Process, substantial review of the sharps safety policy, development of a national minimum dataset for sharp injuries and improved visibility of safety device use using a new national procurement database. 4.4 Medical Gases Sub Group. The Medical Gases Sub Group oversees and provides technical support and direction to NHS Highland, in line with HFS SHTM 02-10, on all non-clinical matters relating to the management of Medical Gases (Piped and Cylinder). This is a multidisciplinary group chaired by the Director of Pharmacy and supported by; health and safety, Estates, medical physics, staffside and operational management. It has met four times over the past year and focused on a range of issues including; a review of procedures, a review of practical training, auditing of hospital and community stocks, dental compressed air, replacement of G sized cylinders to ZX cylinders, and the implementation of Safety Action Notices. 5. HSE Interventions 5.1 Notifications to Health and Safety Executive (HSE) The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) requires NHS Highland to report deaths, types of injury, occupational diseases and dangerous occurrences (specified near misses) that arise out of or in connection with work. Generally, this covers incidents where the work activities, equipment or environment (including how work is carried out, organised or supervised) contributed in some way to the circumstances of the accident. In 2016/ RIDDOR s were reported to HSE, in 2017/ RIDDOR s were reported.

33 All Reported RIDDOR Incidents 5.2 HSE Interventions / Investigations There have been two Health and Safety Executive (HSE) investigations in 2017/2018. The first involved an inpatient suicide in New Craig s hospital in mid July An internal investigation and SAER has been conducted. In addition an extensive programme of baseline environmental / ligature risk assessments are being conducted across the entire site. It is anticipated that the regulator will conclude the investigation findings shortly. The second investigation, which involved a patient who fell and sustained a fractured hip, also occurred in New Craig s in July Not all patient falls are reported to HSE, and the interpretation of which ones should be reported is problematic and done so on a case by case basis and only after thorough internal scrutiny. The regulator has investigated this case, and also reviewed our wider pan highland systems for falls prevention. As with the suicide we await their deliberations which are anticipated soon. Finally, as a result of the HSE investigation in November 2016 into our management arrangements and risk control procedures / systems for and skin surveillance systems for dermatitis, this action plan is now completed, operational units have been informed, the new procedures completed and the online training has been reviewed and updated as requested. 6. Emerging Issues for Overall, 2017/2018 can be viewed as a successful, but as always, challenging year in Health and Safety terms. The focus for the Health and Safety Committee in will be to: Identify the opportunities and risks from Strategic Quality & Sustainability Plan and Annual Operational Delivery Plan, be ready to recognise and act on the anticipated scale, pace and organisational reform anticipated, and associated safety and health impacts that may bring to the workforce and ensure that the agenda and plans remain relevant, focused, supported and flexible. Govern and Support the integrated / shared North Region Occupational Health and Safety Agenda Govern and support an internal health and safety team review (Northern Highland Only) to provide a more efficient service Support and champion a sustainable and meaningful Health and Wellbeing Action Plan Improving the communication on safety, health and wellbeing at all levels Supporting the Statutory and Mandatory Training Agenda Facilitate the Operational Units to deliver on their Health and Safety Management Plans

34 Support Estates to improve their safety performance and compliance. Support the on-going and new Capital Projects Programme and service redesign work 7. Conclusion We, Melanie Newdick and Elspeth Caithness, as Joint Chairs of the Health and Safety Committee have concluded that the systems of control within the respective areas within the remit of the Health and Safety Committee are considered to be operating adequately and effectively. Melanie Newdick and Elspeth Caithness Joint Chairs Health and Safety Committee April 2018

35 Audit Committee 8 May 2018 Item 8.1(8) NHS Highland PHARMACY PRACTICES COMMITTEE ANNUAL REPORT To: NHS Highland Audit Committee From: Alasdair Christie, Chair, Pharmacy Practices Committee Subject: Pharmacy Practices Committee Report 1 April 2017 to 31 March Background In line with sound governance principles, an Annual Report is submitted from the Pharmacy Practices Committee (PPC) to the Audit Committee. This is undertaken to cover the complete financial year and forms part of the supporting arrangements for the Statement of Internal Control, ending with the certification and submission of the Annual Accounts. The remit of the Pharmacy Practices Committee is to consider applications to provide pharmaceutical services within the Board area and to determine whether these applications will be granted, or not. The Committee s consideration of any application is governed by the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 which were amended following the consultation Review of the Control of Entry Arrangements and the recommendations made in the subsequent summary report and came into force on 1 April Further amendments were introduced as the 2014 Regulations came into force on 28 June, In these Regulations there remains, at Regulation 5.10, the framework against which the Committee makes its decision. This is called the Legal Test. The Legal Test states that: An application shall be granted by the Board,. only if it is satisfied that the provision of pharmaceutical services at the premises named in the application is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located by persons whose names are included in the pharmaceutical list. Under the Regulations, the manner in which an application is considered shall be a matter for the Committee to determine. In all circumstances NHS Highland s PPC holds an oral hearing. This ensures that the PPC understands the evidence and that points of clarification can be obtained from both the applicant and any other interested party through listening to evidence and asking questions of those present. The Committee may or may not convene its meetings in accommodation in the area local to the proposed premises and undertakes a site visit to obtain, first hand, knowledge of the local area and of the suitability of the proposed premises. The Pharmacy Practices Committee shall consist of seven members unless the application is for premises in a neighbourhood or an adjacent neighbourhood to the location of a dispensing doctor, in which case an additional member will be appointed by the Board from persons nominated by the Area Medical Committee ensuring wider representation on the committee of whom (a) one of whom shall be the chair appointed as such by the Board; the chair shall be a member of the Board but shall not be an officer of the Board nor shall the chair be, nor previously have been, a doctor, dentist, nurse, ophthalmic optician or pharmacist or the employee of a person who is a doctor, dentist, nurse, ophthalmic optician or pharmacist; (b) three shall be pharmacists of whom i) one shall be a pharmacist whose name is not included in any pharmaceutical list and

36 ii) who is not the employee of a person whose name is so listed; and such pharmacist shall be appointed by the Board from persons nominated by the Area Pharmaceutical Committee; and two shall be pharmacists each of whom is included in a pharmaceutical list or is an employee of a person whose name is so listed; and each shall be appointed by the Board from persons nominated by the Area Pharmaceutical Committee; and (c) three shall be persons appointed by the Board otherwise than from the members of the Board but none shall be nor previously have been a doctor, dentist, nurse, ophthalmic optician or a pharmacist, or an employee of a person who is a doctor, dentist, nurse, ophthalmic optician or pharmacist. The amendments provide that only lay members are now entitled to vote reinforcing the independence of the decisions made. The non-contractor pharmacist is nominated by the Area Pharmaceutical Committee ensuring consistency with appointments to the National Appeal Panel and reinforcing independence. No business shall be transacted at a meeting of the Pharmacy Practices Committee unless the chair or in the chair s absence, the person acting as chair, one member appointed under each of (b) (i) and (ii) above, and two other members appointed under (c) above are present (a minimum of 5 persons). The membership of the committee is specified in the Regulations. The current membership of the Committee is made up from:- Alasdair Christie, Non-Executive Director, Chairman Gaenor Rodger, Non-Executive Director, Vice Chairman Michael Roberts, Lay Member Ian Gibson, Lay Member John (Mark) Sutherland-Fisher, Lay Member Grant Stewart, Lay Member Gareth Dixon Area Pharmaceutical Committee contractor representative Catriona Sinclair, Area Pharmaceutical Committee contractor representative) (vacancy), Area Pharmaceutical Committee contractor representative Caroline Morgan, Area Pharmaceutical Committee contractor representative Andrew Paterson, Area Pharmaceutical Committee contractor representative Fiona Thomson, Area Pharmaceutical Committee non contractor representative Dr. Alison MacRobbie, Area Pharmaceutical Committee non contractor representative Dr. Susan Taylor, GP Sub Committee representative 2 Activity in Year 1 April 2017 to 31 March 2018 There is no schedule of meetings for the PPC; it meets when an application to open a community pharmacy providing NHS services has been received. A declaration of interest has been submitted by one individual. However, only an information preliminary meeting has taken place. In order for this to process to Application stage, we await confirmation of postal code for premises and confirmed building plans.

37 3 Sub Groups This Committee has no sub groups. 4 External Reviews There are no specific reviews of the work of the Pharmacy Practices Committee, however, the decisions of this Committee are subject to appeal to the National Appeal Panel (NAP). The external appeal process to the NAP provides a proxy external review. The grounds for appeal are limited to the following circumstances:- there has been a procedural defect in the way the application has been considered by the Board there has been a failure by the Board to properly narrate the facts or reasons upon which their determination of the application was based there has been a failure to explain the application of the Regulations to those facts where the Board has erred in law in its application of the provision of these Regulations If the Chair of the NAP decides there are grounds for appeal they remit the decision back to the PPC for reconsideration, however, the points raised in one appeal may not necessarily readily transfer to a further application unless the points raised are generic and not specific to the particular application. 5 Any relevant Key Performance Indicators The process, which must be undertaken on receipt of an application, is driven by timescales and requirements set out in Regulations. Similarly, the conduct of the PPC and the reporting of the decision and the appeal process are driven by processes and timescales set out in the Regulations. 6 Emerging issues and key issues to address/improve the following year Formal training took place in February, 2018 when an invited audience of PPC Chair, PPC Vice- Chair and Board Officers convened, to help ensure that Boards and their PPCs understand and adhere to the statutory requirements involved in considering an application to provide pharmaceutical services from defined premises. NHS Highland also held two one-day training sessions for in-house training, which was welcomed by PPC members present as a useful resource to inform and improve the functioning and decision making of the PPC and the procedures required to support the overall process. 7 Conclusion I confirm that the systems of control within the respective areas within the remit of the Committee are considered to be operating adequately and effectively and adhere to the statutory requirements as set out in the appropriate Regulations. Alasdair Christie, Chair Pharmacy Practices Committee 31 st March, 2018