Minutes: Quality and Safety Committee (QSC) Date Wednesday 20 May 2015 Time 10:00-13:00 Venue. 5.3, 15 Marylebone Road, London, NW1 5JD

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1 Minutes: Quality and Safety Committee (QSC) Date Wednesday 20 May 2015 Time 10:00-13:00 Venue 5.3, 15 Marylebone Road, London, NW1 5JD Present Dr Neville Purssell NP GP, CLCCG and Governing Body Member (Chair) Dr David Spiro DS GP, CLCCG Dr Sheila Neogi SN GP, GLCCG and Governing Body Member Richard Christou RC Designated Nurse, Adult Safeguarding, CWHHE Mathew Bazeley MB Managing Director, CLCCG Joan Gordon Brown JGB Practice Nurse, CLCCG Janice Horsman JH Patient Representative Lizzie Wallman Assistant Director for Quality and Patient Safety, CWHHE (Alternate for Jonathan Webster) In attendance Liam Edwards LE Assistant Director, Quality, Nursing & Patient Safety Leroy Cordle LC Associate Director, Contracts Peter Beard PB Senior Commissioning Officer Learning Disabilities and Carers Dr Joanne Medhurst JM Medical Director, CLCH Kate Wilkins JW Assistant Head of Quality, CLCH Jacki Parker JP Quality Manager, Barnet CCG Patricia Grant PG Designated Nurse - Children's Safeguarding Jana Labovic JL South Locality Co-Ordinator, CLCCG Jayne Deegan JD Interim Governance Officer, CLCCG (Minutes) Apologies Michael Morton MM Governing Body Lay Member, CLCCG Jonathan Webster JW Director of Quality and Patient Safety, CWHHE Lavinia Armotrading LA Designated Nurse, Children s Safeguarding, CWHHE Kiran Chauhan KB Deputy Managing Director, CLCCG Eva Hrobonova EH Deputy Director, Public Health Minutes 1 Apologies for absence Apologies were received as above. 2 Declarations of interest No further declarations of interest were raised. 3 Minutes from the previous meeting The minutes were agreed as an accurate record. 4 Matters arising and action log Action 1

2 The Committee considered the updates provided and it was reported: 0544 GP Reporting - Local Issues That for purpose of communicating the reporting requirements, an would not be suitable. Accordingly the Chair proposed a strategy of raising local reporting through the Localities, newsletters and practice managers sessions. Matthew Bazeley was asked to nominate a member of staff to support the Chair and assist in developing a communications strategy which would be brought back to the Committee GP Reporting - Cross Collaboration Working Group That potentially interested parties had been contacted, however no responses had been received. It was proposed that Lizzie Wallman contact Simon Gordon who led the SystmOne Group to ascertain whether the Group could forward the action Integrated Quality and Performance Report - Maternity Metrics That the proposed 'skin-to-skin' metric had been abandoned because of measurement difficulties Integrated Quality and Performance Report - PPH rates That the item be carried forward Integrated Quality and Performance Report - CQC Inspection Princess Louise Nursing Home That a copy of the draft report had been received. Communications would be managed through the SHSOP Project Board. The meeting was advised that safety was being discussed at senior levels to ensure appropriate scrutiny and support was in place. Action: it was proposed that details of the assurance processes together with an analysis of the inspection be brought to the next Committee meeting. 0549/0550 Imperial - Patient Tracking That Liam Edwards and Jaime McFetters jointly undertake an audit of data tracking processes at the Trust and report back to the Committee. LE/JMc F 0552 CWHHE Safeguarding Adults Policy That following receipt of suggested amendments the revised policy was being reviewed by the Collaborative's Compliance team. Once completed the draft policy would be sent to the chairs of individual quality and safety committees and the Collaborative's Quality and Safety Committee prior to submission to the respective governing bodies Children s Safeguarding Quarterly Report Training That providers had been asked to provide details of training in their action plans Telephone and Advice Lines That the radiology advice service was currently outside the remit the contract. The meeting acknowledged that these advice services were both popular and useful to GPs and agreed that assurance was required as to the 2

3 use and quality of such advice lines. Action: it was proposed that Liam Edwards undertake an audit of such advice lines in terms of coverage, response rates and the quality of advice. LE 5 Integrated performance and quality reports: February and March The Committee's attention was drawn to the following issues: Quality & Safety Exception Report Reporting of Serious Incidents within Timeframe: While there has been an improvement over the last four month there still remained issues around the availability of investigators within the provider organisation. Maternity: There still remained unresolved data issues. In response to the concern expressed around the lack of an obvious action plan to address the various issues, Action: it was proposed that Lizzie Wallman would enquire when the next maternity deep dive was to be held by the provider to ascertain whether this was suitable in terms of timelines. In relation to a cold chain incident at UCLH, Lizzie Wallman reported that the incident and issues raised be escalated and a deep dive conducted. Performance Exception Report RTT: There remained challenges but the CCG was meeting the incomplete target overall with performance at 92.3% in M12. In addition there has been an improvement in the CCG incomplete RTT backlog from 949 in M11 to 772 in M12. Diagnostic Waits: The majority of breaches were reported by 2 providers. Cancer Waits: The CCG did not achieve the two-week wait breast symptomatic standard in M12. This was as a result of 30 patient breaches (27 patient choice and 3 administrative errors) however the CCG achieved the standard for 2014/15. The CCG did not achieve the 62 day standard in M12 as the result of 4 patient breaches(2 due to delay in workup. 1 administrative delay and 1 patient choice). A&E and LAS: There had been handover challenges. Programmes were in place to address. It was reported that because of Imperial's continued performance challenges, the Collaborative Quality Committee had invited them to attend a meeting to discuss. After discussion, Action: it was proposed that the Committee's concern over the lack of assurance and clarity available, the following provider questions be escalated to the Collaborative: DV 18 week RTT o Was the monthly trajectory reviewed at each CQG? o Is there a trajectory in place to measure performance? o Was it monitored and if so how often? o Was there an action plan in place to address challenges? o If yes, is it being achieved? Maternity o Was there an action plan in place to address the performance target shortfalls? 3

4 o If yes, is it being achieved? In relation to UCLH s performance, David Spiro advised that discussions were held at the CQG around performance. While a recovery plan was in place this was not discussed in great detail. It was proposed that the issue be raised through the contractual route. In the event no resolution could be achieved then the matter be escalated through the chair. The meeting considered the assurance requirements in relation to IAPT and in particular whether the solutions required by patients and potential patients were being provided. After discussion, Action: it was proposed that a report be made to the Committee as to how quality and assurance in relation to the services is provided for during the commissioning and procurement process. Shared Business Service The Committee noted the reports. 6 CLCCG serious incident report Lizzie Wallman introduced the report circulated. It was reported that: Headlines CLCH showed an upward trajectory in patient safety reporting. However there remained some inconsistencies in terms of provide reporting. Pressure ulcers continued to be an area of concern. New metrics would provide data on repeat causes and contributory factors to serious incidents in future reports. In addition it was reported that the June report would provide further details of 3 incidents reported under the common heading of Confidential Information Leak and sub-optimal care. National Framework In order to simplify the process two key operational changes have been made: Removal of grading Under the new framework Serious Incidents are not defined by grade - all incidents meeting the threshold of a Serious Incident must be investigated and reviewed according to the principles. Timescale a single timeframe (60 working days) has been agreed for the completion of investigation reports. It was planned to issue local guidance to support the changes. Non-Contract Providers Reporting of Incidents In terms of the visibility of incidents recorded by non-contract providers, Action: it was proposed that the process for reporting such incidents be investigated as to how and to where any incidents were reported and lessons learnt shared. 4

5 Report Format It was noted that the format of the report was still work in progress. The Committee noted that while trends were reported on there was a lack of detail to support appropriate learning. It was reported that a database was being developed which would provide the granularity and support recommendations. The meeting proposed that comparison details be provided and new trends emphaised. The Committee noted the report. 7 CLCCG locality risks and concerns register Jana Labovic presented the locality risk and concerns register and drew the Committee s attention to the following incidents: Discharge without notification to GP Practice. The Chair advised of another similar incident. The meeting considered the potential future challenges in terms of Whole Systems and ensuring a seamless discharge pathway. Delay in reporting scanned results to patient. Protocol for review for a patient fainting at South Westminster Centre and use of 111. Repeated procedure cancellations. The Committee recommended the hospital provider reinstate the appointment as soon as possible. The Committee noted the report. 8 Learning disabilities quarterly SAF report and assuring transformation Peter Beard introduced the 2 papers circulated which outlined the process and progress to date on the national priorities relating to improving access to health and social care for people with learning disabilities. Learning Disability Self Assessment Framework (LD SAF) Action Plan The meeting considered the paper which outlined the action plan for the LD SAF for 2015/16. It was reported users of the services and their carers have been actively engaged through a range of methods. The Committee s attention was drawn to the action plan and performance against the targets. It was noted that overall the rating was Amber and the meeting noted the required actions to address. Assuring Transformation Quarter /15 update The meeting considered the update paper as to the implementation of the key recommendations relating to placement and review activity for people with learning disabilities, from the Department of Health Review Transforming Care - a National Response to Winterbourne View Hospital. It was noted as with the London wide picture; local activity appears static, in particular: No placements have been passed to NHS England specialist commissioning team; There have been no discharges over the period, with one recent admission; 5

6 MH section activity remains the same and gives an indication that these placements are appropriate; and No significant change in out of area placements. It was reported that all people are in placements that are appropriate to their needs with processes in place to review their needs on an ongoing basis. In terms of future developments, it was anticipated that the tri-borough JSNA, mental health programme board and big plan implementation will help to deliver progress. Further the wider Assuring Transformation priorities relating to more local community based provision will be progressed through the Assuring Transformation Task and Finish Group. Finally progress against the key recommendations will continue to be monitored via the LD SAF process, the patient registers and assuring transformation data collection. In terms of future reports, it was reported that the action plan would be replaced with a project plan. The Committee: Noted and recommended the implementation of the LD SAF action plans in 2015/16; and Noted the progress of implementation of the key recommendations from the Winterbourne View Review at the end of Quarter /15. 9 Comments on papers for noting There were no comments. 10 Any other business There was no further business and the formal business of the meeting was closed. 11 CLCH quality account presentation Dr Joanne Medhurst and Kate Wilkins introduced the draft quality account for CLCH which was in the process of being consulted on. The attendees proposed the following: More details as to: achievements; systems; the CQUINs framework The addition of detail as to: 6

7 work done around outcome measurements quality across pathways and systems It was reported that the account was to be submitted by 30 May and statements due from commissioners by 27 May. Accordingly a record of the revisions would be circulated in order that the statement could be prepared. In terms of the future year reports it was proposed that consideration be given to the inclusion of details around the key initiatives required by the CCGs. Next meeting 17 June :00 to 12:00 5.3, 15 Marylebone Road, London, NW1 5JD 7