Quality and Clinical Governance Committee MINUTES FINAL. Meeting Time

Transcription

1 Meeting Venue Declaration of Interest Conference Room, Southgate House None Declared Quality and Clinical Governance Committee MINUTES FINAL Meeting Time 3 March am 1230pm Present: Mary Monnington MM Chair, Registered Nurse Member of the Governing Body, NHS Wiltshire Dina McAlpine DMcA Interim Director for Quality and Patient Safety, NHS Wiltshire Christine Reid CR Lay Member, NHS Wiltshire Dr Fiona Finlay FF Designated Doctor, Safeguarding Children, NHS Wiltshire Dr Richard Sandford-Hill RSH GP and Vice Chair for WYKKD, NHS Wiltshire James Dunne JD Deputy Designated Nurse, Safeguarding Children, NHS Wiltshire Lesley Scott LS Interim Head of Adult Safeguarding, NHS Wiltshire Peter Jenkins PJ Medical Advisor, NHS Wiltshire Susannah Long SL Risk & Governance Manager, NHS Wiltshire Louise French LF Head of Patient Safety, NHS Wiltshire Susan Burch SB Head of Patient Effectiveness, NHS Wiltshire Emily Shepherd ES Head of Patient Experience, NHS Wiltshire Helen Forrest HF Lead Infection Prevention and Control Nurse, NHS Wiltshire Isabelle Tucker IT Public Health Nurse, Infection Prevention & Control Lead Emma Higgins EH Patient Effectiveness Manager, NHS Wiltshire Gail Warnes GW Head of Prior Approvals, NHS Wiltshire Teresa Blay TB Head of CHC, FNC & Specialist Placements, NHS Wiltshire Katy Hamilton-Jennings KHJ Commissioning Manager, SARUM, NHS Wiltshire In Attendance: Sophie Cockram SC Quality & Patient Safety Administrator Bianca Lohrenz BL Quality and Patient Safety Administrator (observer) Wiltshire Apologies: Dr Mark Smithies MS Deputy Chairman of the Quality and Clinical Governance Committee and Secondary Care Doctor Marsha Barlow MB Patient Safety Manager, NHS Wiltshire Ana Gleghorn AG Patient Experience Manager, NHS Wiltshire Item 1. Welcome and Introduction MM welcomed attendees and congratulated DMc for her new appointment as Interim Director for Quality and Patient Safety. MM acknowledged the busy period the is facing currently due to contract renewal and CQUINs discussions and finalisation with providers. Page 1 of 6

2 2. Minutes of the last meeting and matters arising (6 th January 2015) CR referred to page 5 and asked for an update regarding the investment of 250k for Community Stroke Services. ES explained that the NEW group are currently working with GWH on putting together a proposal. It was suggested that Ted Wilson provide an update at the next meeting. Action The minutes from 6 th January 2015 were agreed as a true and accurate record 3. Action Tracker See separate document. Items 86, 83, 81, 87, 88 were agreed as complete and will be removed from the action tracker. 4. Quality Report DMc referred to the Quality Report and discussed the Safety Thermometer. There is no assurance that providers collect the data in the same way. There is a piece of work taking place at SFT relating to this. DMc stated that there are high percentages on every harm for SFT. For patients with pressure ulcers (new or old) SFT are the outlier throughout although long stay patient data are included in the figures. The RUH are progressing well with their work on reducing pressure sores. Figures on pressure sores are an area concern for GWH community and this is mirrored in the STEIS reporting, with the majority of pressure ulcers being acquired at home or in residential homes. There is a low skill mix of community nurses, and at present there are only Band 5 nurses visiting these patients. There are a high number of patients with pressure ulcers being admitted to hospital, DMc informed the meeting that the Wiltshire Quality Surveillance Group in conjunction with the Local Authority will be focusing on discussing this with care homes, along with the CQC and Healthwatch. SFT is the outlier in relation to falls, with repeat falls an area of concern. There is a lack of risk assessments, plus when staffing is low falls increase in number. For UTI s SFT is again an outlier with high numbers of Catheter Acquired UTI s due to poor catheter management, and the use of unnecessary catheters. During December RUH went into black escalation, and a planned Quality Visit to the RUH had been cancelled as a result of this. However a visit to the maternity unit at SFT and RUH had been completed. The visit to the RUH ITU and gastroenterology departments will be rescheduled. DMc explained that the plan is to increase the number of quality visits during the coming year to include the community hospitals, smaller providers and mental health units. It is hoped that a patient story will be included in the quality report bi-monthly. 5. Patient Experience/PALS ES updated the group regarding PALS and complaints. There is currently a process review which it is hoped will improve timescales and the quality of responses. The response from the provider who has investigated the complaint will come in the format of a letter addressed to the complainant with a cover letter from the and input and additions from the commissioner for that provider. Trend analysis and learning is shared at the CQRMs. Complaint themes continue to be CHC and Patient Transport Services. FFT will no longer be a CQUIN but a requirement detailed in the Quality Schedule. DMc referred the meeting to page 7 of the quality report which details complaint figures for providers. Mental Health complaints remain low. ES stated that she is meeting with Healthwatch in March along with the Interim PALS and Complaints Manger, and the Patient Experience Manager to discuss the complaints process. Action CR asked that she be invited to any further meetings with Healthwatch relating to complaints as the Board lead for Patient Experience. 6. CQUINs/CAG DMc told the meeting that the National CQUINs were published on 27 th February EH referred to the presentation document on CQUINs for 15/16 and explained the eligibility criteria. The National Goals will seek to incentivise quality and efficiency, and for the first time the scheme looks at reward transformation across care pathways across more than one provider. The Committee discussed Dementia & Delirium which remains an indicator for 15/16, along with Improving Physical Health Care for Mental Health patients. RS-H explained that some patients can be admitted to hospital Page 2 of 6

3 because a relative has made a diagnosis regarding their mental health due to the patient being in a confused state, however this may conclude with the patient being diagnosed with a UTI. This CQUIN will enhance the Find, Assess, Treat, Refer process. New indicators for 15/16 include AKI (Acute Kidney Infection) with the aim to diagnose earlier and prevent the patient being discharged into the community with an AKI. Sepsis is a new national indicator, and had been a Local CQUIN for 14/15 in Wiltshire. Urgent Emergency Care (UEC) also features as a national CQUIN for 15/16 and emphasises the role of community services in treating patients rather than in hospital. There have been proposals from the Acutes which fit with the themes and fit with the mandatory themes. PJ referred to the Mental Health proposals and suggested that these were putting the onus back onto GPs. LF responded by saying that it is about working together and increasing support for GPs in this area with additional training relating to safeguarding, CAMHS etc. RS-H considers that this seems like secondary care is being paid to dump into primary care, and that primary care will need more resources to be able to manage this. The Safety Thermometer and Friends and Family Test are no longer CQUINs but part of the Quality Schedule. 7. Serious Incidents Requiring Investigation (SIRI) LF informed the meeting that a dedicated address for SIRIs has now been set up. Fortnightly Serious Incidents (SIRI) panels are taking place. All incidents from April 2014 are being quality checked and anonymised. Figures for GWH include community services. MM commented that GWH figures could demonstrate under reporting. LF stated that there is no CQC risk of monitoring reporting and that the relationship with the GWH risk team is robust and that they are following guidance. The main themes are that risk assessments are not timely and out of date. Pressure ulcers account for a third of all SIRIs which is community related. GWH are taking robust steps to try and reduce this by rolling out training on tissue viability competency. The situation will be reviewed in due course once training has been continued. Paperwork for reporting SIRIs is lengthy and is being revised and administration procedures streamlined. There were 46 new SIRIs in Quarter 3, giving a total of 120 year to date. There are no Never Events year to date for W, however there had been 2 Never Events concerning non Wiltshire patients at GWH (removal of incorrect mole) and RUH (vaginal swab left in situ). There have been 24 Serious Incidents (SIRIs) year to date 19 of which were Grade 2 incidents with RCAs to be produced within 60 days, and the remainder are Grade 1 SIRIs with RCAs to be produced within 45 days. It was decided at panel that two of the 19 Grade 2 SIRIs will go onto the Never Events reporting. One of these NEs took place at SFT and was a retained throat swab after surgery. As a result of the incident SFT have made major changes to their process and tightened up on their swab count procedures. The remaining NEs took place at University Hospital Southampton (clip left in chest cavity after heart surgery) and one at SFT (punt clip left in scrotum after surgery). SIRI cases closed year to date are 28, 10 are with the Area Team, and a total of 83 SIRI cases closed since April Patient Safety are currently developing an information pro forma for smaller providers. RCAs are monitored at CQRMs and will become a standing reporting item as at present only exceptions are reported. 8. Infection Control HF referred to the Infection Control report and stated that from October to December 2014 there had been 4 MRSA infections one had been a contaminated sample, 2 were wound infections, and one a result of respiratory tract infection. There are 51 cases of MSSA for Quarter 3 50 of which were incubating on admission and were due to soft skin tissue, or indwelling devices. C difficile cases were below the expected target at 79 up to December. The expected rate is 140 for 14/15. GP surgeries have been contacting the Infection Control Nurses regarding advice on Infection and Prevention Control good practice over the last couple of months. There were a high number of cases of gastroenteritis in the acutes in November 2014 but there were no ward closures due to good management of infection. The Infection Control Team have undertaken pilot audits on Infection Prevention and Control practice at 6 GP practices, with a total of 9 practices audited so far. The team is also providing support to the Infection Control Leads at GP practices. The team are also presenting at GP training seminars on IPC practice, SEPSIS and antimicrobial resistance. RS-H offered to look at the proposal. Action Page 3 of 6

4 HF reported that 40 care homes are meeting on a regular basis to self-audit and there has been good feedback so far. There will be a report back on the work programme within the Annual Report for IPC. The Wiltshire Infection Prevention Network (WIN) has been established with 30 out of 500 care homes signed up. The WIN newsletter is circulated to all WIN members and is published on the W website. CR suggested that it be circulated to Practice Managers and GPs as well. HF stated that the Health & Social Care Act is under review particularly with regard to antimicrobial prescribing. HF is attending a training day regarding antimicrobial prescribing and DMc asked her to report back to this meeting. Action 9. Continuing Healthcare TB reported that currently the CHC department are reviewing fast track funded cases as it is believed a third of these are not appropriate for fast track funding. A CHC Nurse Assessor has been recruited to assist with this, and an existing CHC Nurse Assessor is working some hours at the RUH to advise them with regard to fast track referrals. TB continued by saying that CHC funded LD cases are also currently being reviewed. Two CHC cases had gone to the Independent Review Panel both of which had been upheld. One retrospective case which had gone to the Ombudsman for investigation had also been upheld therefore showing that they are supporting our processes. Work on Personal Health Budgets is progressing, they will be made mandatory from 1 st April There are discussions continuing regarding how this area of CHC will be resourced. Neuro rehab patients continue to be part of the CHC department. Referring to Mental Health TB stated that there had been a major safeguarding incident at an independent hospital and all of the service users had been relocated elsewhere. MM asked how many retrospective CHC reviews were outstanding there are 114 ongoing with 97 commissioned out to Care Home Selection. 10. Safeguarding Adults LS referred to the Safeguarding Adults report. The Deprivation of Liberty Safeguards 19 th March 2014 judgement was discussed and applies to domestic settings, including supported living accommodation. There are currently 20 individuals identified by the community teams as needing an assessment to establish whether court of protection applications will be required. There are financial implications for the and currently there is a proposal to use Best Interest Assessors within the to facilitate the assessments and applications. LS stated that there are some new standards used to inform quality and contract monitoring which will be included in provider contracts for 15/16 e.g. referrals for terrorism. LS referred to training for safeguarding for adults and stated that currently the RUH have reported numbers which show non-compliance at every level. LS will be meeting with the safeguarding lead to ascertain why there has been a reduction in training and to produce an in depth action plan and trajectory. Action SFT do not currently have an Adult Safeguarding Nurse. Mental Capacity training statistics show a reduction in compliance and is attributed to recording methods and not actual figures. They are currently working with their Educational Department to use the reporting process for data capture. Action GWH have appointed a Safeguarding Adults Lead for their acute services who will work closely with the Community Safeguarding Adults Lead. There have been 11 safeguarding alerts raised by GWH in Quarter 2, 7 of these were raised by GWH staff. Three of these were Grade 3 pressure ulcers, and 2 were neglect which involved agency staff. MM considered that this was a low number of alerts, LS agreed that there has been an improvement. There is currently a large scale investigation into a care home which had also involved the police and potentially the NMC. The management team of the home has been replaced. MM asked if the home remains open LS confirmed that it is still open but is closed to admissions. DMc confirmed that there are issues regarding skill mix and capacity of staff. MM enquired as to whether the CQC had put measures into place at the home, LS informed her that there was a CQC action plan and that there would be regular reviews of the home by health and social care. Action LS informed the meeting that there is a work based learning programme at the University of the West of England on 20 th March which is for providers and is aimed at assisting participants to develop their Page 4 of 6

5 knowledge and skills and lead to an improvement in practice with regard to the Mental Capacity Act. 11. Safeguarding Children JD referred to the Safeguarding Children report and told the meeting that the CQC report and Leadership Strategy reports are near completion. A new Designated Nurse for Looked After Children (LAC) is now in post within Great Western Hospital. Dr Stuart Murray is preparing a report on LAC. JD referred to the review for LAC in BaNES which took place in June 2014 there are CQC actions arising out of this relating to maternity services and referrals to Social Services. GWH JD referred to the Training Strategy and told the meeting that the is working with the Trust to produce an implementation plan to identify the most appropriate level of training for each staff member and/or staff group Action. There had been one STEIS in August 2014 following which the had requested a health internal management review. A table top learning event was held in January 2015 and action plans for GWH services have been produced. There is criticism regarding the length of time for reporting a STEIS to social care. DMc suggested feeding back into the Quality Assurance Group Action. SFT JD discussed training at SFT and explained that there is not as much understanding regarding the needs of training for staff due to capacity of staff, plus a change in the Director of Nursing and a change in focus. There is less progression in terms of the training strategy than at GWH and RUH. The expect a level of improvement in this area and will be working with SFT to progress this Action. RUH JD informed the meeting that a request had been made that maternity staff are prioritised in terms of training due to STEIS reporting and incidents regarding social problems. The issue around maternity has arisen from the staff from GWH being TUPE d across are Level 2 trained and not Level 3. An improved timetable for training will be produced. Oxford Health JD reported that there are no concerns regarding their training strategy. WSCB JD informed the meeting that there were some concerns regarding GP safeguarding reporting with a mixed standard of reports, there will be a further audit in April & May RS-H said that some GPs are practised at writing these reports because they have had to write them on several occasions, however other GPs are less practised and he suggested training for GPs. Child Sexual Exploitation JD told the committee that due to media coverage and scrutiny over the last 6 months a CSE strategy group had been set up with the working in partnership with Wiltshire Council and Wiltshire Police. There will also be training events for GPs. CR and MM asked that there is more detail in the report to give assurance to the as to whether children are safe in Wiltshire, and so that there can be learning from cases and that it would be helpful to look at themes. They also felt that it would be helpful to be informed of areas of concern. FF stated that there is a summary of learning from reviews and progress made every 6 months. FF suggested that she and JD report from the Wiltshire Wide Web group that she attends and produce an outline of what items could be included going forward in the safeguarding report. RS-H stated that it would be useful to know whether things had improved year on year for example. Action 12. Risk Register SL reported on the Risk Register and stated that the Mental Health care home where there were safeguarding concerns and Fast Tracks will remain on the register over the next quarter as the score is maintained. There was discussion as to whether NHSIII CQUINs, Safeguarding for Children training concerns for maternity services at RUH and Personal Health Budgets should go on the register however the Committee did not agree to this. 13. Clinical Policies Page 5 of 6

6 Managing Back Pain Spinal Facet Joint and Epidural Injections KH-J referred to the above policy and asked for sign-off. MM asked whether there had been any consultation with the public regarding changing the service. KH-J explained that there had been patient engagement in the form of publicity on the website with contact details for requesting information, or via PALS & Complaints. Two workshops had also taken place between July 2014 and March 2015 which had good attendance and comments made by the public had been taken into account. MM asked what were the key issues raised by the public. KH-J stated that for the most part they required clarity on what was actually being commissioned. PJ added that this review means that the has tightened up the policy on non-specific back pain. The policy was agreed by the Committee. Safeguarding Children & Adults Policy JD explained that this new policy merges the two policies for Children & Adults. The policy sets out accountabilities and arrangements. The key changes to the policy relate to the changes to the Adult Care Act which detail definition and categories of abuse and the review of the policy recognises these changes. JD stated that this policy is for the and not providers. CR asked for clarity on who to contact regarding safeguarding JD suggested that he produce a flow chart of contact details Action. The Committee agreed the new policy. Body Contouring Procedures Earlobe Repairs Tattoo Removal Female Genital Cosmetic Surgery GW explained that the above procedures are not normally funded by the, therefore GW had produced individual policy statements for each of these procedures for publication on the website to better inform the public. PJ stated that these policy statements are useful for GPs as a point of reference when discussing these procedures with patients and will help reemphasise that the does not normally fund them. The Committee agreed the policy statements. 14. Any Other Business HF formally invited the committee to attend the Quality & Patient Safety Open Day on 5 th March at Southgate House. 15. Date of next meeting The next meeting will be held at 9.30am on 5 th May The deadline for papers is 21 st April Page 6 of 6