Ref No: 16/10/16a LONDON NORTH WEST HEALTHCARE NHS TRUST INTEGRATED GOVERNANCE BOARD SUB-COMMITTEE

Ref No: 16/10/16a LONDON NORTH WEST HEALTHCARE NHS TRUST INTEGRATED GOVERNANCE BOARD SUB-COMMITTEE Approved Public Minutes of the meeting held on 15 th July 2016 at 10am in Meeting Room 1, Northwick Park Hospital Present Andrew Farrell (Chair) Janet Rubin Dr Vineta Bhalla Andrew van Doorn Jacqueline Docherty DBE Dr Charles Cayley Lee Martin Nigel Myhill Mark Andrew In Attendance Peter Worthington Simon Crawford Jo McCarthy Mitchell Fernandez Danny O Leary Judith Pickersgill Nicola Wales Ginder Nisar Apologies Prof. Taube Jon Bell Amanda Pye Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Chief Executive Medical Director Chief Operating Officer Director of Estates and Facilities Head of Governance Chairman Director of Strategy and Deputy CEO Divisional Head of Nursing, Integrated Medicine Lead Nurse for Quality and Clinical Standards Divisional Lead for Women s Services Supervisor of Midwives Supervisor of Midwives Executive Assistant (Minutes) Non-Executive Director Chief Financial Officer Chief Nurse Item Discussion Action Lead 1. Welcome and apologies for absence Apologies received from those listed above. 2. Conflict of interest None declared. 3. Minutes of the meeting held on 13 th May 2016 The public and private minutes of the meeting were agreed as a true and accurate record. 4. 4.1. 4.2. 4.2.1. Matters arising from the previous meeting and review of the action points The actions register was reviewed and updated. The following updates were noted which were not otherwise captured within the main agenda or the actions register. NWL Maternity Network Dashboard Following the NWL Maternity Network Dashboard report discussed at Page 1 of 10

the May 2016 Integrated Governance Committee (IGC), 17 key indicators were extracted from the report which provided a summary snapshot of performance and quality of maternity services at the Trust. It was proposed that these key indicators would be reported to the Board and to the Finance and Performance Board Committee in the monthly Integrated Performance Report, and that performance on any other Maternity indicator also be reported in the event of a significant issue, with periodic reports on all 49 Maternity indicators. (D O Leary) 4.2.2. 4.2.3. 4.2.4. 4.2.5. 4.2.6. Dr Bhalla enquired whether other Trusts were monitoring performance against all of the indicators or a selection. Jacqueline Docherty advised that the report had already been discussed at the May 2016 IGC with the suggestion of monitoring a selection of metrics which was agreed. Benchmarking comparisons, trends over time, review of pathways for women and emergent issues would be included in the Division s periodic reports to the Board. Dr Bhalla enquired whether the selection of indicators included the right indicators. Danny O Leary advised that the selection provides reasonable balance and that they would be overseen amongst all 49 indicators that would continue to be reviewed monthly by the Division and periodically by the Board. Andrew van Doorn suggested reassessing monitoring after two cycles of reporting. In terms of recruitment of midwives, Janet Rubin enquired why only 18 midwives had been shortlisted out of 85 applicants. Danny O Leary advised that gaps in training and other essential requirements had unfortunately ruled out a number of applicants. Amanda Pye and Danny O Leary noted the comments. The Committee agreed that the indicators would be included in the Integrated Performance Report which was reviewed at the Finance and Performance Committee and subsequently at Board. (D O Leary) (D O Leary) D O Leary/ 5. Clinical Quality and Risk Committee 5.1. 5.1.1. 5.1.1.1. 5.1.1.2. Summary of trends and key issues Lee Martin provided the following summary of items discussed by the Clinical Quality and Risk Committee (CQ&R) during May and June 2016. Critical Care - Dr Husain had attended the CQ&R and presented an analysis of NPH critical care data collected from several resources. The principal issues noted included critical care capacity; correlation with mortality rates; a relatively high number of transfers to other hospitals and the rising acuity of admitted patients. A weekly meeting with Executive Directors takes place to monitor and discuss the issues. A business case had been developed to provide further capacity. In response to Peter Worthington s question, Lee Martin confirmed that transfers to CMH were normally treated as a non-clinical transfer. Janet Rubin had visited CMH and was informed of a patient who had been transferred a number of times between NPH and CMH and the staff member advised that they did not fully understand the reasons. Janet Rubin asked Lee Martin how assured he was regarding the Page 2 of 10

5.1.2. 5.1.2.1. 5.1.2.2. 5.1.2.3. 5.1.2.4. 5.1.2.5. 5.1.3. 5.1.4. 5.1.4.1. 5.1.4.2. 5.1.4.3. transfer process. Lee Martin advised that the issue had not been reported and added to Datix. In response to Dr Bhalla s question, Lee Martin confirmed that staff are briefed on why patients are transferred but would look into the case in question. Jacqueline Docherty advised that going forward the plan was to downscale transfer to CMH and to implement different ways of dealing with such patients on the NPH site. Infection Prevention and Control (IPC) A standing operating procedure would be developed by Estates and IPC for future project work affecting clinical areas to ensure work is undertaken safely around patients, mindful of the clinical environment, patient experience and infection control. The Legionella Serious Incident (Ealing) was reviewed and the final Duty of Candour letters sent to the two confirmed cases. The actions from the external advisor would be monitored and reported to the Infection Control Committee. The report outlined the areas of concern and risk which included insufficient representation by the divisions at the Infection Control meetings; the number of cannula related infections that had occurred; two cases of MRSA; concern expressed by clinical lead that the proposed additional critical care capacity will be co-located on the current Vascular Ward; and since Group B strep screening stopped few cases had been reported in mothers and babies. It was reported that actions in relation to these risks are in progress for the areas outlined and are monitored at the respective steering groups. The divisions have been asked to report to the Clinical Quality and Risk Committee their actions on improving standards in respect of infection control and prevention. In terms of the Group B Strep, Jacqueline Docherty requested to see the presentation referred to in the report as well as benchmarking data. Patient Safety - The CQ&R had received an update from the Patient Safety Group including the Serious Incident report for May 2016, action plan trackers, a report on a wrong blood in tube incident, an update on safety alerts and learning from incidents. Children s Safeguarding The Children s Safeguarding quarter 4 report provided assurance that the service was meeting the statutory responsibilities. The Multi-agency audit of Harrow Mash (Multi-agency Safeguarding Harrow) found that its performance rating had changed from good to requiring improvement. An immediate action plan had been put in place by the Local Authority and would be monitored by the Safeguarding Board. Compliance with training rates in all divisions was increased. Jo McCarthy confirmed that the Trust would comment on the report. The Committee noted the considerable delay in sending the Looked After Children annual report for 2014/15 for Brent to the Local Authority. Maternity actions from a serious case review were overdue. Actions were being addressed and would be monitored through the Safeguarding Board. L Martin L Martin Page 3 of 10

5.1.4.4. 5.1.5. 5.1.5.1. 5.1.5.2. 5.1.5.3. 5.1.6. 5.1.7. 5.1.8. 5.2. 5.3. 5.3.1. 5.3.2. It was noted that the waiting list for Social Communication Assessment was two years overdue and had been on the risk register since 2015. Adults Safeguarding Adults Safeguarding quarter 4 report provided assurance that the service was meeting the statutory responsibilities. In line with the Saville report, an induction programme for volunteers would be in place by July 2016. A clear process for monitoring application of safety Mittens would be presented to the next Safeguarding Board. The report outlined a summary of quality, safety, patient experience aspects from each of the divisions. The CQ&R received a number of policies and guidelines for review and ratification. The above actions would be taken forward by Amanda Pye. Minutes of meeting held in May and June 2016 The minutes of the meetings held on 4 th May and 1 st June were noted. Schedule of Reporting Committees/Groups The Committee noted that the Terms of Reference for the reporting groups were being reviewed. The schedule was noted. 6. Corporate Quality and Risk Committee 6.1. 6.1.1. 6.1.2. 6.1.2.1. 6.1.3. 6.1.4. Summary of trends and key issues The Committee noted the summary of items discussed by the Corporate Quality and Risk Committee (CoQ&R) during May and June 2016. Policies - An update on policies was received by the Committee. The Policy on Policies would be updated in due course. Meanwhile, a process for reviewing and ratifying policies had been produced and disseminated within the Trust. The IGC agreed that once the Policy on Policies has been reviewed by the CoQ&R, it should be ratified by the IGC and then Board, and that there needs to be clarity on delegated authority from the Board to any other Committee, Group or persons to approve any Trust policies A summary of the status on policies would be provided to the next IGC. Information Incidents - A report from the Information Governance Group for April 2016 reported 15 incidents in month with a total of 33 year to date. Andrew Farrell requested that the summary report is more descriptive in future indicating the nature of breaches, and not just their classification, he requested an updated report of the incidents relating to information governance be provided to IGC. FOI Requests 284 FOI requests had been received for the period 1 st G Nisar G Nisar S Crawford Page 4 of 10

November 2015 to April 2016. 100% compliance was achieved for the response time except for one breach in March 2016. 6.1.5. 6.1.5.1. 6.1.5.2. 6.1.5.3. 6.1.6. 6.1.6.1. 6.1.7. 6.1.7.1. 6.1.7.2. 6.1.7.3. 6.1.8. 6.1.9. 6.2. 6.3. Health and Safety The Health and Safety Audit report was presented to the CoQ&R and the recommendations and actions outlined. The CoQ&R would review progress on a monthly basis. Nigel Myhill confirmed to the CoQ&R that the Asbestos Safety Group reports to the Health and Safety Group and provides an annual report of its activities and assurance in respect of safety and legislation. The CoQ&R received an overview report of the Trust s fire safety issues at NPH. Emergency Planning - The Emergency Planning and Business Continuity Steering Group s Terms of Reference had been reviewed and would fall under the remit of Urgent and Emergency Care division. The Emergency Planning Strategy for 2016/17 had been drafted and a training programme would be developed. Medical Devices The Committee received an update on Medical Devices noting that 1025 devices were currently maintained by contractors other than BCAS Biomedical Services via 86 separate contracts. In response to Peter Worthingon s question, Nigel Myhill advised that eventually almost all the devices would be maintained by BCAS apart from a few with exceptional requirements. A report with key measures would be presented to the CoQ&R. Jacqueline Docherty added that a report outlining the percentage of equipment that can be moved to managed service contracts would be useful. Jo McCarthy added that it would also be useful to include plans for standardising of equipment. Nigel Myhill noted the comments and the discussion would be taken back to the CoQ&R. In response to Peter Worthington s question regarding capitalisation on the balance sheet of medical devices, Simon Crawford advised that the assets are capitalised where possible in accordance with the Trust s accounting policies. The CoQ&R received an update on the Corporate Risk Register with 40 risks on the Corporate Risk Register. The CoQ&R received a number of policies and guidelines for review and ratification. Minutes of meeting held in May and June 2016 The minutes of the meetings held on 5 th May and 2 nd June 2016 were noted. Schedule of Reporting Committees/Groups The schedule was noted. 7. Discussion Topics Page 5 of 10

7.1. 7.1.1. 7.1.2. 7.1.3. 7.1.4. 7.1.5. 7.1.6. 7.1.7. 7.1.8. 7.1.9. 7.1.10. Fire Nigel Myhill provided an overview of the Trust s fire safety issues at NPH and advised that the Trust has been operating under Enforcement Notices served by the London Fire Brigade (LFB) in July 2012. Since the issue of the notice; some improvements had been made in part satisfying the notices but further works required in order for the Trust to fully discharge the requirements of the notices and to address the findings of its own fire risk assessments. Monthly meetings continue to take place and Nigel Myhill advised that the LFB are satisfied with progress to date. Nigel Myhill explained that the fire prevention works in the wards must continue at pace on a rolling program in order to address the risks associated with safety and operational continuity. Andrew Farrell enquired whether the Trust has documentary confirmation that the plans are acceptable to LFB. Nigel Myhill advised that the plans are acceptable. Although the Trust does not have written confirmation of that from LFB, the Trust s contracted fire risk assessor provided assurance with the plans and actions to address the issues that had been raised in the 2012 enforcement notices. Andrew Farrell enquired whether additional mitigations were in place, to provide assurance on fire safety until physical works could be completed. Nigel Myhill advised that Fire evacuation training was provided and where the Trust does not have fire separation arrangements in place, each bed has an evacuation slide underneath it. Andrew van Doorn enquired about the decant facility to enable fire safety works to be carried out. Nigel Myhill advised that decant facilities were in place for the works which were being progressed at pace. Jacqueline Docherty added that Nigel Myhill and Lee Martin had recently launched the wards fire works programme at an event attended by operational and clinical staff. In response to Janet Rubin s question regarding operational and financial support, Nigel Myhill advised that the report would be updated in this respect as further discussions had taken place at Committees. A further report would be provided to the January 2017 IGC. Andrew Farrell commented that entries on the Risk Register did not, per se, constitute an action plan and to be clear about the separation of these. Nigel Myhill advised that the Fire Risk Assessment was different from the Risk Register and the action plan was a statutory requirement in response to the Enforcement Notices. The Fire Safety Group and CoQ&R review the risks. Peter Worthington requested that the IGC monitors progress on a six monthly basis and also suggested that an application could be made to the Charitable Funds Committee for funds to accelerate the works and that CCGs should be aware and be approached to contribute to the works. The Executive Team would consider this suggestion as part of the list of bids being considered by the Executive Team. The Committee were not fully assured that the LFB were fully supportive of the Trust s plans and progress against them and asked F/planner Page 6 of 10

that following a meeting with LFB, agreed minutes or other documentation is provided confirming LFB s support and advising on any residual issues. Although monthly meetings take place at which discussions are supportive, Nigel Myhill would ensure this is documented and report back to the IGC. 7.2. 7.2.1. 7.2.2. 7.3. 7.3.1. 7.4. 7.4.1. 7.4.2. 7.4.3. 8. 8.1. 8.2. Water Nigel Myhill provided an overview of the Water Safety Risks at NPH, St Mark s Hospitals and EH along with the management controls in place to mitigate the risks. In response to Janet Rubin s question regarding an action plan for Kingsley Ward, Nigel Myhill confirmed that an action plan was in place to maintain and contain the issues. The medium term plan was to replace the pipes and the long-term plan was a new inpatient unit. The CCG was aware of the issue. Medical Gas Pipeline Systems Nigel Myhill provided an overview of the medical gas pipeline systems and the supply of piped oxygen to NPH, St Marks and EH, the infrastructure, the risks and the projects underway to mitigate the risks. Electrical Report Nigel Myhill provided an overview of the electrical risks at the sites, the current infrastructure, risks and mitigations. Peter Worthington enquired whether each site has a temporary generator. Nigel Myhill advised that an emergency generator should be able to supply 60-70% of normal power requirement. - CMH has a single generator at 90% and will be tested each month. - EH has essential and non-essential back up which is tested monthly. - NPH has 20% back up supply which is not desirable. Although a new generator has been on site for three years it has not yet been connected and a business case has been approved to fund the works to enable connection by December 2016 which would enable 100% essential supply. - A risk assessment would be undertaken in regard to Community. - Nigel Myhill advised that a black start test would be undertaken annually and planning would be required to ensure medical devices have back up supply. An update would be provided to the IGC in November 2016. The Committee welcomed the updates and noted the status in respect of each of the areas. Care Quality Commission (CQC) Update Jacqueline Docherty commented on the successful Quality Summit which had taken place on 13 th July 2016. The CQC and Jacqueline Docherty had presented slides followed by six work group sessions, each of them agreeing to three pledges. Manolis Heliotis assured the attendees on the plans in place to address the critical care issues raised in the warning notice served to the Trust shortly after the inspection. The action plans were being developed and would be submitted to the F/Planner Page 7 of 10

8.3. CQC in a month s time. An annual inspection was expected. Andrew Farrell asked how progress against the action plans would be overseen. Jacqueline Docherty advised that the Executive Team would discuss the monitoring arrangements and an update would be provided to the next IGC. The Committee noted the verbal update. 9. Claims and Inquest Report Q1: Orthopaedic Claims Analysis Item deferred to the next IGC. 10. Harm Free Rates 10.1. Mitchell Fernandez outlined the survey results for June 2016. A total of 1963 patients were surveyed across the Trust of whom 93.5% received harm free care. Performance with the safety thermometer remains positive but marginally below the target of 95%. Although the performance regarding to falls and new pressure ulcers were improving, catheter associated and new VTE was underperforming against the NHS England average. The compliance and results continue to be monitored monthly. 10.2. 10.3. 10.4. 10.5. 10.6. 11. 11.1. Janet Rubin requested further detail in regard to VTE to understand the issues and actions. The next report would contain further detail. Andrew Farrell enquired whether the harm occurs when patients are at the hospital. Mitchell Fernandez advised that harm in relation to pressure ulcers often occurs in other settings such as care homes in which case Jo McCarthy advised that this should be classed as a safeguarding issue. Trends, themes and benchmarking would be useful to ascertain the areas of concern. Jacqueline Docherty informed the Committee that the Imperial College Health Partners were looking into this as part of their Patient Safety Group work. In response to Peter Worthington s question regarding correlation of data with wards, Jacqueline Docherty advised that the detail is collected by each ward and the daily safety breach meetings capture the immediate issues day by day. In response to Andrew van Doorn s question regarding the sample size, Mitchell Fernandez advised that the sample size includes all the patients on the day of the survey. Work was progressing to produce a monthly NHS Safety Thermometer Newsletter for all staff and also to be displayed in wards. Dr Bhalla suggested a Safety Newsletter instead of focusing on Safety Thermometer only. Mark Andrew informed the Committee that a Governance newsletter was being developed which would report on Safety. Jacqueline Docherty suggested one newsletter to cover Governance and Safety/Safety Thermometer. The Committee noted the report. Governance Report Mark Andrew provided an update on the position in relation to patient safety matters, health associated infections, safety thermometer, completed coroners inquests and closed clinical claims. The (M Fernandez) M Fernandez, M Andrew () Page 8 of 10

completed serious incidents and the learning were noted. The Committee noted the new information on reporting trends and categories of serious incidents reported across the Trust. 11.2. 11.3. 12. 12.1. 12.2. 12.3. 13. 13.1. 13.2. 13.3. 13.4. The reporting calendar to Committees would change in order that the report is discussed at the IGC and then reported to Board on a bimonthly basis. Peter Worthington and Jacqueline Docherty agreed that the respective clinicians should attend the Clinical Excellence Committee to discuss divisional clinical reports in relation to incidents. and C Cayley noted the request. The Committee noted the report. External Agency and Accreditation Visits to the Trust The Committee received an update on external agency and accreditation visits to the organisation, the actions identified by the organisations following review, external recommendations and the overdue actions. Jacqueline Docherty noted the areas flagged red and suggested Lee Martin and Amanda Pye work together in respect of updating the actions. Jacqueline Docherty commented that the divisions/department should proactively be sighted on visits and pending actions. Dr Bhalla suggested an annual calendar of visits is established together with a framework to report on actions on a regular basis. This was noted. The Committee noted the report. Local Supervision Authority Report Judith Pickersgill and Nicola Wales informed the Committee that following a number of areas identified for improvement in the 2015 report, the Supervisors of Midwives (SOMs) at the Trust were pleased to report a positive 2016 LSA outcome. A green rating was achieved in all aspects of the audit and the assessors were particularly pleased with some of the initiatives within the service. The statutory aspect of the SOMs audit would be removed from April 2017 and therefore the SOMs would prepare for the new model of supervision, which was expected to be piloted from September 2016. The Trust had expressed an interest to become an early implementer of the new model. Lee Martin advised that a restorative supervision model pilot was in place in some Trusts and would forward the details to Judith Pickergill. In response to Janet Rubin s questions regarding the one amber rating relating to vacancies, Danny O Leary advised that this related to one person and assured the Committee the Maternity service at LNWHT want to be leaders and proactive actions were underway in all aspects. Peter Worthington enquired about previous issues relating to the skill mix of the maternity staff, particularly in relation to productivity per midwife and extent of staff gaining the same experience. Danny O Leary advised that band 5 and 6 staff need to be developed further as, C Cayley L Martin, Page 9 of 10

currently reliance was on band 7 staff. In terms of culture, Danny O Leary advised that as models change, cultures and practices would also change. 13.5. Andrew Farrell thanked the midwifery team on an outstanding turnaround from 2015 to 2016 audit outcomes. The Committee noted the report. 14. Board Assurance Framework (BAF) Simon Crawford advised that the corporate objectives for 2016-17 were discussed and agreed at the March Board with the sub-objectives detailing the key delivery areas and lead directors agreed at the June 2016 Board. During July 2016 the Executive Directors would refine these along with the key performance indicators and delivery milestones. After this the BAF would be updated during August 2016 to reflect the new corporate objectives and sub-objectives along with the associated controls, mitigations and assurances, and a report would be presented with the new BAF at the next IGC. S Crawford The Committee noted the report. 15. 15.1. 15.2. 15.2.1. Quality Metrics The scorecard for May 2016 data was noted. The Patient Quality and Safety Improvement Priorities for 2016/17 were outlined in an effort to support the development and monitoring of quality and safety metrics by integrating all the relevant information into one quality and safety dashboard. In terms of the reported lack of monitoring in regard to the Quality Account and Sign up to Safety Improvement Plan and Pledges, the Committee requested an update to mitigate the risk that was shown reported within the cover sheet of the report. Update to next IGC. The Committee noted the reports. 16. Adult Safeguarding Report The Committee noted the overview report of the safeguarding adults at risk arrangements within the Trust and noted the progress made against the adult safeguarding agenda during 2015/16. 17. Quality Impact Assessments (QIA) The Committee noted the update in respect of the QIAs as at 1 st July 2016. A dedicated session for critical care was completed on 4 th July 2016. The priorities for the next QIA in July 2016 would be pathology demand management and theatres staffing. QIAs for outstanding CIPS were also being completed. 18. Any Other Business No other business to report. 19. Date of next meeting: 16 th September 2016 at 10am, Meeting Room 1, Northwick Park Hospital 20. Forward Planner The forward planner would be updated to reflect the actions discussed at the meeting. Page 10 of 10