Clinical Governance Group

Agenda Item 11.4 Clinical Governance Group The Unconfirmed Minute of the Dunfermline & West Fife Community Health Partnership Clinical Governance Group held on Tuesday, 15 July 2014 at 3.00pm in Conference Room 4, Lynebank Hospital. Attendance Listed in Alphabetical Order of Surname: Core Membership Present: DWF CHP Interim Associate Nurse Director, Nicky Connor PCES & DWF CHP Localities Manager, Lesley Eydmann DWF CHP Head of Clinical Governance, Ann Hatton Service Manager, Learning Disabilities, Margaret Pirie Public Partnership Forum, Vice Chair, John Winton Service Representatives in Attendance: Head of Podiatry, Karen Baxter Lead Nurse, Rhona Brown Head of Physiotherapy, Lesley Bruce CHP Lead Pharmacist, Fiona Forrest DWF CHP Head of Clinical Governance, Karen Gibb Clinical Services Support & Business Manager, Clinical Psychology, Anne Gillespie Head of Speech & Language Therapy, NHS Fife, Nancy Little Head of Occupational Therapy, Anne McAlpine PCES, Service Manager, Lisa Milligan Clinical Services Support Manager, Fay Richmond Clinical Governance Facilitator, Yvonne Robertson DWF CHP Associate Nurse Director, Pauline Small Public Partnership Forum, Vice Chair, John Winton Nurse Team Manager, Paediatric Nursing, Jackie Young Apologies: Legislation Manager (Clinical Services), Sue Anderson NHS Fife Equality & Human Rights Lead, Angela Heyes Infection Control Manager, NHS Fife, David Livingstone DWF CHP Clinical Director, Dr Alan McGovern [Chair] NHS Fife Chief Pharmacist, Evelyn McPhail Head of Improving Health, Belinda Morgan General Manager, Mary Porter Health & Safety Advisor, OHSAS, Ian Scott Staff Side Representative, Lorna Sherriff Public Partnership Forum, Chair, Isobel Vernolini In Attendance: Secretary, Karen Banks [Minute] Team Leader, Child Protection, Fiona Lornie Minute Circulated For Information: Sarah Carr, Clinical Services Facilitator (for Learning Disabilities Service) Grace Cervantes (for NHS Fife Clinical Governance Committee) Fiona Robertson, DWF CHP Management Accountant Originator: Karen Banks Page 1 of 10

1 Apologies for Absence Apologies and attendance arrangements were noted as above. Introductions were made. Nicky Connor (NC) advised the group that this would be Ann Hatton s (AH) last meeting. NC extended thanks to Ann on behalf of the group for her fantastic contributions and influence across Fife over the years and wished her a wonderful retirement. 2 Minutes of the Previous Meeting Held on 20 May 2014 The minute of the previous meeting was confirmed as an accurate record. 3 Actions from the Previous Meeting 3.1 Datix Ref: 34458 - Action Plan is complete. Closed. 3.2 Datix Ref: PCES - Action Plan is complete. Closed. 4 Matters Arising 4.1 Child Protection Service Report [Jackie Young] Refer to Item 5.5. 4.2 Adult Protection elearning Module [Ann Hatton] AH advised the group that she had previously sent out an email response received from Sue Anderson:- All staff training is just an awareness raising training and this will be superseded now by e-learning. Service managers to encourage the e-learning for all staff. Adult protection is not statutory or mandatory e-learning. 5 Service Reports 5.1 Practice & Professional Development Service Report [Pauline Small] Pauline Small (PS) presented the (5.1) Practice & Professional Development Annual Report 2013-2014 (5.1.1) Cancer and Palliative Care Annual Report 2013-2014, (5.1.2) Practice Education Facilitators Report (2013-2014). This report provides an outline of the key activities undertaken by the Practice and Professional Development Unit (PPDU) during the period 1 st April 2013 31st March 2014, which are aimed at meeting the continuing practice and professional development needs of staff within the three Community Health Partnerships across Originator: Karen Banks Page 2 of 10

NHS Fife. The following was highlighted: E-Learning PPDU has continued to develop the provision of on-line resources to support educational provision across the organisation. E-learning systems are valuable tools, which enable individual practitioners to enhance their knowledge and skills, as well as providing the evidence to demonstrate continuing professional development and compliance with existing NHS Fife policy frameworks Resuscitation The CHP resuscitation officer in partnership with colleagues for across the CHP s continues to provide appropriate and focused resuscitation training across the CHP s. 2013-2014 sees a 5% increase in staff attending course offered. In order to make training more accessible and less demanding on staff time; a number of initiatives highlighted from last year s annual report have been completed to support improved and more accessible resuscitation training including: Incorporation of Simman and other training adjuncts with Smart technology e.g. white boards and webinar video to enhance the learning experience, allowing delivery to multiple groups in different locations across NHS Fife. The investment in the development of technology to support learning and training at a distance via webinar video link which went live January 2014. This mode of delivery has increased attendance in Adult Basic Life Support (ABLS) in the first quarter of 2014 and reduced travel time and inconvenience for CHP staff. The development of a pre course e-learning module for staff to access prior to attending the Webinar Video Linked ABLS training. There have been 2340 successful completions for this module since its launch. The requirement for staff (who are required to maintain competencies in both fields e.g. child health) to attend separate sessions has been addressed. These sessions are now offered weekly on a combined basis Professional Development PPDU continues to support national initiatives including Clinical leadership programme, Leading Better Care and Realising time to care, NHS Flying Start, Non Medical prescribing and Effective Practitioner. 5.1.1 Cancer & Palliative Care The cancer and palliative care team within PPDU continue to provide inclusive education and training across NHS Fife linked to the NHS Scotland Quality Strategy and Living & Dying Well and other national drivers. Key areas of education delivery are: Originator: Karen Banks Page 3 of 10

Cancer Education Days Generic Palliative Care and End of Life Issues Bereavement education Communication and Counselling Dementia Education Palliative care in the care home sector Palliative care in the social care sector New education Initiatives As dementia remains a health care priority educational programmes have been developed to prioritise training within this speciality. 5.1.2 Practice Education Facilitators The Practice Education Facilitator (PEF) posts have been successfully established in NHS Fife for 10 years. PEFs continue to work in close partnership with NHS Education for Scotland (NES) and the Higher Education Institutions (HEI) The provision of 6 whole time equivalent PEF posts has diversified to incorporate full time and part time working, increasing the current team to 8 members working across clinical boundaries within both primary and secondary care. In May 2010 a seconded post of Care Home Education Facilitator (CHEF) was established to cover care home settings across Fife and Scottish Government funding has been secured until March 2015. The CHEF works closely with PEFs and for the purposes of this report the collaborative work of the Care Home Education Facilitator will be included in the term PEF The annual report highlights the achievements of the past year and identifies local priorities for the year ahead. The core PEF role allows the team to engage with mentors and other staff with regard to helping develop clinical learning environments which are reflective of the current policy drivers, and ensure quality patient care is at the centre of students educational experiences. This is achieved through the provision of support for practitioners who mentor students undertaking a variety of educational programmes and the management and maintenance of the NHS Fife Mentor Register A table of Priorities (2013-2014), achievements and objectives were detailed. The Clinical Governance Group was asked to note the content of the report and agree onward distribution to the other CHP s for information. The chair commented on the very comprehensive reports. 5.2 DWF CHP Education & Training Annual Report [Fay Richmond] Within the CHP we continue to support the development and provision of education and awareness sessions. We continue to provide target driven training and awareness to staff across several agendas including those specific to their professional background and non clinical topics. Originator: Karen Banks Page 4 of 10

Fay Richmond highlighted the following:- As a CHP we have representation on Learning & Development Partnership and protected Learning Fife Wide Group. The DWF CHP is an active participant in Protected Learning Time (PLT). To support education/training locally we have the following groups - PLT Planning Group - CPR Cascade trainers group Attendance at both this groups has reduced and we and are currently looking at using email to have a virtual grouping. Training and education are supported through PLT, Lunchtime Bytes and one off Education Sessions. FR noted that NHS Fife still awaits the launch of Employee Support System (e:ess). This system will allow all employees to record any training and development undertaken. Access to accommodation suitable for the provision of education is an ongoing issue. Whilst there are many bookable rooms, not all are suitable for learning and the demand can make availability limited. An evaluation of PLT has recently been undertaken across Fife. Part of the evaluation will look at the uptake of sessions offered by particular staff groups. All staff in GP practices and managed services were given the opportunity to complete the online survey. The draft report when finalised will be shared through the appropriate CHP structure. The Clinical Governance Group is asked to note the content of this paper and agree the recommendations. 5.3 PCES Annual Report [Lisa Milligan] Lisa Milligan presented the Primary Care Emergency Service (PCES) Annual Report. The report highlights areas of good practices and future challenges whilst meeting the requirement of the NHS QIS Standard 2004 for out of hours care relating to the production of an individual Annual Report. PCES has made significant improvements under Service Development, Continued Professional Development and working with staff and the Organisational Development Departments involvement. Originator: Karen Banks Page 5 of 10

PCES continues to work with stakeholders towards developing a whole system to support patients in achieving optimal clinical outcomes and the best patient journey whilst ensuring a cost effective, sustainable infrastructure. The Clinical Governance Group is asked to note the work being undertaken to develop services and the content of the PCES Annual Report 2013/2014. 5.4 Learning Disabilities Service Report [Margaret Pirie] Margaret Pirie (MP) highlighted the following areas from her report: Single Point of Access - Community on line referral Form proving very successful. Amanda Leech has been instrumental in taking this work forward. Hill Street Service Evaluation of Nursing Staff (night Shift Working) Following the evaluation of the jointly managed Hill Street Service, nursing input has been reduced. Nursing from Hill Street will link with the new West Fife Service (Quarriers) with regard to 4 patients discharge from ATU and 1 patient who will move from Hill Street. Service is scheduled for September. National accreditation Learning Disabilities Service were awarded a certificate of excellence. Physical Restrictive Intervention System Following review of physical restrictive intervention system in August/ September 2013 it was agreed that MAPA system replaced the CALM system of restrictive intervention system. The roll out of the training programme is expected to be complete in September 2014. Challenges Permanent Forensic Consultant cover awaiting feedback. Management of Attendance Key Drivers for the service Modernisation of the LD Nursing workforce MP was thanked for her extensive report in a complex service area. The DWF CHP Clinical Governance Group are asked to note the contents within the report 5.5 Child Protection Service Report [Fiona Lornie] Fiona Lornie noted The purpose of this paper is to update the Dunfermline & West Fife Clinical Governance Group on developments and service issues during 2013-14 for Child Protection Services in Fife. The NHS Fife approach to child protection is underpinned by the Scottish Government vision for children outlined in Getting it Right for Every Child (GIRFEC); ensuring that a child is safe and situations where child safety is compromised are recognised and dealt with effectively and as a priority. NHS Fife works in partnership with other agencies to protect vulnerable children and contributes to the work for the Interagency Child Protection Committee and the wider public safety Originator: Karen Banks Page 6 of 10

agenda in Fife. Effective child protection depends on the knowledge, skills and confidence of all staff throughout the organisation. To support staff to identify and manage risks and to work in complex and uncertain environments in which vulnerable children and families live, NHS Fife must ensure that the necessary training, procedures and policies are agreed, implemented and evaluated in all areas of service provision. During 2013-14 the NHS Fife Child Protection Team (CPT) has continued to work on a number of key pieces of work. A significant part of the work is undertaken as part of the multi-agency child protection arrangements. Of particular note during this period are: Policies and procedures relating to Child Protection processes have been reviewed and updated to reflect changes in practice, to ensure they reflect current practice accurately and meet the needs of practitioners working with children and young people. Where gaps in processes and practice have been identified, procedures and guidance has been created to ensure staff are fully supported whilst working with vulnerable children and young people. The Child Protection Team has recently successfully filled a vacant post which has resulted in the first full team compliment being in place since 2012. The CPT now has a wide and diverse range of skills, knowledge encompassing skills form a wide variety of health areas which will enable a greater understanding of issues which practitioners are working with on a daily basis. The wide experiences which members of the CPT have will also enable the CPT to respond to queries from a wide variety of staff. A reporting system has been embedded to ensure that robust governance is in place for child protection services. This supports the CPT to self evaluate their work and seek guidance from other services as to what impact advice has had on them. Using the Child Protection Health Steering Group enables the CPT to effectively share information and seek consultation on documents across a wide range of services provided by NHS Fife. It also provides direction, guidance and feedback to strengthen the priorities which the CPT work to achieve. The CPT has also commenced use of MIDIS to record client activity safely and contemporaneously. This will ensure that any information which has been gathered by the CPT will be available for staff when MIDIS is fully implemented across NHS Fife. Challenges Since Jan 2014 there has been an unforeseen number of significant case reviews (SCRs) which have put the CP Team under considerable pressure due to the resources required to prepare for and participate in the reviews. This pressure will continue to be in place over the latter half of 2014 due to the ongoing input which is required and may impact on development work. In addition to the increased workload generated from SCRs there has been an increase in workload from both Interagency Referral Discussions (IRDs) and Originator: Karen Banks Page 7 of 10

provision of telephone support to practitioners. Dealing with these numbers in a small team has impacted on the ability to be fully visible within both CHP and Acute settings. A PLT Session is under planning for early 2015 and the team are actively seeking opportunities to raise the profile of the team by attending staff meetings. The CP Team are involved in self evaluation work to improve services and outcomes for vulnerable children and young people and also to provide evidence of these outcomes for the Care Inspectorate at times of inspections. The CPT contributes by self evaluating their work and by also supporting awareness raising and development of self evaluation in other services of NHS Fife. A programme of Case file audit is undertaken both at a multi-agency level and at a local level are now embedded within the self evaluation framework for child protection. At a multiagency level NHS Fife is committed as part of the partnership to a series of extensive and detailed annual multiagency case file audits. These audits now use the expertise of trained Associate Assessors of the inspection process combined with a range of multiagency practitioners from other services. Alongside this local audits are undertaken by Managers within healthcare to assess and identify current strengths and development needs which can then be dealt with either through the clinical supervision process or through development of practice at NHS Fife level through the Child Health Protection Steering Group. The D&WF CHP Clinical Governance Group was asked to note the work undertaken in Child protection services in Fife to ensure that we protect children and meet their needs. 6 Reports 6.1 PFPI Report Update [John Wilson] John Wilson (JW), Vice Chair, DWF CHP PPF Reference Group presented the PFPI Report Update to the group in relation to PFPI activities during April May 2014. The following points were highlighted: - 14 requests to be involved in activities were sent to Register of Interest (RoI). JW expressed his appreciation of the Queen Margaret Hospital Newsletter. JW believes it is the best piece of communication/information to come out of West Fife. JW also voiced his concern regarding the lack of communication re: the Annual Review date. Karen Gibb to follow-up. KG The Clinical Governance Group was asked to note the report. 6.2 CHP High Level Risk Register [Yvonne Robertson] It has previously been agreed that all D&WF CHP risks assessed as High on the DATIX Risk Management System be collated and reported at each CHP Clinical Governance Group Meeting. The following records these items currently registered. Originator: Karen Banks Page 8 of 10

The report identifies two current high level risks. Management actions are addressing these high level risks. Since the last report, two risks (525 & 285) have been transferred to the Corporate Risk Register. This has been done in line with change to the Equality & Human Rights line management arrangements. The Equality & Human Rights Service will transfer to Corporate Services from 4 th July 2014. One risk (839) has been added to the DWF CHP Risk Register The Clinical Governance Group was asked to note the number of risks on the High Level Risk Register since the last report and the current management actions to reduce the level of risk. 6.3 Medication Report [Yvonne Robertson] The purpose of this paper was to provide details on all DWF CHP medication incidents reported through the Datix Incident Management System during the period 1 January 2014 to 30 June 2014. The following points where highlighted to the group: 37 medication incidents were reported during this six month period. During the time period covered by this report, no major or extreme medication incidents have been reported. There have been eight incidents involving controlled drugs during this period. There is a slight increase in the average number of medication safety incidents from previous six months. The Clinical Governance Group is asked to note the number, type and severity of medication incidents recorded in this 6 monthly reporting period and acknowledge that incidents have been investigated as required and appropriate action taken. 6.4 Major Incident Summary Datix 20212 [Margaret Pirie] Incident Datix 20212 involved a patient of the Community Learning Disability Service who had a package of care supported by Richmond Fellowship. MP described briefly the patient s background and situation. As a result of the incident, a Rapid Event Investigation was commissioned by Professor Scott McLean and was completed by early April 2014. As this patient was part of the Forensic service and external review was commissioned. The reviewer was Dr Tom White Consultant Forensic Psychiatrist. Dr Whites remit was to:- Investigate the factors that might have contributed to the incident. Investigate systems issues that would have reduced the likelihood of the incident taking place Originator: Karen Banks Page 9 of 10

Consider what measures should be in place where he to return to the LD Forensic Service in Future. The group were asked to note the content of the report and agree the recommendations. 7 Any Other Competent Business 8 Items for Information The Clinical Governance Group noted the following items for information: 8.1 Call to Action - Falls Nicky Connor reported the Call to Action Inpatient falls in NHS Fife June 2014. Further discussion was held. 8.2 Fife Moving and Handling for Family Carers Project Evaluation report of Year 6 (2013-2014) 8.3 Scottish Public Services Ombudsman (SPSO) May & June 2014 8.4 Better Together & beyond Summer 2014 Newsletter 9 Date of Next Clinical Governance Meeting: 16 th September 2014 at 3.00pm, Conference Room 4, Lynebank Hospital, Dunfermline. Originator: Karen Banks Page 10 of 10