MINUTES Name of meeting Quality and Clinical Governance Committee Date and time Tuesday 2 May 2017 14:30-17:00 Venue Board Room, Dominion House Name Title Chair Dr Sue Tresman (ST) Lay Vice Chair (Lay Member Quality and Governance) Members Vicky Stobbart (VS) Executive Director of Nursing, Quality and Safeguarding Phelim Brady (PB) Lay Member Patient and Public Engagement In Attendance Apologies Members Apologies Attendees Dr Jonathan Inglesfield (JI) Helen Collins (HC) Elaine Newton (EN) Dr Geoff Watson (GW) Dr Darren Watts (DW) Daniel Lo Russo (DLR) For item 7 Philip Tremewan (PT) For items 8 & 11 Ellie Shaw (ES) Note taker Lucia Magee (LM) Genevieve Ryan (GR) Carol Dunnett (CD) Jane Williams (JW) Jagadish Chakraborty (JC) Niki Baier (NB) For item 9 Medical Director (Commissioning) Associate Director of Quality and Improvement Director of Governance & Compliance Medical Director (Acute)/ Secondary Care Consultant Vice Chair (Clinical)/ GP member Information Governance Manager Designated Nurse, Safeguarding Adults (Surrey-Wide) PA to Executive Director for Nursing, Quality & Safeguarding GP Registrar Placement with CCG Planned Care Commissioning Manager Patient Representative Deputy Director of Clinical Commissioning Patient Representative Director of Contracts 1
Discussion and new actions 1 Welcome, Introductions and Apologies ST welcomed attendees and noted the apologies as detailed above. LM and GR introduced themselves and advised that they were attending as observers, as part of their placements with the CCG. ST reminded all that a) confidential papers should be handed in to ES after the meeting for secure disposal; and b) the meeting would be recorded for administration purposes only, with the recording deleted once the minutes had been approved. By whom Deadline 2 Declarations of Interest The Chair noted the register of Quality and Clinical Governance member and attendees interests included in the meeting papers, with no new declarations received since the previous Committee meeting. The Chair invited members and attendees to report any new declarations or amendments of declarations on the register or any declarations pertinent to items on this agenda. None were received. 3 Quorum As the required quorum was met, the Chair declared the meeting open. 4 Minutes of Previous Meeting held on 7 March 2017 The minutes from the 7 March 2017 were agreed as an accurate record of the meeting. 5 Matters Arising from last meeting: Action Log The Chair advised the areas shaded grey on the action log were complete and would not be discussed unless members had any comment or feedback. Outstanding actions were reviewed as followed: Quality Report RSCH: HC advised that due to the cancellation of the May SI meeting, approval of the item would be deferred to the June SI meeting. Complaints Quarter 3 Report October to December: HC confirmed that the risk relating to the structured diabetes education course is on the risk register. ES to ask risk to be re-assigned to the Clinical Commissioning team to take forward. Overall review of papers submitted to the meeting: ES to liaise with 2
Clinical Commissioning team to ascertain if practise dashboard is part of the papers included in practice visits. Following discussion regarding the use of the practice dashboard it was agreed that HC, JI and DW meet to discuss the indicators used in the report and how they can be reflected in the quality report. Health and Justice Thematic Review July 2016: HC to email Sally Allum at NHS England to ask to note future developments regarding future possibilities of tele-health and video consultations. VS to raise at next QSG meeting. 6 Terms of Reference (ToR) a) Serious Incident Sub-Committee HC advised that the ToR have been altered to be more generic in order to accommodate the wider commissioning remit which G&W CCG had assumed. It was agreed it was too early to amend the membership in the light of the appointment of the Joint AO and Surrey Heartlands implications; these would be revisited in due course. EN raised that the quorum should include a clinical lead. HC agreed to update the TOR to incorporate Recommendation: The committee is asked to: Approve the revised terms of reference Approved the revised terms of reference subject to the quorum section being revised as detailed above. b) CQRM HC advised the ToR have been altered to be more generic in nature in order to accommodate multiple commissioned services and to give clearer detail on membership, quoracy and the expected workplan. Recommendation: The committee is asked to: Approve the revised terms of reference Approved the revised terms of reference. c) CQUIN HC advised of the need for ToR for the CQUIN meeting, and it was noted that she is mindful that each STP will have own CQUIN and there may be a need to standardise. HC agreed to reformat using the standardised CCG template. HC HC 3
Approve the revised terms of reference Approved the revised terms of reference subject to document formatted in CCG approved template. 7 In Year Information Governance Report DLR gave an in year update on Information Governance and advised that at the July meeting, approval will be sought for the IG improvement and work programme. ES to cite on agenda. ES GW raised a point which was discussed at a recent conference attended in relation to the location of data storage companies. DLR confirmed that data storage companies used by the NHS must be based in the UK and provided assurances in relation to the CSU and commissioned providers. DLR provided an update on the requirement for privacy impact assessments which are coming into force as part of the 2018 data protection requirements. This work will form a key part of the IG subcommittee work plan moving forwards. Recommendations: The Committee is asked to: Ratify the Information Governance Sub-Committee s approval of the following: That the existing IG framework (and related core IG policies) remain in force until the end of quarter 1 of 2017/18 Records Management Policy Registration Authority Policy Note the end of year report with respect to the delivery of the approved 2016/17 IG improvement programme and submission of satisfactory IG toolkit The committee: Ratified the Information Governance Sub-Committee s approval of the following: That the existing IG framework (and related core IG policies) remain in force until the end of quarter 1 of 2017/18 Records Management Policy Registration Authority Policy Noted the end of year report with respect to the delivery of the approved 2016/17 IG improvement programme and submission of satisfactory IG toolkit 8 Personal Health Budgets (PHB) Beyond Continuing Healthcare Local Offer and Roll-Out Plan PT referred to NHS England guidance requiring CCGs to develop and publish a local offer for major expansion of PHBs. PT advised that this item has been deferred from June to September Surrey Health and 4
Wellbeing Board, pending further clarification being sought in relation to specified areas. Discussion took place regarding the financial resource and the potential overlap with Individual Funding Requests (IFR) and noncommissioned services. The Committee agreed to note the report, referring financial approval (subject to delegated limits) and formal sign off of the local offer by the Commissioning Finance and Performance Committee (CFP). DW agreed this should be on agenda of CFP and detailed requirements of the paper that CFP would need PT to present. VS was keen to explore the scope for a collaborative approach with other CCGs/ Surrey wide offer, before the item is taken to CFP and the Surrey Health and Wellbeing Board. PT agreed to raise with Surrey CCGs. Note NHS England guidance on the roll out of PHB beyond continuing healthcare and work to date undertaken in Surrey. Approve a local offer outlining groups who could potentially benefit from PHBs and could receive them from Guildford and Waverley CCG for adults and for children and young people. Approve the local offer to be published and available to the public and also be included in the Health and Wellbeing strategy. Agree, subject to approval, the local offer to be considered at September s Surrey Health and Wellbeing Board approval as recommended by NHS England. Noted NHS England guidance on the roll out of PHB beyond continuing healthcare and work to date undertaken in Surrey. Agreed for the Local Offer and Roll-out Plan to be reviewed and approved at the next CFP meeting and, subject to CFP approval, to be considered at September s Surrey Health and Wellbeing Board. ES (to advise KC) PT/VS 9 Committee Effectiveness Report EN advised that following the verbal update given at January s meeting regarding committee effectiveness that the full section of the report relating to the QCG committee is contained in paper 9. EN provided an update on the work undertaken to develop Governing Body new member induction and a discussion followed in relation to a specific induction plan for new committee members. EN agreed to write to committee chairs with a proposal for the induction of new committee members, and advised that the committee secretary would work with committee chairs to expedite this. It was noted that JW has recently joined the committee, ES to ensure JW receives the induction materials proposed and has the opportunity to meet with ST and VS, as Chair and Executive lead respectively. EN ES 5
Note the report Noted the report Agreed the Governing Body will review and action any agreed changes arising from the review. 10 Quality a) Quality Report HC presented the above report and flagged the following issues: RSCH Concerns regarding diagnostic waiting times in relation to echocardiography; HC has consulted the CCG Director of Contracts to request consideration of contractual levers. Agreed that a member of the contracts team attend the July meeting to give a presentation on scope for invoking contractual levers. HC to liaise with the Director of Contacts. PB advised that he attended the RSCH Board Meeting and commented on the different perspectives on quality data being presented. Discussion took place on the need for collaborative working to achieve a shared commissioner and provider understanding, and welcomed the joint remit given to the CCG s Head of Performance and Information to reconcile these. SECamb HC gave the key headlines regarding the impact the RSCH ambulance handover nurse is having on ambulance turn over times and the introduction of new zone car. SABP HC commented that there are many areas of good practice within the organisation but flagged her continued concern regarding psychiatric intensive care unit and the rate of adult suicides and unexpected deaths. In relation to these, HC outlined the assurances received from SABP s Medical Director. Discussion took place regarding other Surrey CCG s response to adult suicides and unexpected deaths. HC advised that the June CQRM is due to receive the annual suicide paper which will shape SABP s direction in this area moving forward, and would share the paper at the July meeting. It was agreed HC would invite SABP s Medical Director and Associate Director for Commissioning of Mental Health for Surrey Mental Health Collaborative to the next committee meeting for a focussed discussion on this area. It was noted the process of investigating SI differs from other commissioned service providers and HC is keen to work HC HC HC 6
collaboratively with the Medical Director to revise the process to ensure it focuses on themes and learning. Review quality performance Discuss additional actions required for areas of particular sub-optimal performance. The committee: Reviewed quality performance Agreed to continue quality surveillance Agreed to seek assurances where specified on the report Agreed to correlate areas of sub-optimal performance with CCG s risk register. 11 Safeguarding a) Looked after Children Exception Report PT presented the looked after children exception report and advised that the 6 month progress update will be presented at the July meeting. Note the looked after Children Exceptions Report Noted the Looked after Children Exceptions Report Agreed to continue to monitor risks and ensure looked after children s arrangements are in place. b) Children and Adults Exception Report PT presented the children and adults exception report and advised that the 6 month progress update will be presented at the July meeting. HC raised concern regarding the care home detailed in the report which has received a CQC notice to cancel registration and the need to receive assurances as to service users placements. PT referred to Surrey s Provider Failure Protocol and gave assurance as to how this would be followed in relation to service users. Recommendation: The committee is asked to: Note the safeguarding and adults exception report Noted the safeguarding and adults exception report Agreed to continue to monitor risks and ensure safeguarding children s arrangements are in place through safeguarding supervision with name and lead professionals and triangulated with the 2016 Section 11 and safeguarding dashboard. 7
c) Surrey Safeguarding Children Board Section 11 Audit 2016 PT presented the Surrey Safeguarding Children Board Section 11 Audit 2016 and advised the next Section 11 Audit will take place in 2019. PB raised concerns regarding the mixed messages reported in the section 11 audit and exception reports and the need for the Committee to receive robust assurances. VS described the governance structure in place across Surrey in relation to safeguarding children and adults. In response to the concerns raised, VS agreed to discuss with the Deputy Director Safeguarding the scope for including updates from Corporate Parenting Board, Improvement and Surrey Safeguarding Children Board in forthcoming exceptions reports to give this assurance. VS Note the report Noted the report Agreed to monitor actions raised through the section 11 audit and ensure safeguarding children s arrangements are in place through safeguarding supervision with named and lead professionals and triangulated with the safeguarding dashboard. 12 Complaints a) Quarter 4 Report (January March 2017) EN presented the complaints quarter 3 report. Note the Complaints Summary report for quarter 4 Noted the complaints summary report for quarter 4 b) Annual Complaints Report 2016-17 EN presented the annual complaints report 2016-17 and advised that this report will be presented at the July Governing Body meeting. Note the findings of the annual complaints report 2016/17, with particular attention to the number of complaints arising from the transfer of services to a different provider. Noted the findings of the annual complaints report 2016/17, with particular attention given to the number of complaints arising from the transfer of services to a different provider. Agreed that the report will be forwarded for approval by the 8
Governing Body in July 2017 and then will be published on the CCG s website. 13 Communications & Engagement Report Quarter 4 Report (January March 2017) The Committee received this report, detailing communications and engagement activity for Q4 and its impact. Recommendations: The Committee is asked to: Note that internal communications needs to be developed further. Therefore managers need to provide input on what works for them and their team in how they want to be informed and how we can encourage two-way communication. This will help shape the internal communications strategy to ensure it reflects the needs of the organisation. Note managers to promote e-brief to staff and provide updates to be included to ensure the organisation has clearer understanding on the work and projects being carried out in all areas. Noted the recommendations as detailed above. 14 Minutes to note from sub-committees Members noted the minutes from the following: Information Governance Sub-Committee, March 2017 Patient & Public Engagement Meeting, January 2017 CAMHS CQM and Contract Meeting, February 2017 SaBP Serious Incident Panel, March 2017 RSCH Serious Incident Sub-Committee, March 2017 RSCH CQRM, February and April 2017 15 Any Other Business a) Update on Primary Care Clinical Academic Group Meetings ST advised that funding ceased for the Primary Care Clinical Academic Group at the end of March 2017. Meetings have taken place to identify how to promote research as part of the CCG s statutory requirement. The Committee will kept updated. 16 Top Three Risks The top three risks were agreed as follows: SECAmb performance RSCH echocardiogram Suicide awareness These would be assessed and reflected on the CCG s risk register as appropriate (and if not already featured). 9
EN advised that GBAF and Corporate risk register was being reviewed with risk handlers to ensure correct classification of risks as either strategic or operational. 17 Overall review of papers submitted to the meeting All agreed that papers submitted to the meeting were reasonable in terms of volume and analysis, and noted how useful it was to have all papers labelled with the appropriate agenda and paper number. It was noted that not all papers had the new report cover sheet attached. ES to ensure that all paper authors have the new report cover sheet. ES Date of next meeting: Tuesday 4 July 2017, 14:30 17:00, Board Room, Dominion House Signature of Chair: Date: 4 July 2017 Signature of Lead Director (Approval for public website): Date: 4 July 2017 10