Enclosure Svi MINUTES OF MEETING: QUALITY COMMITTEE 04 July 2016 Room BG.01, The Woolwich Centre, 35 Wellington Street, SE18 6HQ 10:30 12:30 PART ONE PRESENT: Dr Iynga Vanniasegaram ( IV) (Chair) Diane Jones (DJ) Secondary Care Doctor, Governing Body Director of Integrated Governance GCCG Governing Body Maggie Aiken (MA) AD Governance & Quality Maggie Buckell (MB) Rebecca Moore (RM) Governing Body Nurse Member Commissioning Project Lead for Quality Leceia Gordon-Mackenzie (LGM) Chair, Healthwatch Healthwatch, Greenwich IN ATTENDANCE: Anita Erhabor (AE) Carol Berry (CB) Diane Goodenough (DG) Andrew Coombe (AC) Oliver Lake (OL) Designated Safeguarding Nurse for Children Compliance Manager Patient Safety Manager Lead Nurse, Adult Safeguarding and Care Homes Assurance Partner Transformation South East CSU Fiona Gaylor (JC) Partner Transformation South East CSU Chair: Dr Ellen Wright Chief Officer: Annabel Burn
Mohammed Tamim (MT) Health Protection Programme Manager, Royal Borough of Greenwich (RBG) Myra Stanislaus (MS) APOLOGIES: Governing Body Support Officer Chris Soltysiak Associate Director of Strategy & Performance 1. Welcomes, Introductions and Apologies for Absence Actions The Chair welcomed delegates and introductions were made. Apologies were noted as above. The Chair requested any Conflict of Interest for the agenda be declared. There were none. 2. Minutes of the Previous Meeting 11 January 2016 The minutes of the previous meeting were reviewed and it was agreed they were an accurate record of the meeting subject to the following amendment. Diane Jones (DJ) informed the Committee of the following amendment: Page 4 of 6. 7. Compliance Report. TACT Treatment Access Policy should read TAP Treatment Access Policy. Leceia Gordon-Mackenzie (LGM) informed the Committee that the following should be noted. Page 2 of 6. 1. Urgent Care Centre and Out of Hours Quality Report. Greenbrook Healthcare did a presentation. Their KPI was robust and they have involved Healthwatch with regards to their KPI. LGM checked with the team and they said they have had no contact from Greenbrook on engagement in healthcare. Diane Jones (DJ) commented that the CCG is having weekly discussions with Greenbrook and will bring the issue up with them. Diane Jones (DJ) was concerned that Greenbrook has made such a statement re: engagement with Oxleas if this is not the case. Action: DJ to raise with contracting team for Greenbrook. DJ 2a. Action Log and Matters Arising. A list of actions arising from the Action Log had been circulated with the agenda. Actions were reviewed by the Committee. The following actions were still open, all other actions are closed. Page 2 of 8
There were no matters arising. Action 1. Urgent Care Centre and Out of Hours Quality Report Item 3. AE to forward the Safeguarding KPIs back to Parmjit Rai (PR) for her to look at it. Diane Jones (DJ) reported that contractors think Greenbrook are compliant, and they were informed that the CCG is awaiting information from Greenbrook around Safeguarding. Diane Jones (DJ) asked Anita Erhabor (AE) to give an update. Anita Erhabor (AE) reported that Greenbrook sent the data, but the data they sent did not make sense to her. Greenbrook safeguarding attended the Designated & Named Forum Meeting and tried to go through the data they sent but Parmjit Rai (PR) could not explain it, so was going to go back to the Admin person who compiled the data to try and find out from the Admin person. Anita Erhabor (AE) spoke to Contracting Lead, Busayo Akinyemi (BA) who said the agreement was for the doctor who leads on safeguarding and is attending a safeguarding meeting next week and AE will be attending for adults and children s safeguarding. Open. AE Action 3. Compliance Report Item.7 CB to follow up with Contracting Lead, Busayo Akinyemi to get feedback. Carol Berry (CB) reported on the Greenwich and Bexley Hospice. Greenwich CCG has given them notice. Carol Berry (CB) is not aware if there is an alternative service for the patients to access. They are looking into finding an alternative service, perhaps at Kings College Hospital, but nothing definite has been agreed. Open. CB Action 7 Items for Information Item. 13 Medicines Management need to highlight any quality issues arising from minutes provided. Maggie Aiken (MA) reported that she was unaware if Medicines Management had raised any quality issues. Maggie Aiken (MA) to follow up this with Medicines Management and arrange for a representative to attend the next Quality Committee Meeting. The status for this item should be changed from green to red because it has not been completed. Open MA Action 2. Feedback from CQRGs/Live Quality Issues. Closed. Action 4. Quality Monitoring Process, Calendar & Visits. Closed Action 5. Local Transforming Care Programme for people with Learning Disabilities. Closed. Action 6. Draft Annual Work Programme 16/17. Closed Page 3 of 8
3. OHSEL Patient Engagement Report Oliver Lake (OL) and Fiona Gaylor (FG) (South East CSU), presented the Early engagement and pre-consultation and Our Healthier South East London Preconsultation plan elective orthopaedic care. Our Healthier South East London Responsible for developing the Sustainability and Transformation Plan (STP) in south east London. This work is being jointly carried out by south east London clinical commissioning groups (CCGs), hospitals, community health services and mental health trusts, with the support of local councils and members of the public. Engagement activity led by OHSEL programme and supported by the CCG. Our Healthier South East London is a five year health and care strategy led by a partnership of NHS providers and Clinical Commissioning Groups serving the boroughs of Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark, working with NHS England (London). We are developing the strategy in partnership with local councils, primary and community care services, the six borough Healthwatch organisations and local people and patients. Our five-year plan aims to improve health and services for everyone. It seeks to address a number of challenges, many of them common across the NHS and some specific to south east London. Some of the main points of the discussion were as follows: Partnership programme. Working with 6 CCGs to develop the process. Collaboration. Steering Group chaired by Martin Wilkinson. New guidance out around service change. Andrew Langsley introduces four tests for service change. From the 4 tests is public engagement. NHS England is looking for Minutes of committee meetings, this Quality Committee Meeting and Minutes from GP meetings. The Quality Committee will have a role later in the year around patient engagement. Consultation date was supposed to be early summer but is likely to be late this year. Fiona Gaylor (FG) (South East CSU). Meeting will be on 25 th July 2016. Patricia Kanneh-Fitzgerald needs to attend. After the discussion the following action was agreed. ACTION: Patricia Kanneh-Fitzgerald(PKF) would be tasked to do a briefing paper regarding questions around stakeholder map that would be reflected in our map GRIP and GEOF and feedback to Oliver Lake. Paper to Sept Quality Committee ACTION: Oliver and team to come back to the Quality Committee in Sept to ensure the governance around this subject has been completed. PKF paper to agenda Sept To add to Sept agenda. Page 4 of 8
4. Quality Issues Log Report (This item was dealt with first) Diane Goodenough(DG) reported on the open Quality Issues Log 2016 and the Closed Issues Log. DG informed the Committee that the ED Quality Monitoring Visit (QMV) was done on 4 th May 2016 with Bexley CCG. Only one open for the QEH ED capacity issue. Maggie Aiken (MA) commented that the Site Visit was done and is on the agenda for later. Diane Jones (DJ) commented that other quality issues need to be captured as follows and put on the Issues Log as follows: 1) Maternity - LGT, they have a backlog of referral to treatment which is not put on the Issues Log. The ones not on there need to be added on. 2) Deep dive need to go on the Issues Log for Oxleas around attempted self-harm. 3) Primary Care GP practices. 4) Issue with Urgent Care around safeguarding. Not assured yet around the KPIs regarding safeguarding. 5. Quality Committee Risk Report & Revised Risk Appetite Statement Diane Goodenough(DG) presented the July Risk Register Report, the July Risk Register and Revised Risk Appetite Statement. The main points of the discussion were as follows: Risk Appetite Statement. Risk Appetite is below approved version by Greenwich Executive Group (GEG). CCG has no appetite for financial risks. Timeframe for updating Risk Management framework is November. 14 Risks. Risk 181 Failure to ensure monitoring of quality and safety of services. Risk 245 Failure to ensure quality and safety of Care Homes. Risk 189 Failure to deliver a realistic and sustainable OD plan for the organisation. 2 Risks closed. Risk 193 moved to Risk 194 Risk 194 reduced. Ability of the Governing Body to fulfil its non-financial statutory duties. No risks had the score increased. Risk 259 Lack of available social workers from the borough to jointly complete the Continuing Healthcare (CHC) Assessment. Diane Jones (DJ) commented that PAMS relate to Care Homes - Risk 245 and QAMS (Quality Alert Management System) relate to monitoring of quality and safety of services Risk 181. Diane Goodenough (DG) need to make this clear in the report. Leceia-Gordon-Mackenzie(LGM) commented on raising issues. She tried to have conversation with provider. If not doing anything she will take it further. Page 5 of 8
Diane Jones (DJ) asked how easy it was to allow Healthwatch access to database. Carol Berry (CB) said it was possible as it was web based. Leceia Gordon-Mackenzie(LGM) said she will take information back to Healthwatch and report back. Iynga Vanniasegaram (Chair) asked for Leceia Gordon-Mackenzie(LGM) comments be minuted. Maggie Buckell (MB) raised a question about Risk 189 and asked if the Committee were happy with scoring 12 on the Rating Target. Diane Jones (DJ) commented that Maggie Buckell (MA) was right the target should be green. Diane Goodenough (DG) said she needed to be assured of the actions. The Committee agreed the actions. After discussion the following action was agreed. ACTION: If not happen by due date, review and get Director sign-off. Diane Jones (DJ) to discuss and document it. DJ,DG 6. CCG Quarterly Quality Report (Including: Serious Incidents; Safeguarding HCAIs) Maggie Aiken (MA) presented the Quarterly Quality Report July 2016. This report provides an overview of Quality for NHS Greenwich Clinical Commissioning Group and its main service providers, to highlight good practice identified and ensure focus on key quality issues. The report provides assurance to the Governing Body that the CCG is aware of quality issues and that appropriate action is being taken to understand the situation and improve quality. Maggie Aiken (MA), Andrew Coombe(AC), Diane Goodenough (DG), Anita Erhabor, Mohammed Tamim(MT) all provided a brief summary on their work which is in the report. 7. Quality Monitoring Visits Maggie Aiken (MA) gave a report on Framework for Undertaking Provider Assurance Quality/Safeguarding Visits. The main points from the discussion were as follows: Flow of unit not satisfactory. Poor response on Jet Team. Uniform staff wear. Name badge issue. Page 6 of 8
Patients felt safe. Dignity. Barrier to hot meals being served. Safeguarding concerns. Positives good team work. Clinical areas tidy. Greenbrook doing work with GP. Waiting room. Rails for lockers. Statutory duties. Finance will be going to FPC. New template drawn up based on 220 pages. It will be uploaded onto Datix, once signed off by Directors. After discussion the following action was agreed. ACTION: MA to bring ED report back to Quality Committee Meeting in September. MA 8. Oxleas Quality Account: CCG response (i) Oxleas FT (ii) LGT Maggie Aiken (MA) gave a report on NHS Bexley, NHS Greenwich and NHS Lewisham Joint Statement on Lewisham and Greenwich NHS Trust s Quality Account June 2016 and Bromley, Bexley & Greenwich Clinical Commissioning Group Comments in response to the draft Oxleas NHS Foundation Trust 2015/16 Quality Account. 9. CCG Statutory Duties Review Maggie Aiken (MA) gave a report on the paper Statutory Functions of CCGs (Review). The purpose of the report is to advise the Quality Committee of the process to review NHS GCCGs compliance with its statutory duties. The Quality Committee was asked to note and approve the process. The report was received by the Committee. 10. Equalities & Human Rights Update Carol Berry (CB) gave a verbal update on Equalities & Human Rights. The main points arising from the discussion were as follows: Goals around experience, staff related, make up/ethnicity. Through self-assessment we are achieving. Working with GRIP. Greenwich Equality Forum. Evidence broad statements. From that will come an action plan to help with objectives that will come to this meeting as well as PRG. Equalities scheme will have to report to NHS England. Looking at figures. Workshop this week to sit with members of staff. Look at how we improve black and ethnic minority. Page 7 of 8
Going to Governing Body on 27 th July 2016. 11. CCG Quality Strategy: Key Quality priorities 16/17 Maggie Aiken (MA) presented the Quality Strategy 2015-2018. The Committee felt that more time was needed to look at the document. Comments were requested to be sent to MA. The document will be reviewed and ratified at the Sept 2016 Quality Committee. ACTION: MS to email it to the members. Add Quality Strategy to the Sept Quality Committee agenda. MS Documents for information only: a) Medicines Management Sub Committee Meeting Minutes b) CQRG LGT & Oxleas FT Meeting Minutes (as held since last meeting of the Quality Committee) c) Minutes from Patient Reference Group d) Minutes from SEL 111 Clinical Governance Group e) QEH OOH/UCC CG Minutes f) Local TCP Programme Board Minutes g) Minutes from SI Review Panel h) Minutes from Health, Safety & Wellbeing Group The Quality Committee agreed to note the minutes of the above-mentioned meetings. AOB The Quality Committee proposed that future meetings of the Quality Committee should start at the following times: Part One - 10:00am 12:30pm Part Two - 12:30pm 13:00pm ACTION: MS to re-arrange the meetings and update the invites. MS Date of Next Meeting The next meeting will be held on Monday, 5 th September 2016 at 10:30am 13:30pm in Room 4, Woolwich Town Hall, Wellington Street, Woolwich, London, SE18 6PW There being no further business the meeting closed. Page 8 of 8