Wolverhampton Clinical Commissioning Group WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE Minutes of the Quality and Safety Committee Meeting held on Tuesday 12 th May 2015 Commencing at 10.30am in the Main CCG Meeting Room, Wolverhampton Science Park Present: Jim Oatridge (JO) Lay Member, WCCG (Chair) Helen Hibbs (HH) Chief Officer, WCCG Pat Roberts (PR) Lay Member Patient & Public Involvement Manjeet Garcha (MG) Executive Lead Nurse, WCCG Sarah Southall (SS) Head of Quality & Risk, WCCG Marlene Lambeth (ML) Patient Representative Dr Rajcholan (RR) Board Member, WCCG Lorraine Millard (LM) Designated Nurse Safeguarding Children, WCCG Claire Thomas (CT) Designated Doctor Safeguarding Children, WCCG Katie Spence (KS) Public Health, WCC Liz Hull (LH) Administrative Office, WCCG Part Attendance: Wendy Ewins (WE) Joint Commissioner, WCC Andy Thompson (AT) Information Governance, CSU Jodie Winfield (JW) Nurse Manager Infection Prevention, RWT Ramzan Mohammed (RM) E&I Business Partner in Central Midlands Peter McKenzie (PM) Corporate Operations Manager Apologies: Tony Fox (TF) Surgeon/Secondary Care Consultant, WCCG Geoff Ward (GW) Patient Representative Annette Lawrence (AL) Quality & Safety Manager Declarations of Interest QSC381 The following declaration of interest was confirmed From 1 st June 2015 CT will be the Designated Doctor for Walsall CCG.. Minutes, Actions from Previous Meetings QSC382 The minutes of the Quality and Safety Committee held on Tuesday 14 th May 2015 were accepted as a true and accurate record.
The Action Log from the Quality and Safety Committee held on Tuesday 14 th May 2015 was discussed, agreed and an updated version will be circulated with the minutes. Matters Arising QSC383 There were no matters arising. Feedback from Associated Forums QSC384 Draft CCG Governing Body Minutes The draft minutes were reviewed and noted. Health and Wellbeing Board Minutes It was confirmed that a meeting has not taken place since the last Quality and Safety Committee Meeting. Quality Surveillance Group Minutes It was confirmed that a meeting has not taken place since the last Quality and Safety Committee Meeting. Primary Care Liaison Group Minutes The draft minutes were reviewed and noted. Clinical Oversight Group Minutes The minutes have not been circulated yet. However, MG confirmed that there are no incidents to note that present a risk. Draft Clinical Commissioning Committee Minutes The draft minutes were reviewed and noted. Assurance Reports QSC385 Monthly Quality Report SS highlighted the following key points to the Committee: The Royal Wolverhampton Trust 15 new serious incidents occurred at RWT in April 2015, which is a reduction from March 2015. Confidential information leaks reduced in April 2015 to 2 2
A child death was reported in April and a stop clock has been applied to this incident whilst post mortem results are awaited. 3 incidents have occurred on Ward C41 including 1 C.diff and 2 falls causing serious harm. The incidents will be reviewed once the Root Cause Analysis are available. Cancer Waiting Times Performance continue to cause concern and this will be discussed at the CQRM meeting next week. RWT continues to see an increase in the number of A&E attendances West Midlands Ambulance Service PR expressed concern about terminology used and it was agreed by the Committee that in future fines would be referred to as sanctions. Sickness absence increased during March 2015 to 4.74%, which is 1.15% above the Trust s target of 3.24%. The Committed noted the content of the report and it was agreed that SS would ensure fines are referred to as sanctions in written reports going forward. Black Country Partnership Foundation Trust SS advised that there are no significant issues to report. Care Quality Commission (CQC) A 72 hour CQC review will commence in June 2015, which will include Cannock, New Cross, West Park and Community Services. The Trust is being offered support by the Quality Team, preparedness planning has been shared and fortnightly meetings are taking place. Primecare were visited by the CQC on 14 April 2015 and feedback is awaited. GP Practices will be visited in the near future. Adult Safeguarding It was reported that improvements have been made as a result of visits that have taken place. Pressure ulcers are a recurring theme in not meeting standards and the Quality Team continues to work closely with the homes to make improvements. Health Service Ombudsman (HSO) Investigation CCG/BCPFT HSO published a summary of their report in March, which has been shared with the complainant. 3
Compensation has been delayed due to implications in relation to a child. A joint action plan has been produced and will be monitored by SMT. Formal Complaints Between April 2014 and April 2015 13 complaints have been recorded. Communications & Engagement Update There were no significant issues to report. Quality Matters There has been an increase of incidents being reported, with a rise from 18 in March to 40 in April. Discharge is the leading concern followed by delays and compliance. Quality Review Meetings SS summarised items escalated to Contract meetings, which included: o 117 Policy - currently awaiting sign off o 136 Suites (places of safety) The Trust is limited in suitable locations due to environmental, staffing and risk issues. It was agreed that SS would share the planner for Quality Review Meetings at least a quarter in advance. The Committee noted the content of the report and it was agreed that in future SS would share the Quality Review Meeting planner a quarter in advance. NICE Assurance Group 1 overdue TAG will be raised as an escalated item at the next CQRM meeting. The Committee noted the content of the report. Information Governance (IG) Quarterly Report AT presented a summary of the Information Governance report: The outcome of the IG Toolkit submission was reported as satisfactory, with a score of 86%. 4
The CCG has approved the use of an IG Policy which incorporates the IG Management Framework and the Information Governance Improvement Plan. An IG handbook, which includes all previous procedures, has been produced for staff in line with current legislation. The CCG has completed all actions that relate to the submission of the IG toolkit. An improvement plan will be developed and put in place to reinforce the CCG s compliance. 96% of CCG staff completed their IG training during 2014/15. Security spot checks were also carried out to test staff understanding of the IG Policy. The outcome was that levels of staff awareness are good however there is still work to do to ensure that staff have a clearer understanding of their responsibilities in relation to IG. This will be addressed during training this year. AT and PM gave assurance that the CCG have a robust system in place to handle a Subject Access Request accurately. A new member of staff has been employed within the IG Team and will be on site at the CCG offices two days a week. AT provided an FOI update and will request that this is submitted to the Committee on a quarterly basis. The Committee noted the content of the report and it was agreed that AT would provide the Committee with a FOI Update on a quarterly basis. Infection Prevention Quarterly Update JW attended to inform and assure the Committee of the delivery of Infection Prevention activity as outlined in the Contract Variation Orders (CVO s) and locally agreed Service Specifications. The following key points were noted: 1 case of MRSA Bacteraemia was reported in Quarter 4 for RWT. Following a review the outcome was that the case was unavoidable. The CCG and RWT have both exceeded targets set in relation to Clostridium difficile. Concerns were expressed about this by the Committee and it was emphasised that West Midlands as a whole experience high rates. JW gave assurance that a lot of work is being carried out to address this. SS advised that she is working in conjunction with JW and KS to improve the service specification which will result in a new reporting style based on a new dashboard. The Committee noted the content of the report. 5
Equality & Diversity Quarterly Report RM updated the Committee on progress with Equality and Inclusion support for the CCG between January and March 2015: The employee appointed as a part time Equality and Inclusion Business Partner in March 2015 has left the organisation and a recruitment process has been put in place. The Committee will be updated in due course. RM advised that NHS England have developed a Workforce Race Equality Standard and a briefing document has been shared with the CCG. A deadline has been set as 1 st July 2015 for the baseline data to be published on the CCG Web Site. A discussion took place about the Pre-PEAR Assessment Toolkit and there was some confusion expressed over which is the best toolkit to use. It was agreed that RM will follow this up with Mike Hastings. The Committee noted the content of the report and the following was agreed: The CSU Equality & Inclusion Team to recruit a part time Equality and Inclusion Business Partner. RM to liaise with Mike Hastings about a decision on which toolkit to use going forward. RM to update the Risk Register to reflect discussions at the Committee. Board Assurance Framework SS provided the Committee with an update on performance during the reporting period (January to March 2015) with particular attention being drawn to risks that are recorded on the CCG Risk Register that may impact upon the domains within the Board Assurance Framework. The following key points were noted: SS referred to a confidential risk that was contained within the report and asked that the paper is not shared further. There were 13 live red risks contained within the Risk Register at the end of Quarter 4. NHS England has issued guidance in relation to new domains. The CCG Risk Register has been amended to reflect the changes and it is expected that risk owners will have completed the re-assignment of risk domains before the end of June. 6
PR expressed concern about confusion between the Programme Delivery Boards and Better Care Fund. HH explained that the Better Care Fund will soon be in the operational phase and this should make things clearer. The Committee noted the content of the report. Health & Safety Performance Report SS updated the Committee with progress made during Quarter 4 2014/15, against the CCG s Health and Safety Management Plan. It was noted that: Staff completing their mandatory training is reported to be below the expected %completion. However, a Committee member advised that there appears to be a problem with the data recorded as some employees identified as not completing the training, have done so. A draft Health and Safety Management Plan was shared with the Committee for consideration. Wider consultation will take place with SMT in May and an update provided to the Committee in June 2015. The Committee noted the content of the report and requested that an update is provided by SS in June 2015. Quality Assurance in CHC The Committee reviewed the content of the report submitted by MD. The Committee noted the content of the report. External Placement Panel Review Group Quality Assurance Findings SS summarised the Quality Assurance findings of the External Placement Panel Review Group: The External Placement Panel is a forum made up of representation from the Local Authority and the CCG. The Panel approve funding via a pooled budget for Looked After Children who require specialise placements with an out of area provider. The Review Group requested a formal quality assurance review be undertaken to determine the extent of the quality of care children were receiving in out of area placements. A combined quality assurance review began in February and is due to end in June 2015. 7
Review findings have identified 14 issues that relate to reliability of placement information (due to lack of availability or inability to locate the information), lack of governance/assurance in each of the areas considered, disparity of social worker support and interventions, lack of co-ordinated care and input from Wolverhampton CAMHS culminating in delay in assessments that have been requested requiring escalation and also information governance limitations between organisations. The review findings have been escalated and shared accordingly with responsible parties and actions have been agreed in relation to each item of concern. It is recommended that the Review Group should consider and accept the quality improvements suggested to improve performance of the External Placement Panel and the assurances it can afford to MSMG. If accepted, each action item should be assigned to a responsible individual who will take forward their respective item within an agreed timescale for completion that will be overseen by the External Placement Panel. SS advised that a further report will be shared with the Committee in October 2015 to confirm what the new arrangements are, following which the Committee will receive a regular report from either the Designated Nurse for LAC and/or MSMG. It was agreed that ad-hoc findings would be shared in a monthly report and any exceptions shared as appropriate. The Committee noted the content of the report and it was agreed that MG would raise the content of the Committee discussions in the next Governing Body Private Session. Items for Consideration QSC386 Annual Quality Report SS gave an overview of the Report. Safeguarding Children s Annual Report SS gave an overview of the Report.. Safeguarding Adult s Annual Report LM gave an overview of the report. Quality Assurance in Care Homes Annual Report MHD gave an overview of the report. The Chair requested that MG reports to the Governing Body that the Committee has received annual reports for the 4 areas. 8
Transforming Care Update WE provided the Committee with a report, for assurance, which describes work carried out to date, to deliver the Transforming Care agenda in Wolverhampton following the abuse of adults with learning disabilities at an independent hospital, Winterbourne View. The report was received well by the Committee and it was agreed that the Transforming Care Update should remain as a quarterly agenda item, with any exceptions being reported accordingly. Audit Reports The Committee noted the following audit reports Data Quality, BAF and CQUINS. Policies for Ratification QSC387 There were no policies presented for ratification. Items for Escalation/Feedback to CCG Governing Body QSC388 Equality and Diversity Quarterly Report MG to report Committee discussions to the Governing Body meeting on 12 th May 2015 at 1pm. External Placement Panel Review Group Quality Assurance Findings MG to raise the content of the Committee discussions in the next Governing Body Private Session on 12 th May 2015 at 3pm Annual Reports MG to report to the Governing Body meeting on 12 th May 2015 at 1pm, that the Committee received the following annual reports: Annual Quality Report, Safeguarding Children s Annual Report, Safeguarding Adults Report and Quality Assurance in Care Homes Annual Report. Any Other Business QSC389 None discussed. 9
Date of Next Meeting QSC390 Tuesday 9 th June 2015 at 10.30am to 12.30pm, CCG Main Meeting Room, Science Park. 10