Meeting of Bristol Clinical Commissioning Group Quality and Governance Committee Held on 17th December 2013 At 9:00am in Clinical Commissioning Group Meeting Room Agenda Item: 16 Draft Minutes Present: In attendance Martin Jones (chair) (MJ) Chair of Bristol Clinical Commissioning Group Steve Davies (SD) Bristol CCG Governing Body member Tara Mistry (TM) Lay Member Patient Involvement David Soodeen (DS) Bristol Clinical Commissioning Group Member Patsy Hudson (PH) Governance and Audit Alison Moon () Director Quality and Transformation Sarah Carr () Corporate Secretary (Note taker) Bridget James (BJ) Head of Quality Andy Newton (AN) Head of Performance Emma Savage (ES) Head of Commissioning for Quality Lisa Rees (LR) 1 Apologies and Welcomes Apologies were received from Jill Shepherd and Sue Mulvenna (SM) Head of Medicines Management. Lisa Rees was welcomed to the meeting. 2 New Declarations of Interest Martin Jones declared an interest in the Serious Incident Report, (his wife was a member of the Intensive Team). There were no other new declarations. 3 Minutes of the meeting of 19 th November, Action Log and Matters Arising The minutes were agreed as a correct record It was noted that the BNSSG Clinical Policy Review Group would review the Commissioning policies for on-going access to treatment. The action log was reviewed; members noted those actions that had been completed and agreed these would be removed. Action Action Minutes Page 1 of 9
The establishment of a hot line had been discussed with North Bristol Trust (NBT). The Trust was considering whether the line would be staffed; members were concerned that an unstaffed line would not be functional. It was agreed to defer action 22/10/13 6(1) to obtain details of University Hospitals Bristol Trust (UHB) previous 3 months cancer referral data until January. It was confirmed that pressure ulcer benchmarking data for Bristol Community Health (BCH) had been circulated to committee members. It was noted that BCH was not an outlier compared to other local organisations. A London trust had reported zero pressure ulcers and it was agreed to explore this further. NBT did not report South Gloucestershire Community Services pressure ulcers separately and it was agreed to ask for separate data. There was a discussion about the collection of care home data. It was explained that metrics were being developed for 2014/15 for inclusion in the contract. NBT had completed a validation of skin and urology cancer patients. The NBT team had looked at records for 260 skin cancer patients and offered 3 follow up appointments. The review of Urology cancer patient records was ongoing; the Trust believed a similar number of patients would be recalled. The committee noted the work completed to date and agreed to work with South Gloucestershire CCG to track skin cancer patients called back and to obtain further assurance regarding the number of Urology cancer patients requiring recall prior to the Task and Finish Group meeting the end of January. Bridget James confirmed that she was discussing with Avon and Wiltshire Partnership Trust (AWP) the inclusion of Safeguarding training on the Trust s Risk Register. It was confirmed that future Quality Reports would include a section for Children s Services. It was noted that Kirsty Alexander was lead for Children s Services. Members discussed whether nominated deputies should attend when committee members were unable to be present. This was agreed that Alison Moon would follow this up. It was explained that the Commissioning Support Service (CSU) had been asked to complete a review of the tri-service transfer and this would replace the GP walk through of Urology services. It was agreed to include a GP from the North and West Locality in this external evaluation. Alison Moon would follow this up with Uli Freudenstein Healthwatch had attended the last Quality Surveillance Group. The Quality Premium Performance Indicators were discussed. Andy Newton tabled a paper showing performance for quarter one and two. It was unlikely that the CCG would achieve the NHS Constitution targets for four hour waits and ambulance response times. Information for Domain one, two and three targets was not available. Targets six, seven and eight were locally agreed measures. It was ES ES BJ/ES ES Action Minutes Page 2 of 9
explained that it was unlikely that the target for uptake at the local clinic for Female Genital Mutilation (target six) would be achieved. This was the first year of service operation and publicity for the service was being developed. Alison Moon commented that the target had different risk assessments on the Quality Report and the Area Team information and it was agreed that future assessment would be consistent across all reports. AN/ES It was reported with that Alison Moon and Jill Shepherd were meeting Jane Gibbs & Alison Robinson to discuss how the CCG would support South Gloucestershire CCG as coordinating commissioner for NBT. There was a discussion about the addition of patient experience questions in the Quality Report. It was agreed that the UHB Patient Experience Report provided assurance regarding the Trust s position. It was agreed to work with other providers to gain similar assurance about patient experience. It was noted that the 2014/15 NHS Outcomes Framework detailed patient experience and this would be added to the 2014/15 contract. 4 Update Quality Surveillance Group (NHS England) Alison Moon presented four reports. Members noted the Review of Themes paper. David Soodeen commented on the recent level five banding for NBT by the Care Quality Commission (CQC). It was noted that the CCG had raised this with the CQC and that the banding model was a work in progress. Members noted that the new model provided an additional source of intelligence; it remained important for the CCG to continue to triangulate data with other information sources. Tara Mistry asked how the system would be developed and it was explained that the bandings would be reviewed at regular intervals; the CQC s intention was to develop a ratings system in the future. It was reported that the bandings had been discussed with UHB. Members noted the Regional Quality Surveillance Group minutes. The National Quality Dashboard Update was discussed. It was explained an Integrated Intelligence Tool was being developed to replace the current National Quality Dashboard. There was a discussion about the GP indicator set; it was explained that this fell within the remit of the Area Team and further information was expected. It was agreed to discuss the Primary Care Dashboard with the Area Team. The committee noted the update. Members received the Review of the Quality Surveillance Group Model. It was noted that locally not all participating bodies made returns to the Group. This was an important issue. 5 Chief Nursing Officer Conference Update Alison Moon briefed members on the recent Chief Nursing Officer Conference. The National Nursing Strategy Compassion in Practice developed in response to the Francis Report had been a focus of BJ/ES Action Minutes Page 3 of 9
discussion. Alison Moon commented that there was an opportunity to build the six work streams identified in the strategy in the CCG s expectations of providers. Transparency was a key issue. It was noted that 17 Trusts in the North of England had jointly published safety data; members agreed this was an ambition for the local health community. The message delivered at the conference by Bruce Keogh was that Mid Staffordshire was not an isolated incident; it was important to build confidence in the NHS. Steve Field had reported on the CQC s findings about General Practice. The potential impact of harm events reported in Primary Care was highlighted. The CQC s findings had included a lack of Practice Patient Participation Groups. Tara Mistry commented that the CCG PPI, Engagement and Communications Group was looking at this area; Steve Davies reported that Practice Managers had been asked about their Patient Participation Groups and alongside this the Area Team had been asked to confirm how many Bristol Practices had signed up to the Patient Participation Enhanced Scheme. The overall impression was that Patient Participation was not strong, however it was understood that this was a key are for Practices to develop. Steve Davies asked whether the National Nursing Strategy could be applied across primary care. Alison Moon explained that the standards were relevant to Practice Nurses. She had discussed them with the Practice Nurses on the Locality Groups and would share information more widely at the Practice Nurse Fora. The recent NHS Hospitals Complaints Systems Review had been discussed at the conference, as had the Berwick Report NHS Patient Safety Review. Members were informed that Nurse revalidation was to be introduced. Alison Moon commented that she had been able to speak to a Staff Nurse at the Mid Staffordshire Trust who had been involved in raising concerns and that she would share this learning with local providers. The committee welcomed the updates. 6 Quality Report and Dashboards It was confirmed that amber ratings indicated where performance was off track and plans were in place that would rectify the position; where it was known that a target would not be achieved a red rating should be used. Steve Davies commented that it was important for Practices to develop and strengthen their Cares Registers. It was noted that Practices used different ways to identify carers. It was agreed that Alison Moon would discuss this with Emma Moody. The UHB Quality Report was discussed. The position against the BJ Action Minutes Page 4 of 9
target for the number of cancer patients treated within 62 days from referral had been discussed at previous meetings. Tara Mistry asked if there was evidence that failure to treat within 62 days resulted in harm or poor outcomes. It was noted that in some instances a delay in treatment could allow for further investigation and some late referrals were appropriate. The position against the dementia screening targets was noted; the Trust was confident that actions implemented would improve the position. The Trust was completing exception reports where agreed response times for complaints were not met to understand the causes of delays. Members noted the position regarding MRSA and commended the improved performance compared to previous years. Alison Moon would report to the Clinical Leaders meeting on a system wide response to reduce the incidence of C-dif. A CQUIN to include Primary Care was being considered. NHS England had approached the CCG for views on the development of incentives to reduce HCAI; this was an opportunity to include primary care. It was reported that a business case for an infection control nurse for one year to work with primary care providers was being developed. Members noted the increase in the number of reported patient slips, trips and falls. This would be discussed with the Trust at the Integrated Quality and Performance meeting. It was noted that three serious incidents had been reported and there had been nine falls resulting in serious harm since April. Alison Moon reported that she would discuss Adult Safeguarding issues with the UHB Chief Nurse; this was not related to any specific concerns. Pasty Hudson commented that staff turn-over was not included in the report. It was explained that the data was in the dashboard; it was agreed that this would be added to future narratives. ES The NBT Quality Report was discussed. Emma Savage explained the Trust was developing an integrated performance report that would be presented to the Trust Board at its January open meeting. Performance against dementia screening targets was noted; members were informed that the Trust would be recruiting a Specialist Dementia Nurse. The drop in performance reported would be raised at the NBT Integrated Quality and Performance meeting. There had been a rise in reported C-diff cases in October; the Trust was investigating these to establish causes. A further increase in the number of reported Serious Incidents was reported. The Area Team Director of Nursing, Trust Development Agency, coordinating commissioner and Director of Nursing at the Trust had met to discuss the situation. Members were informed that a quarter one and two national report on serious incidents and never Action Minutes Page 5 of 9
events covering all trusts had been published. The reported figures for NBT did not correspond to the CG records. From January the Trust Director of Nursing would meet fortnightly with the Area team Director of Nursing, The Trust Development Agency and the Commissioning Support lead to review all open Serious Incidents. Emma Savage reported that she was also meeting with the Trust s Safeguarding Lead to look at Serious Incidents. The Trust recognised that improvements were needed. The involvement of Practices in incident reporting was discussed. It was agreed to make clear to all Practices that a reporting route for Serious Incidents and Never Events was available. /BJ Tara Mistry welcomed the focus on reporting and consistency and asked if there were underlying reasons for the trend. Alison Moon explained that each Serious Incident and Never Event had an individual root cause analysis. It had been recommended that NBT establish a Serious Incident Review Panel to identify common themes and issues and understand system issues. The Trust had started this process. Alison Moon explained that the CCG had been focused on the Trust s performance and had reported concerns to the coordinating commissioner. Concerns raised by GP colleagues were shared with the coordinating commissioner and feedback was reported back to Practices. It was noted that there had been a meeting focused on the Trust s performance in July with the Area Team, the CQC, the Trust Development Agency and commissioners. There were now a number of work streams centred on key issues including Adult Safeguarding, concerns about performance against cancer standards, and the number of Serious Incidents and Never Events. The CCG was acting on the concerns raised by GP colleagues and it was important that these concerns continued to be raised with the CCG. Members representing localities on the Committee were asked to report back to report back to their Practice colleagues the action taken and the importance of raising concerns with CCG colleagues. It was agreed to bring a specific NBT briefing report to the next meeting summarising the actions taken and progress to date. It was asked how the Trust reported back to staff about Serious Incidents. It was confirmed the Trust used a number of different approaches to communicate with staff. It was noted that the Trust was concerned by its performance. There was a discussion about adult safeguarding and the understanding of safeguarding issues such as capacity by staff at the Trust. The CCG did not have information about compliance with safeguarding training and it was agreed to raise this at the Integrated Quality and Performance meeting. Work force data had not been added to the report; it was confirmed this would be included in the January report. Locality leads BJ/ES BJ Action Minutes Page 6 of 9
It was noted that BCH continued to report high staff turnover levels. This issue, with particular reference to Community Matrons, Rapid Response and Intermediate Care, would be picked up at the next Integrated Quality and Performance meeting. Funding issues related to social care had an impact on staff moral and it was agreed this should be raised at the Health and Wellbeing Board. Alison Moon commented that it was important that, given the situation, the Chief Executive for BCH was involved in the exit interview process. The AWP Quality report was discussed. The position regarding Adult Safeguarding training compliance was noted. The Trust was focused on the matter and action had been taken to ensure that staff completed training. It was unlikely that the target would be achieved in- year, however significant progress was reported. It was noted that this improvement had come about since the formation of the CCG and that this positive change should be reported back to Practices in the key messages from the Committee. Martin Jones reported that commissioners had confirmed their commissioning intentions and funding had been secured for new Section 136 facilities. Emma Savage informed members that the CSU would be taking on performance and quality monitoring for the South West Ambulance Service Foundation Trust (SWASFT) contract. It was noted that increased primary care involvement in the contract was required and it was agreed that this would be an appropriate subject for a Governing Body seminar the new financial year. Alison Moon reported that the 111 service had suspended the system for verifying red calls on Friday 13 th at 7pm. The 111 service had a system of verifying calls to identify those which not require transfer to hospital. The service had found some risks in the system not identified earlier in the day. The Ambulance Service had been asked to monitor the impact of the service suspension on the Trust over the weekend. Louise Tranmer was investigating the issue. The system for verifying red calls continued to be suspended. The Committee received the Quality Report 7 November Serious Incident Spread Sheets These were received by the Committee 8 UHB Patient Experience Report The report was welcomed by members. It was agreed to share the principles of the 15 step challenge with colleagues in primary care. MJ /ES 9 CQC Children s Inspection Preparation Members were briefed on the background to the pending CQC Children s Inspection. Alison Moon described the process. A set of 100 notes would be supplied to the inspectors by the CCG from which Action Minutes Page 7 of 9
a random selection would be used to track the patient journey from primary care through to secondary care and the services used. This new approach would focus would be on the child s voice and journey. The inspection had been discussed at the recent Link GP meeting which had been well attended. The GP Links would help to identify the sets of notes. The inspection would be highlighted in the key messages and shared with Practices. Members representing localities were encouraged to raise this with their colleagues. Tara Mistry asked if Link GPs had received support regarding the inspection; Alison Moon confirmed that the matter had discussed at length at the GP Link meeting. It was noted that GP Link meetings did not happen in other areas. Alison Moon commented that it was important to highlight to the inspectors the developments resulting from the 2010 inspection. 10 Contract and CQUINs Process Bridget James explained that work was underway with colleagues in the CSU to develop the contract provisions and CQUINs to include in the 2014/15 contracts. Items relating to issues discussed at the meeting would be added to the contracts and a system wide CQUIN was being developed. The process would be completed by the end of February. Martin had comments about quality of discharge letters? And concerns about the delivery system used by the trusts. It was agreed to review the proposals at the January and February Committee meetings. 11 Corporate Risk Register After the last Governing Meeting it had been agreed to collate the risks recorded relating to NBT into one entry, highlighting the concerns. This had been completed and would be added Corporate Risk Register and shared with members. The Risk Management Strategy was under review. It was proposed that the draft strategy would be considered at the January meeting for recommendation to the Governing Body. The Strategy would be shared with members for comment before the meeting. It was noted the revision included an amended Corporate Risk Register. Patsy Hudson asked whether concerns about BCH s staff turnover should be added to the Corporate Risk Register. It was agreed to refer this to the Operations Director as chair of the Community Services Group for consideration. David Soodeen asked whether concerns about the funding for inpatient Mental Health beds should be escalated to the Risk Register. It was agreed to refer this to the Chief Accountable Officer as lead for the procurement for consideration. The Committee received the Corporate Risk Register BJ Action Minutes Page 8 of 9
12 Serious Concerns Log The Committee noted that there were no new concerns. The Committee received the log 13 Contact Us It was agreed that a column would be added to future reports showing whether a query originated from a patient or from a clinician. The committee noted the report and approved the data to be published 14 Any Other Business Members were informed that the CCG had concerns about a local care home and the Care Quality Commission had become involved. Two patients were placed in the home and commissioners had called a multi-disciplinary team meeting to review their care. The care home would be featured on the local TV news. The care home owner had agreed to work with the local authority safeguarding adult s team. The importance of ensuring the safety and care of patients was stressed. It was noted that a Serious Case Review would be published in February. This was related to a case which had recently resulted in the conviction of a parent for the manslaughter of a child. The publication was delayed due to legal reasons. The case had been discussed with Link GPs at the recent meeting and key issues had been raised. There had been a discussion as to how health professionals could add to Records about partners of parents not registered at the Practice. The CCG had raised the need for national guidance on this matter with the Royal College of General Practice. CCG s had been approached to participate in an initiative to pilot the Friends and Family Test along care pathways. It was agreed to explore this further. The Parliamentary and Health Service Ombudsman Report Midwifery Supervision and Regulation had been published. The report followed three families complaints about midwifery at Morecambe Bay NHS Foundation Trust and was critical of midwifery supervision. The CCG would review the recommendations with providers. The recent announcement to move to seven day working for consultants was discussed. It was agreed to raise the implications of this with both NBT and UB at their respective Integrated Quality and Performance meetings. /BJ Action Minutes Page 9 of 9