Introductions were made round the table for the benefit of Sandie Smith who was attending the meeting for the first time.

Annex B MINUTES OF THE PATIENT SAFETY & QUALITY COMMITTEE MEETING HELD ON TUESDAY 11 JUNE 2013 IN THE CONFERENCE ROOM, NEW QUEEN STREET SURGERY, WHITTLESEY, PETERBOROUGH Present: Rebecca Stephens, CCG Lay Member (Chair) Jill Houghton, Director of Quality Dr John Jones, GP Representative Dr Christopher Scrase, Secondary Care Doctor Sarah Shuttlewood, Interim Director of Performance & Delivery Dr Richard Withers, GP Representative In attendance: Maureen Donnelly, CCG Chair Sharon Fox, Trust Board Secretary Gemma Keats, Corporate Governance Administrator Wendy Lefort, Quality and Governance Manager Doreen Simpson, Risk Manager (Serious Incidents) Sandie Smith, Chief Executive Healthwatch Cambridgeshire Paula South, Associate Director Safeguarding Children & Vulnerable Adults Section 1 - General Issues 1 Welcome and Apologies for Absence The Chair welcomed everyone to the meeting. Apologies for absence were received from Jessica Bawden, Glen Clark, Dr Neil Modha, Ruth Rogers, Andy Vowles, Harper Brown and Vi Thomas. Introductions were made round the table for the benefit of Sandie Smith who was attending the meeting for the first time. 2 Declarations of Interest Relating to the Agenda There were no declarations of interest. 3 Notification of Any Other Business There was no notification of Any Other Business. 4 Minutes of the Previous Meeting The minutes of the previous meeting held on 9 April 2012 were agreed as an accurate record, subject to the following amendments in italics: Minute 9, paragraph 1, It was noted that a Patient Experience Forum had been developed in lead providers. Minute 9, paragraph 4, She said that the Quality Strategy should go to the Patient Reference Group for comment. Page 1

5 Matters Arising 5.1 Quality and Patient Safety Committee Action List The Committee reviewed the Action List and updated it where necessary. Ongoing actions would be included on the forward planner. Quality discussions with LCGs/soft intelligence Further to the last meeting, it was noted that there was no mechanism in place yet to pick up the hot topics highlighted in the Patient Reference Group as they focussed one or two hot topics at each meeting to get feedback from the CCG. Jill Houghton asked if the focus of the PRG had changed and it was agreed to discuss this outside of the meeting. Action: Sharon Fox/Jill Houghton. Dr Richard Withers commented that there needed to be further publicity around the Soft Intelligence Line for GPs. Jill Houghton advised that Maureen Walton had been out to the Practice Managers Forum to highlight this. She advised that so far, only two or three GPs had used it. Sarah Shuttlewood advised that this had been raised at the Accountability Review Meetings. Jill Houghton agreed to discuss raising this at the next Member Practice Meeting with Jessica Bawden. Action: Jill Houghton. Sandie Smith said Healthwatch would be able to help with public awareness raising in the future. CCG Assurance Framework Sharon Fox advised the Committee that the Management Team was currently reviewing the scores on the CCG Assurance Framework which would be submitted to the next meeting. Children s Commissioning Peer Review Visit Jill Houghton advised the Committee that she had now received all of the Action Plans from providers and they were incomplete. The Children s Commissioner had been back to the Trusts to raise this issue and agreed to submit a paper to the next meeting. Action: Jill Houghton. 6 Quality Report The Committee received the Quality Review Report which was circulated in advance of the meeting. Jill Houghton advised the Committee that the Report now included the exceptions at the beginning with updated notes in red. There was a new Quality Dashboard in provider contracts and she reminded the Committee of the process where anything that went to red was classed as an exception plus anything else raised. If there were three ambers in a row this resulted in a contract query. If there were two ambers for quarterly meetings this would also result in a contract query. This would be populated as time moved on. The CQC concerns were highlighted in the report as well as healthcare associated infections. Jill Houghton advised the Committee that she was disappointed about the appeals regarding the C.Difficile concerns detailed in the report. It was noted that there were two cases sent through to the Area Team from CUHFT and both were rejected on the grounds that best practice was not followed in Page 2

relation to the isolation of patients. However, potentially this could be a good thing in terms of ensuring that Trusts followed national guidance. The Chair asked why CUHFT appeared to be worse than other Trusts in relation to C.Difficile. Jill Houghton advised that CUHFT still had a number of fundamental issues to address, particularly around the isolation of patients. She advised that no cases had been found where C.Difficile had been passed on from one patient to another but there was still work to be done around antibiotic prescribing. There were also some engagement and leadership issues in relation to attendance at Scrutiny Panels. She advised that CUHFT had asked the CCG to invest 600k in their infection control service and the CCG had declined as this was business as usual. The Trust was asked to look at the fundamental issues before it looked at innovation. Dr Richard Withers commented on antibiotic prescribing and asked how much related to community prescribing and acute prescribing. Jill Houghton advised that there had been three community cases in Cambridge since April 2013 and antibiotic prescribing was not the issue. However, antibiotic prescribing in hospital had been an issue where the formulary was not always being followed. However, many patients at CUHFT had co-morbidities and were appropriately given antibiotics after being reviewed at by a microbiologist and pharmacist. Dr Richard Withers asked if there was a methodology when setting the ceiling targets for C.Difficile. Jill Houghton advised that this was set nationally by looking at a set period during the previous year. Maureen Donnelly commented that the CCGs efforts should be focussed on avoiding C.Difficile. Dr John Jones asked if there were financial implications for the Trust if they did not achieve their target. Jill Houghton advised that this was the case. The Chair highlighted the outcome of the infection control visit to Holland. Jill Houghton advised that the visit had been helpful in terms of the way they managed demand and patient flows in urgent care but not in terms of infection control. Jill Houghton agreed to highlight this to the Clinical and Management Executive Team. Action: Jill Houghton. Maureen Donnelly highlighted that some Trusts were rated as red for safeguarding children training. Paula South advised that there were ongoing issues around the collection of data. Jill Houghton advised that historically there had been no target set for safeguarding training. This had now been agreed through the local Safeguarding Boards where it was discussed extensively and agreed. Maureen Donnelly said it would be useful to have a note about the new target and progress against trajectory in future reports. Paula South advised that the CCG was asking providers for much more detail. Sarah Shuttlewood said she was glad this had been set and advised that it was in the contract with providers and any reds would incur a contract query. The Chair commented that there was a lot of blue on the dashboard that could turn red. Jill Houghton advised that if this was all green she would be worried that targets were not ambitious enough. The Chair highlighted that there was no column for the Queen Elizabeth Hospital and suggested that this was added to future reports as their quality performance affected the CCG. Jill Houghton advised the Committee that QEH would not have a dashboard like this one as theirs would be agreed with their CCG. Dr John Jones suggested including the information the CCG did know about QEH. Maureen Donnelly commented that the Dashboard was good and gave a good summary. She suggested adding Page 3

an indication of progress against trajectories because it was important to see if there was improvement. Action: Jill Houghton. The Chair commented on the evidence and board assurance about CPFT at page 10 of the report and asked what the red/amber meant. Jill Houghton advised that at the last CQR meeting, she had read the report that had gone to their Board and found that they had suspended the school nursing service in January 2013 but had not informed the commissioner. It was noted that CPFT stated they were compliant for seeing children within 18 weeks but then they were going onto a second waiting list where they could be waiting up to a year to be seen. She asked CPFT how their Board was apprised of these issues. It had been suggested that a CCG to Board meeting would be held with the Trust to discuss this. Jill Houghton advised that a remedial action plan was in place for the waiting lists and CPFT had promised to resolve the secondary waiting list by October 2013. Maureen Donnelly advised that the CCG would be holding a Board to Board meeting with providers in the Autumn. The Chair highlighted CCS s progress against the target for the Harm Free Care Thermometer. Jill Houghton advised that the CCG continued to work with CCs on this. There was some difficulty as CCS had their own target of 93% which was different to the CCG target of 95%. The Chair highlighted the CQC Standards in the Report and that PSHFT had not started to address these. Jill Houghton advised that she had not received any feedback on this yet and there was no official report yet. The Quality Surveillance Group (QSG) had received a verbal report from the CQC stating they had found the same concerns in Peterborough City Hospital as they found in Stamford. PSHFT was working through the process and the Director of Nursing had provided more evidence that they were compliant. Doreen Simpson advised that Lincolnshire CQR meeting was held last week and they would be undertaking a visit to Stamford Hospital. There was a good working relationship with Lincolnshire and the issues had been around documentation and there were plans in place to resolve this. Dr Christopher Scrase said he was concerned about Stamford Hospital and asked if there could be an underlying problem. Jill Houghton advised that there had been two information sharing meeting with Monitor, the CQC and the Local Authorities on PSHFT and it was considered at the QSG that there might be a need to call a Risk Summit. Jill Houghton advised the Committee that the presentation of serious incident information had been reviewed and there was now a fuller section in the Quarterly Patient Experience Reports. Doreen Simpson explained the separate report on open Serious Incidents was a good way to keep track of progress. There were some themes identified in the report. There had been a number of falls at the CCS run Intermediate Care Centre and this was being reviewed. There had been more Serious Incidents reported that had not come to light in the previous year at CPFT, which could be due to a new Risk Manager in place who had more focus in this area. Dr Richard Withers commented on timelines and asked if it was normal for CPFT to have had four deaths and five suicides in the last three to four months. Jill Houghton advised that there had been a deep dive and national suicide data had been reviewed and this showed that CPFT was not an outlier. She advised that Professor Louis Appleby had completed a review on this and the Report would be shared with the CCG when it was complete. Jill Houghton assured the Committee that CPFT was within normal parameters. Dr Christopher Scrase commented on the open Serious Incidents and Page 4

commented that he would expect to see a lot more pressure ulcers. Jill Houghton advised that there were very few grade three or four pressure ulcers. There were a large number within the community. Dr Christopher Scrase highlighted that CUHFT had not had any pressure ulcers. Jill Houghton advised that this was correct and advised that the Trust was good at managing these. Sharon Fox commented that some of the information in the Report could be patient identifiable and suggested that the Report could be taken in the Part 2 meeting. Sharon Fox agreed to work with Doreen Simpson on this outside of the meeting. Action: Sharon Fox. Dr Richard Withers asked for a description of a Serious Incident. Maureen Donnelly suggested that the link to the national guidance was circulated to the Committee for information. Action: Doreen Simpson. (http://www.nrls.npsa.nhs.uk/resources/?entryid45=75173). Dr Christopher Scrase described the system in place in his hospital where there was a Committee in place that decided if something was a Serious Incident. Jill Houghton commented that she was aware of some hospitals that had this system in place but the CCG providers did not and a filtering system in place could be of concern. Dr Christopher added that his Trust over reported to ensure incidents were all identified. The Chair asked if the issues such as problems with Colorectal surgery were happening now, would they be picked up in the current system. Jill Houghton advised that this was the case. However, Sarah Shuttlewood said that this relied on trusts reporting incidents and the soft intelligence tool could help with triangulating this information. Jill Houghton advised that something could be reported and there would be 48 hours to decide whether it was a serious incident or not. Dr Christopher Scrase advised that doctors were not good at using electronic reporting systems. He said that they tended to use email rather than the correct systems. Jill Houghton advised the committee that the quality report also included a section on care homes. She advised that she had met with the CQC manager for Cambridgeshire and there were no warning notices in place which was pleasing. It was noted that the CQC manager was very proactive with a nursing inspector background. It was noted the problems reported at Soham Lodge had been resolved. Maureen Donnelly asked if this only reported on the homes that were under the Local Authority. She commented that the health service had to be concerned about all homes. Paula South advised that all care homes across the patch were included in the database and were on different tabs so it was clear where services were commissioned. It was a full picture. Sandie Smith asked if this information was shared with the Local Authority. Jill Houghton advised that this was the case. The Chair commented on the unmet standards and that they were very black and white but did not give a sense of how serious this was. Paula South advised that there was a need to report where there was the detail/activity behind it. It was important to be cautious about what information was in the public domain. It was agreed to discuss what to bring to the Committee in future outside of the meeting. Jill Houghton advised that the CQC was the body that took regulatory actions. It was important to work with them as it was Page 5

CCG patients in these settings. Dr Richard Withers commented that historically there were issues in terms of doctors and district nurses going into homes reporting issues as a 'mole' with a full investigation in the end. Maureen Donnelly said this was linked to the soft intelligence process and how this information was fed back. Jill Houghton suggested that when there was a strategy meeting with the Local Authority, there should be GP attendance to make them aware of the issues. Maureen Donnelly suggested that this was taken through LCG meetings. Paula South advised that the adult safeguarding lead would always talk to the GP, where there were care home issues, about what information they had. Maureen Donnelly commented that GPs would be used as an early warning/soft intelligence source as they were going into homes each week. Action: Jill Houghton. The Committee noted the Quality Report. 7 Quality Account Statements The Committee received the report on the draft Quality Account Statements for non Foundation Trust providers: Cambridgeshire Community Services (CCS) and Hinchingbrooke Healthcare Trust (HHCT). Wendy Lefort welcomed feedback from the Committee on the Statements. The Chair commented on the report for CCS and that the comments around how they engaged with their patients and that this was part of their core business came as a surprise and asked if there was anything that the CCG could be learning from them. Jill Houghton advised that there had been a Risk Summit about quality concerns. In terms of feedback, it was important to only deal with the facts. The CCGs feedback was factual and was in the public domain. She commented that their Quality Account was a very good descriptive Quality Account. Dr Christopher Scrase commented that the Quality Action came across quite favourably but did not concur with the reds reported in the Quality Report. Maureen Donnelly commented that anything could be written in a positive light. The Committee agreed the CCG statements for inclusion in the non-ft provider Quality Accounts and where changes were required to the statements for inclusion, agreed a validation process within the required timescale for feedback to providers. 8 Patient Experience, Incident & Serious Incident Report The Committee received the Patient Experience, Incident & Serious Incident Report. Jill Houghton advised the Committee that the Report also included information on independent contractors as these were part of the PCT and it was important to report them in terms of the legacy point of view. This would not be included in future reports. Jill Houghton advised the Committee that soft intelligence about care homes was collated using a database. The Care Home Register would be presented to the Committee in the Part 2 meeting next month. Page 6

Dr Christopher Scrase asked if people were using PALS to report problems. He was aware that patients used PALS as a weapon and was concerned the service was used as a surrogate measure of care delivery. Jill Houghton agreed that people would not contact the CCG unless there was a problem. She advised that this Report would no longer include independent contractor concerns as these were now dealt with by the Area Team. However, it was noted that PALS continued to receive a number of these calls as people were not satisfied with the response from the Area Team and the PALS team provided assistance where possible. Jill Houghton suggested that complaints were included in future reports as there was a gap there. The Chair asked what action was taken now that the Committee had received the Report. Sandie Smith suggested that this Report could be received by the Patient Reference Group to triangulate the information. Sharon Fox said this could be considered by the Patient Reference Group. Jill Houghton advised the Committee that the Report used to be used as a performance report on the PALS service in the PCT, however more emphasis needed to be put on patient experience and suggested taking this to the Patient Reference Group to ask them how best to utilise the information. Action: Jill Houghton. Dr Richard Withers commented that this Report should be used as a statement of where the CCG was for people to use if they were moving to the area. Dr Christopher Scrase asked if the Friends and Family Test was a good measure. He said if he was a patient he would think there was something wrong with CUHFT. Jill Houghton advised that work was ongoing with CUHFT on this and the methodology of the Friends and Family Test was flawed. Sarah Shuttlewood commented on the benchmarking for this system and advised that the Finance and Performance Committee had asked for this with like for like hospitals. Jill Houghton suggested that this was taken to the Patient Reference Group and that a working group was established to agree what this should look like. Maureen Donnelly commented that much of this linked to soft intelligence. Jill Houghton advised that the Committee would receive the PALS Quarter 1 report art the next meeting and a refreshed version of the Patient Experience Report in future. Action: Jill Houghton. The Committee noted the Patient Experience, Incident & Serious Incident Report. 9 PSHFT Unannounced Visit Report The Committee received a verbal update on the PSHFT Unannounced Visit Report from Paula South, Associate Director Safeguarding Children and Vulnerable Adults. Paula South reminded the Committee that there had been an increase in external safeguarding referrals, therefore a visit was undertaken to PSHFT. She advised that nine people were on the Visit Team and they visited nine wards. There were positives and negatives to take away from the visit. It was noted that the focus on clinical practice was positive and the Team had spoken to front line staff and patients and all patients felt safe, they were treated with respect and courtesy. However, there was a patient that had said they felt lonely and sad in their room. There were other comments from patients that the DNAR was not explained to the family, care at the hospitals was tops, it was a lovely hospital. She advised that there were some good examples of Page 7

discharge planning and record keeping. It was noted that there were some minor concerns in terms of staff and children s safeguarding, particularly around discharge from ED by a Junior Doctor and protocols around 16 and 17 year olds. The main concerns in terms of adult safeguarding were around the lack of clarity about the training required and what staff had received. She said skills and knowledge were not as expected and staff were unable to link the Mental Capacity Act/Deprivation of Liberty to care. There was no formal risk assessment in place. There were staff that did not see pressure ulcers developed in hospital as a safeguarding issue. The main issue identified in the emergency department was ensuring privacy and dignity was achieved and that handover of patients/telephone calls between staff was overheard by other patients. Paula South advised that the visit team spent the whole day at PSHFT and feedback was given to senior colleagues on the day. She advised that behind the scenes PSHFT had started to look at the recommendations and there was a proposal to increase the staffing level in the safeguarding team to a clinical role. Paula South advised the Committee that she had written a report on the findings which had been shared with the PSHFT Chief Executive and Director of Nursing. On the whole they were content with the contents of the Report and they had put together a team to take forward the actions. The Chair asked of their single point of contact referral process would be changed. Paula South advised that PSHFT would be ensuring that front line staff were able to make safeguarding referrals. The Committee noted the verbal update. 10 Quality & Performance Integrated Dashboard The Committee received the Quality & Performance Integrated Dashboard which was a report led by Sarah Shuttlewood. It was noted that there was a need to review the Assurance Framework scoring and this Committee should be taking the lead on asking the questions around quality. Sarah Shuttlewood acknowledged this. Maureen Donnelly commented that the way the questions had been asked was badly designed. The Chair felt that as the Patient Safety and Quality Committee, she thought it should have some insight into how the CCG was rating itself. It was noted that this was a national framework out for consultation. Jill Houghton advised that there was the ability to include text. It was noted that the final Dashboard would be published in the Autumn. The Deadline for feedback was 11 June and it was agreed that Sarah Shuttlewood and Jill Houghton would discuss the feedback outside of the meeting. It was highlighted that some of the feedback did not relate to what had been discussed during the meeting and Sarah Shuttlewood would discuss this with Wendy Lefort outside of the meeting. It was agreed to discuss how the Committee would receive this information in the future. Action: Jill Houghton / Sarah Shuttlewood. Maureen Donnelly advised that some comments were made on this at the Finance and Performance Committee and these should be included in the feedback. It was agreed that the A3 document was not useful for the Committee to receive in future. The Chair commented that the paragraph on patient experience on page 11 was another lever to ensure the CCG got this Page 8

right. Dr Richard Withers commented that it would be useful to understand what was behind this information/data and how it was collected. Sharon Fox suggested this was a topic for discussion at a CCG Governing Body Development Session. It was agreed that Sharon Fox and Sarah Shuttlewood would discuss this. Action: Sharon Fox / Sarah Shuttlewood. Sandie Smith asked if the same applied to patient experience and the story behind positive experience. Jill Houghton advised that there would not be any soft intelligence included but would be qualitative data. Sandie Smith commented on qualifying the national statistics with local information. Jill Houghton advised that this would be done via the Friends and Family Test for A & E and there was also one in place for maternity services. There was also the GP satisfaction survey which was undertaken annually. The Committee reviewed the quality element of the integrated dashboard, considered if the indicators on the CCG Balanced Scorecard and the quality element of the CCG Assurance Framework were appropriate to provide Board assurance on the quality issues in the CCG and considered if the committee wished to comment on the NHS England East Anglia CCG Assurance & Deliver Pack prototype. 11 Date of Next Meeting The date of the next meeting was confirmed as Tuesday 9 July 2013 in the Willow Room, Lockton House, Clarendon Road, Cambridge, CB2 8FH. Author: Gemma Keats Corporate Governance Administrator 25 June 2013 Page 9