Present: Sheila Dilks (SD) (Chair) Hayley Cavanagh (HC) Sarah Clein (SC) Anne Eccles (AE) Brian Green (BG) Tanya Jefcoate- Malam (TJM) Dr Andy McAlavey (AMcA) Helen McCairn (HMcC) Dr Julia Riley (JR) Pam Smith (PS) Helen Wormald (HW) Also in Attendance: Jenny Dodd (JD) Carol McRae (CMcR) Louise Milner (LMi) Barbara Perry (BP) Pauline Roberts (PR) Debbie Telford (DT) Clare Jones (CJ) QUALITY IMPROVEMENT COMMITTEE Minutes of the meeting held on 8 th October 2014, Conference Room E, 1829 Building Chair, Lay Member, NHS West Cheshire CCG Quality Improvement Manager, NHS West Cheshire CCG Programme Manager Complex Care, NHS West Cheshire CCG Designated Nurse Safeguarding Children, NHS West Cheshire and NHS Vale Royal Clinical Commissioning Groups Head of Quality and Safety, NHS West Cheshire CCG Primary Care Manager, NHS West Cheshire CCG Medical Director, NHS West Cheshire CCG Director of Partnerships, NHS West Cheshire CCG Clinical Lead for Quality and Safety, NHS West Cheshire CCG Lay Member, Patient and Public Engagement, NHS West Cheshire CCG Designated Nurse Safeguarding Adults, NHS West Cheshire and NHS Vale Royal Clinical Commissioning Groups Assistant Chief Officer, NHS West Cheshire CCG Locality Lead Customer Solutions Centre Cheshire and Merseyside Commissioning Support Unit Clinical Quality & Performance Co-ordinator, Continuing HealthCare/Complex Care, Cheshire and Merseyside Commissioning Support Unit Senior Prescribing Advisor, Medicines Management, Cheshire and Merseyside Commissioning Support Unit Pharmacy Advisor, Medicines Management, Cheshire and Merseyside Commissioning Support Unit Locality Lead for Continuing Healthcare, Cheshire and Merseyside Commissioning Support Unit Governing Body and Committees Administrator, NHS West Cheshire Clinical Commissioning Group Agenda No. 14-035 Welcome and apologies Item Action by The Chair welcomed everyone to the meeting and noted that apologies have been received on behalf of Paula Wedd and Rob Nolan. Page 1 of 12
14-036 Minutes of the previous meeting 13 th August 2014 The minutes of the previous meeting were agreed as an accurate record, with the following amendments: Page 1 Julia Riley s job title is to be amended Page 4 GP Incidents wording is to be amended to highlighted that GPs do not undertake Significant Event Analysis in isolation... Matters Arising There were no matters arising to be discussed. Action Tracker The updated Action Tracker was agreed as accurate, and it was noted that all items have been completed, included upon the agenda, or are updated as follows: 14.005 GP Quality and Development Issue of timeliness and quality of clinical communication to be raised at next CoCH quality and performance meeting. AMcA provided an update and noted that letter templates have been agreed, and the content of the letters from varying departments have been discussed. However, it is important that work is also undertaken in primary care to ensure that referral letters from GPs to consultants provide all necessary patient information. 14.019.f - Patient Vaccination Public Health England is investigating an issue in relation to a pertussis vaccination. It was agreed that BG will follow up on this issue. 14.029.a Hospital Intelligent Monitoring Scores CoCH Hyper Acute Unit mortality figures to be shared with RN. It was agreed that BG will follow up on this issue. 14.029.b New and closed Serious Incidents Reports Significant Event Analysis Consideration to be given to addressing analysis training through the training being undertaken on behalf of CCG JR noted that the significant event analysis will be the main learning used to improve training, and the new training model is currently being written. The greatest challenge will be to agree the most beneficial way to incentivise primary care, and further details were provided. 14.029.d National Patient Survey Report to be prepared for GB, detailing work to be undertaken, who by, timeliness and expected outcomes AMcA noted that this work is currently being undertaken and will be available for the December 2014 meeting of this committee. 14.034.a Learning Disabilities Self-Assessment process Consideration to be given to re-launching patient register. This item will be placed on the agenda for the December 2014 meeting of this committee. BG BG AMcA CJ 14-037 Declarations of Interest There were no non-standard declarations to be noted. Page 2 of 12
14-038 Nursing Home Update HMcC provided an update to the committee, noting that a due diligence review has been undertaken in relation to Continuing Healthcare, Funded Nursing Care and Complex Care, and a clinical commissioning group team has been brought together to monitor and progress these issues, and further details were provided. Discussions took place in relation to ensuring that all provider nursing home and care home contracts are included within the North West Framework. This work is currently being refreshed and the review is expected to be complete by February 2015, and it was agreed that energies should be focused on having providers signed up to the new framework, which will be operational from March 2015. DT provided details of how contracts are managed where the provider has not signed up to the North West Framework. Additional details were provided on the differences between the old and new frameworks and it was noted that the main difference relates to the costing of contracts. It was agreed that exceptions to the new framework should be discussed within the clinical commissioning group team, and can be agreed by HMcC. HMcC also noted that a significant area of risk for the clinical commissioning group is the Care at Home contract, which is a PCT legacy issue. The local authority is currently undertaking recommissioning for providers, and additional details were provided. It was agreed that this issue will become a standing item upon the agenda for this committee. This issue was discussed and HW noted that an improvement in care at home has been visible since the advent of integrated teams. JR raised the concern relating to the limited funding available to the integrated teams. This was discussed and it was agreed that this issue should be progressed in to the Ageing Well programme of work. The following points were highlighted from the Nursing Home update paper: From June 2014 the Commissioning for Quality and Innovation scheme form has been altered to capture a breakdown in pressure ulcer information, and further details were provided. The Clinical Quality and Performance team is working with Cheshire West and Chester Council to develop the multi-agency risk rating. Meetings are held regularly to discuss the information and actions around the providers that are being highlighted as high risk for either authority or both authorities. This now includes Infection Control data. The latest version highlights not only the providers that are currently being monitored but also those that are moving up the list, for various reasons. Medicines Management have reported the information relating to the individual providers activity, for August and September 2014, and further details were provided. There has been a joint approach in relation to quality monitoring nursing home providers within the NHS West Cheshire Clinical Commissioning Group area. Cheshire and Merseyside Commissioning Support Unit s Clinical Quality Co-ordinator and CJ RN Page 3 of 12
Cheshire West and Chester Council s Contract and Quality Management team have been conducting joint reviews where this has been possible and further details were provided. Updates for specific homes were highlighted as follows: Atherton Lodge is currently subject to a safeguarding review, and a full suspension of new complex needs placements is in place. Chapelfields The public protection unit have confirmed that no criminal proceedings will take place in relation to the safeguarding investigation. Kings Court A new manager is in place and there are no new safeguarding referrals or concerns reported. Willows A concern has been raised in relation to a safeguarding and Datix referral in relation to a grade 3 pressure ulcer, which is currently under investigation. A professionals meeting will be arranged to progress this issue. Discussions took place in relation to the possibility of improving the publication of care home performance data. In response to questions raised, the following points were noted: During quality visits to homes, the main focus is on clinical issues Updates for the risk analysis at Appendix 2 are not available in a timely manner for this meeting and, therefore, the Home by Home tables provide the most current information. Consideration will be given to making the number of residents in each home more visible. An appendix is to be added which lists the teams and organisations involved in the ongoing multi-disciplinary work. Confirmation is to be sought that Dr Philip Milner is providing feedback in to primary care, regarding the work being undertaken in relation to Care Homes. LMi LMi AMcA SD noted that there is increased assurance that issues are being monitored appropriately, and that the report has progressed significantly from its original format. Details were provided on the current methods of sharing information and further details were provided of work still to be undertaken to ensure that the systematic sharing of information is in place. Managing Medicines in Care Homes National Institute for Health and Care Excellence Guidance PR provided the background to the document and noted that it provides recommendations for good practice on the systems and processes for managing medicines in care homes. The document was discussed and the following points were highlighted: Residents should be able to manage their own medication, unless a risk assessment has indicated that this should not be the case. There are a number of implementation tools available for care homes to assess their compliance with the guidelines and to assess their medicines policy Page 4 of 12
Details were provided on the current work being undertaken to ensure that appropriate medicines management is in place and discussions took place in relation to the implementation of the guidance, and who is accountable and responsible for the safe and effective use of medicines in care homes. It was agreed that BP will consider how best to progress this work, and an update will be provided for the February 2015 meeting. BP The Quality Improvement Committee noted the contents of the nursing home update. 14-039 Pharmacy Minor Ailments Scheme BP provided the background to the paper, noting that paper outlines a proposal for the transitional management of the transfer of accreditation for community pharmacists providing a Minor Ailments Service (Pharmacy First) in West Cheshire to a self-assessment model. It is proposed that the expiry date of current Harmonisation Of Accreditation Group certificates that have expired, or will expire, before 1 st December 2014 is extended to 31 st December 2014, which will enable pharmacists to continue to provide the service until they have completed the training required for self-assessment. The proposal was discussed and it was noted that a designated person has been identified to ensure that the accreditation process is complied with, and who will circulate a letter to pharmacists detailing what is required, and by what date. Discussion also took place in relation to which pharmacists are involved within the minor ailments scheme, and which conditions they manage. BP noted that the minor ailments scheme will be re-launched during selfcare week, and further details were provided. The committee approved the extension of Harmonisation of Accreditation Group certificate expiry dates to 31 st December to facilitate continued provision of the minor ailments service during the transition to self-declaration of competence to provide the service. 14-040 Published National Institute for Health and Clinical Excellence Quality Standards The Quality standard links have been forwarded to the appropriate clinical and commissioning leads. 14-041 Quality Improvement Report The Quality Improvement Report was discussed and the following points were noted: Hospital Intelligent Monitoring Scores The scoring of both Wirral University Teaching Hospital and Countess of Chester Hospital NHS Foundation Trusts have not changed from the previous report. Serious Incidents status Countess of Chester Hospital NHS Foundation Trust There has been an increase in the number of Grade 3 pressure ulcers Page 5 of 12
reported, and the Trust is working to address this issue. There has also been one Grade 4 pressure ulcer reported. Cheshire and Wirral Partnership NHS Foundation Trust Grade 3 pressure ulcers There has been an increase in the number of pressure ulcers reported, although a number of these are expected to be undeclared. Both Trusts are working closely together to share and learn best practice, and both will be attending at a pressure ulcer event scheduled for 20 th November 2014. Closed Incidents Work has been undertaken to drill down in to a number of closed cases, to identify any possible learning. It was noted that all incidents are reviewed by the Serious Incidents Group prior to closure. Unexpected Death of Patients The number of cases recorded was discussed and BG noted that a number of these cases have now been undeclared, and further details were provided. In relation to learning from these incidents, SD noted that a mistake does not need to have taken place for learning to be taken from the incident and this was discussed further. BG noted that consideration is currently being given to how patient incidents are tracked back in to primary care, in order to identify any possible gaps within services and JR also noted that work is being considered to undertake full Root Cause Analyses, tracking a patient back in to primary care, and details were provided of the current reporting processes. GP Reported Incidents JR noted that significant work is being undertaken to progress this issue and the Datix reporting system has been radically revised and simplified. AMcA and BG are currently launching the new system at GP Networks and this has been well received. A small number of GP practices are not currently reporting incidents, but a Commissioning for Quality and Innovation scheme incentive is in place to attempt to progress this. Further details were provided on the work being undertaken to progress this issue. Thematic Review of Complaints and Patient Advice and Liaison Service Data PALS The review considered the last 12 months of data, and 45 services. The majority of complaints were in relation to patient transport services, with a significant proportion of those complaints relating to mental health. Complaints by Provider There have been a significant number of complaints in relation to Continuing Healthcare, with patients addressing their concerns to their local Member of Parliament, and the majority of complaints relating to retrospective cases specifically. Discussions took place and it was agreed that AMcA will suggest to the Commissioning Delivery Committee that a letter is circulated to those involved in retrospective cases that work is being undertaken to address the issues with these cases, for information purposes. It was also agreed that an update on Continuing Healthcare will be requested for the December 2014 meeting. Discussions took place in relation to complaints which are registered with NHS England, for GPs and pharmacists, as this information is not made available to clinical commissioning AMcA Page 6 of 12
groups. It was agreed that this is an issue that should be raised at the Quality Surveillance Group. AE queried whether there is any way to identify children issues within the complaints and CMcR stated that this would require a manual trawl of all complaints. CMcR will consider if this is possible for Children and Mental Health complaints. Issues and Concerns Countess of Chester Hospital NHS Foundation Trust Mortality The Trust s Summary Hospital Level Mortality Indicator for May 2013 to April 2014 has been rated as amber by NHS England as a concern to be closely managed. BG noted that this is due to a discrepancy on systems used for this data and provided further details of the discrepancy. The Trust s figures are improving, although there is further work to be completed. It was noted that the governing body has requested additional clarity in relation to this issue, and this committee will continue to monitor the Mortality figures. One to One Midwifery Countess of Chester Hospital NHS Foundation Trust has escalated a number of concerns in relation to this service, specifically in relation to midwives deviating from national best practice, and further details were provided. As a result of this, these concerns have been shared with NHS Wirral Clinical Commissioning Group and a contract query has been issued. Further details in relation to the contract query are currently awaited. This issue was discussed and a concern was raised in relation to the unhelpful behaviour of the Trust s managers in relation to One to One Midwifery and this issue has been raised at the One to One Midwifery quality and performance meeting. It was noted that the midwifery service will shortly be re-tendered, and One to One Midwifery may apply for the tender. Cheshire and Wirral Partnership NHS Foundation Trust activity on staffing levels has been higher than planned and HC provided additional details. Details were also provided in relation to the timetable for handover of Mental Health and Learning Disabilities management to the Mental Health Assurance Board. Partners for Health Mersey Internal Audit Agency have undertaken a review of the service, and further details were provided. Some required evidence is still awaited, and this will be utilised to support the proposed contract extension. Infection Control The Infection Prevention and Control service has been re-commissioned and, from 1 st October 2014, Cheshire and Wirral Partnership NHS Foundation Trust will now be the provider of the service across West Cheshire and Vale Royal. The following points were highlighted: There has been 1 case of MRSA reported, which was found to be unavoidable. There have been 16 community cases of C.Difficile and an urgent meeting was scheduled to discuss this further. During August Countess of Chester Hospital NHS Foundation Trust reported an outbreak of Carbapenemase-Producing Enterobacteriaceae (CPE), and Ward 50 was closed as a result of this. A full investigation is being undertaken in to the outbreak. 18 th November 2014 is the European Antibiotic Awareness Day. PW CMcR Page 7 of 12
Safer Staffing Countess of Chester Hospital NHS Foundation Trust has undertaken a staffing review, which shows an increase of 42 WTE posts since 2013, and further details were provided. Cheshire and Wirral Partnership NHS Foundation Trust has undertaken a staffing review, and further details were provided. It was noted that the staffing for Juniper Ward fell to 71% for August 2014. Assurance has now been received that, after a recent recruitment process, this issue has been addressed. Primary Care AMcA welcomed TJM as a part of the primary care development team and provided details of the significant programme of work being undertaken to support primary care development. Discussions took place and it was agreed that this issue will be scheduled for in-depth discussion at the December 2014 meeting of this committee. Mental Health and Learning Disabilities the Mental Health and Learning Disabilities aspect of quality and performance monitoring will shortly move to the Integrated Provider Hub. This information will be presented to this group within the Key Points report, with exceptions included within this report. Commissioning for Quality and Innovation schemes Details were provided on the progress of agreement, and accountability and non-achievement were also discussed. Safeguarding Children Care Quality Commission action plan the Designated Nurse for Children in Care is now in post. GP attendance at case conferences submission of reports for the review of child protection case conferences has not met the required standard during the last 4 quarters and this issue was discussed further. Local Safeguarding Children Board Section 11 Audit In response to the recent audit, in order to strengthen the clinical commissioning group s safeguarding arrangements, some actions have been identified and further details were provided. Female Genital Mutilation Dataset SD requested that assurance is sought from the clinical commissioning group s Trusts that they have introduced procedures to support mandatory data collection. Child Sexual Exploitation Further to the Jay Report, in to events reported in Rotherham, a significant piece of work is being undertaken by the Local Safeguarding Children Board nationally, and further details were provided. Currently, Child Sexual Exploitation is a part of GP Level 3 safeguarding training, with 12 hours of training to be completed within a 3 year period. However, available on-line training does not extend past level 2 training, and this is to be reviewed. Adult Safeguarding Cheshire and Wirral Partnership NHS Foundation Trust Following the last committee meeting in August 2014, not all of the information had been provided by the Trust by the agreed timeline of the end of September 2014. During the review of three Serious Investigations, concerns were raised as to the involvement of the Trust s safeguarding team in the identified safeguarding concerns raised within the reports. A meeting was called to include the clinical commissioning group s Head of AMcA AE Page 8 of 12
Quality and Safety, Designated Nurses and the Associate Director of Nursing for Cheshire and Wirral Partnership Trust on the 2 nd October 2014. Assurance has been provided that the information will be received by the end of October or before. Grosvenor Nuffield A meeting has taken place with the new Matron, which was very positive and productive, and the timescales for completion of work has been agreed. Partners for Health the provider has submitted the additional information in the agreed extension timescale Vale Court Nursing Home Owned by Four Seasons Homes (No3) Ltd The provider is registered to provide both residential and nursing care for up to 56 residents. Significant improvements have been made and sustained in the past weeks and Cheshire West and Chester Safeguarding team are no longer involved in any monitoring or investigations in the home. Cheshire West and Chester Council contract team, supported by the Cheshire and Merseyside Commissioning Support Unit Quality lead, have completed a joint annual quality visit. The Care Quality Commission Inspection report is not yet published. The Quality Improvement Committee: a. Scrutinised the issues and concerns highlighted and identified any further actions for members of the quality improvement committee b. Identified any exceptions and concerns that need reporting to the governing body c. Discussed the information provided in the thematic review of complaints and patient advice and liaison service data reported and identified any further actions d. Supported the further development of the GP Quality Group as outlined within this report e. Supported the further development of the Primary Care Quality Dashboard f. Noted the continued development of the Datix Incident Reporting System g. Supported the further analysis of the GP Patient Experience Survey and its incorporation into the Primary Care Programme and Quality Dashboard. h. Noted the progress against Commissioning for Quality and Innovation Schemes, Quarter 1 April June 2014 i. Noted the current position reported by the Designated Nurse for Safeguarding Children/ Children in Care and identified any further assurances required j. Noted the update on the use of additional funding from NHS England for Patient and Public Involvement, being utilised for patient leaders 14-042 Key Points Report The report was discussed and the following points were noted: The over-performance of community services will be discussed outside of this meeting. The increase in Children placed Out of Area is disappointing, although it is noted that this is a national issue. Page 9 of 12
14-043 Paediatric Diabetes Services Peer Review This item was deferred to the December 2014 meeting of this committee. PW 14-044 Safeguarding Children and Adults at Risk Annual report AE and HW presented the annual reports to the group and noted that it is intended to present these papers to the governing body meeting on the 20 th November 2014. The following points were highlighted from the report: The Care Act has progressed to Royal Assent and this will place adult safeguarding arrangements on a statutory basis and bring in new duties as of 2015. Contractual arrangements with the main service providers are in place for adults, and similar work will now be undertaken with the smaller providers. Partnership working has taken place between health and Cheshire West and Chester Council and a review was undertaken to characterise the themes and trends identified during safeguarding investigations. The Learning and Development sub-group of the Local Safeguarding Adult Board will be devising an event to raise the importance of leadership to promote and safeguard the health and wellbeing of our communities. Work continues to be undertaken as a result of the Ofsted and Care Quality Commission inspections relating to children s safeguarding, and services are improving, and the Local Safeguarding Children Board continues to support this work. AE and HW requested that any further comments on the document are returned to them. The Quality Improvement Committee noted the contents of the report and accepted assurances that the clinical commissioning group is meeting its statutory responsibilities in relation to safeguarding children and adults at risk. 14-045 Children in Care AE provided the background to this document and the following points from the report were highlighted: The 2014 Care Quality Commission review identified improvements in services since the previous inspection in 2010 A Designated Nurse for Children in Care post has been filled and there is confidence that this progress the work currently being undertaken. The increase in the number of Children in Care is national issue and, locally, assurance has been provided to the Local Safeguarding Children Board that these children have been appropriately placed in care. Monitoring will continue in relation to the capacity of service providers. Page 10 of 12
A number of children are place Out of Area due to the lack of foster carers available in the Chester area. National information relating to this is published in December 2014 and this can be utilised to assess whether a commissioning issue exists. Discussions took place in relation to the Integrated Needs Assessment and it was agreed that this will be brought to a future meeting of this committee. Discussions also took place in relation to Health Passport, and the benefits of this work. AE requested that any additional comments are returned to her. The Quality Improvement Committee noted the contents of this report and accepted assurances that NHS West Cheshire Clinical Commissioning Group is meeting its statutory responsibilities in relation to children in care and is working to achieve those responsibilities identified in the report as not yet achieved. 14-046 Equality and Diversity Jenny Dodd provided the background to this paper and noted that the clinical commissioning group has statutory duties in relation to equality and diversity, which the governing body has delegated to this committee to manage. This paper provides details of a recent judicial review into the actions of Sandwell Council, which highlighted the need for all public sector bodies to ensure that the appropriate assessments and consultations are undertaken at an early stage in the decision making process, and suggests a more robust process for the clinical commissioning group to take in considering the equality impact of decisions taken. The following points were highlighted: The Law has not changed, but this has highlighted the rigor on how Courts will uphold equality and Diversity. Scrutiny and consultation needs to take place before service change. The clinical commissioning group has undertaken work with Andy Woods, CMCSU, on the processes to be completed. Additional work will be undertaken with Programme managers to further address this. Discussions took place and it was agreed that the processes need to be more efficiently embedded within business cases. Further discussions took place and it was agreed that JD will provide an update to the next meeting on the clinical commissioning group s current position in relation to the processes, i.e., the current position, the desired position, and how to achieve this. It was also agreed that the Action Plan will have definite dates for completion of work, rather than saying ongoing. JD The committee noted the briefing paper on the Sandwell case and approved the recommended pre-equality analysis process. Page 11 of 12
14-047 Reporting Back to Governing Body Children in Care 14-048 Any Other Business There was no other business to be discussed. Date of Next Meeting: Wednesday, 10 th December 2014 Time: 2.30pm 4.30pm Venue: Conference Room D, 1829 Building Page 12 of 12