Quality Assurance Committee (QAC) Minutes of the meeting of the Quality Assurance Committee of the Sheffield Health and Social Care NHS Foundation Trust, held on Monday 25 TH April 2016 at 1pm in Rivelin Boardroom, Old Fulwood Road, Sheffield S10 3TH. Present: 1. Mervyn Thomas Non-Executive Director/Chair 2. Sue Rogers Non-Executive Director 3. Ann Stanley Non-Executive Director 4. Richard Mills Non-Executive Director 5. Clive Clarke Deputy Chief Executive 6. Liz Lightbown Chief Nurse/Chief Operating Officer In. Attendance: 7. Dr Rachel Warner Deputy Medical Director 8. Dr Jonathan Mitchell Associate Medical Director, Governance 9. Tania Baxter Head of Integrated Governance 10. Jason Rowlands Director of Governance, Planning and Performance 11. Kevin Clifford Chief Nurse, Sheffield CCG 12. Giz Sangha Deputy Chief Nurse 13. Sharon Sims PA to Director of OD/Board Secretary (Notes) Apologies: 14. Phillip Easthope Director of Finance 15. Jane Harriman Deputy Chief Nurse, Sheffield CCG 16. Kevan Taylor Chief Executive QAC Item 13i No. Item Lead Welcome & Apologies The Chair welcomed everyone to the meeting and noted apologies. 1/4/16QAC 1 Declarations of Interest There were no new declarations of interest 2/4/16QAC 2 Minutes and matters arising from the meeting held on 22 nd February 2016 The minutes of the meeting held on 29 th March 2016 were agreed as an accurate record. Matters Arising 3/2/16QAC Governance Specialist Directorate The Chair reported that he had spoken to Ms Lightbown in relation to the reason this item has been deferred. It will be rescheduled in due course. 1
3/4/16QAC 3 Regulation and Governance a) Care Quality Commission (CQC) Update Mr Clarke presented the CQC update to the Committee for assurance. The Chair referenced the reports and noted that there was some slow progress against the action tracker and referenced the action in relation to fridge temperatures attributed to medicines management. Mr Clarke responded that EDG had received and discussed a paper with a number of options, and further options were being considered. The Chair asked whether there was any risk to patients. Dr Warner responded it was more a financial risk rather than a patient risk. Mr Clifford reported that the risks to patients in our in-patient wards would be minimum. There would be a higher risk in GP Practices if vaccines were not stored at the appropriate level. Ms Lightbown responded that the incident investigated last year in relation to unsafe vaccines was in at the Brierley practice The GP practices under Clover group are all compliant. Mr Clarke reported that the CQC had visited Woodland View and Longley Meadows and the reports had been circulated. Action plans have been drafted. Mr Clifford felt that the latest CQC visit to Longley Meadows had not reported a significant improvement. Mr Clarke responded that the Directorate have since introduced senior nurse intervention at the unit to progress the action plan and give assurance on safety and leadership. The Chair acknowledged this intervention and that, following discussion the Board felt that progress was also being made, and assurance received that new practices and changes would be embedded and there was some stability until the end of the financial year, whilst working with the Local Authority on a new model of care. Ms Lightbown added that she would be visiting Longley Meadows to meet with the senior nursing team and she would be attending an exec to exec meeting with the CCG. Mr Clifford added that the purpose of the meeting was for the CCG to be reassured. Mr Clarke also reported that there had been two Mental Health Act Compliance visits which have been discussed at the MH Act Committee. The Chair raised the query of restrictions and whether this was a deprivation of rights. Dr Warner responded that this has been discussed and there will be procedures written for each unit, there will be some units due to client group that will need to enforce restrictions. Mrs Rogers asked if there were problems with searches in line with the NHS England contract recommendations. Dr Warner responded that the guidelines and protocols would be considered and the use of the Mental Health Act would be the primary decision maker whilst dealing with each case individually. Ms Lightbown added the importance of policy and code of practice and introduction of Trust s policies to enable staff to work safely and effectively Mr Clarke reported that he had visited Pinecroft after the inspection and met the staff, they had been positive and shared their experience of CQC visit and the areas they had made improvements on. processes are in place to monitor the action plan. i. Peer Review Inspection/Programme Mr Clarke reported that an action from the CQC visit was for the Trust to conduct its own Inspection/peer reviews. Following discussion on the process at EDG, a pilot review had taken place at Longley Meadows using the 5 CQC domains. This was undertaken by a senior managers and himself. There will be a rollout programme across the Trust Ms Baxter reported that the review was conducted over a 2 day period with time to review and feedback and share with the team to develop their learning. She acknowledged that there were various visits happening across the Trust and there is a 2
need to share information and ensure that the inspection team have the most up to date and accurate information and available. Mrs Rogers asked if this programme could be sustainable with the level of input from senior staff. Mr Clarke responded that the pilot was undertaken with additional resource and directorates need to be mindful of this when the schedule is being devised. There are currently a number of different visits in the Trust which may need to be reviewed. Mr Rowlands reported that the outcomes from the peer reviews will also be shared with other teams and services. The Chair and non executive directors welcomed this programme and it was agreed that the Committee would receive updates on progress (frequency to be agreed) CC a) Quarter 3/4 Reports i. Q3 Complaints Ms Hedland presented the Quarter 3 Complaints report to Committee. She reported that there had been 29 formal and 36 informal complaints and 339 compliments, during the quarter with a response rate of 52%. She gave a breakdown by directorate and noted the response times of the Community directorate had declined. Dr Warner responded that she had spoken with Mr Ayers, Service Director who had acknowledged that there were some capacity issues in conducting these investigations and historically they are the directorate with the largest number of complaints. Dr Warner asked if it was possible for her to receive monthly updates on response times by directorate that she could take to EDG. Mr Clarke responded that EDG will continue to monitor this area. Dr Warner added that following the review of complaints process a new system of managing complaints will be implemented. systems and process are being monitored and that EDG will be monitoring directorate response times. ii. Q4 Care Pathways and Packages Update Mr Clarke presented the Quarter 4 Care Pathways and Packages project group update to the Committee. He reported that clustering and reviews are hitting 98% and 89% respectively. As part of the executive portfolio changes, a new group will be formed within the governance directorate under Dr Warner which will focus on and monitor all outcome measures used in the Trust. The CPP Project group which Clive leads will be disbanded and the CPP work and monitoring will feed into the new group. The Committee felt that more information on the new group and outcome measures would be beneficial. Dr Warner agreed to schedule this for a further meeting. clustering and reviews are monitored. iii. Annual Governance Statement DRAFT Ms Baxter presented the draft Annual Governance Statement to the Committee. She reported that it had been presented at a Board of Directors meeting and Audit and Assurance Committee and presented here to capture any further comments. This statement does also link to the Annual Report. The final version will be completed by mid May. The Chair asked the Committee to forward any further comments to Ms Baxter. 3
e) Monthly Updates i. Regulation Dashboard Ms Baxter presented the Regulation Dashboard to the Committee for information. She noted that some narrative and information had been updated following previous requests. The Committee received this report for information prior to its presentation to the Board. ii. Safety Dashboard Ms Baxter presented the Safety Dashboard to the Committee for information. She reported that there were a high number of restraints, with 35 of these are attributed to 3 service users on 3 separate wards. The reports being developed and discussed at EDG that run of the new system will include special cause variations of which this anomaly is. The Chair noted hat the number of serious incidents had risen. Ms Baxter responded that there has been a further incident with medicines management which will be investigated. The Chair reported that he had recently met with Peter Pratt, Chief Pharmacist who had defined what a serious incident and near misses specifically relating to medicines would be and how it is different from a Trust type incident. Ms Lightbown asked if there were any patterns emerging in relation to verbal and physical assaults on patient and staff, whilst stable there looks to be a high number of incidents, some recorded as major. Dr Warner responded that EDG will be receiving information on this area and she would share this with this Committee. The Committee received this report for information prior to its presentation to the Board. 4/4/16QAC 4 Quality Accounts (2nd Draft) Mr Rowlands presented the 2 nd Draft of the Quality Accounts to the Committee. He reported the report is almost complete and the final version would be shared with EDG and the Board of Directors and signed off at the Audit and Assurance Committee and the Extraordinary Board meeting in May. Mr Mills suggested that an explanation is added in relation to the rating on information governance. The Chair asked that any further comments should be directed to Mr Rowlands. 5/4/16QAC 5 Community and Specialist Community Mental Health Teams (CMHTs) Response to Service Users Survey and Action Plan Ms Lightbown presented a paper to the Committee outlining the actions the Community and Specialist Directorate are taking in relation to the results of the Service User staff survey. She reported that the Directorates are disappointed with some of the results, in particular service users not knowing how to access out of hours services. They have met with the Picker Institute to look at the data in more detail and developed an action plan which has been presented to EDG and the Board of Directors. Mr Ayers, Service Director added the meeting with Picker was helpful and identified that a lot of areas scored average. There were a small number of older adult service users who took part in the survey which may have affected the results against contacting out of hours services. Ms Lightbown added that the Directorates are working on engagement with all service users and their families to ensure the terminology used is clear and they know who to contact out of hours, the information should also be contained in care plans. 4
Dr Warner reported that there will be a directorate audit of care plans in June to ensure information on out of hours/crisis contact is provided. The Chair reported that this report is for information and to update the Committee. 6/4/16QAC 6 Corporate Risk Register Ms Baxter presented the Corporate Risk Register to the Committee. It was noted that this paper has also be presented to Audit and Assurance Committee. She reported that the layout has been changed highlighted the major changes this quarter from EDG discussions. The risk assessment matrix is being reviewed and discussed in various forums to ensure it aligns with the NHS Litigation Authority, this will be incorporated into the Risk Management Strategy and presented to the Board. She noted that Internal Audit review our processes to ensure the right risks are escalated. Mr Mills asked whether (3326) was a risk, following discussion in Finance and Investment this could be a cost pressure and asked if there were further cost pressures. Ms Baxter responded that it remains on the register as the action for the Director of Finance has not taken place. Ms Baxter suggested she liaised with Mr Easthope. TB The Chair reported that the new format was clear and easy to read. 7/4/16QAC 7 NHS Investigation (Jimmy Savile): the Lampard Review Trust Action Plan update Ms Lightbown reported that this report was presented to the Board in 2015. The paper detailed the outstanding actions. Recommendations (1) Visitor policy and (9) Internet usage for service users policy would be presented to EDG for ratification. Recommendation (7) DBS system checks and renewals was discussed at EDG and the HR Director will be updating EDG on progress. Once the recommendations have been signed off by EDG a final report will be presented to the Board of Directors. The Chair reported the update had been received for assurance and acknowledged that problems experienced with DBS which may have caused some delays. 8/4/16QAC 8 Any Other Business Committee Function The Chair reported that, in line with the executive portfolio changes he was meeting with Dr Warner and Ms Lightbown to discuss this Committee structure and future agenda items. An action log will also be introduced from May, similar to the one used for Board of Directors. There will also be a debrief directly after the meeting for the Chair and Dr Warner as Quality Lead to identify if any issues need escalating to the Board before the minutes are received. The Terms of Reference for this Committee will also be forwarded with May s papers. Date and time of next meeting Monday 25 th April 2016, 1pm to 3pm in Rivelin Boardroom Apologies to: Sharon Sims, PA to Deputy Chief Executive Tel (2716370) sharon.sims@shsc.nhs.uk 5