WELCOME AND APOLOGIES

APPROVED Minute of Meeting of the NHS Grampian Clinical Governance Committee on Friday 30 th January 2015 at 9.30am in the Conference Room, Summerfield House, Eday Road, Aberdeen Present: In Attendance: Dr L Lynch, Non-Executive Board Member Mr T Mackie, Non-Executive Board Member (Chair) Mr E Sinclair, Non-Executive Board Member Dr J Fitton, Clinical Governance Clinical Lead, Aberdeenshire Ms J Fletcher, Clinical Governance Clinical Lead representative from Mental Health & Learning Disability Services Ms W Forrest, Public Representative Ms C Gracey, Clinical Quality Facilitator (attended to observe) Mrs P Harrison, Infection Control Manager Dr V Hegde, Clinical Governance Clinical Lead, Ophthalmology Mr G McLean, Clinical Governance Clinical Lead representative for Moray (video conferenced for part of the meeting) Mr C Matthews, Unit Operational Manager, Accident and Emergency Dr M Metcalfe, Clinical Governance Clinical Lead, Acute sector Dr H Moffat, Chair, Area Clinical Forum Dr C Provan, Clinical Governance Clinical Lead, Aberdeen City (attended from 11.00am) Mr D Shaw, Dental Practice Adviser Mrs E Smith, Director of Nursing & Quality Mr S Thomson attending on behalf of Mr Pfleger for Pharmacy and Medicines Management (video conferenced for part of the meeting) Dr D Webster, Consultant in Public Health Medicine Mrs L Tait, Professional Lead for Clinical Governance Mrs F Shepherd, Committee Secretary By Invitation: Item Ms S Carr, Associate Director of Allied Health Professionals, Adult Support & Protection Lead (Agenda Item 4.2.1) Dr J Iloya, Consultant in Dental Public Health (attended with Mr Shaw for Agenda Item 6.1) Ms P Smart, Nurse Consultant Child Protection (Agenda Item 4.2.2) Ms S Swift, Head of Nursing Women and Children s (Agenda Items 4.3) Ms L Lever, Risk Management Advisor (Patient Safety) (Agenda Item 5.3) Ms C Ward, Optometry Lead (attended with Dr Hegde for Agenda Item 6.2) 1. WELCOME AND APOLOGIES The Chair welcomed everyone to the Committee and introduced those who were attending for agenda items. Mr Mackie also welcomed Dr Lynch and Mr Sinclair, Non-Executive Board members to their first Clinical Governance Committee meeting. Apologies were received from Dr N Fluck, Ms P Gowans, Professor M Greaves, Professor S Logan, Dr A Palin, Mr D Pfleger, Cllr A Robertson and Mr M Wright. 2. MINUTE OF MEETING HELD ON 14 NOVEMBER 2015 The minute of the meeting was approved. 3. NHS GRAMPIAN CLINICAL GOVERNANCE COMMITTEE: MATTERS ARISING ACTION LOG (Strategic risk 583) The action log was checked by the Committee to ensure all matters arising were being addressed. 1

3.1 Short Life Working Group: Review of recent engagements with Healthcare Improvement Scotland Sectors and Services provided an update on the outstanding recommendations within their reports. 3.2 NHS Grampian Improvement Plans Mrs Smith referred to the paper prepared by Mr Alan Gray, Director of Finance and advised that from the date of the three published reports (Healthcare Improvement Scotland review of Quality and Safety, the unannounced Older People in Acute Hospitals inspection and the Royal College of Surgeons of England). An immediate action plan was developed to progress and implement actions by 31 March 2015. A draft comprehensive improvement programme was also produced focussing on addressing the findings from the three reports, with the priority actions agreed by the Board and Scottish Government. The improvement programme had been sent out globally inviting staff to provide input/feedback by completing a feedback form or emailing comments. She invited members for their comments or to provide feedback to either herself, Mrs Tait or Mrs Shepherd. Dr Lynch asked when a working group, to monitor actions would convene. Mrs Smith advised that the improvement programme was to be agreed by the Scottish Government and thereafter a group would convene hopefully by the end of February 2015. For information to be meaningful and understandable Mrs Forrest requested numbers along with percentages to be included in future documents to aid understanding of the context. The Committee noted the report and asked to receive regular updates. 4. QUALITY AND SAFETY (Strategic risk 853) 4.1 External Review Report (including updates on recent visits) The Committee s attention was brought to NHSG s review activity over the past 3 months: As requested by the Cabinet Secretary for Health, Wellbeing and Sport, all health boards were asked to complete an assessment of progress against the 75 recommendations to the Vale of Leven Hospital Inquiry Report. NHS Grampian completed the assessment and this was submitted on the 19 January 2015. A report on this item will be presented to the Board meeting on the 6 February 2015. Medical Cause of Death Certification: The new scrutiny process will commence on the 13 May 2015. New mandatory training modules will be provided by NES and will be available for all clinicians by mid February 2015. In answer to Mrs Forrest s question around procedures and guidelines for speaking with families, the Committee was assured that information will be included in the mandatory training module on speaking with families/relatives and leaflets will be available to share with relatives. The Joint inspection of Children and Young People (Aberdeen City): The draft report had been signed off on the 27 January 2015 by the Chief Executive for factual accuracy. A risk was highlighted around the limited sharing of the report and the lack of time to quality check the self assessment before final submission. This issue will be raised at the Healthcare Improvement Scotland Liaison Co-ordinators meeting on the 27 February 2015. Healthcare Improvement Scotland provided NHS Grampian the opportunity to consult on 2 draft standards for Care of Older People in Hospital and Bowel Screening. These were widely distributed across the organisation. Healthcare Improvement Scotland will be undertaking a piece of work to review their current library of standards. A key aspect of the prioritisation process is establishing 2

whether the current Blood Transfusion Standards 2006 are safe, are currently being used within the service and have up to date evidence to underpin each standard statement. The questionnaire against this will be completed by the 3 February 2015. Mrs Tait welcomed staff/services who were interested, to read over standards, and feedback comments. NHS Grampian Mental Health Services received accreditation by the Scottish ECT Audit Network (SEAN). The Committee were updated on the revised Healthcare Associated Infection standard. There had been delays in finalising the criteria. The revised standards will be finalised by the 2 February 2015 with the self assessment developed by the end of March 2015. Thereafter, Boards will have six weeks to complete the self assessment, with reviews commencing at the beginning of May 2015. The Committee noted the contents of the report including the risks and was assured improvements were being made towards the compliance with the National Standards and risks were mitigated by involving the Quality, Governance and Risk unit staff in all scrutiny work. 4.2 Protecting Vulnerable Groups: 4.2.1 Adult Protection Ms Carr provided the Committee with an update on this item and explained NHS Grampian s legal duties where a person is an adult at risk. The facts and circumstances of the case will be reported to the Local Authority and staff will provide information and records as requested. In response to a request made at the August 2014 Clinical Governance Committee meeting, this paper provided clarification on what was in place in NHS Grampian to support NHS Grampian staff to be aware of their roles and responsibilities in relation to the Adult Support and Protection (ASP) Act. The paper also provided an update to the Committee on further work since August 2014 as below: NHS Grampian is a committed partner on each of the three Adult Protection Committees (APCs). There is one Grampian Interagency Policy with very detailed supporting procedures for the Support and Protection of Adults at Risk of Harm. From 2012 it was agreed that ASP training would be mandatory. Training options include; e-learning; face-to-face, bespoke training and refresher training using real case studies. It was estimated that 80% of NHS Grampian s staff had received some form of ASP training. The Multi-Agency Protocol for ASP medical examinations in the Grampian area was approved by all 3 APCs in December 2011. NHS Grampian had responded favourably against the NHS Board recommendations from the National ASP in NHS Grampian Accident & Emergency Settings Project. The Committee were informed of new developments. There had been an increase in referrals/reports to adult protection services on wound care and work had been progressed with NHS Grampian Tissue Viability colleagues and all 3 Local Authority Adult Protection Services. This had enabled Adult Protection Services to get prompt information that could prove crucial in determining whether or not ASPs need to proceed to further investigation. The volume of ASP referrals from NHS Grampian staff reporting concerns to the Aberdeen City Adult Protection Unit is significantly higher than in Aberdeenshire and 3

Moray. Awareness raising will be included in the 5 work streams. A question was raised around awareness, of ASP legislation with independent contractors eg dental and ophthalmology. Ms Carr agreed to engage with these partners. The independent contractors agreed to include ASP on their local Clinical Governance Group meeting agendas. Action: Dental, Pharmacy and Ophthalmology. Mr Mackie asked if there were any implications on ASP with the Health and Social Care Integration. Ms Carr advised there was already strong partnership working as Grampian was already a multi-agency partnership. The Committee agreed the recommendations to note the ongoing actions taken to raise staff awareness of their roles and responsibilities in relation to the Adult Support and Protection Act and to ensure compliance regarding the duty on NHS Grampian and its staff to co-operate. 4.2.2 Child Protection Ms Smart highlighted the key issues in the comprehensive paper including the disaggregation of the NESCPC three area Child Protection Committees which were well established in Aberdeen City, Aberdeenshire and Moray. The Chief Executive Officers oversee the functioning of the three Committees. The decision is still awaited on whether a Fatal Accident Inquiry will be held around the death of Alexis Matheson. The FAI Unit requested further information from NHS Grampian on actions and progress made following the NHS internal and independent external reviews. Ms Smart mentioned from reviewing Datix reports and case reviews relating to child protection a recurring theme in NHS Grampian Maternity services highlighted the lack of confidence in managing some child protection situations and that specialist child protection support was limited. It was established the need for a Specialist Midwife for Child Protection, funding had not yet been agreed to recruit to this post. Interim arrangements were in place to provide regular case supervision to Community Midwives and practitioners on a case by case discussion. Mrs Smith provided some background information of the significant case review into the death in 2007 of Alexis Matheson. This investigation had taken a long period of time due to legal requirements. NHS Grampian had already actioned many of the recommendations from the Procurator Fiscal. Dr Lynch referred to the key risk around the delay in establishing a Specialist Child Protection Midwifery post. Ms Smart confirmed that this was included in Workforce Planning. The Committee asked how child protection would embed into the Health and Social Care Integration. Mrs Smith agreed to discuss this at the Chief Executive meeting of which the Chief Operating Officers attend. Action: Mrs Smith The Committee agreed to note the report and consider child protection training at a Committee development session. 4.3 Discharge and Transfer Collaborative Update on Improving the Discharge Process Ms Swift referred to the report prepared by Ms Alison Hardy, Associate Director of Nursing (Acute) and Ms Natasha Burke, Clinical Governance Co-ordinator. The Discharge and Transfer Collaborative was set up in response to an audit of discharges from hospital wards across NHS Grampian to care homes. The group acknowledged that issues raised applied to discharges to care homes, patients discharged home or transferred between hospitals. 4

Feedback from ward staff on their experience of the discharge process highlighted varying practices in medicine prescribing, transport, including transporting equipment, quality of discharge letters and multi-disciplinary planning. NHS Grampian and the Ambulance Service had differing policies for discharge and were working collaboratively to improve. A second audit was undertaken in June 2014 and the following projects, improvements and processes were now in place: The Director of Quality and Nursing s contact number was provided to Care Home Managers to raise any issues of poor quality or unsafe discharges. The Discharge Lounge re-opened in December 2014. Patient discharge and transfer pause was being piloted. This form will be completed before a patient leaves the ward and signed off by the Registered Nurse. Discharge was a theme incorporated in the Back to the Floor programme. The patient admission and assessment documentation discharge section had been amended to incorporate the 5 must do s of discharge. Discharge tracker will monitor more complex discharges in real time. A cross sector huddle met daily to discuss discharges and transfers. An e-learning discharge package module was being developed for junior doctors. The key risks around workforce shortages and the impact of the running of the Discharge Lounge without appropriate staffing levels were highlighted. Dr Lynch referred to the audit of discharges and asked if there would be a 3 rd cycle of audits. The Committee noted that the audit was continuing and acknowledged the need for time to embed improvements. Other Non-Executive Board members had raised this at Board level. Dr Lynch acknowledged the good work and improvements being undertaken and stressed the importance in being kept informed. The Committee noted the work undertaken by the Discharge and Transfer Collaborative and supported the continued efforts of the collaborative, as a multidisciplinary, cross sector team to drive the improvement in quality forward, The Committee agreed to report this item to the Board. 5. NHSG CLINICAL GOVERNANCE COMMITTEE AREAS OF ASSURANCE: PLAN FOR 2014 (Strategic risk 853) 5.1 Healthcare Associated Infection (HAI) Report and Bimonthly Report Mrs Harrison referred to the HAI report which included local surveillance data and detail around the four unannounced senior management environmental audits which took place in Mental Health and Learning Disability Services in October 2014. Wards which were audited require support to improve. An action plan was completed, and the wards will be re-audited at the end of February 2015. Updates were provided on the items previously reported: Work is nearing completion on a learning package to raise awareness of waste management procedures and waste management policies are being updated. Releasing staff to undertake training and education for Face Fit testing of masks was being monitored at the Ebola Core group. The Committee were provided with an update on the short life working group outstanding points 8 and 9 in the action plan as below: Point 8: A review of our quality assurance arrangements for infection prevention and control audits will be undertaken: Audits were now embedded in the bi-annual audit programme and 5

monitored by the Infection Control Committee. Point 9: observations in relation to cleaning of beds. Introducing a pilot bed busting team in Aberdeen Maternity Hospital and Emergency Care Centre: This was progressing well in the Maternity Hospital but proving a challenge at the Emergency Care Centre. Progress was being monitored by the Equipment Group with updates provided to the Infection Control Committee. The Committee noted the report. 5.2 Grampian Managed Clinical Networks (MCN) in Grampian The Committee noted this report and asked that Mr Smith, Director of Modernisation attend the next Committee meeting to discuss 5.3 Adverse Events Improvement Plan Mrs Lever provided the Committee with a note of progress and future plan for the management of adverse events. Mrs Lever referred to NHS Grampian s Guidance for the Investigation of Complaints and Incidents. There had been delays in obtaining the ratification of the proposed NHS Grampian Policy for the Management of and Learning from Adverse Events and Feedback but will be for ratification at the Grampian Area Partnership Forum (GAPF) on the 28 February 2015. The draft policy was being applied by the management groups in the Acute Sector and Mental Health Services. The content of the policy had been well received, with the exception of challenges surrounding the completion of level 1 review in 90 days (national framework timeframe). The key points from the paper were highlighted as below: There had been an increased uptake in staff accessing training in Investigation Skills and Root Cause Analysis (RCA). It was identified that there were inconsistencies within the organisation regarding the involvement of patients, families and carers following an adverse event. It had been endorsed for staff to be open and transparent with families and carers. A further 40 staff had been trained and another 80 will be trained in the skills and principles of Being Open. A draft proposal was being introduced on Statutory Duty of Candour for Health and Social Care Service. The revised improvement plan will identify the training and support that staff need to meet the expectations of the national framework and the duty of candour. To conclude a variety of workshops on adverse events and shared learning notices had been facilitated for various groups and services and sectors had been requested to repeat their adverse event self assessment to identify gaps to inform a revised improvement plan. The internal auditors PricewaterhouseCoopers had conducted an audit into the management of and learning from clinical adverse events. The Committee will receive this report at a future meeting. The Committee noted the report and progress to date and supported the self assessment process to identify gaps to inform the revised improvement plan. 6. SERVICE REPORTS (Strategic risk 586) 6.1 Dental Mr Shaw reported on an item of concern previously reported. The cancellation of dental paediatric general anaesthetic lists which had resulted in 300 children on the waiting list for tooth extraction. Additional nurse support had been agreed but is delayed due to training issues (6-9 months). Mr Shaw introduced Dr Iloya, Consultant in Dental Public Health who highlighted that this was a significant patient safety issue with no progress being made. He noted that an SBAR was presented to the RACH Manager with no response as yet. Dr Iloya 6

asked the Committee for RACH and Aberdeen City CHP to work on the recommendations in the SBAR for a resolution. Dr Provan agreed that this continued as a high risk issue and was included in the Aberdeen City report. Dr Provan supported the practical interim solutions to work on the recommendations to resolve. Dr Metcalfe was not aware of this issue and would investigate out with the meeting. Action: Dr Metcalfe The Committee supported the interim arrangements as laid out in the SBAR to reduce the waiting list. 6.2 Eye Health Network (EHN) Dr Hegde tabled a paper outlining action points. The Chair asked for this update to be circulated to Committee members along with this unapproved minute. The Chair asked for papers to be submitted in advance of the meeting to allow members time to read prior to the meeting. 6.3 Pharmacy The Committee noted this report. 7. SECTOR/SERVICE REPORTS (Strategic risk 853) Sectors reported on their In-patient Survey results 2014 and Aberdeen City, Aberdeenshire and Moray reported on the preparedness for the Children and Young People s Bill. 7.1 Aberdeen City Dr Provan pointed out that the theme of this report was around recruitment and retention and provided an update on previously reported items: Health visiting recruitment continues to be a challenge and is impacting on delivery of services but gaps are being addressed through skill mix and reviewing the delivery model and therefore minimising risk. Despite the identification of additional resources, nurse staffing recruitment at Woodend Hospital and the Links Unit continued to be challenging due to vacancies. To manage the patient and staff safety risks the Links Unit was relocated to Woodend Hospital. Government funding had been identified to help with the delayed discharges and had been allocated to the Links Unit to support nursing staff. Dr Provan updated the Committee on the additional requested items: The Scottish Inpatient Patient Experience Survey: Work was on-going. The Elderly and Rehabilitation Services had utilised the noise monitor in two ward areas but this had not proved effective as the monitor did not record any pattern. Implementing Children and Young People (Scotland) Act 2014 GIRFEC: This had been a challenge due to staffing levels within Health Visiting. The Service was fully aware of the requirements of the Act and were working towards this despite the difficulties. Mrs Forrest asked if the Child Protection Lead post had been advertised. Dr Provan responded that this was not been advertised yet. These issues had been escalated to the Chief Operating Officer for Aberdeen City and the Deputy Chief Executive. Dr Provan asked the Committee to report to the Board around the workforce issues at Woodend Hospital, Links Unit and Health Visiting. The Committee agreed to include this in the report to the Board. 7.2 Aberdeenshire Dr Fitton provided an update on HMP Grampian. Staffing continued as a concern, posts had been advertised and a business case for additional staffing had been drafted. Dr Fitton 7

provided an update on the Fatal Accident Inquiry. Prisoner s medical information was completed electronically and a paper record is included when transferring from one site to another. There was one current Ombudsman case in Aberdeenshire, and an action plan was developed and monitored. Aberdeenshire preparation and progress on the implementation of the Children and Young People Act: NHS Grampian Children & Young Peoples Act implementation plan is now agreed and Aberdeenshire GIRFEC management group were effectively working to progress the plan. In response to Mr Sinclair s question around increase in workload for staff to implement this Act. Dr Fitton replied that this may impact on the Health Visiting team and noted that although this was valuable work it does add to the workload. Dr Fitton highlighted that there were clear guidelines for information sharing included in the GIRFEC NHS Grampian Action Plan. 7.3 Acute Dr Metcalfe acknowledged that a sector report had not been prepared for today s meeting. He referred to the paper on the Acute Sector Clinical Governance Group Improvement of Governance arrangements. Dr Metcalfe informed the Committee there will be a sector report prepared for the next meeting on the 15 th May 2015. Dr Metcalfe provided the Committee with a verbal update on the challenges in the Acute Sector from the beginning of the year as below: Admissions had escalated from the 1 st January 2015. During the festive period there was an increase by 25% to the Emergency Department. The Emergency Department had now improved functioning. There was a newly appointed Consultant in Accident & Emergency and senior medical staff were being recruited to reduce the number of Locums. There were waiting time issues in Orthopaedics with recent investments in the service starting to show results. There were plans to improve capacity in Endoscopy; this will be refined within the next few months when the new Consultant starts. Currently looking at productivity in Plastic surgery and Dr Metcalfe agreed to look at the issues raised at today s meeting in RACH around dental paediatric general anaesthetic lists. Dr Fitton referred to the four day closure for GP s and intimated that if approached and planned GP s may consider opening during that period but noted there would be financial implication to provide this arrangement. GMED Mr Matthews highlighted 2 high risk issues previously reported, which were no longer a concern. Medical leadership of GMED was now undertaken by Dr Hogg. Sessional medical staff were now employees of NHS Grampian from the beginning of January 2015. Mr Mathews highlighted the areas of concern previously reported around pressure in clinicians covering the out-of-hours rota; this was now a medium risk. Several initiatives were being looked at to encourage GP s into the service. The Committee noted that GMED had dealt with a significant increase in the number of patients on the 27 th December 2014 compared to the previous year. Women and Children s Services The Short Life Working Group Review of recent engagements with HIS: update on recommendation 10 was noted. In the absence of a representative the Committee noted this update. 8

Dr Gray s Hospital In the absence of a representative the Committee noted the Sector report. 7.4 Mental Health and Learning Disability Service (MH&LDS) Ms Fletcher referred to the lack of consultant medical staff which was now a high risk and discussed the 4 vacancies which are increasing to 5 in May. These vacancies had been advertised nationally and internationally. Various options were being looked at to continue to provide a quality and sustainable service. Ms Fletcher referred to the new area of concern: Increase in nursing vacancies. She highlighted that this was a recurring issue for the service. Recruitment plans included external adverts, canvassing and working with the Government in an attempt to increase the student numbers. All available RGU stage 3 nurses had been appointed. Support had been sought from the Director of Workforce to look at innovative ways of attracting candidates to Mental Health Services. Nursing management had reviewed the skill mix and experience to ensure equitable spread across the service. The Committee agreed to report the staffing issues to the Board and the Staff Governance Committee. 7.5 Moray CHSCP In the absence of a representative the Committee noted the Sector report 7.6 Public Health Dr Webster reported on the new areas of concern: There was no identified administrative support for out of hours incidents, but discussions were ongoing. Previously the access databases were not supported by IT and funding had been requested for software support, this had now been resolved. There was a national decision to reduce funding for healthy working lives. Dr Webster referred to the items previously reported: The Ebola outbreak assurance of preparedness included releasing staff to undertake training and education. The Health Intelligence/Ehealth redesign was now noted to be a high risk. A paper had been produced for the Executives on implementing the new arrangements and discussions were ongoing. Dr Fitton requested information on the effectiveness and outcomes of the alcohol brief interventions. (ABI s) Dr Webster agreed to include this in the next report for the Committee Action: Dr Webster 7.7 Research and Development In the absence of a representative the Committee noted the Sector report 8. ITEMS FOR NOTING AND INFORMATION The Committee noted the following reports: 8.1 NHS Grampian Clinical Governance Committee Areas of Assurance Plan for 2015 (for noting). 8.2 Review of the Clinical Governance Committee Constitution (consultation). The Committee were asked to feedback any comments to Mrs Shepherd. 8.3 NHS Grampian s Response to Vale of Leven Hospital Inquiry Report (for noting). 8.4 Quality Matters (Sharing learning across NHS Grampian) (for noting) 9

9. AOCB Dr Lynch raised a question from within the Dr Gray s sector report around the lack of staff for the surgical assessment unit. Mrs Tait responded that this had been raised at a senior level to agree funding to maintain the service when the winter pressure placed additional demands on the system. The extra beds had helped and commitment for funding had been agreed until March 2015. 10. REPORTING TO: 10.1 The Chairman agreed to report the following items to the Board and the Performance Governance Committee: Discharge and Transfer Collaborative Dental Paediatric General Anaesthetic Waiting Lists Workforce Issues (Health Visiting, Woodend/Links Unit and Mental Health) 10.2 Assurance on Clinical Risks The Committee agreed they felt adequately assured regarding the following risks: 586 Future services are not developed in partnership with local authorities, third sector, independent contractors and the community high risk 853 Risk patient safety is compromised and is not evidenced in practice high risk 11. DATE AND TIME OF NEXT MEETING The next meeting will be on Friday 15 May 2015 from 9.30-12.30pm in the Conference Room, Summerfield House. 10