2 Minutes of a meeting of the Governance and Risk Committee held on 25 th June 2008 held in the Boardroom at Trust Headquarters. TOP THREE RISKS DISCUSSED 1. Decontamination Wrightington Theatres 2. BAF reporting 3. SMR rates action planning Present: Mrs L Barnes,(chair) Non Executive Director LB Mr C Chandler, Medical Director CC Mr Robert Collinson, Non Executive Director RC Mr Robert Armstrong, Non Executive Director RA Mr Albert Mandall, Non Executive Directro AM Mr Ian Boyle, Deputy Director of Finance IB Mrs Gill Harris, Director of Nursing & P.S. GH Mr L Higgins, Non Executive Director,Chairman LH Mr B Livingstone, Executive Director HR BL Mr D Evans, Associate Director, Estates & Facilities DE Mrs M Thompson, Deputy Director Nursing & PS MT In attendance: Mrs P McCann, Non Executive Director Mr R Sachs, Head of Quality & Safety Mr P Williams, Strategic Projects Lead Mrs H Hand, Trust Board Secretary PM RS PW HH 1. Apologies Apologies were received from Mr T Chambers, ED of Operations. 2. Minutes of the last meeting The minutes of the last meeting held on 27 th May 2008 were received and approved. LB reported that in future the minutes would be more detailed and that in addition it was intended to ask the chair of the quality board and the risk and environmental management committee to give a verbal report on the key issues they have discussed. This would be a standing item on the agenda. 3. Matter Arising Page 2: ALE: LB reported that the strategic map issue had not been actioned, instead IB would provide an update later. i. Action Sheet 1
The action sheet was received and all completed actions noted. Ii Joint Venture Paul Williams presented a report to the committee regarding the non compliance declaration for decontamination. The trust are members of the Mersey Joint venture involving 8 trusts. It was taking longer than anticipated to finalise the contract and a paper was scheduled to go to the July trust board on this matter, that would see the proposed solutions in place between September 09 and Jan 2010. The delay was due to the need for In Health to build the new premises. The Leigh, Wigan and 3 of the Wrightington theates are compliant and the issue was around theatres 1 4 at Wrightington. Interim measures had been explored with Morcambe Bay Trust, Synergy was already supporting theatre 8 at Wrightington and also Don Forrest was the authorised person for decontamination had done a futher stocktake, with a further solution possibly being dropping in another mobile unit. A report would come to the August board with the most appropriate solution. LH stated that the matter had to be resolved by the August board and LB responded that Peter Kay had given assurance on safety of patients to the board on several occasions. CC confirmed that this had indeed been debated on several occasions and there were no concerns around patient safety and risk of infection. RA asked if there was capacity anywhere else to deal with the problem and PM noted that the matter had gone on far too long and needed urgent resolution. RC asked if Synergy were not best placed to offer a solution as they were already providing support to Theatre 4. PW responded that there were a number of options that still needed to be fully explored and that Synergy had only recently been taken over and were still settling down from their merger. AM expressed concern about the delays in the consortium and felt other options needed to be explored. GH reported that the E and R committee had recorded one of their key risks as the endoscopy unit decontamination and felt this also needed to be picked up. AM reiterated the need for a solution by August and RA suggested getting Synergy to undertake a whole term key solution in the short term. Action: PW to inform TC that the paper needs to have the full range of options with firm dates for a solution by August. LH would speak to AF. HH to ensure the item was a high priority on the next board agenda. Iii Terms of Reference The revised terms of reference were received and it was agreed to submit these to the next meeting of the Audit committee for approval. Action: HH to ensure on Audit committee Agenda. Iv Health & Safety Executive manual handling 2
At the last meeting RS had reported on a visit by the H&SE on non clinical manual handling related to medical records store. An improvement notice had now been served on the trust with regard to this, in particular the Hawthorns building. The action plan was now being implemented as a matter of urgency and GH was liaising with the Clinical Support Services division to ensure that all actions were completed. 4. Board Assurance Framework LB reported that all NEDs had been invited to attend the meeting today to enable them to have full input into the discussion. A workshop had been held to identify the board s key risks and GH thanked RA for his help in preparing the revised document. Workshops had also been arrange for General Managers, Head of Nursing to communicate this as the key document to show what was being achieved in terms of assurance. GH requested comment on the document. PM congratulated GH on the document and GH confirmed that the high scores were recorded on the corporate risk register and this had been reflected in the IBP. Action: HH was asked to check that an annual review of the BAF was included in the internal audit calendar. Action: Page 4. GH agreed to make explicit the reference to the Quality Board in addition to the REMC responsibilities for grading of risks. GH explained that anything graded over 15 would appear on the corporate risk register managed via the quality board and REMC and if the score is above 20 they will refer this to the BAF. It was noted that scores could move up and down and therefore did not need to be managed at the BAF level. MT confirmed the committee structures would manage how this was reported up to the BAF. RA confirmed that it was inappropriate for every individual issue to impact on the board agenda. GH gave an example of how this had been managed in the past within the committee structure. The committee considered the BAF scores and made the following amendments: No. 46. Wrightington fails to achieve an 08/09 surplus No 45. Agreed to leave objective but to turn risk to green No 2. Failure to achieve infection control No. 24. RS to check if target % is set in IBP No 21. Non- compliance with H&S requirements resulting in improvement notice No23. Agreed move to include as a sub set within No.22 and to give joint responsibility to GH/CC Nol44. Agreed to split risk into a a and b and give TC responsibility for b. No.42. Failure to achieve significant assurance on the SIC regarding risk management No. 39. Agreed to separate risks into two. RS to check dates for both of these. Assign lead as AF. 3
No. 11. Agreed to combine with 12 as a sub set. No. 8. Failure to increase NW market share for relevant services within agreed case mix by?% No. 5. Include use of resources and quality into the objective to achieve good and change to 08/09. Action: RS to make all changes. GH suggested that the document was revised on a monthly basis by exception ie. Only added or increased scores or anything that a committee member wished to raise. The scores would be revised via the Quality Board and REMC. Action: GH to produce an updated 6/9 page report. 5. Auditors Local Evaluation IB outlined the requirements for reporting and advised the committee on a meeting held with the company Dynamic Change that produced the performance accelerator software which was a tried and tested document management system that would support the ALE, HCC, Monitor and NHSLA monitoring and reporting processes. The external auditors KPMG also recommended this software. It was hoped to get Executive approval to purchase the software and then implantation would be in 2 phases with phase 1 being the data warehouse for management reporting. It would take 6 to 9 months to fully integrate the system. IB went on to report that the trust had received a 4 for the final two elements of assessment giving an overall score of good for 07/08. A written action plan would come to the next meeting that was working towards achieving a level 4 overall next year. A meeting to discuss this was planned between GH/IB/HH and RS. Action: AM requested IB to share the report with the IM& T strategy board. MT left the meeting at this point. 6. Standards For Better Health The Executive lead had been agreed as detailed on page 2 but those responsible for evidence collection needed to be added. RS stated that the template had been improved upon from last year to help identify gaps and prioritise where more work was required. RS confirmed to PM that the report would go to the quality board 4 times a year. Action: Update with core evidence to be produced by July. LH left the meeting at this point. 4
RS confirmed progress would be mapped across the four quarters. GH suggested this be added to the 9 page summary document to ensure quarterly review. It was agreed the performance accelerator software would help to support the monitoring when in place. 7. Serious Untoward Incidents Report for June The amended template was presented by RS. LB commented on the concerns that the SUI were not being closely followed up and so it had been decided to bring the report to the committee. Further suggestions for improvement in the template included a better explanation of what the today s date referred to. 8. NHS Litigation Authority The update provided by RS was noted. A member of staff had been seconded into post to support the trust in achieving a successful Level 1 assessment and moving towards a Level 3 assessment. 9. Global Trigger Tool GH reported that had been useful to receive a report of the risks from the GTT ie. From a presentation to the quality board which had identified key areas of harm, and a further report would be produced to see if incidences were reducing. An exceptions report would come forward from the Quality Board. 10. Quality Board The first meeting had been held in June. More work was being done on the terms of reference to ensure that the G and R, quality board and REMC all butted up together. The board had reviewed SUIs that were ready for closure and has initiated the SBAR communication tool. There were no other exceptional items of note and the next meeting was due to take place in a week s time. 11. Risk & Environmental Management Committee LB expressed disappointment at the attendance levels. GH confirmed that emails had been sent to all general managers regarding this and that deputies would only be accepted on authorisation. LB fully supported GH on this matter, stating that GMs would be expected to send an explanation to the G& R Committee if they did not attend. The MSK risk register had been updated and the legionella and asbestos issues had been down graded due to new plans in place. Endoscopy decontamination issues had been picked up and PB had shared the action plans for medicine. It was noted that this had not been scored above 20 on the risk register. Action: GH to write to Peter Stross for update on Don Forrest s options paper. 5
12. SMR Task Force CC reported on the first meeting. An action plan was to go to the Trust Board. Dr Foster representatives had attended the meeting and had agreed to work with the trust on an in depth analysis. The trust was expecting to be low down in the league tables that were to be published in October and so there was time to demonstrate improvement from actions being taken. It was likely however that the score would be the worst in the North West. A number of actions were already in progress and a paper on right patient right bed had been presented to meeting point. Information was being gathered on a weekly basis. Mike Parks had also been asked to bring a paper to the task force on drug improvements. AM noted the action plan for reducing drug errors. CC confirmed that the GTT will provide more intelligence to add to the action plan. Action: HH to ensure SMR placed as top priority on the Trust board agenda. 13. Any Other Business Action: Committee reports to feature higher up on the agenda to allow time for fuller discussion. Action: EDs and NEDs who had been unable to attend the BAF training must attend one of the other planned sessions. 14. Date of Next Meeting The next meeting was noted as 29 th July 2008 at 10.30 am in the Meeting Room at Trust HQ. 6