Item 8.2 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST BOARD OF DIRECTORS TO BE HELD ON WEDNESDAY 25 January 2012
CLINICAL GOVERNANCE REPORT ACTION Six policies were presented for approval (see appendix 1) FOR REVIEW The Trust Board is asked to consider, and review, the use of the Trust Board Quality Checklist which has been developed for the West Midlands Strategic Health Authority (SHA) (see appendix 2). DASHBOARD REPORT An update of the revised clinical governance dashboard is presented. Key exception issues are highlighted (See appendix 3). ASSURANCE Assurances are provided in regard to the monitoring of Care Management policy, Care Quality Commission (CQC) regulation visit action plans and local clinical governance arrangements. UPDATE ON KEY PRIORITIES – Director of Quality Improvement and Patient Experience A wider report is presented in appendix 4 relating to key priorities from the Director of Quality Improvement and Patient Experience portfolio. The paper identifies a range of issues including: • Quality Strategy • Recovery and Inclusion • Strategy for Professional Nursing 2014 • Safeguarding update (Trust Board is specifically asked to note the revised structures reported) • Service User and Carer Experience: o Real time feedback pilot o Carers strategy o Service User engagement o A new approach to ‘customer relations’ • Allied Health Professionals workforce strategy
SIGNIFICANT ISSUES This report reflects the meeting of the CGC on 6 December 2011 and 3 January 2012.
DASHBOARD EXCEPTION REPORT (See appendix 3) The dashboard has now been reported in its revised form for the past three months. The format has developed in line with those original indicators which were prioritised by the Trust Board last year at the Quality Account discussion. The focus of discussions at the last meeting were priorities
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relating to patient safety and previous exceptions.
SERVICE RECONFIGURATION ISSUES – ADULTS OF WORKING AGE (AWA) Community Estates Rationalisation The committee reviewed details of proposals to rationalise the community bases for a number of adult community teams in AWA central zone. The committee was assured that adequate arrangements were being put in place to manage the change and ensure that service users were supported through this process. It was noted that whilst the focus of the changes had been to reduce costs, that there was a neutral balance of changes overall which impacted on patient care. Acute In patients The committee reviewed details of an assessment of bed capacity within AWA. The committee approved a proposal to test capacity for a trial period through the reduction of beds across all wards. AOT teams The committee reviewed details of proposals to consolidate the number of AOT teams across the organisation. The committee was assured that adequate risk assessment had been taken of the proposal and that the risks were being appropriately managed.
ASSURANCE Care Management & Care Programme Approach (CPA) Policy implementation The committee received a review of CPA / Care Management monitoring arrangements undertaken by the Clinical Quality Group. The committee was assured that actions were being taken to improve monitoring arrangements against the core standards planned to be in place by the end of March – reflecting the transition to the new RIO patient record system. CQC (Care Quality Commission) visits The committee approved action plans in response to the CQC compliance visits to Psychiatric Intensive Care Units (PICUs) in July 2011. An update of actions taken was reported in January 2012 and the committee was assured that actions taken were in line with the requirements of the plan. Clinical Governance Arrangements Local risk registers have been reviewed by the committee for: • Secure care • Older adults services • Liaison services (initial register) A significant risk identified by secure care in relation to the telephone system was highlighted however assurance was provided that this had been adequately addressed and actions taken to significantly reduce the risk. Prison compliance issues The committee received a report from the HMP Prison Healthcare Clinical Director highlighting work which was intended to review processes concerning recent medicines management incidents. The committee received assurance of actions which have been undertaken in response to medicines management arrangements and further review which is taking place. Safeguarding (See also item in appendix 4) The committee received a report from the Safeguarding lead. The report provided assurance that there are currently no completed Birmingham Safeguarding Adult Board serious case reviews that require action for BSMHFT to implement. The committee received assurance on one action required from a Birmingham Safeguarding Children Board recommendation and actions were being taken as required.
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EXTERNAL REPORTS West Midlands Quality Review Service (WMQRS)- Peer review report The committee received the report of the West Midlands Quality Review Service peer review which was undertaken in the Trust and wider health economy in July 2011. The review reflected on services for Adults, Early Intervention and Dementia services. The peer review report highlights a range of areas of good practice including the following: • The Zinnia Centre • Staff training passport • A number of initiatives to support the physical health needs of service users • Excellent joint working and collaboration with ‘Youthspace’ and the Early Intervention and Assertive • Outreach services • Good information for service users and carers. The report highlights two significant areas of concern: •
Home Treatment teams – the pressure on staff who are part of the oncall service. This is subject to action to review and agree revised rotas.
•
Compliance with NICE guidance in relation to the use of CT scans for service users with Dementia. (The Trust has previously reviewed these issues which were not considered to be high risk and were not funded by commissioners).
Other issues identified in the report suggesting further improvement include: The lack of integration between Health and Social services Staffing levels and capacity of the recently commissioned Improving Access to Psychological Therapies (IAPT) service • Quality variance between services across the organisation • Development of clinical guidelines and in some areas a lack of clarity of patient pathways • A view of a level of disconnect between staff and senior management • Robustness of follow up arrangements in relation to pilots / projects and also service user feedback The committee agreed to develop a response and action plan which will be reported to Board by March 2012. • •
Quality Checklist The committee received a summary of the Burdett report ‘Sustaining Quality During Turbulent Times‘ which was commissioned by the local Strategic Health Authority and reviewed issues identified in the check lists proposed for use by Trust quality and safety committees. These are to be incorporated into future committee preparation arrangements. A summary report in relation to the Quality Checklist for Trust Board is set out in appendix 2. National figures - assaults The committee reviewed national published data for assault incidents on NHS staff, published in November 2011. The report shows benchmark figures for all NHS Trusts. Our figures were reasonably comparable with other mental health trusts. However there were a small number of comparable Trusts where the level of incidents were significantly less and where it was agreed further information would be helpful to identify elements of best practice. The level of assaults has increased within the Trust over the past year, though further review is required of most recent data to confirm that actions previously identified are having an impact. This exercise is contingent on the implementation of the new risk management database reporting module. Training is scheduled for January to enable full analysis of data to be provided. It is anticipated that a full review will be available by March 2012 and reported to the committee.
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BOARD DIRECTOR SPONSOR Peter Lewis, Medical Director Dee Roach, Executive Director of Quality, Improvement and Patient Experience
APPENDICES 1 – Policy Assurance Summary 2 – Quality Checklist – Managing Quality in Turbulent Times 3 – Summary Dashboard and exception report 4 – Update On Key Priorities – Director of Quality Improvement and Patient Experience 5 – Notes of the Clinical Governance Committee held on the 6th December 2011. Background papers This report relates to papers presented to CGC on the 6 December 2011 and the 3rd January 2012.
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Appendix 1 POLICY ASSURANCE SUMMARY Meeting held on 6 December 2011 Policy Title No
New/ revised?
Lead Director
Key Issues
Committee
1
Date final version approved
Consultation 3 Period
Workforce
Nov 11
Sept 11
Workforce
Nov 11
Sept 11
Health & Safety
Nov 11
Sept 11
2
RS29
Risk Management training ©
R
OD
HR 24
Induction ©
R
OD
R&S 21
Manual Handling ©
R
QIPE
New/ revised?
Lead Director
Maternity, Paternity and adoption Employment Break
R
ODP
Merged policy previously three separate policies
R
ODP
HMP Medicines Possession
N
DSD
Updated to reflect latest legislation and national requirements. This policy was consulted on within the Prison only. It was approved for a short period as an urgent item. Subject to re approval within 6 months.
Meeting held on 3 January 2012 Policy Title No
HR08 HR13 C06b
This policy relates to all statutory and mandatory training requirements. The policy has been updated to reflect a review of the processes for monitoring training and the impact of training. The policy has been updated to refine the processes for monitoring and demonstrating induction training in line with CNST requirements. Minor amendments made to reflect latest best practice.
Key Issues
Committee
1
Consultatio 3 n Period
Workforce
Date final version 2 approved Dec 11
Workforce
Dec 11
Aug 11
Prison Governance
Dec 11
-
Sept 11
NOTES 1 – ‘Committee’ - This identifies the relevant director led committee to which the policy relates to. Brackets ( ) identify where a policy had been previously approved by a sub-committee 2 – ‘Date final version approved’ – This reflects the requirement for a final version sign off date for the policy before it is presented to Clinical Governance Committee. 3 – ‘Consultation period’ – This reflects the requirement for all draft policies to be sent to all Directors and Clinical Directors and published on the intranet for a minimum of four weeks for review. © - highlights a policy which is required for CNST accreditation.
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Appendix 2 QUALITY CHECKLIST- MANAGING QUALITY IN TURBULANT TIMES The Burdett Trust for Nursing has been commissioned by the West Midlands region to undertake work to support the focus of service quality across trusts. Two publications have been produced: •
Putting Quality first in the Boardroom (2010)
•
Sustaining Quality during turbulent times (2011)
The second document has recently been issued which sets out five key checklists for use by NHS Trusts. These checklists relate to: •
Board Quality
•
Quality and Safety Committee
•
Quality Strategy
•
Quality report
•
Patient stories
A copy of the report has been circulated separately to Board members. Checklists for the Quality and Safety committee and also Board have been reviewed by the Clinical Governance committee. It is proposed that this is used for future agenda development. The Quality and Safety committee checklist also informs the one proposed for use by Trust Board this has been reproduced below. As a result of discussion, comments are provided on the table below in relation to those areas where the Clinical Governance committee contributes to the checklist requirements. The use of the checklist further strengthens arrangements against the Monitor Quality Governance framework connected to sections: 1a, 1b, 2a, 3b and 3c. The Quality Strategy checklist will be incorporated into the Trust Quality strategy.(see appendix 4). .
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BOARD QUALITY CHECKLIST Preparation
Prompts
Will this agenda inform us about the quality of patients’ experiences, clinical effectiveness and patient safety? Do we have sufficient time to discuss the relevant reports on this agenda?
Is a patient story being reported? Are patient safety walkabouts being reported? Is there a report about staff experiences? Is there a quality report/dashboard? Is there a report from the Quality and Safety Committee?
If we are hearing from patients or staff have we agreed how we will manage these items? (see also the Patient Stories checklist, p17)
What will these items tell us about progress with our quality strategy? Who will facilitate the discussions and debrief with the board?
Trust Response Walkabouts will be reflected by reports from Quality support and enhancement visits (which will reflect all quality visits undertaken). The Quality dashboard reflects priorities / indicators agreed by Trust Board as part of the Quality account prioritisation process last year. The CGC reports to the Board on a monthly basis. All local programmes are required to demonstrate arrangements for involvement of service users and carers. Local programmes are required to ensure that arrangements are in place for the local CGC to be representative of all staff groups and for staff to be communicated with.
During the meeting Has anything happened since the meeting papers were circulated that is relevant to the discussions today about quality?
What intelligence have we gained from walkrounds?
Is there new information that changes the key messages or recommendations in the papers about quality? Have quality or safety concerns increased, decreased, or been ameliorated? Is there anything else we need to be informed of or do something about today? What does this feedback add to our understanding of the quality of patient care? What does this feedback reveal about staff morale and organisational culture? What are the quality hotspots that require further investigation? What actions need to be taken and by whom?
What is the quality report/dashboard telling
What can we conclude about the quality of patient
Do board members feel that anything is missing? What have we learnt about patients’ experiences? (see also the Patient Stories checklist, p17) What have we learnt about staff experiences?
Prompts for Board members to consider.
Prompts for Board members to consider. Prompts for Board members to consider. Prompts for Board members to consider. Issues will be highlighted from the enhancement visit reports. The outcome of each enhancement visit includes an action plan where any issues are identified. The dashboard report will identify actions
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us? (see also the Quality Report checklist, p14)
What assurances is the Quality and Safety Committee providing us with? (see also the Quality and Safety Committee checklist, p9)
care? What are our levels of harm? What are the trends over time? What are the most significant clinical risks? Are there any early warning signs of failure? Do we have shared goals for improvement that everyone is working to? How do we know we have improved? Do we have sufficient capability and resources to undertake the work? What actions need to be taken and by whom? Which information before us today has the Quality and Safety Committee previously reviewed? Have we heard from the Chair of the Committee? What were the Committee’s conclusions and recommendations? What actions need to be taken and by whom?
identified by the Clinical Governance committee.
The Clinical Governance committee report reflects all matters reviewed by the committee. The chair of the committee is a member of Trust Board.
Review Have we had a good discussion about quality issues today?
Are we demonstrating sufficient ambition for patients?
Do we have a good understanding of the quality of patient care? Are there gaps in the assurances we received today? What could we have done differently? What do we now need to do to improve things? Have we been accepting of any deterioration in quality or safety? Are we sufficiently focused on improving quality, despite the challenging operational environment?
Prompts for Board members to consider.
Prompts for Board members to consider.
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Appendix 3 SUMMARY DASHBOARD AND EXCEPTION REPORT The following exception issues are highlighted: 1.1: Untoward incident trends The level of detailed reporting against incident report trends has been limited due to the implementation of the new risk management database. Core data has been circulated to local managers to reflect recent incidents. Training sessions are taking place in January for extracting data which should mean that a full variance report will be available in the next two months. The implementation of the system has also impacted other dashboard reports, listed below. • •
Safeguarding Infection Control
1.2.1 / 1.2.2: Incident reporting timeliness A number of exceptions for serious incidents from operational teams (20%) have been identified against initial reporting timescales. The timescales are set by national and local SHA policy. Details of the incidents are reported to commissioners and any delay is therefore identified. It is proposed that individual programme /zone reports will be provided for those exceptions in future reports. 1.2.3 Serious Incident reviews: The committee noted the overall reduction in outstanding reviews. However the number of reviews completed in December was significantly reduced due to seasonal leave. An up to date version of the dashboard report is provided in the patient safety report. 1.4.1 Health & Safety Risk Assessments The committee previously reported by exception a delay in the completion of the annual health and safety assessment programme (which is scheduled by calendar year). This occurred as a result of staff sickness within the health and safety team. Whilst the full schedule has not been completed, significant improvement has been achieved and the remaining sites will be completed in the first two months of this year. 1.6 Infection Control A summary dashboard report relating to the Infection Control report is provided.
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INFECTION CONTROL SUMMARY DASHBOARD INDICATOR
Aug11
Sep11
Oct11
Nov11
Dec11
Comments: Rosemary Suite was temporary closed to admissions due to an outbreak of Norovirus. 5 patients and 6 staff were involved. The ward closed for 10 days.
SIs Infection Control
nil
nil
Yes
Surveillance: Reportable incidents
nil
nil
nil
No actions required.
Audit programme compliance
no
no
no
The programme of audits is in line with schedule. However 4 teams were identified where action plans have not been confirmed. This has now been addressed.
Decontamination - Audit compliance
yes
yes
yes
No actions required. Audit programme is compliant.
no
no
no
There is one outstanding action which relates to Bruce Burns unit- to replace kitchen cupboards which is being managed jointly with HEFT.
nil
nil
nil
No actions required.
EHO inspection reports compliance PEAT inspections score < = 3 Other issues
Mattress and Bedding audit completed September 2011. The standard of Trust mattresses on a whole was found to be compliant; although isolated incidences of mattresses having 1 or more decontamination non-compliance were reported on the self-assessment audit returns. The standard of Trust bed frames was also found to be compliant, although attention was drawn to the impact of wear and tear on bed frames, and how this may impede decontamination.
Estates and Facilities Deep Cleaning Programme Deep Cleaning was conducted in the following areas during September 2011, October 2011 and November 2011: Dan Mooney House, Zinnia, Uffculme Centre, Hertford House, Hillis Lodge
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Domestic Services – new national specification The Department of Health have issued new Specification for the Planning, Application and Measurement of Cleanliness Services in Hospitals. PAS 5748:2011. The two pilot schemes are underway with risk assessments of the elements to be cleaned and the functional areas to be cleaned being undertaken at Zinnia and Ashcroft. The results of these will be communicated to Infection Prevention and Control Department to obtain their input as to the risk scores before the scoring is finalised.
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Appendix 4
UPDATE ON PRIORITIES Director of Quality Improvement and Patient Experience QUALITY STRATEGY The Quality Strategy plan has been amended to display the national requirements of the Quality Account for 2012 and the quality checklist identified in appendix 2. As a result, a programme of consultative / workshop events are being held with a range of operational teams to widen involvement. It is proposed that this will be completed in February to enable the strategy proposals to be presented to the Board for review in March 2012. A project structure has now been approved for the development of an integrated approach to dashboards and data reporting across the Trust. This is being developed and pilotted within a small number of teams across each division. The proposals were recently shared with the West Midlands Quality Observatory and the Trust received positive feedback. A programme of ‘Quality Support team’ visits has now commenced and is informed by an informal monthly corporate review of ‘hotspots’ across the organisation. It is intended that the general approach of sharing key issues/ potential indicators of quality variation across departments will be reflected in the dashboard as this evolves. Teams identified by the hotspots reviews are prioritised for quality visits in order that any potential issue of quality variation is tested before further action is identified. The outcomes from the Quality Support visits are to be reported through the Clinical Governance enhancement visit process to ensure an integrated and thorough approach to operational review.
ASSOCIATE DIRECTOR FOR RECOVERY AND INCLUSION The postholder is concurrently combining induction, including recovery-specific internal and external network development and information gathering with regard to the scoping assessment of the Trust, based on the Implementing Recovery through Organisational Change (ImRoc) process and tools; produced and published by the Centre for Mental Health. They detail ten key organisational challenges which any organisation has to consider and address if it is to successfully and systemically provide comprehensive services based upon recovery principles. The Centre for Mental Health Implementing Recovery project currently involves 29 organisations, either as demonstration, pilot or network sites and we expect to be able to directly engage with some of these Trusts as part of our own continuing development process. It is expected that the assessment process will be complete in February 2012 and this will inform and enable the development of an implementation plan. One of the important and emerging themes is the wide variance in the understanding of the concept of recovery across the Trust. Nationally, there is no set model or commonly agreed definition of Recovery, but successful practitioners appear to work to a set of values or ideas. Concepts of hope, empowerment, value, meaning and opportunity are often mooted.
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Without prejudging the necessary wider Trust debate and agreement, recovery is generally seen to be about individualised approaches and having a satisfying and fulfilling life, as defined by each person. Recovery does not necessarily mean ‘clinical recovery’ (usually defined in terms of symptoms and cure) but it should mean ‘social recovery’; building a life beyond illness without necessarily achieving the elimination of the symptoms of illness. Recovery is often described as a journey, with its inevitable ups and downs, and people may often describe themselves as being in recovery rather than recovered.
STRATEGY FOR PROFESSIONAL NURSING 2014 A Trust intranet page is currently being prepared to promote the strategy. Hard copies of the strategy are being printed and each registered nurse will be provided with a leaflet explaining the values underpinning it. Discussions are taking place across zones and programmes to confirm local activities that support the strategy. These will be captured in Contribution Statements, which will be received at the Senior Nurse Forum in February. This will promote strategic alignment. Other current work streams include: a) Refreshing the nursing pages on the Trust intranet b) Establishing the structures for nursing governance c) Setting up nursing journal clubs across zones and programmes to promote evidence based practice d) Establishing a nursing practice and policy group e) Establishing a model of nursing for BSMHFT f)
Developing a business case for setting up a centre for nursing development within the BSMHFT
Lead roles for work packages for 2012/13 are to be advertised on the intranet as development opportunities. Those who take on a lead role will gain experience in coordinating projects and will work under the tutorship of a senior nurse. BSMHFT Professional Nursing Standards 2012/13: As part of the strategy for professional nursing, six standards have been identified as priority for the next financial year. These pertain to professional nurses: •
Understanding their responsibilities and accountability
•
Being able to articulate the values underpinning the strategy for professional nursing
•
Understanding responsibility for reporting poor practice
•
Using research based information
•
Using critical thinking skills
•
Articulating responsibility for assessing student nurses
Actions to achieve the standards and measures for improvement and monitoring arrangements have been agreed at the Senior Nurse Forum. Fitness to Practice (Nursing): The Deputy Director of Nursing and Quality has convened a working group to establish practice and policy relating to nursing fitness to practice. This will be to refresh and extend the current policy to reflect NMC
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guidance. The aim is for matters, which may impact on a professional nurse’s fitness to practice, to be reported to and overseen by a suitably senior professional nurse from the outset. Areas that the policy will address are: •
Lack of competence
•
Misconduct
•
Character
•
Ill health
SAFEGUARDING UPDATE Membership of the Birmingham Safeguarding Children’s Board Changes are being implemented by the Birmingham Safeguarding Children Board to rationalise and refocus the existing Board. The changes will lead to the Board becoming predominantly commissioner focussed and the number of health representaives will reduce dramatically. Currently all commissioners and providers are represented. A Health Safeguarding Executive Group is being established and this will feed into the Board. The current health members will now attend. The group will be represented at the Board by the Director of Nursing for the Commissioning cluster. Notwithstanding these changes Dee Roach will continue to attend the main Safeguarding Board on the basis that the Board felt that the Trust needed to continue to be represented given the prevalence and presence of parental mental illness and substance misuse in many of the serious case reviews that have been carried out in the city.
SERVICE USER AND CARER EXPERIENCE Real-Time Feedback Pilot The kiosks and mobile devices remain active in all locations, surveys are being updated, used regularly, and staff are still able to generate reports to support service improvements. Feedback has been displayed on large screens in all the pilot locations, and results shared in Clinical Governance meetings and committees. The pilot is now being evaluated against a number of criteria identified at the start of the project. This will include everything from ease of use of the technology, data collection and reporting processes and dashboards, right through to the quality of staff engagement, survey design, service user and carer interest/responses and how the feedback is used to make improvements. Recommendations arising from the pilot will be presented shortly to Trust Board on the next steps and potential roll-out within BSMHFT, including the requirements needed to be in place to ensure that ‘real-time’ feedback adds value and is complimentary to the range of approaches that are being use to gather information on service user and carer experience. The 2011 – 2012 Patient Experience CQUIN is linked with this project and to report all the required milestones have been met. Carers’ Strategy A comprehensive consultation exercise is currently being undertaken in order to obtain engagement and feedback from carers in the development of our new Trust
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carer strategy. The draft document has been widely circulated within the Trust as well as in a number of carers groups and forums across Birmingham and Solihull. Our colleagues from the Meriden Project have arranged ‘open door’ events that have been scheduled in each ‘zone’ in the Trust. Information about these events has been distributed to an extensive range of stakeholders and carer organisations. Feedback from consultation events, the carers’ groups/forums, other stakeholders, carer governors as well as staff will be collated by colleagues from the Meriden project and used to ensure that the final strategy represents and addresses the needs and priorities of our carers. The final document will go to the Clinical Governance Committee at the beginning of March, for final Board approval at the end of that month. A carers' event is planned for Friday 27th April 2012 - this will be used to launch the strategy as a focus to share issues and views between carers and staff. Service User Engagement ‘User Voice’ and ‘See Me’ are now united under one management structure. In order to avoid any confusion a new name is to be agreed for the service user engagement team. Service users and staff have been invited to suggest names and service users will make the final decision. The BSMHFT service user engagement strategy (Everyone’s Business) will be reviewed and updated this year. As with the carers’ strategy, this will be consulted upon widely. The challenge for the organisation will be in ensuring that this is seen as a priority for all our staff, teams and services, in seeking to involve and engage service users at every level within the organisation. A new approach to ‘customer relations’ The BSMHFT Complaints and PALS teams will be co-locating at Ardenleigh at the end of January. A number of opportunities have been identified to ensure that service user and carers receive a faster and more helpful response from the organisation when they ask questions, raise concerns or make a formal complaint. By undertaking a review of the pathways and processes, it is possible to ensure that resources are deployed in a way that meets the ‘customer’ needs. Critical to the success of this work is the involvement and support of clinical and operational staff, as more collaborative working will ensure local and organisational learning from the feedback and drive appropriate service improvements. To this end the new pathway will be designed in collaboration with nominated colleagues from different divisions, and the new process/pathway will be assured by service user and carer representatives.
ALLIED HEALTH PROFESSIONALS WORKFORCE STRATEGY The change plan for physical therapies and restructure of the portfolio for the Associate Director for AHP and physical health and wellbeing is nearly complete. The new structure delivers two new roles to date with a third to be recruited to shortly. Firstly, health instructors will deliver broader health and well-being support across life style factors, promoting and supporting increased physical activity and support to adopt healthy choices of food and drink.
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Training and supervision, hosted jointly across AHP (Allied Health Professional) disciplines, will enable the delivery of health and well-being support to in-patient services. The training package and supervision structures will enable the delivery of wider support to develop the quality of well-being support delivered through activity workers and STR staff. Secondly, the redesigned structure has enabled the creation of a new tissue viability lead role to support ward staff across the Trust and enhance mitigation of safeguarding challenges as a result of skin integrity break down. The last phase of this change programme will be the appointment of a continence care lead to lead on this agenda that is core to essence of care and addressing dignity in care. This is on track and will be in place hopefully by the end of the financial year. The Occupational Therapy leadership structure has been agreed across AWA and Secure & Complex Care and is being implemented. This will develop quality and drive enhancement / assurance around professional and clinical standards within teams, and drive practise development to align to the outcomes framework, PbR (payment by results) and Trust business priorities- namely enablement to live well in the community.
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Appendix 5
TRUST CLINICAL GOVERNANCE COMMITTEE Uffculme Minutes of meeting held on Tuesday 6 December 2011 Present Dee Roach Prof Chitra Mohan Martin Herriott Peter Hughes George Georgiou Jon Kennedy Rajashree Ray Gill Wainscott Nicky Bradbury Jeremy Kenney-Herbert
Rob Evans Frances Allcock Sue Coffee Mark Hillier Amanda Gatherer Sheila Richards Peter Lewis
Chair – Exec Dir. of Quality, Improvement & Patient Experience AMD and Director for Effectiveness & Governance Associate Director for Recovery & Inclusion Associate Director of Governance Clinical Director – Addictions Clinical Director – AWA (part meeting) Clinical Director – BEN and Consultant Psychiatrist Clinical Director – CAPS Clinical Director – MHSOP Clinical Director – Secure and Complex Care Clinical Director – Solihull Dir. of Organisational Development & Performance Improvement (part)
Head of AHP and Physical Health Services Head of Patient & Public Involvement Head of Psychology Interim DSS – Adults of Working Age Medical Director (part)
In Attendance Fausteen Falconer Angharad Newbold Diana Markman Nigel Barnes Satpal Gill Angela Graham JulieAnn McCabe
Assistant to Peter Hughes – Notetaker Clinical Governance Manager Assoc. Director of Service User & Carer Experience Director of Pharmacy & Medicines Management Head of Employee Resourcing & Staff Experience (rep C Berry) Head of Learning & Development Tutor, Learning & Development
Apologies Chris Berry Stuart Wix
Deputy Director of Human Resources Deputy Director of Nursing & Quality
These minutes are presented in order of discussion. ITEMS FOR APPROVAL 11/227 The following policies were APPROVED • Risk Management Training Policy • Induction Policy • Manual Handling 11/228
Approval on DNA (Did Not Attend) charges was deferred to February 2012. Presented by Angela Graham and JulieAnn McCabe. It was highlighted Page 18 of 23
that the number of DNA occurrences has fallen however it was suggested that this could be the result of improved ease of booking, not the imposition of the charge. Discussion continued on the impact of the DNA charges. It was confirmed that charges are levied both ways ie L&D are charged if courses are cancelled. Further it was confirmed that at present the money withdrawn as a result has not benefited any department and is held in a separate finance code. There was a general view that the committee should further review the DNA charging, however it was felt that this would be more appropriately undertaken in February. Amendment (03.01.2012) – Trust Board had been seeking detailed assurance on compliance. In discussion, the committee proposed that 100% compliance is unachievable and it was suggested that the target should be 95% compliant. Further it was recommended, by JAM, that a compliance of less than 75% should be highlighted as an issue and this was supported. Action: Review of DNA charges to be presented to the February 2012 meeting of the committee 11/229 RECONFIGURATION • Assertive Outreach – presented by Rob Evans & Mary Elliffe. RE made clear the reasoning behind the decision to reconfigure AO and explained that the current seven teams were to be reduced to five teams with a more equitable caseload for each team of about 100 cases. This reconfiguration is planned to be complete by March 2012. ME outlined the risks and actions being taken to mitigate these risks and asked the committee to be aware that this is taking place and to be assured that the risks are being managed. • (Peter Lewis & Frances Allcock joined the meeting). • Acute Services – presented by Jon Kennedy & Elaine Murray. This service is tasked with saving £1m. JK explained the various options available. These included closing a ward and amalgamating a number of home treatment teams to reduce manager numbers. A ‘ward’ could equal a number of beds in various zones and the plan is to close beds as they become available. It was stated that commissioners have a responsibility in this issue as it is at their behest that this trust be working closer to the national norm. It was agreed that updates be provided to the committee once the in-patient reductions had been tested. 11/230
WORKFORCE REPORT Presented by Satpal Gill. Satpal asked the committee to ensure their staff are allowed time, in work, to complete the staff satisfaction survey, 52% of those issued have been returned so far.
11/231
AVERTS report Presented by Dave Jeffery who explained that the AVERTS team has Page 19 of 23
AG JAM
experienced difficulties in not having data sets for four courses. AVERTS trainers are to be embedded in teams across the Trust. DJ spoke of projected compliance levels (with current resource) of 92% for personal safety courses and 75% for manual handling courses however there is an inability to drill down to determine the demand for courses. The annual requirement for a one day update training session has been lengthened to include a three month ‘grace’ period. There is currently a non-compliance of 44% and this group of staff are now required to attend the five day training course because they did not attend the one day update session. The committee were assured that this extension is clinically permissible. Administrative support is to be provided directly from the Corporate Clinical Services admin resource. Action: DJ to return to the committee with an update on all the issues he highlighted. 11/232 MINUTES OF MEETING HELD 1 NOVEMBER 2011 The minutes were agreed to be an accurate record of the meeting with the following amendment. 11/217 (should read) ‘Highlighting the main risk around the lack of recording of diagnosis’ 11/233
ACTION LIST – see sheet
11/234 MATTERS ARISING FROM PREVIOUS MEETINGS 11/210 HMP Medicines Management – George Georgiou reported that of the 11k doses administered, 11 were reported as serious incidents. This trust has challenged the national guidance around delivering a ‘maintenance’ level of medication to inmates incarcerated for six months or less. Evidence of bullying and the selling on of drugs has been found and this has resulted in this trust reducing the ‘maintenance’ level of medication to 14 weeks. GG reminded the committee that this is the busiest prison in Europe, inmate turnover is high and we are caring for twice the number planned for. GG has spoken to our commissioners advising them of their risk in this area and it was understood that the risk was shared. The committee was assured by the report presented by GG. 11/038 Psychiatric Liaison – Peter Hughes reminded the committee of the background to this item and for which now there is no outstanding action to be completed although, at the time, the wish by the committee was for the improvements to be embedded in the operational policy. Due to the changes to city wide RAID teams, Psychiatric Liaison will report back to the committee when governance arrangements are in place. 11/235 DASHBOARD REPORT – presented by Peter Hughes Outstanding risk alert now completed. Page 20 of 23
SW
Item 1.2.3: PL asked about SI grades since May 2011, he was assured that these will be checked before the report is submitted to the Trust Board. Issues were raised about incidents. In response to concerns that some SI’s initially reported may not always be in line with criteria. Clinical Directors were reminded that a timely management report (within 3 days of the incident) is important as services should not make assumptions that there is nothing for review unless relevant information is provided to the risk management department. In such circumstances a detailed management report, signed off by the CD should be submitted to demonstrate that there was nothing untoward relating to the incident. 11/236 PHYSICAL HEALTH COMMITTEE – presented by Sue Coffee Sue highlighted the need for Team managers to look at completed physical health assessment forms against caseload. The data presented from ‘insight’ showed limited assurance that physical health forms were being completed. However there were a number of factors which suggested that this was not an accurate reflection of current compliance. There was general discussion on the impact of the physical health committee and how it can work more closely with operational programmes/ zones in order to support further improvement. DR requested that a work plan be developed which would ensure that the physical health committee was focusing on ensuring that core requirements were being met. Action1: All clinical directors to talk to SC re physical health assessment activity before January 2012
SC
Action 2: Work of PHC to be presented to this committee in January 2012 for review
SC
11/237 PATIENT EXPERIENCE REPORT – presented by Mark Hillier and Diana Markman MHr presented the report’s highlights Diana Markman advised the group of the redesign of the PALS and Complaints departments in order to develop customer service. She also talked about the Real Time Feedback project and described the next steps. 11/238
COMPLAINTS REPORT – presented by Diana Markman
11/239 RESUSCITATION COMMITTEE REPORT – presented by Martin Herriott MH asked that the committee be assured that DNAR (Do Not Attempt Resuscitation) is being managed well. Available training has been reduced with the removal of the 2hr training session from OLM. There was discussion on the current arrangements for monitoring statutory and mandatory training in relation to resuscitation. Due to issues with the OLM database it was not possible at present for ELS training to be reflected accurately on the database. Page 21 of 23
Action: Report back to this committee on the capacity of the available training
MHt
LOCAL GOVERNANCE ARRANGEMENTS 11/240 SCC & Specialties – JKH presented the Programme risk register. The committee reviewed the top risk highlighted and sought assurance that actions had been taken to be assured of reduced risk. It was reported that the issue had been raised with James Longmore and has been discussed at the senior director’s meeting. Action: The outcome of the discussion between JKH & James Longmore to be reported to Peter Hughes. 11/241 MHSOP – presented by Nicky Bradbury The Programme was advised that it should review its top risk as it was too generic to provide any use or meaning. Action: Revised risk register to be presented for next risk report (March).
JKH NB
NB
11/242 HMP Birmingham – A report had not been received in time for circulation. George Georgiou provided a verbal update. Action: HMP risk register to be presented at January meeting
GG
11/243 RAID – George Georgiou provided a verbal update. RAID & Liaison governance were being merged. Formal CG arrangements to be built in. Clinical governance currently being overseen by GG. Action: RAID / Liaison risk register to be presented to next meeting.
GG
The following items were presented by Peter Hughes and noted by the committee 11/244 CQC ACTION PLAN – to be reported to this committee monthly 11/245 QRP UPDATE – The report highlighted that the staff survey was the most significant issue which impacted on our profile. It was proposed that this was reviewed further through the workforce committee. 11/246 WMQRS – The report from the WMQRS was noted. An action plan and response was required. This would be co-ordinated and reported back to this committee in February 2012 Action: WMQRS action plan and response to be presented for approval in February 2012 PH 11/248 External SI Review Action Plan It was noted that the action plan presented had been developed from the work shop. DR thanked all those who had contributed to the day. The action plan had further been circulated to all attendees for final comment / amendments. The committee approved the plan. (Updates to be reported as part of risk report). 11/249 ANY OTHER BUSINESS Page 22 of 23
Nigel Barnes – A monthly medicines update (draft) was circulated to members of the committee for comments Next Meeting Tuesday 3 January 2012.
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