meeting date: 26 may 2016 summary report agenda item: 12 enclosure · pdf file ·...

1 Accountable Director: Lead Executive Director for each CommitteeBoard Meeting Date: 26 May 2016

SUMMARY REPORTMeeting Date: 26 May 2016Agenda Item: 12EnclosureNumber: 12

Meeting: Trust BoardTitle: Approved Board Committee MinutesAuthor: Lead Executive Director from each CommitteeAccountable Director: Committee Chairs

Other meetings presentedto or previously agreedat:

Committee Date ReviewedKeyPoints/Recommendationfrom that Committee

Each Committee asshown

Meeting dates asshown

Purpose of the report

To provide Board members with the most recently approved minutes fromCommittees of the Trust Board.

Consider forActionApprovalAssuranceInformation

Strategic goals this report relates to:To deliver high

quality careTo support people to liveindependently at home

To deliver integratedcare

To develop sustainablecommunity services

Summary of key points in report

Main Issues discussed at each Committee & implications for overall Trust business A summary of key issues from the most recent Committee meetings can be found in the relevant

reports to the Trust Board (ie prior to the minutes being approved and being available)

Key Recommendations

To note the content of the minutes for information.

2 Accountable Director: Lead Executive Director for each CommitteeBoard Meeting Date: 26 May 2016

Is this report relevant to compliance with any key standards?YES OR NO State specific standard or BAF risk

CQC NoIG Governance Toolkit NoBoard AssuranceFramework No

Impacts and Implications? YES orNO If yes, what impact or implication

Patient safety & experience NFinancial (revenue & capital)

N

OD/Workforce NLegal N

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CHARITABLE FUNDS COMMITTEE MEETINGFRIDAY 20TH NOVEMBER 2015, 9.00AM TO 10.30AM

IN EXECUTIVE MEETING ROOM, WILLIAM FARR HOUSE, MYTTON OAK ROAD,SHREWSBURY, SY3 8XL

Present: Mike Ridley (MR) – ChairSteve Gregory (SG) (part)Sarah Lloyd (SJL)Diana Owen (DO)Andy Rogers (AR)Mat Morgan (MM)Becky Davis - Minute taker

1. Apologies Julie Thornby (JT)Ros Francké (RF)

ACTIONBY:

2. Minutes of meeting held on 7th August 2015MR welcomed everyone to the meeting as the interim Chair. MR also welcomed MatMorgan, Regional Finance Trainee, to the meeting as an observer.

DO commented that the Charitable Funds accounts have not yet been submitted tothe Charity Commission as we are waiting for the Audit certificate. Submission isdue by 31st January, so it will be on time.

It was noted that the League of Friends are concentrating their fundraising efforts onhospitals.

The minutes of the meeting on 7th August 2015 were agreed as a correct record ofthe meeting.

3. Draft Terms of Reference (ToR), including membership

The revised draft Terms of Reference have been circulated. SJL has been throughthem with RF. It was noted that information regarding our legal duties andregulations is missing from the document.

It was confirmed that if items requested for funding are connected and thecumulative total is more than £20k, applications would come to this meeting forapproval. If items are not connected and are less than £20k per item, they wouldcontinue to go to the relevant fund manager for approval. MR asked the group toconsider the appropriate wording of this ruling, which will be inserted into the ToRdocument.

MR will clarify the situation regarding the bullet point made about fundraising after hismeeting next week.

The ToR will be brought back to the next meeting.

RF/SJL

All

MR

4. Q2 quarterly report

DO circulated the quarter two report and noted that the funds have dropped by £25k.

Contributions received have been mostly from the League of Friends. The

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Community Hospital Fund has now been spent.

Ludlow HospitalThe Ludlow Hospital Legacy fund still has a large balance. This has not beendiscussed with the staff yet. SJL asked the group whether we could ask the staff atthe hospital if they would still like to use the money to improve the reception area atLudlow Hospital. SJL will get in touch with Rachael Brown and Andy Matthews todiscuss this further.

Property Services will need to be approached for approval to make to make thealterations to the reception area at Ludlow Hospital.

MR asked regarding the move of the maternity ward to the main block and SJLconfirmed that this is being discussed. A meeting will take place with SG, SaTH,Estates, and SJL to explore this.

There has been a change in the way that we are charged for the vacant space atLudlow Hospital, as the income comes from another source. A meeting will takeplace to discuss what this means for us operationally, and whether it will reduce ourflexibility.

DO issues reminders to the service managers at Ludlow occasionally, to remindthem that the fund is available.

DO informed the group that the interest rate is very low on this account.

SJL

5. New Legacy at BridgnorthDO reported that we have received a legacy for Bridgnorth Hospital this week, whichtotals £136k. We are uncertain of the background of the legacy, but we know thatthe estate was split 4 ways. The letter that came with the donation says that it is forBridgnorth Hospital, but no further instruction was given.

DO has spoken with Rachael Mole regarding the legacy and she has suggested theyrefurbish a room on the ward that would make it suitable for relatives and also foruse by people with dementia.

Any requests for how the fund is to be spent will come back to this Committee fordiscussion and approval.

MR asked if we need to recognise the donation with the family of the deceased. DOconfirmed that Bridgnorth Hospital are sending the thank you letter.

MR suggested a letter is sent to the family later on to inform them of how the fundhas been spent. MR also suggested that there is a celebration and ribbon cuttingevent on behalf of the Trust to acknowledge the legacy and work carried out.

DO

6. Liaison with League of FriendsMR will send a note to the Committee to update them after his meeting on Mondaywith the League of Friends.

MR

7. Approval of Expenditure over £20k

DO informed the Committee that she had received the final information last nightregarding the scanner for Ludlow Hospital, and circulated this at the meeting fordiscussion.

The League of Friends will pay for the scanner and the maintenance of it, at £53k.There are revenue costs of £8800 annually, plus a non-recurring set up cost of £2k.

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DO reported that Rachael Brown will ask the League of Friends if they might pay forthis.

DO confirmed that we have a draft agreement with SaTH, but it is not yet signed.

SG suggested that we enter into a 12 month agreement with SaTH rather than a 4year agreement.

The activity will be completed and generated by SaTH, and they will receive theincome from this. SaTH will then pay us. It was agreed that we should explore howwe can use the equipment to generate income going forward.

SJL confirmed that some work has been completed over the last 3 months to seewhether we can deliver the service. It has been suggested that the equipment wouldbe used 2 days per week by SaTH, which means it would be available for 3 days perweek.

The Committee approved for the above expenditure to go ahead.

8. Our approach to fundraising

AR suggested that we could publicise the work that we have completed throughlegacy funding, if the families involved are happy for us to do so.

MR suggested that if the other charities that have benefitted from the Bridgnorthlegacy are publicising their work as a result of this, we need to ensure that weequally acknowledge the work completed with our share of the donation.

9. Any Other BusinessSJL reported that the Charity Commission guidance called ‘The Executive Trustee’will be sent to the Board in January. DO will obtain an electronic copy of this.

MR will let the Board know that the legacy has been received for Bridgnorth Hospital. MR

10. Date of next meetingFriday 19th February, 9am to 10.30am, Executive Meeting Room, WFH.

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AUDIT COMMITTEE

Minutes of meeting held on Tuesday 5th January 2016at 9.15am in K2, William Farr House

Present: Peter Phillips (Chairman) Non-Executive DirectorSteve Jones Non-Executive DirectorNuala O'Kane Non-Executive DirectorRolf Levesley Non-Executive DirectorJulie Thornby Director of Corporate AffairsLisa Randall Director, RSMRos Francke Director of FinanceAllison Rhodes Grant ThorntonGrant Patterson Grant ThorntonPeter Foord Corporate Risk Manager

Attendees ToPresentReports:

Terry Feltus Local Counter Fraud and Security Management Specialist

In attendance: Anita Bishop Minutes Secretary

ITEMS ACTIONSPRIVATE MEETING OF THE NEDS AND AUDITORSA private meeting of the Non-Executive Directors and the Auditors took place.

1.0 APOLOGIES:Apologies were received from Alex Hire. The Chairman welcomed GrantPatterson back to the Audit Committee.

2.0 DECLARATIONS OF INTERESTThere were none.

3.0 MINUTES OF MEETING HELD ON 6th OCTOBER 2015 Enc 1CORRECTIONS:Item 1 – Should have read “The Chairman welcomed to the meeting NualaO'Kane and Steve Jones, the new non-executive directors.”

Subject to the above corrections, the minutes were approved as being a trueand accurate record by those present.

4.0 MATTERS ARISING FROM THE MEETING Enc 2HELD ON 6th OCTOBER 2015

Steve Jones advised that he wished to have sight of the Trust BusinessStrategy plan. It was noted that Mel Duffy, the new Director of Strategy hadjoined the Trust this week, and would be working to develop the BusinessStrategy. Additionally Tricia Finch, Head of Business Development would alsobe joining the Trust very soon, and the progress of the Business Strategywould be taken forward by the Resource & Performance Committee.

TrishFinch

4.1 Appraisal System Review – Julie Thornby VerbalThis item was a follow up from an Internal Audit report which was finalised inMarch 2015. Julie advised that all recommendations from the Audit had now

Enclosure 1

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been completed, and the new system had been simplified and piloted.

A presentation of the new Appraisal System had been demonstrated to Truststaff at the recent Trust Away Days, to encourage a higher take-up by staff andto reinforce the Trust objectives. A random sampling of paperwork would becarried out, in line with new system recommendations.

4.2 Service Line Reporting – Ros Francke VerbalRos advised that the previous work for Service Line Reporting had been de-prioritised and had lost its’ sense of purpose, however, staff had undertakensite visits, to see what systems other Trust used.

A new focus on Service Line Reporting would be progressed in next 12months, as part of Ros’s development plans. It was recognised that there wasa need for staff to buy in and build up some momentum. There was a need tolink the data with existing systems, and Ros had asked the InformationManagement Team to carry out an evaluation to ensure that the rightcompatible systems are brought in.

Ros noted that there was an external drive for implementation of Service LineReporting by Commissioners, and it was part of the Trust’s objectives to delivera system in the near future. The CCG intended to monitor the progress of theTrusts systems, however, it was noted that the Trust needed EPR in place togo forward.

RosFrancke

4.3 Arrangements for the appointment of external auditors Enc 3– Julie Thornby

Julie advised that the Trust needed to appoint external auditors by the end ofthe year. The requirement was underpinned by national legislation andguidance.

A discussion took place regarding the need to check that no members of theAudit Committee had any conflicts of interest to external auditors. Rolf advisedthat his son currently works for Grant Thornton, and questioned if this would bedeemed a ‘conflict of interest’ in relation to Rolf’s holding a place on theAppointing Panel? The Chairman thanked Rolf for raising the matter, it wouldbe considered but thought unlikely.

It was noted that Grant Thornton had been the Trust auditors since 2011, andprevious to this, they had worked with the Trust as part of the AuditCommission. Grant Patterson advised that he was seeking legal advice if theTrust could ‘reappoint’ or ‘extend’ the arrangement with Grant Thornton if theTrust wished to take choose this option, or whether the Trust would need to‘reappoint’ through a tendering process. Grant Patterson advised that thecompany had rotated their partners every 5 years.

A discussion took place about the options that may be open to the Trust, eg.Joining up with other organisations to get a better deal – but this may requirethe sharing of information. This may provide a procurement process saving,but not a work cost saving.

Ros advised that she had been individually approached with regards to theTrust being interested in joint procurement processes, and would bring thedetails to the attention of the Audit Committee members if the costs were foundto project significant cost benefits.

The proposals and plans were considered and approved. All agreed by allpresent. Julie would work with Procurement and provide an update at the nextAudit Committee meeting.

JulieThornby

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4.4 Princess House Environment Action Plan – Peter Foord VerbalPeter advised that issues had been raised regarding the flooring, which hadbeen badly stained over the years, and had been recognised as an infectioncontrol risk. There were also problems with the temperature control in thebuilding, however, spot heating and cooling had been provided when required.Physiotherapy had highlighted a lack of patient privacy, therefore rooms hadbeen allocated for use if there was a need for a more private location. Thereception desk was not always manned, and a review would be undertaken ifmore services were located to Princess House if there was a need to allocatemore staff in the future. It was noted that the building did not belong to theTrust, but was held via a tenancy agreement.

4.5 Service Level Agreement – Ros Francke VerbalRos apologised that she had been unable to provide a schedule for themembers to view. The schedule had been reviewed but needed a lot morework. An internal contract meeting was scheduled to take place in the nextcouple of weeks, and a clearer position would be established. The currentfocus of SLA’s related to 3 at a value of £50,000 and 20 at a value of £10,000,and also the signing off of the SSSFT SLA.

It was agreed that establishing the current position was important so that therewere no future surprises. There was a risk from services eg. APCS of overperforming, which could equate to a substantial amount of money. If the SLA’swere not signed off, then an agreement needed to be drawn up. An updatewould be brought to the next meeting.

RosFrancke

4.6 Community Hospital Lockdown Arrangements & VerbalBusiness Continuity Plans – Peter FoordWhitchurch and Bridgnorth Community Hospitals had been assessed, and dueto the age of properties not all recommended work could be carried out, someminor changes were to be carried out. Ludlow and Bishops Castle to becompleted and an action plan would be drawn up.

Pete Old

4.7 Hoist for Dental Patients at Oswestry Health Centre – Peter Foord VerbalRos advised that the matter was now close to a resolution, and it wasdisappointing that there had been a considerable delay in moving the matterforward. The details had been discussed at a Capital and Estates meeting, anda business case had been drawn up. Procurement and installation of the hoistwould follow soon.

PeterFoord

4.8 Hospitality Report – Julie Thornby Enc 5Julie advised that with regards to hospitality payments for the Diabetes serviceon training events, an analysis of prescribing patterns had been undertaken bythe Chief Pharmacist, and no trends had been identified that suggested thediabetes staff had been influenced in their prescribing patterns via thesponsorship. Rita O’Brien is able to provide prescribing data on request.

Questions were asked why pharmaceutical companies would sponsor trainingevents, if they did not get a direct gain, however, it was our nurses tend tocontinue prescribing patterns set by consultants.

The content of the report was noted, and no additional assurances wererequested.

4.9 Review of CIP and QIA at Quality & Safety Meetings Verbal– Julie Thornby, Rolf Levesley

It was noted that the recommended actions did take place and an action logwas now in place.

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5.0 NEW ITEMS

5.1 Review system for ensuring compliance withCQC Essential Standards - Peter Foord Enc 6

The committee members discussed the content of the report providingassurance for the process to ensure that the Trust complies with the CQCrequirements for the Trust’s inspection that would take place on 7th March2016. Each clinical area would carry out a ‘self-assessment’ to ensure thatthey met with the regulations, a small team would then follow up to offer adviceand support about how to achieve the regulations. A CQC visit had takenplace at Stoke Heath prison and a number of shortfalls had been addressedthrough the implementation of an action plan. Steve Gregory had contacted anumber of other Trusts to share learning from their previous inspections, and anumber of Trust staff would be visiting Robert Jones and Agnes Hunt hospitalnext week to discuss their recent CQC experience. A Board Development Daywas scheduled to provide the committee members with further informationregarding assessments and good practice.

The content of the report was noted and the committee members tookassurance from the staff support plans that were in place.

5.2 Local Counter Fraud & Security Management Specialist Report- Terry Feltus

a) Local Counter Fraud Specialist Update Report for the period01 April 2015 to 30 November 2015 Enc 7

Terry explained the difference between the two roles of Local Counter FraudSpecialist (LCFS), which targeted anti-fraud bribery and corruption to preventfraud; and Local Security Management Specialist (LSMS), which deals withsecurity and theft, protection of staff eg. The security of buildings.

Progress has been made with Counter Fraud, however, there had been a 30%reduction in allocated working days, therefore, compromises had been made inthe workload to merge the 2 jobs into one role, however, Terry advised that hestill hoped to achieve a green rating on the indicators for the Trust. Currentlythere is a considerable amount of work being undertaken regarding securitymanagement, and the on-going situation would be kept under review. It wasplanned that assessments would be carried out to define the associated risks.A sum of £2,826 had been recovered and further outstanding claims werevalued at around £10,000. Due to the nature of work the monies recoveredwere of small values and the main of the work was targeted at the preventionof fraud, which was an intangible figure.

A discussion took place regarding the failure of 8 nursing homes where properchecks had not been completed for patients that had passed away andpatients that had moved out of the area. False claims had been made forincontinence products, however, Terry advised that checks were now beingcarried out on a monthly basis, using a robust procedure and the problemshouldn’t arise again.

Terry advised that following the completion of the National Fraud Initiative tomonitor expenses (which is completed every 2 years) duplicate claim entrieshad been found to have been submitted by staff for different periods of time. Itseems that the manager had not processed the entries in a timely manner andso staff had resubmitted claims when they had not been paid. A new systemhad now been put in place to prevent this type of error occurring again.

Nuala noted that fraud seemed to be very small scale, and that the committee

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could take assurance that even small scale fraud was being detected. TheTrust had a very good anti-fraud culture that was brought to the attention ofstaff as part of their induction schedule, and fraud awareness was regularlynotified in newsletters and Trust articles.

The content of the report was noted.

b) Local Security Management Specialist Update Report for the Period01 April 2015 to 30 November 2015

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Terry highlighted that with regards to the self-review tool, to achieve a greenrating, you could have a mixture of green and amber ratings and still achieve agreen rating, Each of the ratings were weighted, therefore, there was a focuson the more weighted items to keep the overall rating as ‘green’.

The Local Security Management strategy document would be available by theend of April 2016, and details would be brought to the next Audit Committeemeeting.

A discussion took place regarding overseas visitors, their access to NHSservices and what this would mean for front line staff. When new guidancearrived the details would be brought to the attention of the Audit Committee.


TerryFeltus

c) Anti-bribery Policy and Procedure Enc 9

Terry advised that the policy had been brought up to date, and there had beenvery minor changes. The procedure for the ‘Declaration of Private Interests’register would have planned ‘spot checks’ to be carried out, to ensure that theregister was up-to-date.

The content of the policy was noted and the amendments were approved.

BREAK

5.3 Review of Procurement Arrangements – Ros Francke Verbal

It was noted that this item had been on the Audit Committee agenda severaltimes, as it had been suggested by the Audit Committee Handbook. Currentlythe Audit Committee had only been reviewing Single Source Arrangementpurchases, the Committee discussed whether there should be more reportingin addition to Peter Phillips now attending the Procurement Committeemeetings. It was agreed that Peter Phillips could bring any matters of interestto the attention of the Audit Committee, if required.

PeterPhillips

5.4 Review of Terms of Reference – Peter Foord Enc 10Minor changes had been made to the Terms of Reference. A furtheramendment would be required to reflect the Audit Committee being appointedto oversee the appointment of external auditors.

Steve Jones questioned whether the Terms of Reference should include anarrative related to the CQC Well Led Standard.

JT will reflect and include as next revision.

Following a discussion, further amendments were put forward, and it wasagreed that a revised document would be brought to the next meeting.

JulieThornby

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5.5 Clinical Audit Update – Peter Foord Enc 11

Peter advised that the paper gave a half yearly update of the Clinical AuditPlan for next year. A discussion took place regarding the frequency of thereport, and it was agreed that the reports should stay with half yearly. ClinicalAudit was reported through the Quality and Safety Committee, and the detailswere brought to the attention of the Audit Committee to ensure that any links torisk were recognised.

Steve Jones queried the front sheet of the report regarding ‘Key Standards’and that there was no detail for the impact and implications. Peter woulddiscussed the matter with Dee Radford and ask for clarity in future reports.

The content of the report was discussed and the content was noted.

PeterFoord

6.0 STANDING ITEMS

6.1 Workplan - Peter Foord Enc 12For information. No questions were asked.

6.2 ‘Well Led’ Management of Risks – Peter Foord Enc 13

Peter Foord presented a paper outlining the Trust position against the Monitor/TDA guidance on meeting the CQC Well Led Standard. It was reported thatthe risks on both the Board Assurance Framework and Corporate Register hadremained stable for sometime. The key risks had been identified at a BoardDevelopment session. The Committee agreed that these were the key risks tothe organisations objectives.

A discussion took place on the coverage of quality and whether this should berepresented to a greater level across the framework. It was noted that qualityrisks are represented to a far greater degree across the rest of the riskmanagement framework.

Julie informed the committee that this would be further covered at a BoardDevelopment workshop.


6.3 Board Assurance Framework – Peter Foord Enc 14The Risk Manager had reviewed the BAF entries, and has considered the BAFand Risk Management as a whole against the CQC Well Led domain. Thatreview has concluded that the entries are the right strategic risks against theorganisational objectives and had made recommendations in relation to therisk ratings for Financial Targets, Transformation: Local and National Contexts,Transformation: Systems and Fire Arrangements. A recommendation has beenmade for more assurance for Clinical Quality and Safety.

The content of the report was noted, and gave assurance that the BAFreflected the risks to the organisational objectives.

6.4 Corporate Risk Register - Peter Foord Enc 15Peter advised that the Corporate Risk Register was presented at the Boardmeeting in November 2015, and the Corporate Risk Register had beenreviewed by Lead Directors and updated.

The Complaints Policy has been reviewed and substantially updated. Aworkshop was held with manager and members of the Patient and Carer Panelto influence this update. The aim was to make the policy more user friendly

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and person centred.


6.5 Directorate Risk Register – Peter Foord Enc 16 FINANCERos advised that the Finance Risk Register had now been input on to the DatixSystem.

The content of the report was noted and no questions were asked.

6.6 Regulatory and External Body Report – Peter Foord Enc 17From Q&S committee, no questions were asked.


6.7 Risks From Other Committees - Peter Foord Enc 18The content of the report was noted and approved.

6.8 Procurement Arrangements – Ros Francke Enc 19 Single Source Arrangements –Ros advised that 2 x Montcalm high-low beds had been purchased, and afurther 6 would be ordered. The beds were deemed to be an investment forthe Trust, and were cost effective replacement beds. Research had beencarried out to ensure that they were the most appropriate bed specification forour services needs, and the recent purchases would enable us to have a totalof 8 beds (2 in each community hospital) enabling staff to manage patientsbetter with less intensive staffing.

6.9 Suspensions/waivers to standing orders There were none.

6.10 Losses and compensations report VerbalNone.

7.0 AUDIT ITEMS

External Audit

7.1 Progress Report – Allison Rhodes, Grant Patterson Enc 20The content of the Audit Plan was in-line with the work prescribed by auditingstandards. In the audit findings report that will be brought to the meeting in thesummer will advise of the outcome.

A paper regarding the management of fraud and corruption would be circulatedto the committee members as soon as it had been drafted, rather than waituntil the next meeting. The committee members were asked to review thedocument and feedback any concerns that they may have.

The Value For Money conclusion had changed this year, and an update wouldbe brought to future meetings.

The Extra Ordinary meeting of the Audit Committee would take place onTuesday 31st May 2016 at 2pm in the Executive meeting room.

AllisonRhodes

Internal Audit

7.2 Progress Report – Lisa Randall Enc 21

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The ‘Procurement Savings’ audit report had received a ‘green substantialassurance’ opinion, which was very positive. However, there were threerecommendations from a previous review that had only been partiallyimplemented or not implemented. These recommendations need to be closed.

The ‘IT Key Financial systems review’ had received a green substantialassurance’ opinion, and the audit did not highlight any significant IT risk to theTrust.

The audit report - Transformation Governance Arrangements (focus on ICS), itwas identified that there was a need for more focus on the quality of theservice being provided; in reports about service changel; recommendationshad been made and an action plan would be drawn up.

Lisa highlighted that due to the time constraints of the meeting, the verbaldelivery and discussion for this item were limited to only a few minutes, shewould appreciate an earlier time slot on the next Agenda so that she could talkmore in depth about the progress of the internal audit plan.

The content of the report and progress against the Internal Audit Plan wasnoted by those present.

8.0 RISKS IDENTIFIED TO BE REPORTED TO THE BOARD Allocation of days for Security Management and Counter Fraud, there was

work to be done.

9.0 MINUTES FROM THE QUALITY & SAFETY MEETING Enc 22September and November 2015 finalised minutes of the meetings, forinformation only.

9.0 ANY OTHER BUSINESSThere was none.

11.0 DATE OF NEXT MEETINGTuesday 5th April 2016 at 14:00 in K2, William Farr House

2016 Meeting Dates:

Tuesday 5th April 2016 14:00 – 17:00 in K2, WFHTuesday 31st May 2016 Extra Ordinary Meeting to approve the accounts, Executive Meeting RoomThursday 5th July 2016 09:30 – 12:30 in K2, WFHTuesday 5th October 2016 09:30 – 12:30 in K2, WFH

Signed: ………………………………………………………… Date: …………………………….Chairman

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Enc 1 MINUTES OF THE QUALITY AND SAFETY COMMITTEE

HELD ON WEDNESDAY 18 FEBRUARY 2016, 10:00 – 13:00, ROOM K2, WILLIAM FARR HOUSE, MYTTON OAK ROAD, SHREWSBURY

ATTENDEES Nuala O’Kane, Non-Executive Director (NOK) - Chair Mike Ridley, Chairman (MR) Steve Gregory, Director of Nursing and Operations (SG) Dr M Ganesh, Medical Director (MG) Julie Thornby, Director of Corporate Affairs (JT) Jane McKenzie, Non-Executive Director (JMcK) Sally-Anne Osborne, Deputy Director of Operations (SAO) Paul Devlin, Deputy Director of Operations (Transformation Lead) (PD) Andrew Thomas, Head of Nursing & Quality (AT) Dee Radford, Lead Nurse for Quality (DR) Rita O’Brien, Chief Pharmacist (ROB) Milly Smith, Volunteer Representative (MS) Roger Buckley, Volunteer Representative (RB) Jayne Williams, PA to Director of Nursing and Operations (JW) – Minute Taker GUESTS/ OBSERVORS: Elizabeth Jones, Infection Prevention Control Nurse Julie Harris, Safeguarding Lead Mark Donovan, Patient Experience Lead (MD) Peter Foord, Corporate Risk Manager (PF) 1. Welcome from the Chair

NOK chaired this meeting in RL’s absence. NOK welcomed those present to the meeting

and in particular introduced the two observers’ Julie Harris and Liz Jones.

2. Apologies Rolf Levesley, Non-Executive Director (RL) Jan Ditheridge, Chief Operating Officer (JD)

3. Declaration of Interest

There were no declarations of interest from those present at the meeting.

4. Minutes of the Meeting Held on 21th January 2016

The minutes of the meeting held on 21th January 2016 were agreed as a true and accurate record with the following exceptions:- 1. Page 5, Action 21.01.16/4 – ‘Urgent Care’ should read ICS. Amend minutes and

Action Log.

2. Page 7, Last paragraph symptomatic should have read ‘asymptomatic’ and reference made to ROB should have been SG.

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3. Page 11, Section 11, para 3, this paragraph needed to be re-written. ROB provided

the text. ‘ROB informed the Committee that there are 12,000 doses of drugs per month administered in prison. There are only 1,000 medicines administered per month in hospitals! We need to acknowledge this in context; low number of medication incidents reported, therefore we are confident, the majority of the time that that the controls in place are working.’

4. Page 12, paragraphs 1 and 2 to be re-worded. ROB provided the text. ‘ROB said if we were given a target for medicines incidents it would have to be 0. All we can do is mitigate against the risks with good control measures i.e: procedures. There is always going to be a human factor element that we cannot eradicate’. ‘RL said that he found this report very informative. He asked ROB whether we are made aware of and record all incidents; and whether someone could not record an incident. SG said that recording of incidents/errors is a professional responsibility.’

5. Page 14, third bullet point (top of page) Burse should read ‘Nurse’

5. Matters Arising

1. Action Log A review of the action log resulted in the following update: 19.11.15/06 – JT provided the criteria which will now been incorporated into the complaints procedure. This action was closed. 21.01.16/01 – CAMHS – SG provided an update; we have some historical benchmarking information but this doesn’t specifically draw out complaints. We are waiting for the next issue of the national benchmarking data to be released but we can also obtain this information by asking one of the providers for this. This action was closed. 21.01.16/02 –. An update was provided and is noted under Matters Arising point 3. This Action will remain open pending the initial review and marked as on-track. A recommendation was made by the Committee that the register of policies is brought back periodically to the Quality and Safety Committee meeting. 21.01.16/03 – Action Completed and can be closed. 21.06.16/06 – PD provided an update. A summary of the update is noted under Matters Arising point 4. Action to PD to provide a further verbal update will be given at the March meeting and the action to remain as on-track. 21.01.16/08 – DNA Figures - An update was provided by SAO. A summary of the update is noted under Matters Arising point 5. The action was closed. The action log was accepted by the Committee. 2. CAMHS SG said that what we have agreed is to bring CAMHS back as a thematic review. The more immediate issue was the medical input into the CAMHS team and the team consequently being concerned about that. We have had some dialogue with the Commissioners then their proposition came forward to be less reliant on doctors and be more multidisciplinary which would include psychology. PD has been doing some work

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ensuring that we are currently safe; working with the team leaders. We are as assured as we can be with the issues that were raised around staffing. This will need some investment; this is something the Commissioners are aware of. We need to ensure we have a credible clinical model going forward which meets the needs of the local population and this is work we are doing with the Commissioners. 3. Policies – An updated position The policies listed below were reviewed by the Quality & Safety Operational Group in November 2015. A list was provided at this meeting just for information. A few observations and questions were raised by members of the Committee. JT asked if all amendments to this list can be emailed to her following this meeting. JT advised the Committee that the list will be re issued to owners for a status update and we will be asking the owners to clearly identify which are policies, which are protocols and which are no longer are required and can be removed. The list will be updated and brought back to a future meeting. SG reminded everyone that in the Quality Strategy it states that where a policy is a legitimate policy and the review by the owner does not take place within the agree timeframe; we should issue an Internal Compliance Notice. Action DR to liaise with JT on timing for this list of updated policies to be brought back to the Quality & Safety Committee. Action 21.01.16/02 refers.

4. Recovery Plan and Quality Impact – TeMS PD presented this report to provide further information to the Committee in relation to Telford Musculoskeletal Service (TeMS) which is the new Telford integrated service that we are operating on behalf of the economy, following the last meeting of the Committee where concerns relating to the number of patients waiting were raised. The report provides an update of the current position re: Patients waiting to be appointed, Current Booked Waiting List, Current RTT position and a plan for TeMS to reach a 4 week waiting time target. In terms of an update and what is coming out of our recovery plan, we have introduced by way of this service a new model of care which will take activity away from the Community; this involves using extended care practitioners as part of that pathway along with GP’s with special interests to deliver some of the services which were previously being delivered by Consultants in hospital. As part of our investigation into how we can make sure that our lead times for services are being achieved; we have noticed that our biggest source of delay is relating to a lack of capacity with that grade of staff, so we have a number of things in place which has generated additional capacity into the system which isn’t currently in the system. We have been addressing how we would use that capacity and in the report you will see that what we actually will be looking for is a reduction in the current booking horizon weeks for GPs with special interests (GPwSI), Extended Scope Practitioners (ESP), T&O Upper and Lower Limb, T&O Spine and Rheumatology. This will allow us to run additional clinics. This is the key drive for our waiting list and we will see from our booking horizon target that we are committed to working to a 4 week pathway. In terms of how patients come into the system we are still observing that of all the patients that come into our single point of entry, approximately 70-80% of them are triaged at the first stage into physiotherapy then the remaining 20% will go into a medical led part of the system. We are confident that once we have these capacity issues dealt with and we have the staff in place we can look to bring the booking horizons down. In terms of risk and affordability this contract is delivered through a cost and volume trading base so the more people we see we are absolutely clear that the patients accesses the service are accessing appropriately so the triage into the service is critical and is performing particularly well so we do know that the patients. This gives the Commissioners assurance that we are dealing with the kind of patients that need that service. For every patient that accesses our pathway; there is a fee attached to that and when we talk about increasing capacity, we are then assured that the income related to that cost will follow.

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That concludes the main approach with resolving our waiting list issues. MR asked whether this is wholly funded by the Commissioners; PD responded to say the current position is there are two parts of funding for this; one being a calculation currently being drawn up in terms of predicted patients we will between now and the end of March and that will be multiplied by the pathway fee and be funded until the end of March. Going forward for the annual amount of pathways we are forecasting we will see in the service the Commissioners are budgeting on that basis. MR question was answered by PD that Yes, this is wholly funded by the Commissioners but currently is not sitting in a signed contract with the organisation so what we have to do, which we are working on urgently is, take what has been agreed in the set-up of the service and prior to the launch of the service and have that clearly defined in a contact identifying the pathway fee and the activity we are forecasting for the year. The critical thing now is to get a signed contract to make sure everyone is clear about what’s been agreed. 5. Did Not Attend data (DNA) – Update and assurance re: figures The reason for the significant drop in the DNA rate is due to a breakdown in service areas; we scrutinise high levels of non-attendance. There has been a noticeable dip in the overarching figure and is within the tolerance. SG added to SAO update by saying that we have released a media statement today (18th February) as this is a national; we report a 3.2% DNA in January. The two things which have gone out into the media are firstly, encouraging people to attend; we cannot guarantee someone’s health and wellbeing if they do not attend and secondly, we are actually encouraging people also to advise us if they do not need to attend so that appointment can be offered to another person. NOK asked whether there is any particular reason why people do not attend, is it because we don’t have a system whereby people can choose their own appointments and is it purely that we don’t give a choice to patients. SAO responded to say that patients are given a choice; some patients are contacted to ring and make their appointment themselves (partially booked) and some are contacted with an appointment already made for them. MG said that partial booking seem to be working well as we are giving the choice to the patient. Do we send reminders, ie: text, SAO said yes we have a mix of approaches and have found that text messaging is proving very effective. PD described a comms solution; TeMS is part of an integrated MSK system where we have a parallel service running alongside that for Shropshire. What we have tried to do is standardise our system processes. We have noticed that within the hospital they have an automated appointment reminder that will automatically contact patients and say ‘we are looking forward to seeing you on this day at this time, please press 1 to confirm you can still attend’ so they don’t rely on people to do that as we do. There are some hot spots in MSK with 10-16 weeks on booking horizons which can have an impact on DNA as people are less likely to attend especially if we have not got recurring reminders chasing them. When we were asking SaTH how they bring their DNA rate down; they are operating a different access policy to us, they only allow 1 DNA and the patient is referred back to their GP whereas in SCHT we allow two DNAs before we refer back to GP; we are reviewing our access policy currently. JMcK said that It’s very labour intensive to ring patients; an automated system is probably the best way forward. PD responded to say its variable in their ability to contact people as people are not always home as most calls are made in the day even when they have given their preferred contact number.

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6. Quality and Performance Report

Executive Summary DR presented this report to provide the Quality and Safety Committee with an overview against relevant sections of our performance for 2015/16 with the position as at 31 January 2016. Are we caring and responsive? We saw an improvement in the reported unmet needs for people with a Learning Disability back to 100% in January. Response times for complaints improved in January following three months of not achieving our internal target of 95% and were compliant in 100% of cases. Delayed Transfers of Care reduced from the 17% seen in December to 12% in January and we continue to be proactive and escalating issues within the local health economy as they arise. Friends and Family data for the Trust is not available at reporting however will be updated verbally at this meeting. We are moving on with providing an electronic response method via the smart phones that staff have to increase electronic returns which provide instant feedback. Inpatient response rates have significantly improved during January (rising from 10% in December to 36% of discharges in January) again due to the introduction of electronic tablets on the wards for volunteers and patients to use. We submit our data via UNIFY to NHS England every month. In December within NHS North Midlands we were third lowest (of seven Trusts) in terms of response rates. We have worked hard to increase our response rates in January and going forward and have seen an increase from 1.3% of all contacts (community services) to 4.67%. Are we effective? Data entry within 21 days remains amber for the year to date and stable in January – 96.75% against a target of 100%. The Unexpected Deaths indicator remains red - we did not report any unexpected deaths in January so the number remains at three for the year. Data for January was not available for bed utilisation, did not attend rates and overall length of stay, however, all three of these indicators remained green in December. Are we well led? We continue to see an improving position in relation to appraisal rates in January – we are now at 82% (up from 78% in December) against a target of 90%. The same position is seen for information governance requirements (now 87.34% against a target of 95%). Mandatory requirements compliance has increased from 84.39% in December to 85.78% in January and has therefore achieved the 85% target. The percentage of all leavers reduced from 1.16% in December to 0.54% in January but the indicator remains red for the year to date. Finally absence due to sickness increased slightly from 4.43% in December to 4.58% in January. This month’s increase appears to be seasonal as the top reason for absence was coughs, colds and influenza at 16% of all days lost. Are we safe? We have not seen any further incidences of Clostridium Difficile in Community Hospitals since the one reported in December leaving our total for the year at four. Safety Thermometer data shows a slight reduction in the Harm Free Care rate to 94.81% (against a target of 95%) but the percentage of patients that did not have a new harm (one acquired in our care) remained stable at 98.37%. The increase was seen in community hospitals with patients being admitted with pressure ulcers. We remain compliant for the second month running with the requirement to screen at least 95% of patients admitted to hospital for their risk of developing a venous thromboembolism. We reported two pressure ulcers grades three and four in January – both in community settings. These will be reviewed through our processes at the beginning of March. We did see an increase in the number of falls that resulted in serious harm to patients – five

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were reported in January, four of which were in Community Hospitals and one in an outpatient setting. These are being investigated at present. The following points were raised against sections of this report and are recorded here for completeness and action: Page 5 & 6

DTOC - A discussion took place around Delayed Transfer Of Care. DR referred to the red ratings on page 5. SAO said that we have put in a process to look at identifying harms and consider whether the delay is contributing to harm. In a community hospital patients still continue to receive on-going care if their transfer either to an acute or home is delayed. Most of our delayed transfers are currently due to delays in care capacity but we are working with the Councils to address this. We need to review the person’s needs at a point when they were booked to go home and see whether their needs have increased whilst they are awaiting transfer. SAO assured the Committee that each incident is looked at individually. As of today, 18th February; SAO reported that we had 16 people currently delayed.

SG added to the discussion; we are expecting the 16 people who are delayed to receive the right care which will come out of duty of candour. We need to make sure where we are sited on that, duty of candour applies because we may have caused harm by delaying some of these transfers into the right care setting. We need to ensure that their care plans have been responsibly delivered against any delay that might have been incurred by lack of e.g. Social care capacity.

Action to SAO to bring an update back to the March meeting in regards to this matter in terms of an Audit Plan and a Care Plan.

RB asked JT about compensation claims and whether all of the claims are upheld. JT responded and said that some are upheld; some are not and are dealt with on a case by case basis and can range from patients to staff. SG gave an example of a claim that was upheld; A patient’s home was damaged when equipment was delivered to their home.

RTT - MR asked for clarification within the report for Referral to Treatment (RTT) non admitted patients; this is showing as red in December 2015 at 93.89% against a 95% target. SG asked PD to confirm 100% whether the % is on open clock current RTT; PD responded and advised MR and SG that we cannot guarantee 100% by the end of March but can confirm that our RTT is compliant on open clocks.

Page 7 Waiting times - MR asked a question about waiting times – Child Development Centre. An agreement has been reached with the CCG to fund 12 additional MSK assessments in 2015/16. MR asked how the CCG have come up with a figure of 12. SG responded to say, the Commissioners have identified the people, we went back to the Commissioners and identified how we would spend the additional money on these individuals. MR asked SG whether he believed that the CCG expect us to avoid all these breaches if they give us this additional money; SG responded to say that the Commissioners know that this will not address all the breaches. This new pot of money will bring the appointment date for children newly referred in February forward from November to July. All children on the waiting list and joining the list will continue to breach whilst they are waiting for assessment. SG said that a further 20 additional assessments will be required in April to June 2016/17 to respond to the entire backlog of children waiting. A formal request to Shropshire CCG is being developed. Page 12 Appraisals -A significant increase in the number of staff receiving appraisals within a year was seen in January 2016 – 82% compared to 78% in December 2015. SG

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informed the Committee that this was partly due to a great improvement within clinical divisions, especially Community Hospitals and OPD. SG asked PD and SAO whether they predict that we will achieve an appraisal rate of 90% by the end of February 2016; both SAO and PD responded to say yes, they did think we would reach 90%. SG talked about Training and the figures which were highlighted in the pack we received from the CQC; some red areas were identified e.g. Fire. SAO and PD confirmed that by the beginning of March we will be within target. The Committee noted the content of this report.

7. Patient Experience Report – including Q3 complaints and PALS update Mark Donovan joined the meeting to present the Patient Experience Report. Summary of key points the Committee were asked to note:

Information about FFT scores and trends up to January 2016

Summary of 2015 Sit & See themes and trends

Patient feedback SharePoint latest

General patient experience updates. At the 21 January Quality & Safety Committee meeting MD said the report that was discussed provided a great deal of comments and visuals under the new themes we have developed. Much of the information focussed on the last 6 months of Friends and Family (FFT) and survey data.

The report MD is presenting today focuses more on FFT including January 2016 and Sit & See activity for 2015. Thematic information will be explored in more detail on a quarterly basis. MD said that the Patient Experience team are continuing to encourage staff and find new ways of sustaining and increasing our FFT response rates. The Feedback Intelligence Group (FIG) will be looking at this in more detail.

FTT MD produced some charts which will help present the data to the Quality and Safety Committee. The pie chart shows which areas our patients feel we need to improve on and clearly highlights the Environment and Facilities categories as the largest concerns. The other charts show a range of data; 98.09% recommend our services. This trend is moving in the right direction. Our response rates are averaging 400 with a huge increase in January, after a lot of hard work, to 1097.

Sit and See Observations Analysis 2015 The charts show that we had an 86% positive score for the Sit and See Observations which were undertaken by trained staff and volunteers in 2015. Again drilling down, the Community Trust main concerns came from the environment and facilities type issues as with Friends and Family Test (FTT) data. Podiatry chairs was mentioned as something we should look at.

Sharepoint Within the last three weeks we have managed to obtain over 90% staff responses to over 250 improvement backdated July to December FFT comments and 2015 Sit and See observations across the Community Trust from staff on our new SharePoint Site. This is a great leap forward in changing the way we do things and joining the loop, especially in light of comments in the staff survey that patients do not feel they have feedback on patient experience. Learning and actioning is key for staff and for improving the service for patients. Continued promotion of this new practice and results will be prioritised.

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General Patient Experience Updates o Dementia – Activities around dementia continue in both Whitchurch and

Bridgnorth Hospitals in particularly. Volunteers have now started undertaking activities with dementia since the ‘break the cycle week’.

o Carers – The Shropshire Local Health and Social Care Economy has been chosen as a pilot along with Staffordshire University for work around carers. This will focus on patient stories and narratives.

o Feedback Intelligent group (FIG) will meet in April 2016 to undertaking an analysis of the final quarter of 2015/16 feedback services.

o Local Health Economy (LHE) Patient Experience Group – meeting regularly and discussing and actioning new joint initiatives and sharing practice and joint working.

o Patient and Carer Panel – meets on 19th February with a comprehensive agenda. Patients, volunteers and partners will be attending along with the CQC. MD extended the invitation to attend this meeting to all the Q&S Committee members. .

o Training - Different feedback methods of training for existing and new initiatives will be taking place after Easter with staff and volunteers. Some Patient & Carer Panel volunteers will be leading on this. Another 19 volunteers were trained from Ludlow League of Friends were trained during February by our staff in key mandatory areas.

o Patient stories and national events – We are continuing to undertake more stories taken by trained staff and volunteers within the Community Trust. One of our Patient & Carer panel members has been asked to be a key speaker at Warwick University for the Elisabeth Garett Anderson Programme supported by the NHS Leadership Academy. The event is about Leading into the Future: Values into Action-Engaging partners to deliver person-centered care. The Community Trust Patient & Carer panel representative will share her patient story that she has already told in a variety of forums within the Trust.

Next Steps – Priorities

Communication and staff awareness - Work is continuing to happen across the Community Trust, so staff can access and assist with actioning and learning from patient experience feedback information. Themes, word clouds and other publicity material will be distributed during February and March will be distributed around Shropshire and Telford & Wrekin Trust services.

Electronic Devices - We need to continue to plan, encourage and facilitate more teams to use devices instead of paper where possible. This is happening in some services like Community Hospitals, MIUs and School Nursing.

Patient & Carer panel thematic work with Equalities and Young people groups will continue to develop over the next few months.

Peter Foord (PF) presented pages 6 -10 of the Patient Experience Report covering Complaints and PALS

Complaints and PALS The number of complaints received for Quarter 3 was 23. In Q3 eight complaints were upheld or partly upheld. For Q3 Stoke heath prison received the most complaints (5) and CAMHS the second highest (3). The largest subject area of complaints is in clinical treatments/Error; total of 13. It was noted that none of these complaints related to staff attitude over this period. It was recognised and noted by the Committee that 1 complaint exceeded the response time target. The Committee were also asked to be mindful that our complaints manager has

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been on long term sickness leave since December 2015. We have a bank/temporary manager in place now and any support we can give would be greatly appreciated. In terms of PALS a total of 55 enquiries were received by the PAL team in Q3; all enquiries have been dealt with. Compliments; 127 Compliments were received during this period. NOK asked PF what we count as a compliment; is it a formal procedure of something as simple as a thank you cards etc., PF responded to say it could be a card, emails, verbal thanks, feedback forms etc., and said we actively encourage comments; we receive complaints but it is very rewarding to receive a thank you from someone whether that’s received from a patient, relative or another member of staff. It was noted that the majority of our compliments are received in the hospitals. MR also commented on the 7 compliments we received from Stoke Heath Prison; and asked whether these compliments were received from prisoners or staff? PF was unable to clarify but agreed to look into this; he said it may simply be that the compliments have been saved up for a period of time and sent to us in one batch. MG noted that we have received both complaints and compliments for CAMHS (14 compliments, 10 complaints) in Q3 period and was pleased to say that the quality of service is very good. PF did add at the end of the discussion that it should also be noted, in relation to CAMHS Complaints, that they have had to deal with a change of clinician which may have some bearing on the figures. MR asked that the Carer Report is brought to this Committee once it’s been completed by the Patient & Carers Group. Action 18.02.16/01 to JT/MD to bring this back to either the March or April meeting. NOK thanked both PF and MD for a quality report and for their attendance at the meeting to present the data.

8. Equality and Diversity Report

JT presented this report to the Quality & Safety Committee with an update of the Trust’s recent work on equality and Diversity since the last report in September 2015. Highlights noted by the Q&S Committee : JT said that this report is all about making sure all our service responsive to individuals. Our staff are feeling respected which fits our Values and also meets our legal requirement under the Equality Act. Last year Equality was one of the themes of our ‘Away Days’ where we had speakers in. This year we have appointed three equality and diversity ‘champions’ in place for each of our main groups of services and in the ‘Everyone Counts Working Group’ we are working with those champions within the Trust to progress work in their areas (children and young peoples’ services, inpatient and outpatient services, and adult community services) working with the teams in their areas to self-assess our services for their strengths and identify areas for further work in relation to equality and diversity. Currently Children’s services are further ahead with Yvonne Gough leading for health visiting and a piece of work which Yvonne has completed is attached to the report. MD is working on a series of activities with all three ‘champions’ which they will be looking at over the next few months. JT said that the ‘Everyone Counts Working Group’ remit is to help develop the culture of the Trust so that everyone understands equality and diversity as part of making ‘Everyone Count’, and to make sure that both Service Delivery Groups and the Trust as a whole are

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working on practical equality improvements that will benefit patients and colleagues. The Group has developed an action plan that it is working to (this was also attached to the paper). JT also informed the Committee that we have signed up to a National Initiative ‘Enable’ (discussed at the December Board meeting) which is an organisation based in Shropshire that is nationally recognised as a supported employment service for people with disabilities. Enable have committed to working with our managers, supported by HR, to explain how they can assist individuals with learning disabilities. A presentation on this initiative will be given at the CTLG meeting. NOK thanked JT for this very comprehensive report. JmcK expressed a wish to be involved in ‘Enable’; Action 18.02.16/02 - JT to make contact with JMcK out of this meeting.

9. Healthwatch Enter and View Reports for Community Hospitals The Healthwatch reports were presented to the Committee by SG. The four hospitals; Whitchurch, Bridgnorth, Market Drayton and Ludlow were visited by Healthwatch Shropshire between October and November 2015 and will also go out into community teams in 2016 which is also good news. So, we have the Sit and See, Healthwatch and what the staff say in the Staff Survey about us which all together gives us some very comprehensive information. Where there were particular actions identified within the reports which required us to do something about them, we have pulled out separate action plans to address those. SG asked all Committee members to study the four reports and feed any comments back to DR and SAO. SG said we have already made some comments back to Healthwatch and what we are doing to address some of the actions. Going forward; an overarching action plan is being developed to pull all the actions together in one place. SG also said that we; the Trust do not have any issues with the CQC having sight of the reports. Action 18.02.16/03 to SAO to pull together an overarching action plan to bring back to the Quality & Safety Committee. . Following receipt of the Healthwatch reports; Healthwatch representatives met with JD and Stephen Chandler, the then Director of Social Care to discuss issues around delayed discharge that had been raised at all the hospitals. NOK said that she found the reports very positive and insightful.

MR asked about Ludlow, Day Room and whether we planning to use this room. SG responded to say yes, the plan is to use the day room but pointed out the bigger issue as being the use of this room to enhance someone rehabilitation when they have been delayed going home; enhancing their recovery. We need to look at productive uses for the day room and this will be captured on the Ludlow action plan. MR then asked about Whitchurch and GP cover; how serious is this issue and is it an on-going problem. SAO responded and said yes, unfortunately it is, we have had a temporary GP in there for a considerable time now but a long term model is being looked at now with one of the GP practices. RB asked whether our reports are on the Healthwatch web site. SG confirmed that we have agreed with Healthwatch that they can, be but we have not checked the web site to confirm whether they are on there or not.

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10. Service Delivery Group Dashboards – February 2016 SAO presented this report; the purpose of this paper is to provide the Committee with the headlines from the Service Delivery Group (SDG) Quality Dashboards produced in February 2016 reflecting January 2016 data. Community Hospitals and Outpatients Division SAO talked about the key points from the Community Hospital and Outpatients Division dashboards. Medicines Incidents: We can expect more unannounced security and medicines management visit out of hours. These have already raised some issues that are currently being addressed; these visits focussed on patient charts, handover information etc., Twenty one medication incidents reported during the month across the four hospitals Incidents: We have seen an increase in patient falls resulting in serious harm during January. There were two falls at Bridgnorth, one patient transferred to Birmingham where she sadly died, the coroner has received our report and we await the outcome. One other patient at Bridgnorth fell and sustained a dislocation of their hip. Infection Prevention and Control: One incident at Bridgnorth relating to isolating patient with MRSA and agreed with IPC to isolate in two bedded bays as no single side ward available. Mortality reports: There were no Unexpected Deaths reported for Jan 2016 and no issues raised from CSM review of Local Mortality Reviews for December. Mazars Southern Health Report: For information NHS England has published an independent report into the deaths of people with a learning disability or mental health problem at Southern Health NHS Foundation Trust, and highlighted a system-wide response. The report was commissioned by NHS England (South) following the death of Connor Sparrowhawk in July 2013 in a unit in Oxford run by Southern Health NHS Foundation Trust. This Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 report is available via this link: https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf The Medical Director and the Mortality Group are reviewing the findings and recommendations.

Workforce Metrics: Appraisals – 80% Sickness Absence – 6.4% It was noted by SG that there was no figure reported for mandatory training; SAO said that she would check this figure and update the report accordingly.

Feedback from Visits: Bridgnorth, Bishops Castle and Ludlow took part in a Mock CQC inspection with critical friend from the TDA, some areas / issues for addressing are required and feedback has been given to the heads of department. Actions are in place to address the areas raised. Health watch report and action plans were shared with both hospitals at their ward meetings.

HMP/YOI Stoke Heath had the annual offender Health Commissioners Quality review on 2nd February 2016. Positive verbal feedback received. The lead pharmacist commented on

https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf

https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf

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significant improvements in medication rooms and the implementation of safe processes. All reviewers commented on good relationships and rapport between nursing staff and patients, and also the wider multi-disciplinary team. The cleanliness of healthcare facilities was good, but the private contractor needs to provide cleaning schedules for all healthcare areas. The prison have been asked to review prison officer staffing levels, in that there is no officer presence within the healthcare centre during core clinic time. Long term condition management was praised and highlighted as good practice. The CSM has been asked to speak at prison conference for North Midlands to advise others on how to manage long term conditions in prisons. There were no comments made by the Committee on the content of the data for Community Hospitals and Outpatients Division. Community Services Division SAO talked about the key points from the Community Services Division dashboards. Key risks:

Blood glucose meters trust wide (score 6). Contract signed by execs but problems with EU tender monetary thresholds. Procurement tasked to explore NHS regional and national contracts to use these to progress. Trust policy updated and SOP written, sent to policy ratification group on 28.1.16. Team leaders compiling a list of all meters needing replacement. Dental - Replacement meters being sent out to staff with NEO meters. This is now on the Corporate Risk Register

Diary Issues/Omitted Visits (score 12). Compliance with Trust guidance on record management is adhered to. Implementation of EPR will remove all risk.

Provision of equipment – demand (score 12). Service review by Trust and CCG expected imminently. Financial risk, no risk to patient care. Option appraisal paper to Feb Resource and Performance Committee.

Incidents: Two serious incidents reported during January - one pressure ulcer and one fracture fall. Medication incidents – six reported in January. Learning from Feedback: Thirty compliments submitted to Complaints and PALS team for logging; one complaint relating to CNRT. Safeguarding: There have been three safeguarding alerts in January; two relating to concerns about discharge from acute services and one relating to patient choice. Workforce Metrics: Appraisals 79% Sickness Absence – 5.25% Mandatory Training – 86.97%

Cross Divisional Update – adults Clinical Effectiveness Programme: The Clinical Effectiveness Programme for 2015/16 remains on track for completion. Managers are required to provide proposed audits for 2016/17 Clinical Effectiveness Programme by early February. Audit proposals received at the meeting for Q4 2015/16

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audits and surveys; Audit of compliance against NICE Guidance 183 – Drug Allergy.

. Children’s’ Quality Dashboard SAO talked through the Key Risks for the Division relating to quality of care:

Referral rates and waiting times Shropshire CDC (score 12). Weekly waiting list validation, monthly review of trends, risk assessment of each child’s needs – agreement about type of assessment

Dental Practitioner Workforce (score 12) Raised at HR and Workforce Group MSK related health issues for dental team (score 12) Exploring the installation of

aids and adaptions to relieve potential strains on staff Senior/Specialist Dental Practitioner/Officer Recruitment (score 12) Raised at HR

and Workforce Group Specialist IT support for Community Dental Service (score 15) Raised and

developing an action plan with IT

CAMHS – Large Caseloads (Score 9) Review of current workforce and establish recruitment needs

Workforce Metrics: Appraisals – 89% Sickness Absence – 3.36% Mandatory Training – 92%

Learning from Feedback: FFT: Departmental feedback on actions through SharePoint. Excellent response to actions from Imms and Vaccs team and Children’s Dental. Sit and See: Four actions as a result of Sit and See; one for Health Visiting and three for Shrewsbury Dental, the latter of which are complete.

Complaints: In January two complaints received; one relating to CAMHS and the other to School Nursing Service.

Safeguarding: Seven incidents in January:

Concerns raised relating to a referral where the notes indicated several incidences of bony injury

Health Visiting - Not informed of meeting relating to LAC

CAMHS – referral not made to CAMHS for child with multiple problems when moved to the area

School Nursing – Childs health records missing

FNP – concern about behaviour of father

Health Visiting - not informed of changes to early help meeting

School Nursing – child’s case not allocated to worker

MR raised concerns as there are several incidents and asked how are they being missed. PD responded by saying, if we take the third bullet point and discuss that one, CAMHS referral not made to CAMHS for a child with multiple problems when moved to the area; PD said everyone who comes into the service has a complete screening carried out, our team on this occasion noted multiple problems were evident of the patient record, but they for whatever reason did not have the information in the file to see and understand the story around how the child had been picked up; there was a lack of intelligence around who is doing what for this child. NOK asked for confirmation whether these were safeguarding alerts or incidents; are these

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near misses that could have led to harm; this is not clear within this report. Julie Harris, Safeguarding lead agreed to look into the issue of ‘harm’ and whether we caused harm. This committee does not need the detail just some assurances, the actions and the learning. MR asked for assurance that these incidents have not come to light because we have caused harm. Action 18.02.16/04 to Julie Harris to report back to the Committee. SG noted that the % mandatory training for the Community Hospitals, on Page 5 of the report is showing as blank. SAO agreed to have the report updated for the next meeting. SG noted that PD had recorded no serious incidents in January 2016; SG asked PF to include Duty of Candour information in the future reports. Action 18.02.16/05 to SAO to include Duty of Candour data in this report going forward. SG also noted that the SI data is incorrectly recorded on this report. We did in fact have a recorded SI whereby a dentist extracted an incorrect tooth. This is not classed as a never event as no long term harm was caused and SG confirmed that also no complaint raised by the parents of the said child. A route cause analysis is being performed and will be included in the next report resented to the Committee. Action 18.02.16/05 to SAO; include a route cause analysis in the report going forward.

11. CQC Pre Inspection Briefing Provider Level Report This report was presented to the Committee by SG. NOK made a comment on the excellent, informative and comprehensive report received from the CQC which gives us an idea of where the CQC may focus their attention and how they view the organisation (this is November data). SG highlighted the key issues to the Committee: It’s important we know what the organisation is about and have some understanding. We are not expecting people to be able to quote the vision and values but to have some general understanding. Top three clinical risks (any Director or Senior Manager should be able to articulate our top three risks if asked by the CQC):

Staffing

o Community Hospitals

o CAMHS

Quality Challenges

Culture

JT reiterated that these are not the top three on the BAF (these are a different Top Three). We are being supported by the TDA. The Internal Audit report is linked back; make sure we are compliant for 365 days a year and not just w/c 7th March! If you have any comments to raise on the report please feedback to JT today as the deadline to feed back to the CQC is today, 18th February. MR made an observation on the first report; pre-inspection. There are two pages of comments re: hand wash basins and asked why? He asked whether we should be putting money towards rectifying this and why this has not been addressed. SG responded to say that the delay is due to a dispute we are having with our current provider of Estates and Facilities services; it’s not just the issue of the hand wash basins.

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MR also asked about the beds at Whitchurch being too close together; what are we doing about this? AT responded to say that in addressing this issue we would have to close 11 beds to move the beds further apart. SAO said that the closeness of the beds has not caused any privacy & dignity complaints to be raised by patients; SG responded to say that we are not causing harm and the distance between the beds is compliant with the rules. Overall SG said that the report was a great way of presenting everything together and maybe we should be looking to do a similar report ourselves on an annual basis. The Committee agreed.

12. Internal Audit Report – Internal Preparation for CQC visit There were no items raised on this report by the Committee.

13. Safer Staffing Report

SG presented the two reports together, Community Services and Community Hospitals and Outpatients as there have been a couple of national updates about staffing.

1. Since April 2014 reporting on inpatient staffing levels, each month we submit a return for Inpatient Services through UNIFY system. There is currently no requirement re: Community Services but we have chosen to report these figures along with the inpatient figures.

2. In addition, the Carter Review came out a few weeks ago and one of the recommendations in this review we will be a requirement for us to report our ‘care hours’ . There is still some discussion on-going about those care hours will be calculated.

Community Services This report seeks to identify any triangulation between incidents, staffing levels, sickness, appraisal levels and mandatory training within the 8 Interdisciplinary (IDT) teams. SG then presented the Community Services Safer Staffing Report and highlighted the key points: 1. The project to improve team resilience by merging Bridgnorth and Much Wenlock

Nursing teams on to one site by mid -March 2016.

MR asked SG for some background on this merger; SG said going forward there are three particular challenges:

the Intelligence around acuity and dependency

Vacancies

What is the right model moving forward in terms of localities and also building into that the Integrated Community Services model as well so we see it as a whole.

The proposal going forward will be looking at localities and equally as important we should consider when recruiting about not specifying a fixed work base. We need to be sensitive when talking to GPs and the CCG in terms of how this gets translated. We will also need to do a quality and impact assessment. NOK asked whether both teams are concerned about merging, SG said that the staffing concerns were more around Much Wenlock and the other concern was that the GPs may express concern that they may be losing something as a result of the merger. Some conversations have taken place already. There is no real clinical concern; it’s more a practical concern about being flexible to work in another location.

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2. Review of the demand V Capacity challenges facing the Telford South team

Staffing levels: within the IDTs are aligned to minimum staffing levels agreed by the Team Leaders assessing the week to week workload Incidents: In January the IDTs reported 7 staff incidents as per the table above. None of the incidents relate directly to inadequate staffing levels. Vacancies: Of the current 8 team leader positions across Shropshire and Telford 4 are currently out to advert. On review of this position it is noted that two posts had been supported for 6 months with interim backfill awaiting a final position on the New ways of Working project, one is a team leader taking up a long awaited CPT post within the Trust and the fourth is taking a position outside of the Trust to be closer to home and family. A newly appointed Matron will commence on the 4.4.16 and for the first time each IDT will have matron support within their team. Vacancies are being appointed to in a timely manner and no issues relating to recruitment have been identified.

Sickness Absence: Sickness absence for nurses increased to 6.72% from 6.43% in January 16. This relates predominantly to long term illness Appraisal Rates: Appraisal rates in January are at 79% with an anticipated rise to 90% by the end of February 2016. Recovery plans are in place for each team to achieve this. Mandatory Training: Mandatory training remains static at 87% and will continue to be prioritized as part of the daily workload.

14. Safer Staffing Report – Community Hospital and Inpatients SG said we have for two years submitting data and that’s only our fill rate. Key for us is around the summary of key points:

1. There has been no reported harm to patients as a result of staffing levels/incidents. 2. Overall staffing fill rate is 107.7% 3. Registered Nurse vacancies will be down to 2.65 wte when recruited staff are in

post and skill mixing is completed. However, 2.60 wte RN’s are currently working their notice.

4. Reduced agency usage in January (219 shifts) compared to December (272 shifts).

Immediate concern is the drop in the registered Nurses. Nationally, there is conflicting information around staffing, with a 1 registered nurse/8 patients ratio (not endorsed by NICE) in terms of staffing, some reports are saying that if you don’t do the 1/8 there is an increase in mortality, then we have our own staff saying we need more un-registered staff compared to registered there are different views of what is the right and SG suggests a future Board or Q&S Committee meeting takes time to have a bigger discussions including CSMs and Ward Managers.

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At a future Board or Quality & Safety Committee meeting. Action 18.02.16/07 to DR/SG to include CSMs and Ward Manager’s discussion on staffing. A lengthy discussion took place around registered/non-registered staff. The Committee asked for this to come back to a future Quality & Safety Committee meeting to discuss in more detail. Action 18.02.16/07 to DR to build into a future agenda. On this subject NOK expressed her personal respect for non-registered staff; with the right training they do an excellent job and provide excellent patient care; SG agreed. Going forward SG gave assurance to the Committee that we have safe staffing levels, all our shifts are covered, staff vacancies are looking healthier; all of which are positive. SG also advised the Committee that post April this data will be reported differently.

15.

Ludlow Hospital Inpatient Ward – Monitoring of Impact of Change Following the Transfer of all In-Patient beds to one Area on the Ground floor adjacent to the existing Dinham Ward. SG presented this report and highlighted the conclusion of this report:

1. Positive feedback received from both patients and staff. 2. Incidents in the 6 months after the transfer are lower than the number of incidents

prior to the transfer. 3. No access issues for patients to be admitted in to the beds with 78% of the patients

allocated a bed on the same day as the request. 4. Length of stay at Ludlow currently under the combined average length of stay for all

the community hospitals. 5. Medication incidents generally decreasing.

Action 18.02.16/08 to SG to report back in 6 months’ time when we reach the 1st anniversary of implementation of the change. MR suggested that the report can also go to the Full Board and the Public Session – the Committee agreed. SG was pleased to say that since the change was made, we have received no complaints in terms of access to beds from anyone, including the LoF or from the local MP; we should be able to take some comfort from this. JT added to this informing the Committee that there was actually one issue raised by an MP, an individual felt they were unable to access a bed in a timely manner but this was during the month of the change. NOK asked whether we have made any progress with utilising the space upstairs now. SG said that currently we have not made progress but confirmed that the area is underused, under occupied and we should be able to put that are to better use.

16. Policies for Notification None this meeting.

17. Risks/Assurances:

Risks identified at the meeting: None at this meeting.

Assurances given at the meeting: None at this meeting.

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16. Any Other Business JmcK raised a question about the cuts to non-emergency Ambulance Services which has been announced by the CCG. How will this impact on our DNAs if patients are unable to physically get to their appointments. SG said if this happens a Quality Impact Assessment will be carried out; if there is an impact we would report back on that.

Date and Time of Next Meeting Thursday 24 March 2016, 10.00 am – 13.00 pm, Seminar Room 5, SECC, Royal Shrewsbury Hospital, Shrewsbury, Mytton Oak Road, SY3 8XQ

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MINUTES OF THE QUALITY AND SAFETY COMMITTEE HELD ON THURSDAY 24 MARCH 2016, 10.00 – 13.00,

SEMINAR ROOM 5, SHREWSBURY EDUCATION AND CONFERENCE CENTRE ROYAL SHREWSBURY HOSPITAL

ATTENDEES – check membership Rolf Levesley, Non-Executive Director (RL) - Chair Mike Ridley, Chairman (MR) Jan Ditheridge, Chief Executive (JD) part meeting Dr M Ganesh, Medical Director (MG) Nuala O’Kane, Non-Executive Director (NOK) Paul Devlin, Deputy Director of Operations (Transformation Lead) (PD) Dee Radford, Lead Nurse for Quality (DR) Rita O’Brien, Chief Pharmacist (RO’B) Roger Buckley, Volunteer Representative (RB) Lucy Wilkinson, PA to Director of Strategy – Minute Taker GUESTS: Angela Cooke, Head of Nursing and Quality, Adults (AC) Karen Taylor, Service Group Delivery Manager (Community Services)(KT) Andrew Thomas, Head of Nursing and Quality, Adults (AT) Jo France, Head of Nursing and Quality, Childrens (JF) Cath Molineux, Nurse Consultant (CM) Liz Watkins, Infection Prevention & Control Nurse (LW) 1. Welcome from the Chair

RL welcomed those present to the meeting. RL gave an additional welcome to AC and

AT and thanked them for joining the meeting.

2. Apologies

Apologies were received from:

Steve Gregory, Director of Nursing and Operations (SG)

Sally-Anne Osborne, Deputy Director of Operations (SAO)

Julie Thornby, Director of Corporate Affairs (JT)

Jane McKenzie, Non-Executive Director (JMcK)

Milly Smith, Volunteer Representative (MS).

3. Declaration of Interest

There were no declarations of interest presented at the meeting.

4. Minutes of the Meeting Held on 18 February 2016

The minutes of the meeting held on 18 February 2016 were agreed as a true and accurate record with the following exceptions:- 1. Page 6 - MD clarified the information regarding the additional MSK assessments by

commissioner. 2. Page 9 – MR queried where the compliments for Stoke Heath Prison had been

received from. Action: DR to look into and let MR know. 3. Page 12 - Implementation of safe processes around prison office staffing levels

within the healthcare centre, NOK confirmed you can feel quite vulnerable when alone in a cell with someone. Action: AT to speak to Wendy Sweeny and report back to the committee on assurance around this process.

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4. Page 14 – MR queried if there was an update on the issue of hand wash basins, he agreed to bring this matter up later in the meeting when Liz Watson was in attendance.

5. Matters Arising

1. Action Log

21.01.16/01 - CAMHS Thematic Review – RL queried the timing of the review, RO’B confirmed it would be later this year. 18.02.16/01 - MR queried if the Carers Report was available yet, DR was still waiting to hear from the Patient & Carers Group. The action log was accepted by the Committee 2. Wheelchair Services – Quality of Life The Committee previously raised concerns regarding patient waiting times in Wheelchair Services. KT confirmed a recovery plan was put in place in February and the number of patients waiting more than 18 weeks is reducing. KT explained this service recorded initial referral and receipt of wheelchair times as opposed to most services who record initial referral date and first contact date. Of those patients waiting more than 18 weeks 10 patients were waiting for a wheelchair, the remaining were waiting for modifications or a renewal. Service leads are to produce bridge reports for new referrals that don’t already have a wheelchair to ensure they are seen more quickly. The majority of patients who don’t already have a chair will currently use a buggy and a decision has been made to change this to a chair. 3. Update re TeMS Contract PD confirmed this was being picked up by Ros Francke, Director of Finance and Andrew Nash, Chief Finance Officer, Telford CCG and it is close to being finalised.

6. Quality and Performance Report

Executive Summary DR presented this report to provide the Committee with an overview against relevant sections of Trust performance for 2015/16, with the position as at 29 February 2016. Are we caring and responsive? There has been a reduction in Delayed Transfers of Care (DTOC); it has been confirmed the Trust has received a higher number complaints this month with 13 across a number of services; the trust continues to see an increase in the number of friends and family surveys competed including an improved rate for CAMHS where the Trust has struggled historically. This could be helped by the use of electronic versions. Are we effective? There have been four unexpected deaths YTD two of which were within Community Hospitals (CH). Length of Stay (LOS) has decreased to 17 days from 21 days in January, the year to date (YTD) figure is 19 days against a target of 20 days. Are we well led? Staff appraisal rates appraisal are improving, as is performance against Information Governance (IG) requirements, however we are still below target. Mandatory training compliance remains above target at 88%. Sickness absence increased in February to 5.51% with a rise in back pain, HR and Occupational Health are working together to try and improve this.

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Are we safe? There has been one further case of Clostridium Difficile (CDiff) bringing the yearly total to five against a target of two, analysis of the incidence showed there was nothing staff could have changed, the patient was transferred from an acute setting and was treated with antibiotics. Safety thermometer data shows Harm Free Care at a rate of 94.96% against a target of 95%. Two pressure ulcers were reported a grade 3 and grade 4. The number of falls previously reported were reviewed at the RCA Challenge meeting in March. The following points were raised against sections of this report and are recorded here for completeness and action: DTOC

RL queried where the Trust is with availability of care packages for DTOC in terms of working with social services, PD confirmed the Urgent Care Working Group discusses the flow of patients through the system to match hospital needs and to continue the flow into the discharge rate required, more attention is required in this areas to maintain and make further improvements. There are high variances in discharges from acute services which the Trust struggles to accommodate, to bring more level discharging into Trust services we need to be robust, to better predict and accommodate flow. The Trust is fortunate to be in a good position for bed availability. JD explained there were five patients with DTOC last week which has reduced significantly from sixteen. The majority are small numbers but this creates big percentages.

The ongoing care required when patients were not transferred to CH beds initially needs to be looked at for commissioners, there needs to be access to palliative care and CH beds need to be used in a more focused way.

There needs to be a change in the way patients are admitted which will create some issues, conversations are taking place to decide the best way to use community beds. We need to ensure when one area improves due to increased focus, we don’t lose sight of other areas; a system needs to be developed where everything is being focussed on.

Pressure Ulcers

MR asked for clarity around pressure ulcers, a patient transferred to the Trust from an acute setting already had an ulcer, the claimant states they received inadequate care within the acute setting and with the Trust. The Trust Risk Manager has met with the ward manager to assess the impact of liability and gather more detail to ensure the Trust provided adequate ulcer management. DR confirmed the grade 4 pressure ulcer was regarded as avoidable.

MR queried the process around Serious Incident (SI) meetings, DR confirmed the Trust meets with commissioners, they ask the Trust about its processes and for further clarity around any issues, this is to ensure commissioners are content with any investigations and to share any information.

Falls

RL asked if there was anything the Committee needed to know regarding the spike in the number of falls a few weeks ago, was this systemic or a trend. DR confirmed all recent falls were reviewed as were additional historical falls, this was helpful to enable the Trust to identify any shared problems. The fall in Whitchurch hospital was investigated, the death of the patient was not a result of the fall they sustained and nothing further came out of the review. Actions going forwards for staff to remind patients to call for help when finished in a bathroom and IPC are to look at the pedal bins provided for hand towels, they were not a factor but it is something to look at going forwards. AT confirmed there was more detail in Enclosure 5, Disability Access Assessments have been arranged on all CH wards one example of what this will cover is that all call bells are in the right place.

Staff Appraisals

JD highlighted the Trust has hit the 90% target for staff appraisals for the first time, but

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queried how service and quality leads will maintain this over the next year. PD confirmed there is a month on month improvement of available information through the Service Delivery Group, enabling the team to routinely have a plan. The group aim to review key policies and reports using a very visible scorecard every month for monitoring and rationalising. The existing reporting is at a high level with the aim to have this at team level within the next couple of months by using the InPhase system; the performance team are helping to construct this to make it a regular tool. KT confirmed her team are at 95% for staff appraisals, with data improvement and direct reports weekly from the performance team KT can check the information and cascade it to team leaders and beyond to team level, stressing the importance of training and appraisals to ensure it is a priority.

Care Quality Commission (CQC) Feedback

JD highlighted the initial feedback from CQC showed some staff was unsure of the Trust Vision; this could be managed through the appraisal process as well as to ensure staff are supported in managing their caseloads. Staff shouldn’t be meeting managers just once a year for their appraisal, there should be regular catch ups, as a process to ensure a quality appraisal. AC confirmed the use of the ESR system to schedule appraisals as well as additional meetings through the year. Trust objectives are discussed at team meetings at the beginning of the year and reviewed at subsequent team meetings. JD asked how often managers meet with their direct reports, are managers confident that meetings cover where the Trust is aiming to go? AC and KT were not sure this happened, as often the day job took over. JD explained feedback highlighted that conversations with line managers are not visible; staff don’t understand the Trust Vision and staff don’t feel valued. KT confirmed staff meetings are not given the priority required and need to be more visible regardless of the additional time pressure; managers need to understand the impact of communication. RL confirmed it is important to communicate within teams and it needs to be a priority. JD explained meetings with direct reports should not be cancelled, as a line manager you have to give yourself permission to not cancel these meetings, as a leader you need to support your team. A more standardised format to 1:1 meetings may help to get across the message that these meetings are important.

Mandatory Training

JD took the opportunity to remind Board members that IG training needs to be completed if they have received a reminder to say theirs has expired.

JD asked the committee to discuss the current target for mandatory training of 85%, as a Committee are we OK that 15% of staff are not compliant? Is the target high enough? The Trust will need to decide, should the target be 100% as in other organisations or should we allow an error margin. KT raised that some staff are on long term sickness and unable to complete their training. RB felt it would be useful to know the reason for not achieving a 100% target; it would give a different perspective. RL asked if a target of 95% would be more appropriate and accept that 5% of staff won’t achieve the target. NOK wanted to acknowledge the improvement made, with the target previously at 75% it has proved that raising the target has worked on improving completion rates, it is unfair to set a target that we know is unachievable, however 95% is absolutely achievable. Action: The Committee agreed to change the target to 95%.

CAMHS

MR queried the CAMHS short term action plan, PD explained additional clinics funded by commissioners are taking place and have had a positive impact, the Trust position is to plan to maintain a higher level of cover, however additional funding from commissioners is short term. Going forward nothing can be done without additional funding, certain staff skills are required to ensure workforce capacity and not exceed the 18 week wait and ensure patients are safe. The waiting list is constantly prioritised and reprioritised to ensure the more acute patients are seen more quickly.

Referral to Treatment (RTT)

JD highlighted the underperformance for RTT, PD confirmed the update in the paper for the last meeting has moved on quickly. JD asked how this was being tracked, PD

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confirmed through this Committee and Resource and Performance Committee (RPC). JD asked how this was shown as there is no reflection of recovery plans within committee reports. Action: Going forwards this information is to be included within this report, to show if RTT is off track, if so details will be required of the recovery plans to be put in place.

MSK

PD provided a quick update on MSK as requested by MR. Sign off is currently with Resource and Performance Committee (RPC) and will be completed end of March. This will give the ability to draw activity direct in the patient information system which has been accepted by Shrewsbury & Telford Hospitals NHS Trust (SaTH) and commissioners. The Trust can look at bringing in an additional capacity plan, to ensure an increased level of activity from the beginning of a service. SaTH are to agree if extra sessions are available to clear the existing backlog.

CAMHS Paediatric Consultant

NOK asked if there was any development with the appointment of a paediatric consultant within the CAMHS team. Unfortunately the candidate has removed themselves at the last minute. JD confirmed initial conversations to change the team model and provide medical leadership have taken place, NOK asked if recruitment will be paused until the model has been agreed. RL wanted assurance that this would not increase the risk of harm to patients; MG confirmed the issue with consultants leaving has not led to an increased risk. The introduction of the health and wellbeing for 0-25 year olds will change the current service which only covers patients up to the age of 18. PD explained work is already underway to highlight the changes this will bring to the required skill mix and to be clear what is required; the team are already beginning to make changes.

Trust Board Visits

MR and SG undertook a Trust Board visit to the IDT team in Oswestry, a question was raised, why have separate ICS and IDT teams when there is lot of crossover, what would be the pros and cons of merging the teams, not just in Oswestry but across the county. JD confirmed ICS is a separately commissioned service, they facilitate early discharge and work on admission avoidance for the acutely ill to be treated in the community, IDT provide planned care within the community, there are some areas where this may cross over but the teams are not the same. As their work progresses teams will understand more of a blend of IDT working close to primary care and acute working. This is not a quality issue. KT confirmed there is close working taking place to identify opportunities for the teams to work together as opposed to merge.

RL found his Trust Board visit to the Shrewsbury DAART team very interesting, and wondered if there was an increased role for the team to take in keeping patients out of an acute setting. JD confirmed the expansion of DAART would be looked at under the review of ambulatory care pathways.

7. Healthwatch Enter and View Reports for Community Hospitals – updated action

plan

AT presented the report to the Committee and the following key points were noted:

SAO requested an overarching plan following the visit from Healthwatch. There is an action plan included as part of the paper with concerns expressed around the food in CH, patient services such as television and radio, a focus on facilities i.e. the use of day rooms and dining rooms and in Whitchurch the skill mix needs to be looked at. All recommendations have had actions and lead names applied to them plus a completed progress update. AT has challenged one recommendation around the use of a butterfly to identify dementia patients, the butterfly scheme is an opt in scheme by patients or carers, it is not to be used as a label or an identification scheme.

JD confirmed the Trust had asked Healthwatch to visit, they undertake a range of visits, objectives and activities to support in the local community and have spent an

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enormous amount of time within acute trusts. The people involved have a long history of patient or public involvement. Although they have not received much official training they do understand what good looks like and are able to get feedback from members of the public who have been patients. When the feedback is received the Trust doesn’t necessarily do everything recommended, the feedback is taken in context with what else we know, some recommendations are reasonable but all are worth thinking about. JD asked if there was a sense of what success looks like. How will we know when we have got there?

Following the Trust Development Authority (TDA) infection control visit an action plan has been drawn up and presented to the committee, AT confirmed validation of completion of actions. RL felt it may be a worthwhile to do a short quick exercise to look back and see what has changed. JD felt this could be cross referenced with the system wide plan.

MR asked if there was any progress on the Ludlow day room refurbishment. JD wasn’t sure this needed to be done. Action: AT to check if any work was planned and report back to the committee.

MR asked if there was any progress on the provision of GP cover at Whitchurch. The decision on whether to merge two or three GP practices has delayed any decisions on this. JD confirmed it was the Trust’s intention to employ a substantive GP given the situation. The plan for the new model of working is to be updated, possibly using a salaried GP provided from Bridgewater Medical Practice temporarily. Whilst cover is being provided so there was no risk to the service.

8. Service Delivery Group Dashboards – March 2016

PD and AT presented the report to the Committee and the following key points were

noted: The Service Delivery Quality and Safety meeting covers key risks to quality discussing incidents, learning from falls, safeguarding issues and infection control with subsequent action plans discussed and validated. There is more work to be done around ownership and feedback on improvement. Work with Patient Advice and Liaison Service (PALS) to ensure they have contacted service managers where necessary. The group also monitors sickness absence, mandatory training and discusses any feedback from external audit, CQC and TDA visits. Community Hospital and Outpatients Division

JD asked for clarity around section six of the report on Safeguarding. AT explained the Trust had to take a Section 42 following an enquiry on the service by the Local Authority (LA), a FAST positive patient is one showing signs of a stroke. In some cases the Trust are best placed to undertake the enquiry as staff have the relevant expertise. AT confirmed there is no risk, but a couple of actions need to be undertaken in relation to safeguarding adults. RL asked if there was a training issue following the Section 42. AT explained an allegation was made about an inadequate response to a patient suffering a stroke, after the enquiry and a period of reflection additional training has been undertaken not specific to the team involved.

MR queried the five duties of candour, AT confirmed there are no details around these, they have been seen previously, in a high level duty of candour report within the original dashboard. Five is reasonable for one month.

Community Services

RL queried the two safeguarding alerts for February, if they were significant and if any action is required. Both were within care homes, AC confirmed there was a Section 42 for a related patient who acquired a brain in jury in care. The patients husband was her responsible adult not power of attorney, the husband had not been following the management plan when the patient was in a home setting, causing problems when the patient returned to the care home. The husband didn’t understand the

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patient no longer had capacity, staff worked with the husband to put in a more robust care plan and the husband is now much happier.

Childrens Quality Dashboard

One thing to note is the dramatic improvement in the level of engagement for updating the SharePoint website which is working well, with the aim of seeing the impact of new emerging themes and original areas to improve on.

MR asked if there was a risk following the reduction in the Health Visiting (HV) budget for Telford & Wrekin (T&W) budget. PD explained the reduction of £220k income will lead to a reduction in the service. The team are working with commissioners; this requires an efficiency change in service delivery. An impact assessment and plan have been formed and are acceptable to both parties, the loss of income will mean a reduction in the service, the required outcomes are no longer achievable with the new level of resource. PD confirmed there will be a reduction in staffing but this would happen through natural wastage.

MR asked for more information around being unable to schedule new childhood immunisations. This relates to the child health information system taken on by Birmingham Community Healthcare for a regional wide provision, during the transition the Trust has had to put mitigation in place to boost the gap between going live and the system being problem free. The team are currently doing work arounds to make sure they don’t lose sight of any child’s vaccinations. PD confirmed he is happy with the mitigations put in place but there are still children at risk. JF confirmed the team are liaising with GPs to schedule vaccines and develop our own local system to reduce the risk of a delay in routine immunisations, not having the vaccine or potentially having 2 vaccines. The risk has moved from commissioners to the Trust as there was previously a working system. JD confirmed the action is out of the Trusts hands however staff are trying to mitigate the risk, commissioners have been unable to delay the transfer even with the gap in the service.

9. End of Life Audit Report

CM joined the meeting to present the End of Life Audit Report and the following key

points were noted:

The clinical audit took place just over 12 months ago, and implementation started February 2015.This was the first clinical audit around EOL for many years. In July 2015 the EOL CQUIN looked at EOL care within patients’ homes and CHs, the Trust aims to also look above and beyond the CQUIN. Community Nurse (CN) case notes and expected deaths within CHs were reviewed retrospectively from Jul-Sept 2015, two general themes emerged. 1. The aim wasn’t to just count the number of patients on an EOL plan but to look at

how well documented the plan is and to see if there is any evidence in the patients notes, or broader priorities and clinical indicators, there wasn’t good evidence documented around spirituality, although this may have been discussed with patients it had not been documented.

2. 2 EOL plan not used or if so not used well, another audit will need to take place with different parameters, with training around the EOL plan on going to catch new entrants to the organisation. Training around palliative care needs to be reviewed to provide a structured programme.

The EOL plan training is open to care home staff as well as Trust staff. The training team at Mercian House are unable to provide admin support for this training course and staff from care homes have a better attendance rate than Trust staff. Once Trust staff have attended they have to update ESR manually to reflect their attendance. Some GPs have identified that they do not wish to use the care plans, this has been raised with CCGs and Trust staff have been asked to raise incidences on Datix to try and gain an understanding of the fear of using the plans. KT confirmed a lack of engagement with some GPs, there is possibly some misunderstanding around who is

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best to initiate the plan, this can be done by a nurse. Discussions have taken place with the CCG to see about the possibility of some joint training with GPs and nurses.

ROB queried the required medication for EOL patients, GPs are not always providing prescriptions as per the EOL plans, there is some confusion around what is included within the ‘just in case’ boxes. Karen Stringer (GP) has now joined the EOL Group which should help with resolving any issues. One key issue is the lack of prescribing for higher doses of Diamorphine, GPs may not have training within EOL like the CNs so there may be fear and anxiety around prescribing higher doses.

JD felt there needed to be direct links within the team to improve the way the team communicate, also there needed to be more detail within the conclusions in the report.

JD asked CM if she had anything she would like to say to the Committee regarding the recent initial CQC feedback. CM felt it was a very positive experience as EOL lead and the feedback is helpful in terms of identifying gaps in the role. It highlighted the need for dedicated time for EOL. It helps that CM now receives relevant Datix reports which can be analysed and reported to the operational group. JD asked if the Trust were to receive a warning notice for this area would that be reasonable. CM felt that would be a little harsh, the Trust does provide good EOL care. EOL training is delivered to team leaders for them to disseminate to their teams, therefore it is not unreasonable to have 50% of staff trained. All were given the opportunity to attend and the training wasn’t mandatory. CM explained to CQC the responsibility fell at team level, to cascade information so team members were aware. JD felt it needed to be clear how many were expected to attend and by what date to set the bar, whether this is classed as training or awareness. The sessions are only 1 hour long.

The audit shows that even in cases where the EOL plan wasn’t followed, good care was still given, the process to engage with GPs needs to be integrated.

MR found the report very interesting, is it reasonable and satisfactory that there is only 76% compliance for issues around nutrition and hydration and only 57% for assessment of clinically assisted hydration and nutrition and discussions with the patient and family/carers? Evidence of this should be at 100%. Assisted hydration is a grey area, whether artificial hydration should be given is included within the EOL individual assessment.

GM queried if all patients should have an EOL plan, CM confirmed yes if the patient was an expected death there should be a plan in place. GM confirmed in the case of children it is clearly identified when a senior clinician starts the EOL plan, it has to be signed by a senior clinician. The philosophy is that a joint decision is made but it does require GP sign off, it is not expected that a GP or nurse will do in isolation. GM felt it would be challenging for a GP to complete if there was insufficient training as they could be challenged for accountability, it should be included within their training and it is in the Trusts hands to take forwards.

RL found the report useful. JD felt it didn’t reflect all actions required it needs to be updated to include more detail to reflect discussions at the EOL Group. The report needs to be bought back regularly to the Committee for sight on important issues.

MR asked if records of patients are incomplete for EOL care, should the Trust be worried about patient records generally. The problems with the EOL plan is bringing all involved parties together, the notes are fragmented and only tell half a story, different information is held by GP notes, hospital notes and community team notes. There is a danger this is similar in other areas, leading to concerns about the quality of records. JD confirmed this is a broader issue, the Trust has a range of record reviews, Action: These need to report to the Committee for an annual check.

10. Revalidation for Nursing Staff

AC presented the report to the Committee and the following key points were noted:

The Trust needs to raise awareness with clinical staff that as of 1 April 2016 all nurses and midwives will need to revalidate. There have been various methods to raise the profile across the organisation, information at staff away days; raised by the HR team;

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roadshows; 1:1 support offered; national nurses day. Staff will be emailed one month before validation is due to be offered help. It has been identified that there is some confusion around lead validations with IT issues at registration. Staff will be contacted regularly by email prior to date of validation due to the amount of information some may wish to upload.

There are a small number of staff who won’t want to revalidate so will leave the organisations. Work needs to be done to make staff aware what can be used within their portfolios to make it a less frightening experience for some.

JD asked if there was a risk to the organisation is it similar to staff forgetting to register, if staff slip is there a process in place? Those arrangements are already in place and are no different to registration. There has been some confusion over renewal and revalidation dates, a fee is payable every year for renewal and the revalidation is the fitness to practice.

NOK asked if people can fail revalidation. AC confirmed it is a robust process to provide evidence of fitness to practice; pulling a portfolio together takes time. There can be an issue when not much prep has been done, the Trust can assist with examples of what can be used as evidence, so it isn’t seen as a massive pieces of work. RB asked who assesses the portfolio, AC explained an initial discussion takes place with another registered nurse regarding CPD and a form is signed to say the discussion has taken place, followed by a conversation with your manager around evidence, again this is signed off and put on file, to be uploaded the month revalidation is due. AC confirmed there is an internal process to randomly select portfolios to look at.

GM felt staff should be supported to reduce anxiety around the process and be given time to complete the process. NOK asked if those qualified for a long time would struggle more as this wouldn’t be common practice. JD confirmed the process isn’t that different to how it was previously, it may be difficult for nurses who don’t invest in development or value reflection. There will be a mix, some staff will have always done this, any nurse who has completed post registration education will have covered modules on portfolios.

11. Feedback following CQC Compliance Inspection March 2016

JD presented the report to the Committee and the following key points were noted:

JD asked the committee for reactions on the initial feedback letter from the CQC, there is currently an opportunity to respond to assumptions, to provide more evidence if available or where the Trust recognises the need to do something quickly and therefore have either taken actions or recognised actions and are working on them. It is recognised that this is not the final report but there is the opportunity until tomorrow to submit further evidence and JD would like to hear the Committees or individual’s perspective.

RL queried if there was anything as a matter of urgency, JD confirmed there was an issue with staff being called into work due to staff shortages, the same thing was witnessed in an unannounced visit. There was a specific concern regarding substance misuse and a lack of medical oversight which needed immediate action; and an issue with a lone worker at one site, a member of staff wasn’t sure if a nurse would come if the panic bell was pressed. The draft report due in 3-4 months time would be the next chance to offer additional information.

GM confirmed that the substance misuse team does provide a direct link for supervision of staff, prescribing and medication changes are carried out by GPs. GM has been reassured via email that all appropriate processes are in place and feels there is no concern in this area and there is no clinical incidence. GM is assured the Trust is doing all it should be, JD asked how he has assurance and GM confirmed he has seen staff appraisal documents which show that there are relevant processes in place.

RL felt there is a strong message in the feedback around providing assurance or

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reassurance. JD reflected, the way questions were answered didn’t necessarily give outside confidence that there are policies in place, that staff are aware of the data quality processes, more references could have been made for clinical governance purposes.

NOK felt as a member of the Board that they receive a compete overview of the Trust and evidence is available to support that. Not everything is just accepted at face value, but as a non- exec member it is not appropriate to drill down into the detail.

The Trust may not have reflected how sophisticated it is. Being a small organisation staff know each other so can be reassured that things are as they should be when informed by a colleague, assurance will need to be framed differently going forwards.

MR queried if the Committee should assume checks on agency and bank staff have been revalidated and checked. As a Committee there are a range of things in place for challenging the use of agency staff.

KT gave an example of a nurse using out of date information. She was treating an EOL patient, whilst checking she was in line with Trust policy, there was no signal to access the most recent policy so she referred to a 2007 version which she had to hand, however this copy had been cross referenced with the latest 2012 version, this wasn’t mentioned in the feedback.

JD explained the initial feedback was shared as staff needed to hear it. In terms of challenging the feedback the following issues were highlighted: o MIU staffing – action is in place to ensure when a RCN is on their own in

Bridgnorth a HCA is also available. o EOL –it will be made clear that not all staff were intended to attend the training

sessions. o Community adults - evidence from the staff survey o Poor incident reporting – the available league table shows as an organisation we

are not poor in this area some teams don’t report as well as others. o Staff survey - actions are in place o CAMHS – are not poor in Telford, they have good facilities and the noise issue

will be dealt with. The Trust is comfortable it is aware of issues within the CAMHS service.

o Cleaning of toys – this will be sorted in child development, dental and inpatient areas, it is to be challenged as there is no other evidence.

o Substance Misuse - action will be taken to ensure changes to the process, to ensure the Medical Director is notified.

RL thanked JD for providing the detailed feedback and felt it had been very helpful. He also asked to congratulate staff from the top to the bottom of the organisation for all the hard work that has been done in preparation for the CQC visit.

12. Infection Prevention and Control (IPC) Quarterly Report

LW joined the meeting to present the report and the following key points were noted:

LW confirmed SG had approved the report. DR had previously updated the committee on the C Diff case in Bridgnorth. As a whole the Trust has had 5 cases of C Diff within a twelve month period against a target of two, all cases have been deemed unavoidable, patients did require antibiotics, were treated appropriately and are all now fit and well and have been discharged.

Any areas that score below 90% during an IPC visit are then self audited. The main issues for low scores within CH are detailed below: o Cleaning issues –dust o Equipment dispensers o Limescale on taps – this can be a big problem, a water softener has been

installed at Whitchurch CH, hopefully this will ease the problem. o Staff bare below elbows – no one was picked up on this by CQC and it is looked

at during all IPC visits o Laundry – this is in hand and meetings are taking place with the Estates team, the

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next meeting is due to take place in June.

The C Diff target set for 2016/17 by the CCG will remain at two over a twelve month period. This will be challenging but there are lessons to be learnt from this year.

The TDA head of IPC Deb Adams visited Trust services in the Oswestry Health Centre and the DAART team at Robert Jones & Agnes Hunt Hospital (RJAH). Following this visit an internal improvement notice was issued to all services within the Health Centre and DAART concerning standards of cleaning, the location of equipment and disposal of waste, an action plan is being developed. The issue with the Dental team has been raised previously and was dealt with at the time, however they have reoccurred so this needs to be looked at.

JD queried that cleaning of toys was mentioned by the CQC. This is picked up on self audit tools for HV, MIU, Children’s Services, it is to be added to school nurse tools and discussions are ongoing with speech and language teams with the possibility of providing a standard operating procedure for toy cleaning across the Trust. The challenge for the CQC is if the toys are on sites which Trust teams use but the toys don’t belong to the Trust. RL felt Oswestry Health Centre was significant, there are many services within the building so cleaning and maintenance can be an issue. AC and KT confirmed they have found the same issues on more than one occasion so processes need to be in place to ensure once an issue s dealt with it is maintained.

PD thanked IPC for supporting teams around the Trust proactively whilst recognising and being mindful of the structures and resources available to teams. Responsibility for some of these areas is not always specified within anyone’s role, this needs to be picked up to ensure they are covered by someone’s remit. The workforce needs to be considered, with the possibility of more clinical support staff. It is reassuring that it is visible that issues are picked up within audits and are being taken forwards.

Additional training is required for volunteers on the wards at Bridgnorth CH; this is underway however the Trust doesn’t want to lose volunteers due to training requirements. LW confirmed many volunteers has received IPC training in particular staff who operate the tea trolley and work within the League of Friends (LOF) Café on site, this is to ensure hand hygiene compliance. Further work needs to be undertaken to convince volunteers they need to be bare below the elbows, to educate them why and explain the reasoning behind it. Improvements are being seen, but this can sometimes happen when IPC staff are seen, the message needs to be reinforced that it is for the benefit of the patients. It needs to be handled carefully to avoid volunteers leaving over this issue.

13. Mazars review of deaths of people with a Learning Disability or Mental Health

problem

MG presented the report to the committee and the following key points were noted:

MG wanted to assure the Committee that there are relevant processes and systems in place for undertaking mortality reviews. There are no challenges from the review and the Trust is doing a good job. Going forwards the way deaths are recorded can be changed, currently there is no electronic way of identifying patients, and hopefully the new Electronic Patient System (EPR) will rectify this.

RL found the considerable evidence of being already compliant, very helpful and clear suggestions have been made.

AC asked if there was anywhere a new member of staff to the organisation could be signposted to see the Trust definition of what is classed as a disability for an adult. GM confirmed there is a lack of domain for this. AC sends in monthly data for a report but it is felt that better data collection is required.

14. Safer Staffing Report – Community Services

KT presented the report to the Committee and the following key points were noted:

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KT explained that Community Services don’t use Unify for data submissions for their reporting. The service is aiming to triangulate staff incidents within Community Services’ team with staffing levels. This hasn’t proved possible historically due to no identified incidents. An incident was identified by the South East IDT Team at Bridgnorth in February, it was reported that there were adequate staffing levels.

There has been an issue with inadequate staffing levels for a Continuing Healthcare patient (CHC) which involved a member of staff working through their lunch break and extending the length of their shift, when drilled down it became apparent the staff member chose to stay on to support an EOL patient, when agency staffing was withdrawn. This issue has been raised with the CHC teams and has been resolved with suitable actions in place to resolve any future similar situations.

There are a number of clinical vacancies in the South Shrewsbury IDT Team and a number of actions are in place to resolve this issue, a recovery plan is in place going forwards. The aim is to have both Shrewsbury team working more closely during the recruitment periods.

KT has looked at the reasons given for individuals leaving their roles, various reasons given were from wanting to work closer to home to the workload of the roles. One staff member commented that when they joined the service each day was planned, however the role is now more responsive and more fluid. This didn’t mean more patient visits per day just a change in the work required. KT confirmed more work needs to be done to merge different cultures from different teams, an action plan is to be produced with simple steps to achieve this.

RB queried the appraisal rate of 93% and how many this was in terms of staff numbers, he felt as a percentage it didn’t give a clear picture. KT confirmed it covered 200-250 staff member in total. RL stated that suitable progress has been made with hard work by managers.

KT confirmed to RL that the staff merger in Bridgnorth was still going ahead with HR support and is due to be completed by mid-April.

15. Safer Staffing Report – Community Hospital Inpatients

AT presented the report to the Committee and the following key points were noted:

There were twelve staffing incidents reported in February none of which resulted in harm to patients. They were mainly down to unplanned sickness, bank and agency staff not attending for pre booked shifts, therefore leading to an increase in workload for existing staff.

There is currently vacancies for 4wte across the inpatient wards in the CH’s, two nurses have been recruited and are due to commence shortly, the remaining two vacancies are both at Ludlow CH, interviews were held on 14 March.

Whitchurch CH currently has five nurses who are serving their notice, of these, two are leaving for a promotion within the NHS, the others have cited personal reasons. AT will look at their exit interviews with Clinical Services Managers to find out if there is any further information on their reasons for leaving. There is a recruitment drive at Whitchurch on 7 April so hopefully that will prove successful.

Ludlow currently have three nurses due to go on maternity leave.

The key actions required are to continue to recruit registered nurses; a proposal has been submitted for a revised ward establishment to use care assistants and propose a nurse practitioner role to help with mental health issues. The overall staffing fill rate is 101.2%.

RL stated there has been a dramatic spike in sickness with three nurses on long term sick, AT confirmed two are due back this week, and that there had been a viral cough and cold illness going round in February.

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16. Policies for Notification:

None at this meeting.

17. Risks/Assurances

Risks identified at the meeting:

Nurse validation – If existing staff are not prepared to revalidate and are happy to leave, will this create a staff shortage issue for the Trust, therefore possible increase in agency spend.

End of Life Audit Report – information around EOL care discussions/actions is not being recorded accurately in medical records, in light of this, could there be further areas with inaccurate patient records.

18. Any Other Business

None at this meeting.

Date and Time of Next Meeting 21 April 2016 from 10.00 – 13.00 at Haughmond View Medical Practice

1 | P a g e DRAFT Quality and Safety Committee minutes _ 21st April 2016

Minutes of a meeting of

QUALITY & SAFETY COMMITTEE Held on 21st April 2016 at 10:00am

The Board Room, Severn Fields Health Village, Shrewsbury. SY1 4RQ Present : Rolf Levesley, Non-Executive Director (RL) Mike Ridley, Chairman (MR) Nuala O’Kane, Non-Executive Director (NOK)

Jane McKenzie, Non-Executive Director (JMcK) Steve Gregory, Director of Nursing and Operations (SG) Dr M Ganesh, Medical Director (MG) Julie Thornby, Director of Corporate Affairs (JT) Sally-Anne Osborne, Deputy Director of Operations – Adults (SAO) Paul Devlin, Deputy Director of Operations - Children (PD) Andrew Thomas, Head of Nursing & Quality – Adults (AT) Dee Radford, Lead Nurse for Quality (DR) Rita O’Brien, Chief Pharmacist (ROB) Jo France, Head of Nursing & Quality – Children (JF) Roger Buckley, Volunteer Representative (RB)

In attendance: Deborah Hammond, Learning & Development Manager (DH) Mark Donovan, Patient Experience Lead, (MD) Jayne Williams, PA to Director of Nursing & Operations (JW) Apologies: Jan Ditheridge, Chief Executive (JD) Milly Smith, Volunteer Representative (MS) Minute number: Year/ month/ minute

Agenda Item title Action

2016/04/01 Declarations of Interest (Agenda Item 3) None were declared at this meeting

2016/04/02 Minutes of the Previous Meeting held on 24th March 2016 (Agenda Item 4) The minutes were amended as follows:

Page 5, Trust Board Visits, line two should read ICS not IDS.

Page 6, last paragraph of item 7, second from last line should read Bridgewater Medical Practice not Bridgnorth Medical Practice.

The minutes were then agreed as a correct record.

2016/04/03 Matters arising not covered by the rest of the Agenda (Agenda Item 5)

Action Log Monitoring 21.01.16/1 CAMHS Thematic Review – SG agreed to include implications and impact of the tender in the review. 18.02.16/01 Carers Report – DR said the final report will be included on the May agenda. 18.02.16/02 Enable – JMcK and JT will arrange to meet with Fiona McPherson to get involved with this initiative. This will also be one of the items on the May CTLG agenda. 24.03.16/02 Stoke Heath Safe Practices with Healthcare AT confirmed that an annual Prison Safety Audit is conducted and a list of ‘at risk’ prisoners is held. AT was confident in the systems;


giving assurance to the Committee. JMcK requested a copy of the initial assessment undertaken on all prisoners as they enter the prison. AT agreed to provide this information to JMcK. This Item was closed at the meeting. 24.03.16/05 Ludlow Day Room Refurbishment – This item was completed but SG said for completeness AT to write a letter of thanks to the League of Friends.

Urgent Care update re potential harm to patients SAO led a discussion on Delayed Transfer of Care (DTOC) and whether we were causing harm. Where identified deterioration of the patient is evident we look back on all cases to determine whether DTOC was a contributing factor. SAO also gave an example of a patient who went home with a wraparound care package; if we had not done this, the patient would have ended up in long term care. SAO said we have shared our processes on identifying harm and set targets and aspirations.

Quality Strategy – verbal update on progress A summary sheet for Quality Strategy is on the agenda for the next Informal Board meeting. The three Heads of Nursing and Quality are running a series of engagement events whereby they will share the Quality Strategy.

Whitchurch GP’s update SG briefly touched on the latest position with regards to Whitchurch GPs. He also informed the Committee that this issue is on the next R&P Committee agenda. SG agreed to circulate the brief to all Q&S Committee members and all NEDs.

AT

AT

SG

Monitoring of Action log from the previous meeting This items was discussed under minute No. 2016/04/03

2016/04/04 Quality & Performance Report (Agenda Item 6) The Executive Summary was presented by DR and outlines the Trust’s performance for March 2016 and is aligned to the CQC domains of quality – caring, responsive, effective, well led and safe services. Are we caring and responsive? Some data for March under this

domain were not available at the time of reporting. We saw a drop in

compliance against targets for responding to complaints – this was

due to capacity issues in the team which is now back to full strength.

The percentage of Delayed Transfers of Care remains stable at 10%

but is still above the 3.5% target. As previously reported we continue

to all we can to ensure that people’s discharges are not delayed.

Friends and Family data was not complete due to the timescales for

UNIFY at the time of reporting – a verbal update will be provided at

the meeting. There is a drop in performance for 18 week RTT for

non-admitted patients. This indicator is no longer monitored

nationally however the Trust continues to monitor this indicator

locally as part of its performance framework. Performance for

February is 93.76% against a 95% target.

An error in the Caring and Responsive figures was highlighted by DR

as she presented the report; Page 3, number of complaints should


be 67 not 79.

Wheelchair Services is still an area of concern. MR and JMcK asked

SAO for an update – SAO explained that the delays were in the

waiting list not capacity. The waiting list is measured from point of

referral to completion. If a wheelchair requires modification it is

looked at per individual; an assessment is made as to whether the

patient may be at risk of harm if this modification is delayed – this

then becomes urgent.

Another question raised by JMcK to AT in relation to MIU and the

number of patients coded as ‘left without being seen’. AT took an

action to prepare a paper for the May Q&S Committee.

Are we effective? We reported an unexpected death at a

community hospital in March 2016. This brings the number of

unexpected deaths in Community Hospitals for the year to three.

This was reviewed by the Mortality Group on 14 April 2016. Overall

length of stay has increased from 17 days to 20 days but remains

within target. MG gave a little more information on the unexpected

death; 93 year old patient, UTI infection – a sample was not sent for

testing and failing in some recording was identified. An investigation

and a Root Cause Analysis (RCA) is being done; MG will report back

on the findings at a future Q&S Committee meeting. The RCA will

also be shared with all 4 Community Hospitals.

MR asked SG what the target for length of stay will be set at for

2017/18; SG said that 15 days will be the aspirational target.

Are we well led? The position relating to appraisals has deteriorated

from the 90% we saw in February due to the inclusion in the data of

bank staff. However, permanent staff figures for appraisals remains

stable at 90%. Information Governance rates are still below the 95%

target. Sickness Absence rates are the highest since January 2013

largely due to seasonal illness and possibly also due to periods of

sickness not being closed on ESR about which action has been

taken. The first meeting of the Quality and Safety Delivery Group

has taken place; workplans will feed up into the Q&S Committee

meetings.

A report written by Capsticks, a specialist health and social care law

firm relating to Liverpool Community Health NHS Trust was

mentioned in this report. SG advised the Committee that the

Capsticks report would be discussed at Board.

Are we safe? We saw improvements in the percentage of people

screened for VTE risk in Community Hospitals and also the rate of

Harm Free Care (NHS Safety Thermometer) in March. Both of these

have exceeded their target for the month. However, we did record

one fall as a serious incident as a patient sustained a fracture but it is

not clear if this was caused by a fall she sustained in hospital or

AT


whether she had been admitted with the fracture. Investigations are

ongoing.

The Committee accepted the assurance provided by the report in relation to the Trust’s performance as at March 2016.

2016/04/05 Culture Working Group (CWG) (Agenda Item 7) DH joined the meeting to deliver the progress against Culture Working Group Implementation Plan 2014-17. The Committee were asked to consider if the activities of the CWG support our direction of travel; is anything missing in light of the recent CQC visit and our staff survey results. The committee was also asked to consider what they and the Board can do to support the CWG. The Culture Working Group is making good progress against its implementation plan, which is regularly reviewed and updated with new plans and initiatives as things progress. There is still work to be done to keep our plans on track such as:

Freedom to Speak up Guardian - a series of options for consultation will be circulated to staff via Inform, existing focus groups (e.g. Community Trust Leadership Group) and JNP.

SALS (Staff Advice and Liaison Service) pilot to be arranged, perhaps in conjunction with the Freedom to Speak up Guardians consultation above.

Human Factors (or a more accessible name) theory and applications to be included in the upcoming Leadership programme for all leaders B6 and above. JT said to be mindful that this should not just be B6 and above; this is important training and should be available to everyone.

Possibility for further Human factors education for all staff to be included in new Freedom to Speak up Guardian / SALS coordinator role.

New Leadership programme proposals to be linked with the New Managers’ Handbook.

Our first PULSE survey results to be analysed and fed back into Culture Working Group before disseminating to all staff.

Everyone Counts focus group to solicit BME staff experience feedback.

‘Values into Actions’ is a piece of work being run by Organisational Development; SG informed the Committee that this piece of work will be taken to the Transformation Programme Board in May. Acknowledgements: RL thanked DH for this report. This will return to the Q&S Committee quarterly. The members felt it was a very comprehensive report and highlighted for the Committee the important work that the CWG are doing. MG congratulated the whole team and acknowledged the definite change in culture.

2016/04/06 Themed Review – Patient and Staff Experience (Agenda Item 8) MD joined the meeting to deliver a presentation which was well received by the Committee and generated some useful discussion. A copy of the presentation is attached to the minutes at Appendix A.


The review was undertaken to further develop the Trust patient and

carer feedback systems. So far we have:

• Built a team of staff & volunteers

• Gradually brought in a range of qualitative & quantative

methods to look at service user feedback

• Implemented FFT, Sit & See/Observe & Act, Patient Stories

and focus groups

• Brought data collection, analysis & action together through SharePoint/Meridian and the Feedback Intelligence Group (FIG).

Our F&F figures are at 90%; people would recommend our services to others. We have also had two new volunteers joined this year and we need to ensure we support them as much as possible.

JT suggested that topic’s raised by people using our services (not just F&F); should be included in the SDG reports. An action was given to MD/DR to liaise with PD/SAO for future reports.

MD said that the Environment is still one of our biggest issues; the FIG have invited a member of the Estates team to their next meeting to try and address some of these issues. MD sits on the Local Health Economy Group to discuss specific patient experiences over numerous services. As the Community Trust is not always the complete pathway of a patient’s journey; we should be measuring the entire pathway and not just our bit.

SG said that we need to ensure the good news items are out in the local press; develop strong working relationships with the press and produce a monthly ‘Good New Stories’; this is being developed by MD and Andy Rogers.

MD/DR

2016/04/07 Service Delivery Group Dashboards; April 2016 (Agenda Item 9) This paper provides the Committee with the headlines from the Service Delivery Group (SDG) Quality Dashboards produced in April 2016 reflecting March data. AT presented the Adult SDG Quality Dashboard and JF presented the Children’s SDG Quality Dashboard. Adult SDG Quality Dashboard The keys risks for the Adult division were discussed. A few areas were talked about in more depth:

Patients with dementia/one-one supervision – we are out to advert for an Advanced Nurse Practitioner (ANP) with Mental Health background/skills.

Number of Serious Incidents reported = 2 o Patient fall at Ludlow o Ludlow MIU

Incidents/Themes brought to the attention of the Quality & Safety Committee highlighting the increased number of medication incidents within the Shrewsbury South IDT - A recovery plan is being developed and will be shared with the Chief Pharmacist and Trust MSO. ROB said that the omissions in the report were due to work allocation not being done quick enough.


Workforce Metrics – Appraisals complete 92.6% slight increase; where Mandatory training remains static at 89.3% and a 1% improvement in sickness absence at 5.58%. Children & Families SDG Quality Dashboard The key risks for the division were noted by the Committee. No incidents reported. No Duty of Candour. Workforce Metrics - Appraisals complete 93.24%; Mandatory training at 91.7 with a new 95% target which has been shared with Managers. Sickness absence at 4.91% hotspot areas is CAMHS and Health Visiting South Shropshire. Safeguarding - School Nursing (Telford & Wrekin) - high

safeguarding caseloads, action plan with mitigations in place

following discussion with Julie Harris, Named Nurse for Safeguarding

Children and Young People. Escalation to SDG risk register

requested at SDG Q&S meeting. This has been highlighted as a Risk

as it’s a small team of School Nurses with 20-40 children per nurse

which is too high! This is being raised at the next Safeguarding

Board meeting.

MG asked JF whether we are supporting our school nurses; JF

explained that yes we are, the funding has been reduced. We are

looking at the 0-19 agenda and working with Health Visitors to work

with/support the school nurses; skill mixing. We are talking to

Commissioners; they are aware of the cost pressures. In terms of

caseload Telford and Wrekin have less school nurses than we have

in Shrewsbury and Oswestry.

2016/04/08 Data Quality – Referral to Treatment Internal Audit Report (Agenda Item 10) DR presented this audit report and informed the Committee that the report had already gone to the Audit Committee but was deferred at the meeting to a future meeting. An audit of Data Quality – Referral to Treatment (Incomplete Pathways) was agreed as part of the 2015/16 approved Internal Audit Plan. Part of the NHS pledge is to put patients at the centre of everything

they do, which involves making sure that patients are diagnosed and

start treatment as soon as possible. As a result patients have a legal

right to start non-emergency NHS consultant-led treatment within a

maximum of 18 weeks from referral, unless the patient chooses to

wait longer or it is clinically appropriate for the patient to wait longer.

‘Consultant-led’ means that a consultant retains overall clinical

responsibility for the service, team or treatment.

The Overall Conclusion: The review has highlighted that there is a

process in place for the recording of referral times however; the

application of the process needs strengthening. Based on sample

testing of data in support of the ‘open clocks’ reporting data for

October 2015, errors in regards to the recording of referral dates

were not consistently reflective of the actual referral dates and in

some cases the date stamp on receipt was not recorded. It should


be noted, however, that the sample testing highlighted errors which

would not have affected the accuracy of the performance against the

Referral to Treatment indicators. From the testing it was also

identified that validation checks of breaches were found to not be

consistently undertaken. Whilst the data collection and calculation of

the Trust’s compliance with the performance indicators is consistent,

the underlying data as described consisted of weaknesses in terms

of accuracy and reliability. Our opinion, therefore, reflects these

findings.

Internal Audit Opinion: Taking account of the issues identified, the

Board cannot take assurance that the controls upon which the

organisation relies to manage this risk are suitably designed,

consistently applied or effective. Urgent action is needed to

strengthen the control framework to manage the identified risk.

An action plan has been developed and is in the process of being

updated and training embedded – this will be monitored to ensure

compliance.

SG informed the committee that he had met with the auditor to

discuss this report and said that there wasn’t a major issue with the

reported data and he is confident that we have reported correctly

although he could not give complete assurance that we have the

right systems in place; we will be addressing all the critical issues

raised in the audit report. SG also informed the Committee that there

is no requirement to report this data but we have a monthly meeting

with the TDA where we share this information. The Chair asked for

some assurance from SAO and SG that the issues are being

addressed. SAO was actioned to re-audit (internal audit) and

bring back to the June Q&S Committee meeting to give

assurance that the issues are being addressed and resolved.

SAO

2016/04/09 Inspection Reports – HMP/YOI Stoke Heath: (Agenda Item 11) SAO presented these reports.

CQC Visit following Requirement Notice The purpose of this unannounced visit was to inspect those aspects that were of concern at the previous CQC inspection in April 2015. The report shows that the inspection team considered aspects of care under the domains of quality and found that these had been addressed since the previous visit. The only recommendations the Trust should progress related to complaints management and infection control audits both of which will be addressed.

NHS England - Clinical Quality Visit Report This annual announced visit was carried out on 02 February 2016. Feedback from the visit was positive and the team were congratulated on their progress to date. The report highlights positive areas such as clinical supervision in place, long term conditions management being progressed and the development of new prisoner information packs. The report indicates that no areas were considered as requiring remedial action (red), some outcomes were graded as amber meaning that areas require further development and some were green meaning that the majority of areas were covered with actions


in place. The report also summarised challenges including lack of prison officer support at medication hatches, the provision and siting of grab bags and maintenance issues. The Divisional Manager for Community Hospitals and OPD has required an action plan to be developed by 03 May which will be reviewed at the SDG Quality and Safety meeting in May. Key headlines from the two visits were discussed: Positive:

Working relationships

Notes improvement in Wellbeing

Clinical supervision

Long term conditions

Production of information packs for prisoners Negative:

Management of complaints

Support for prisoners – additional posters

Hand hygiene

Waste/duplication of medications – ROB said this was down to a storage issue; patients being moved to different wings; the drugs are not always moved with the prisoner so duplicates are ordered – notification of moves needed in a timely manner so drugs moves can be coordinated. ROB also informed the committee that there are only a handful of patients at Stoke Heath that have controlled drugs.

RL said there has been a lot of progress made and in light of the negatives we have no red flags.

2016/04/10 Safer Staffing Report – Community Services (Agenda Item 12) SAO presented this report and highlighted the key issus: Area to note for two reasons is the Shrewsbury South IDT. Vacancy levels increased last month, as reported previously and medication omission incidents increased. Whilst there is no direct correlation between the two factors it must be assumed that the team are not functioning to their optimum. Recovery actions are in place. SG said that following regular discussions with the South IDT they would be very keen to share their experiences with the Board. We are looking at better ways of working i.e. possibly North and South becoming one team. RL asked SAO if the sickness could be mapped against the teams – this would be a more useful graph for this report. An Action was given to SAO to address this for future meetings. Key Actions: The vacancy levels within ICS and use of agency is being reviewed as part of the ‘Review and Do’ project. Recruitment to band 5 therapy posts in the North and South have been particularly problematic. We are now reviewing what banding is required, how this position can be made more attractive and re advertising. The assistant CSM for ICS will undertake an audit to identify the number of duplicate assessments that are undertaken by therapists for

SAO


patients throughout one episode of care.

Trust OTs have commenced work, following the ECIP support, to develop a model of OT delivery that provides as much OT patient support as possible in the patients home. The primary meeting took place on the 4th April with proposed models for review anticipated within a month.

Shrewsbury North and Shrewsbury South now have their core functions; team leader, admin and triage collocated. The caseloads have also been reviewed to provide greater resilience whilst both teams have vacancies. Week one appears positive.

2016/04/11 Safer Staffing Report – Community Hospital Inpatients (Agenda Item 13) SAO presented this report and highlighted the key issus:

There has been no reported harm to patients as a result of staffing levels/incidents.

The overall staffing fill rate is 102.2%.

Registered Nurse vacancies in the community hospitals will be 0.51 wte when all appointed staff are in post.

There are 6.0wte RN’s who are currently working their notice at Whitchurch Hospital. SG met with the team; some disharmony in the team; SG ran a truth’s session. Of the 6 leaving only two will remain but in different roles. It is worth noting that there were no major clinical concerns highlighted by the CQC. SAO noted also that we are still maintaining safe staffing levels. To keep agency staffing to a minimum we have not fully opened MIU at times; MR asked how many agency staff we are predicting to need for April as opposed to March; SG responded to say that he expects that the level will further reduce. A recruitment day is being held on 7th April. SAO said that the open day was very successful; HR were on site, we recruited one Registered Nurse and a significant number of support workers – 10 people in total. A further three people will be interviewed who were unable to attend the open day.

There is 3 RN staff currently working their notice in the prison. These posts are being advertised.

Key Actions:

Recruitment of Registered Nursing in advance of staff vacancies that are due within the next 2 months.

Proposal submitted for comments for a revised ward establishment which includes alternatives to enhanced patient supervision. Papers submitted for QEIA meeting on 11th April.

To actively manage staff sickness.

To complete staff appraisals.

2016/04/12 Medicines Management Report (Agenda Item 14) ROB presented this report and focussed on the CQC visit and current risks. New governance reporting arrangements: A quarterly medicines management group is now incorporated into the Quality and Safety Delivery Group.


CQC Inspection: The recent CQC inspection highlighted two areas of concern in medicines management.

One expired drug was in the controlled drugs cabinet. There were no patients prescribed this drug, so there was no possibility that it could have been administered at this time. The normal process is that controlled drugs are checked daily by nurses to ensure that the actual quantities tally with the register balance. This check should also include an expiry date check. On this occasion, the drug had not been segregated whist awaiting disposal by an authorised person. Action taken: a small amendment to the standard operating procedure was made to require an expired controlled drug to be segregated (in an enveloped clearly marked “Expired – awaiting destruction”). This has already been communicated to all hospitals. In addition, the pharmacy staff will incorporate controlled drug checking into the usual monthly checks done on all the other drugs. This has already been initiated. Necessary amendment to the standard operating procedure was completed immediately.

CQC expressed that in their opinion, a small proportion of incidents warranted being highlighted as “Serious Incidents”. For clarity, none of the patients in this list suffered “permanent harm”. However, in future, more scrutiny will be made of the initial classification made by the reporter / handler and advice sought from the Risk Manager. Reference will be made to the NHS England Serious Incident Framework https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2016/03/serious-incdnt-framwrk-faqs-mar16.pdf and this has been highlighted to incident handlers with instruction to bear in mind the severity of the incident and potential for patient harm at the time of reporting. They will need to liaise with the Risk Manager for advice.

Risks: There There have been recent concerns regarding inaccurate data on

discharge summaries generated by the escript system licensed from SaTH. The inaccuracies only seem to affect the discharge summary generated by GPs and not the screen view or other documentation that is generated by pharmacy staff. Only GPs can generate the discharge summary since this is a confirmation of what medicines they are prescribing on discharge. As this is a prescribing decision, they are the only personnel permitted to do this. Strategies to ensure accuracy of the discharge summary include manually writing the discharge summary or amending the record where necessary prior to electronic transmission. Some GPs themselves suggested that they should check the

discharge summary “Print Preview” against the drug chart prior to

sending electronically to the primary care GP.

The issue has been entered onto the risk register. GPs at Bishops Castle practice have expressed concerns over the escript system to the SCHT Medical Director. Action: A guidance document on how the process of producing a Print Preview and if needed, subsequent amendment prior to sending the discharge summary has been sent to all GPs following

https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2016/03/serious-incdnt-framwrk-faqs-mar16.pdf




their input. In addition, the rollout of the electronic patient record (that includes electronic prescribing and administration records) to the community hospitals has been prioritised to Phase Two. Also on the risk register is the requirement for upgrading of the controlled drug cabinets. The legal requirements have been given to Estates advisors. ROB has contacted the Controlled Drugs Liaison Officer (a Police Officer) who has surveyed the hospital premises and provided exemption certificates on the grounds that that the existing arrangements provide low risk of breaches of security. The exemption has to be reviewed on an annual basis. This in turn gives assurance to the Board that there is no risk. ROB was actioned to look at including on a quarterly basis a summary of controlled drugs within the Performance Report; ROB to liaise with DR.

ROB

2016/04/13 Policies for Notification (Agenda Item 15) None at this meeting.

2016/04/14 Risks: (Agenda Item 16) SAO to check that RTT is on the risk register.

SAO

2016/04/15 Any Other Business: (Agenda Item 17) None at this meeting.

Date and time of next Meeting: Thursday 23rd June, Haughmond View Medical Practice, Severn Fields Health Village, Shrewsbury. SY1 4RQ from 10am – 1pm.

meeting date: 26 may 2016 summary report agenda item: 12 enclosure · pdf file ·...

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