Council of Governors: Summary Sheet · 2019-12-23 · SUMMARY REPORT Report to: Board of Directors Date: 11th September 2019 Subject: Quality Assurance Committee Summary Report to

CoG 31 October 2019 Item 7

Council of Governors: Summary Sheet

Title of Paper: Significant Issues Report: Quality Assurance Committee

Presented By: Sandie Keene CBE

Action Required:

For Information

x For

Ratification

For a decision

For

Feedback Vote required For Receipt

To which duty does this refer:

Holding non-executive directors individually and collectively to account for the performance of the Board

x

Appointment, removal and deciding the terms of office of the Chair and non-executive directors

Determining the remuneration of the Chair and non-executive directors

Appointing or removing the Trust’s auditor

Approving or not the appointment of the Trust’s chief executive

Receiving the annual report and accounts and Auditor’s report

Representing the interests of members and the public

Approving or not increases to non-NHS income of more than 5% of total income

Approving or not significant transactions including acquisitions, mergers, separations and dissolutions

Jointly approving changes to the Trust’s constitution with the Board

Expressing a view on the Trust’s operational (forward) plans

Consideration on the use of income from the provision of goods and services from sources other than the NHS in England

Monitoring the activities of the Trust to ensure that they are being conducted in a manner consistent with its terms of authorisation and the constitution

Monitoring the Trust’s performance against its targets and strategic aims

How does this item support the functioning of the Council of Governors?

Governors are responsible for holding NEDs to account and will do this by receiving significant issues reports and questioning NEDs on how they are holding the board to account.

Author of Report: Sandie Keene CBE

Designation: Non-Executive Director & Senior Independent Director

Date: October 2019

31 October 2019

Item No 7

BOARD OF DIRECTORS MEETING (Open)

Date: 11th September 2019 Item Ref: 20bii

TITLE OF PAPER

Quality Assurance Committee Summary Report to the Board of Directors in respect of Significant Issues

TO BE PRESENTED BY

Ms Sandie Keene, Chair, Quality Assurance Committee Non-Executive Director

ACTION REQUIRED

For assurance

OUTCOME

To report items of significance discussed at the Quality Assurance Committee on 29th July 2019

TIMETABLE FOR DECISION

To be discussed at September’s Board of Directors meeting.

LINKS TO OTHER KEY REPORTS / DECISIONS

Minutes of the Committee

STRATEGIC AIM STRATEGIC OBJECTIVE BAF RISK NUMBER & DESCRIPTION+

Strategic Aim: Quality & Safety Strategic Objective: 1.1 Effective Governance, Quality Assurance and Improvement will Underpin all we do. BAF Risk No: A101iii BAF Risk Description: Trust governance systems are not sufficiently embedded which may reduce the effective means by which executive directors can consistently and continually be held to account for the delivery of sound strategies, effective management of risk and the quality of service provided by the organisation.

IMPLICATIONS FOR SERVICE DELIVERY AND FINANCIAL IMPACT

Timely Reporting to the Board of Directors

CONSIDERATION OF LEGAL ISSUES

None identified

Author of Report Sandie Keene Designation Chair, Quality Assurance Committee (Non-Executive Director)

Date of Report August 2019

SUMMARY REPORT

Report to: Board of Directors

Date: 11th September 2019

Subject: Quality Assurance Committee

Summary Report to the Board of Directors in respect of Significant Issues Presented by: Sandie Keene, Chair, Quality Assurance Committee

Author: Mike Hunter, Executive Medical Director

1. Purpose

To report to the Board of Directors, items of significance discussed at the Quality Assurance Committee meeting held on 29th July 2019.

2.

Summary

Board members will receive the minutes of the Quality Assurance Committee held on 29th July 2019 in October 2019. However, the meeting is reviewed and the Committee agreed by means of this report to notify the Board of Directors of the following significant issues:

Regulation Dashboard

The Committee received the Regulation Dashboard and has requested to be sighted on the work of the Workforce and Organisation Development Committee across the areas of the staff survey that relate to Health and Safety and safety and quality issues, including the involvement with the Health and Safety Executive, at a future meeting. Infection Prevention and Control Annual Report 2018/19 and Programme 2019/20 The Committee would like to alert the Board of Directors with regards to the assurance received and concerns raised in terms of the flu vaccinations, as well as to the lack of compliance with completing the surveillance forms. Due to a change in the legislation around flu vaccinations, it has now been confirmed that it is no longer appropriate for the Director of Nursing to have oversight and accountability for the Trust’s flu vaccination programme. This now has to be undertaken by a doctor, occupational health physician, GP (if in Primary Care Services) or Medical Director. This has been discussed at the Executive Directors Group and the options available were considered. As a new contract for provision of Occupational Health Services with PAM Group is in place, a decision was taken that they will be commissioned to undertake the flu vaccination programme for this year.

It is now with Human Resources and the PAM Group for the delivery of the programme. Structured Judgement Review Deep Dive Session The Committee would like to report to the Board of Directors that it received positive assurance and understanding relating to Structured Judgement Reviews. Litigation Annual Report The Committee would like to alert the Board of Directors that in view of the absence within this report of looking at themes and trends, the Committee has limited assurance that the Trust is developing any learning or putting measures in place to reduce its impact in the future. The Committee also noted that the current systems and processes do not enable the Trust to do the work properly. Report on Lessons Learnt – Corporate Affairs (FastTrack & Compliments) The Committee would like to alert the Board of Directors that it was not assured by this report but did recognise that other work has been undertaken to understand how the situation occurred. The Committee noted that the Serious Incident investigation report will be brought to a future meeting. CQUIN’s – Quarterly Progress Report (Q1) The Committee was assured by this report but a theme was identified around some concern with IMST’s ability to respond to requests for system changes.

3. Actions

For the Board of Directors to note the issues raised and receive assurance that the Quality Assurance Committee has taken appropriate action.

4. Contact Details

Sandie Keene, Chair of the Quality Assurance Committee.

BOARD OF DIRECTORS MEETING (Open)

Date: 9th October 2019 Item Ref: 15

TITLE OF PAPER Quality Assurance Committee Summary Report to the Board of Directors in respect of Significant Issues and Minutes from 29 July 2019

TO BE PRESENTED BY Ms Sandie Keene, Chair, Quality Assurance Committee Non-Executive Director

ACTION REQUIRED For assurance

OUTCOME To report items of significance discussed at the Quality Assurance Committee on 23rd September 2019.

TIMETABLE FOR DECISION

To be discussed at October’s Board of Directors meeting.

LINKS TO OTHER KEY REPORTS / DECISIONS

Minutes of the Committee

STRATEGIC AIM STRATEGIC OBJECTIVE BAF RISK NUMBER & DESCRIPTION+

Strategic Aim: Value for Money Strategic Objective: We will provide sustainable services through ensuring value for money, reducing waste and unproductive time for staff BAF Risk No: A401ii BAF Risk Description: Trust governance systems are not Sufficiently embedded

IMPLICATIONS FOR SERVICE DELIVERY AND FINANCIAL IMPACT

Timely Reporting to the Board of Directors

CONSIDERATION OF LEGAL ISSUES

None identified

Author of Report Sandie Keene Designation Chair, Quality Assurance Committee (Non-Executive Director)

Date of Report October 2019

SUMMARY REPORT

Report to: Board of Directors

Date: 9th October 2019

Subject: Quality Assurance Committee

Summary Report to the Board of Directors in respect of Significant Issues Presented by: Sandie Keene, Chair, Quality Assurance Committee

Author: Mike Hunter, Executive Medical Director

1.

Purpose

To report to the Board of Directors, items of significance discussed at the Quality Assurance Committee meeting held on 23rd September 2019.

2.

Summary

Board members will receive the minutes of the Quality Assurance Committee held on 23rd September 2019 in November 2019. However, the meeting is reviewed and the Committee agreed by means of this report to notify the Board of Directors of the following significant issues: Mental Health Legislation (MHL) Q1 Performance Report 2019/20 The Committee received the quarterly performance report covering Mental Health Legislation. The Committee was assured with the work and oversight of the Group, acknowledging that more work is required within services to ensure we are fulfilling our statutory obligations in this regard.

3. Actions

For the Board of Directors to note the issues raised and receive assurance that the Quality Assurance Committee has taken appropriate action.

4. Contact Details

Sandie Keene, Chair of the Quality Assurance Committee.

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Quality Assurance Committee (QAC)

Minutes of the meeting of the Quality Assurance Committee of the Sheffield Health and Social Care NHS Foundation Trust, held on Monday 29th July 2019 at 1.00pm in Rivelin Boardroom, Fulwood, Tudor Building, Old Fulwood Road, Sheffield S10 3TH Present: 1. Sandie Keene Non-Executive Director, Chair (SK) 2. Richard Mills Non-Executive Director (RM) 3. Dr Mike Hunter Executive Medical Director (MH) In Attendance:

4. Liz Lightbown Executive Director of Nursing, Professions & Care Standards (LL) 5. Brenda Rhule Deputy Chief Nurse (BR) 6. Jane Harriman Deputy Chief Nurse, NHS Sheffield CCG (JH) 7. Andrea Wilson Director of Quality (AW ) 8. Rita Evans Organisational Development Director (RE) 9. Tania Baxter Head of Clinical Governance (TB) 10. Marthie Farmer PA to Medical Director (Notes) (MF)

Apologies:

11. Clive Clarke Deputy Chief Executive/Director of Operations (CC) 12. Margaret Saunders Director of Corporate Governance (Board Secretary) (MS) 13. Michelle Fearon Director of Operations & Transformation (MicF) 14. Jonathan Mitchell Associate Medical Director for Quality (JM)

Minute Item Lead

Welcome & Apologies The Chair welcomed everyone to the meeting and noted the apologies.

1) Declarations of Interest There were no new declarations of interest.

2) Minutes of the meeting held on 24th June 2019 The minutes of the meeting held on 24th June were agreed as an accurate record.

3)

Matters Arising & Action Log 4) Safety Dashboard Dr Mike Hunter responded to the action on the post meeting note that was to be provided to the Chair with regards to the unexpected findings on the safety dashboard which was dealt with, in the Open Board Trust Meeting as a narrative that was brought by Dr Mike Hunter about poorly and unwell people

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that were getting the medical care they needed and that the low number of incidents have since been tested within operations and things were felt to be generally calmer. Meetings on Bank Holidays A discussion has taken place around meetings around bank holidays and will the forward planner be checked for the next year paying particular attention to school holidays and bank holidays to ensure that dates can be assessable to everyone. Infection Prevention and Control (IPC) Quarter 4 Performance Report Liz Lightbown provided feedback to the Chairs request around the annual mattress audit with regards to whether the mattresses audited were in use or in storage. All mattresses that were audited were in use and that there was an issue around the mattresses in storage being put in the wrong bags and the clinical waste company not wanting to take them until they were in the right bags and were stored but have now all been removed. Service User Engagement Group – Quarterly Assurance Report Q4 Dr Mike Hunter commented on the on-going review being undertaken by Health Services Research ScHARR, University of Sheffield, Professor Scott Weich are doing around the recent changes to services, Andrea Wilson is chairing the group that is overseeing that project and an interim report will be brought to the next Committee meeting in September. Complaints Annual Report Jane Harriman requested if the of the request that the CCG has written to the Trust and asked for a recovery plan by the 13th August could be brought to the next meeting in September. Action Log: Members reviewed and updated the action log accordingly. The Chair commented on the Governance arrangement around the Service User representative which was scheduled for September. Three Governors has shown an interest and are keen to be on the Committee. There has however been an issue around a conflict of a Governor being on a Committee where their role and responsibility is to hold the Chair and Non-Executive to account for the work of the Committee. There is a concerned around conflict and Tania Baxter has agreed to have discussions with Samantha Stoddart with regards to gaps with service user representation in Committees that are accountable to this Committee and may the attendance be spread out to have longer term work done on looking into what the role and responsibilities would look like for a Governor Service User representative at a Committee that is accountable to the Board. Tania Baxter will provide more feedback at the next meeting in September. Dr Mike Hunter commented on the action point around the Terms of Reference for the Quality Assurance Committee, where Liz Lightbown helpfully offered to contribute to a rationalisation of the terms of reference and that it would be efficient if Andrea Wilson and Tania Baxter were asked to now work on these and bring it back to the next or a future meeting.

AW

AW/MS

TB

AW/TB

MH

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Dr Mike Hunter will have discussions with Dean Wilson around the staff survey and the feedback for this Committee on the regular reports for the progress against the quality initiatives in order to provide assurance to this Committee that changes are being made.

Safety and Excellence in Patient Care

4) Safety Dashboard The safety dashboard was received for noting and the following key areas were highlighted by Dr Mike Hunter. Dr Mike Hunter drew the attention of the Committee to the number of restraints which has continued to increase for a second occasion in the past three months. The updated narrative view on the large number of restraints and the increase is mainly accounted for by two service users on PQ, both of whom were subjected to large numbers of multiple restraints. It is an acceptable argument that people do arrive into our services in varying degrees of distress and that would more feedback be required for the multiple restraints. Dr Mike Hunter will do a post meeting note and provide more feedback on the detail around this at the next meeting. The Chair drew the attention to the spike on self-harm. Dr Mike Hunter commented that the increase is due to one service user on one ward which has self-harmed themselves on several occasions during this period. Dr Mike Hunter will do a post meeting note and provide more feedback on the detail around this at the next meeting. The general trend for the reduction in all incidents continues for assaults on Service Users with 8 data points below the average which will now allow for a recalibration downwards on the control measures.

MH

MH

5) Regulation Dashboard Dr Mike Hunter presented this report and highlighted the following two key areas;

Health and Safety Executive The current position is graded as requires improvement, which was graded by our self-assessment as Health and Safety does not supply us with a grading. Richard Mills commented on the report that was received at Workforce Committee on Health and Safety was not assuring and needs to be cross checked and added within this report. The Chair commented that the Committee has not seen the report from the Health and Safety inspection, and does not know if it is handled in the same way as the CQC report with regards to the report back, monitoring and action plans etc. Andrea Wilson commented that the Health and Safety Committee is monitoring it with an action plan in place and that the Executive Directors Group did receive and approve the updated position

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statement on the internal monitoring of the outcomes of the Health and Safety Executive Report in regards to where the Trust is. This report was submitted to the Workforce Committee last week. The Chair commented that the Committee is not responsible for the oversight of this, other than that this Committee wants to be assured and have the oversight that any issues on safety are being addressed. Dr Mike Hunter suggested that due to it being a significant issue it would be good if an audit to facilitate across all committees could be established. Liz Lightbown will inform and follow this up with the Executive Director Group and the Director of Human Resources. The Chair commented that due to the Committee not being sighted on the report and that there are issues that do have an impact on safety, the Committee would like to see an overview of the issues within the report that do connect with safety and quality. This Committee would like to request to be sighted on the work from the Workforce Committee, across the areas of the staff survey, Health and Safety issues that relates to safety and quality along with the Health and Safety Executive at a future meeting.

Accessible Information Standard

Due to the Trust taking all the action it possibly can and being reliant on other systems to being able to receive the information in the right format rewording of the original action is being done on the action plan as this being one of the CQC actions. The Trust will be writing to the CCG to inform them that the Trust has completed all the actions and in regards to what needs to done which will then allow for the closure of this action. The Committee would like feedback and will track it within the CQC updates. Liz Lightbown will follow this up with the Director of Human Resources and the Executive Director Group and provide feedback to the Committee.

LL

LL

LL

6)

Infection Prevention and Control Annual 18/19 Report and Programme 19/20

Brenda Rhule presented this report and highlighted the following key areas: The key areas for the surveillance in compliance are Burbage, Endcliff and G1 and although there has been an improvement more work is still needed at ward and team level on it’s not being completed and how they can be supported to do it better. Brenda Rhule and Katie Grayson will visit the wards to have conversations and support. Mattresses failed the audit due to stains and being bottom down. For this period there have been two outbreaks of Norovirus and assurance

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can be given that the protocol was being followed by the MT doctor and that the only people that are authorised to close the wards is Liz Lightbown or Brenda Rhule. MRSA compliance did not have a good uptake on the assessments. Brenda Rhule and Katie Grayson will visit wards to establish the best way of doing the assessments on where they need to be completed. Brenda Rhule, Christopher Wood and the City of Sheffield are doing some work around the consistent approach to a physical health forms and assessments due to the issue around the electronic physical health assessment form. There has been a change in the legislation around the flu vaccinations and has now been confirmed that it is no longer appropriate for the Director of Nursing to have oversight and accountability for the flu vaccination program and that it has to be undertaken by a medic, occupational health physician, GP if in Private Care Services or Medical Director. This has been discussed at the Executive Directors Group which looked at the options and as a new contract with a new Occupational Health, PAM Group is in place a decision was taken that they will be commissioned to undertake the flu vaccination programme for this forth coming period. It is now with Human Resources and the PAM Group for the delivery of the programme. The Infection, Prevention and Control nurse will liaise with the Director of Human Resources and PAM Group as appropriate, as vaccines have been purchased and would be transferred from our stock to PAM Group to utilise. The Chair commented that the Trust needs to ensure that the action plan achieves a better outcome and higher percentage uptake than what was achieved last year. Due to a new provider this Committee cannot be assured that the performance on this will improve. The Chair commented that the Infection Prevention and Control Annual 18/19 Report and Programme 19/20 report does miss a number of opportunities to give more assurance and explanation on what is been done and happening around issues and if the common themes are being addressed. The Committee will alert the Board with regards to the assurance, and concerns raised in terms of the flu vaccinations as well as to the compliance of completing the surveillance forms. The Committee was partially assured by this report.

7) Structured Judgement Review Deep Dive Session Vin Lewin presented a presentation on Structured Judgement Reviews. The Committee would like to report to the Board on receiving positive assurance for understanding the level of Structured Judgement Reviews.

8) 360 Assurance Internal Audit Infection Control Update

360 Assurance Internal Audit Infection Control Update was received for noting

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and the following key areas were highlighted by Liz Lightbown:

There were 8 risks and 9 actions. Of the three medium actions, two have been completed and one is due and on track for the end of December. On the six low risk actions, five have been done and is one outstanding and due by the end of August. Liz Lightbown does meet monthly with Brenda Rhule and the Lead nurse on Infection, Prevention and Control, Katie Grayson to keep an oversight on it. The Committee was assured by the report.

9) Quality Impact Assessment (QIA’s) of 19/20, Cost Improvement Plans (CIPs) Report as at 4 July 19. Liz Lightbown presented this report and highlighted the following key areas: This is the first report for 2019/20 Quality Impact Assessment that has been undertaken for five Corporate Directorates. A Clinical Executive Scrutiny Panel has gone through the QIA’s and has approved them all. Cost Improvement Plans are still outstanding for Human Resources (HR) and IMST, and have not submitted QIA’s. There is no saving expected from Psychology and Allied Health Professionals, Strategies and Partnerships or Corporate Governance. Clinical Services in the Care Network have identified around £600k worth of their £1.5M for cost improvement, and is it being anticipated that there will be QIA’s coming forward for which a Clinical Executive Scrutiny Panel will be scheduled. The Chair noted that the HR and IMST cost improvement plans is not on track and that the Committee will wait for a report to be received in due course. The Committee was assured by this report.

General Governance Arrangements

10)

Litigation Annual Report Dr Mike Hunter presented this report and highlighted the following key areas: This report is a detailed list of particular cases and exposure to a litigation risk. A general principal of expectation from the Committee would be that those who have an oversight and responsibility for these areas are to make them successful.

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The Chair commented that the Committee has limited assurance on this report and would further like to congratulate the people on putting the report together as its better than last year’s report. The Chair asked if a sentence with in the report could be changed to read; “Consideration will be given as to the risk and impact this issue poses to the Trust whilst the revised governance system for litigation cases is being established.” The Chair commented that the Trust is saying that we are not giving with regards to risk and impact on litigation and that we are lying ourselves open, which would not be very save and could we rather be looking at it whilst we are establishing new governance arrangements if that is what the Executive Directors Group decides to do. The Committee would like to report to the Board in view of the absence of looking at themes, trends the Committee is able to identify the cases and the progress but that the Committee has limited assurance that the Trust is developing any learning from this and in putting measures in place to reduce its impact in the future and that the systems and processes do not enable us to do the work properly. The Committee had limited assurance.

11) BAF Samantha Stoddart presented this report and highlighted the following key areas: Rewording was done to some of the strategic objectives based on the work that was done with the Board in February and March. There are two new risks, and there has been no other change to any of the other risks that has been carried over from 2018/19 in terms of assurance. The Chair commented that there has been very little movement. The appendix will be forwarded to members of the Committee after the meeting. Samantha Stoddart enquired on one of the controls on Lessons Learnt from Investigations, Reviews of Care, Mortality Reviews that are shared across the Trust in a variety of ways, with an amber assurance rating and as there is a should do action gap in assurance which was identified by the CQC around the inconsistency of learning lessons, and on what was heard today if it would change the assurance. Dr Mike Hunter commented that this will be picked up by the Executive Director Group to look at the ratings etc. BAF Risk A104, which Board asked for access to our services in particular around the question of SPA. This risk does require reworking as it focuses mainly on high level KPI’s that gets reported regionally and nationally and does not focus on the question of assessing and waiting of the core services at SPA as well as the transfer between SPA and recovery. This risk needs to be revised on wording and the inclusion of what is within

MF

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the risk as a Quality Assurance Committee Risk alongside Operations. The Committee was assured by this report.

12) Corporate Risk Register (CRR) Aligned Risks Samantha Stoddart presented this report and highlighted the following key areas; Since its last presentation to QAC in April 2019, Risk 3917 - Inability to deliver routine assessment through the EWS within the 3 week timescale has been closed and is now reviewed and managed at a directed care network level. Two new risks have been added:

Risk 4222 – Risk to patient safety and service quality due to some medicines management practices falling below expected standards. This risk relates to pharmacy.

Risk 4240 - Risk that the Trust may not improve the quality of patient care due to being unable to evidence the completion of all must do and should do actions. This risk encompasses all the CQC action plans.

There are quite a number of risks for oversight at Quality Assurance Committee, two high risk and two new risks, but there has not been any movement in the residual risk rating. The next iteration for the CRR to the Executive Director Group at the end of month, managers will be asked to have a closer look at their actions to ensure that any action should mitigate a risk and if it not then why is it there. Dr Mike Hunter commented with regards to the Ligature Risk on the risk register as a static risk due to the acute care modernisation and the timely progressing of it. The Executive Directors Group needs to check if all actions are captured and being maintain around the volumes and capacity on risk 3916, which focuses around the CQC telephony and although there is a bit more granularly understanding about some of it that started up in SPA. Risk 4124, needs to be relooked at in light of the performance information. The Chair asked if risk 3916 and 4124 can be reviewed, one on the action plan and the other on the risk rating. Andrea Wilson will follow this up with Operations. The Committee was assured by this report.

AW

13) Report on Lessons Learnt – Corporate Affairs (FastTrack & Compliments) Dr Mike Hunter presented this report and suggested that the Serious Investigation Report that has been commissioned be brought to a future meeting of the Quality Assurance Committee.

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The Committee will alert the Board that the Committee is not assured by this report but do recognise that other work has been going on, and that the Committee is happy to wait for the Serious Investigation to be brought to a future meeting. Andrea Wilson commented that the investigation is complete and that she will be meeting with Linda Wilkinson in August and that it could be brought to the Quality Assurance Committee at the September meeting.

AW

Efficient and effective use of resource through evidence based clinical practise

14) CQUIN’s – Quarterly Progress Report (Q1) Dr Mike Hunter presented the CQUIN’s – Quarterly Progress Report for quarter 1 and highlighted the following; This paper is to give the Committee an overview of what is required for the CQUIN’s programme this year. There is not a lot of performance to report within quarter one, but on is the screening and brief advice metrics around alcohol and smoking which has been reported on has shown a reasonable promising picture. Although there was a reasonably degree of confidence around people being allocated to a particular CQUIN’s and in making progress and with Operations being on top of this, a concern has been raised in a number of areas around IMST in supporting and getting data reported in. The Committee would like to alert the Board that the Committee was assured by the report but that a theme was identified within the meeting this month around some concern with IMST in responding to the requests from various parts and on things from the organisation to enable them to do their job and to assure this Committee. The Committee was assured by this report.

15) Research and Innovation Assurance Report.

Dr Mike Hunter presented the Research and Innovation Assurance Report and highlighted the following;

The Group has now been reconvened and are meeting regularly and the research performance in the Trust is exemplary.

Dr Mike Hunter suggested that Nick Bell and Michelle Horspool be invited to this meeting to talk more on the Research and Innovation agenda. The Chair suggested that for any future deep dives that the forward planner is looked at to see if it can be accommodated. Liz Lightbown added that Michelle Horspool, the Deputy Director – Research is also a senior nurse and is working on a nursing research report due to the significant increase over the last 18 months and would it be good to incorporate this with the suggestion made by Dr Mike Hunter. The Chair suggested that Dr Mike Hunter and Liz Lightbown meet and get this

MH/LL

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commissioned together. The Chair asked that Andrea Wilson and Tania Baxter to look at the forward planner to when this could be scheduled to be received by this Committee. The Committee received a positive report and was assured by it.

16) CQC Well-led inspection Action Plan Update Dr Mike Hunter introduced the report. Andrea Wilson highlighted the following key areas: The paper received is as it was at the 28th June. The July position is that there has been a significant progress with the Recording of Supervision and that the appropriate forms have gone live on the 1st July. The remaining work is on training and supporting people on how to use it and on making them aware of the forms. This action can now be closed down for the CQC. Some of the actions around the issues for the telephony can also be closed down in the CQC action plan, however the Trust will be proposing a new action due to solutions that was thought to work but necessarily have not worked and have created other needs that needs to be redefined. This action will be picked up in a conversation with the CQC at the quarterly engagement meeting on the 30th August. Nurse Call systems are still outstanding, which was a CQC action that only applied to Forest Close in terms of Bungalow 3 will be starting as the business case has been approved. The Chair commented that the assurance the Committee needs is with regards to everything that needs to be done is done or not or is being recorded as being extended with a new date. The Consistent Recording of Supervision action the CQC found around supervision was happening but that there was no system for doing it. Dr Mike Hunter commented that there are two things that do need attention being phones and policies where we need to see evidence of a change. On Medicines and Supervision changes have been made and do we need to see the evidence of the success of the change. The Committee was not assured by the report but did receive some helpful reassurance and look forward to being backed with full assurance at the next meeting in September.

16i) CQC Well-led inspection Policy Update Dr Mike Hunter presented the CQC Well-led inspection Policy Update and highlighted the following key areas;

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The Executive Directors Group has been receiving regular updates according to individual portfolios with everything rated as red, amber or green. The concerned areas are Finance, Human Resources, Nursing and Professions and Operations where there are still 22 policies that are not in date with another 45 due end of September. The Chair commented that the Committee is not assured by the required action from the Executive Directors Group on the 27th June that all 67 policies will be in date by the 1st October. Liz Lightbown apologised and commented that the numbers have not been updated and is not accurate on the report. The Chair requested to have an updated report with accurate figures at the September meeting. Dr Mike Hunter commented that the correct figures can be circulated on a proposed post meeting note but that the actual risk itself is captured within the Corporate Risk Register around not doing the CQC must and should do’s. The Chair commented that the Committee only has limited assurance around the completion of so many policies and will seek the accurate figures and a further report in October that it is done. The Committee only had limited assurance.

17) QAC Terms of Reference (Improved and Reviewed) QAC improved and reviewed Terms of Reference was deferred to the next meeting In September.

Evaluation / Forward Planner

Confirmation of Significant Issues to Report to the Board of Directors The Committee agreed the following should be included in the Significant Issues Report to the Board in September: The Regulation Dashboard This Committee would like to notify the Board of Directors that the Committee discussed the Regulation Dashboard and as more assurance is needed on the information surveillance he Committee has therefore requested to be sighted on the work from the Workforce Committee relating to safety and quality, across the areas of the staff survey, Health and Safety along with the Health and Safety Executive at a future meeting. Infection Prevention and Control Annual 18/19 Report and Programme 19/20 The Committee would like to alert the Board of Directors to the concerns raised around the compliance in completing the surveillance forms.

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The Committee would further like to inform the Board of Directors of concerns regarding the flu vaccination programme. There has been a change in the legislation, which states that it is no longer appropriate for the Director of Nursing to have oversight and accountability for the flu vaccination program; which now has to be undertaken by a member of the medical staff, an occupational health physician, GP if in Private Care Services or Medical Director. This was discussed at the Executive Directors Group, where it was agreed that the new Occupational Health Provider, the PAM Group will be commissioned to undertake the flu vaccination programme for this forth coming year. The Committee could not be assured that the action plan would achieve a better outcome and higher percentage uptake than what was achieved last year with the CQUIN’s bar being raised to a minimum of 60%. Structured Judgement Review Deep Dive Session The Committee received a positive presentation on the process of Structured Judgement Reviews and do have assurance around the understanding of the Structured Judgement Review process. Litigation Annual Report The Committee would like to report to the Board of Directors that in view of the absence of looking at the themes and trends that the Committee was able to identify the cases and progress but that the Committee had limited assurance in that the Trust had developed any learning from this or have put any measures in place to reduce the impact in the future and that the systems and processes in place do not enable the Trust to perform the work properly. Report on Lessons Learnt – Corporate Affairs (FastTrack & Compliments) The Committee would like to alert the Board that the Committee was not assured by this report but do recognise that there is other work being done and that the Quality Assurance Committee will wait for the Serious Investigation Report to be brought to the September Meeting. CQUIN’s – Quarterly Progress Report (Q1) The Committee would like to alert the Board that the Committee was assured by the report but that a theme was identified within the meeting this month around some concerns with IMST in responding to the requests from various parts of the organisation for things to enable them to perform their job and provide assurance to this Committee.

CLOSE

Date and time of the next meeting Monday 23rd September 2019 at 1.00 pm– 3:00pm

Rivelin Boardroom, Tudor Building, Fulwood

Apologies to PA to Medical Director