cwm taf local health board · 2015. 11. 14. · clinical governance committee draft cgc v3 19.07.12...

CLINICAL GOVERNANCE COMMITTEE

Draft CGC v3 19.07.12 Approved by Chairman ONLY To be approved by CGC at next scheduled meeting of 25.10.12

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CWM TAF LOCAL HEALTH BOARD MINUTES OF THE MEETING OF THE CLINICAL GOVERNANCE COMMITTEE HELD ON THURSDAY 19th JULY 2012 RHONDDA/CYNON MEETING ROOMS, YNYSMEURIG HOUSE, ABERCYNON. PRESENT: Cllr C Jones - Independent Member (Chair) Mr G Bell - Independent Member (Vice Chair) Professor V Harpwood - Independent Member IN ATTENDANCE: Ms A Hopkins - Director of Nursing Mrs B Rees - Director of Primary, Community & Mental Health Services Mr C White - Director of Therapies & Health Sciences Dr P Davies - Assistant Director (Operations) - Mental

Health & Child & Adolescent Mental Health Services (CAMHS)

Mrs L Williams - Assistant Director of Nursing (Regulation & Legislation) Interim Assistant Director Patient Care & Safety

Mrs A Gristock - Head of Clinical Education Dr J Geen - Assistant Medical Director, Research & Development (Consultant Clinical Biochemist) Mrs L Guard - Community Health Council Representative Mrs J Williams - Head of Quality & Effective Practice Ms J Harries - Chief Pharmacist (Taf Ely Locality) Ms N John - Director of Public Health Mr S Harrhy - Board Secretary/Director of Corporate Services Dr S Aslan - Assistant Medical Director-Clinical Audit & Effectiveness Invited Presenters: Mr K Conway - Assistant Medical Director Mr C Chaplin - Senior Quality Improvement Manager Mr C Beadle - Head of Operational Health, Safety and Fire Mr M Gibbs - Training and Development Manager Mr R Salter - Healthcare Scientist Mr M Henry - Laboratory Manager



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Secretariat. Allison Thomas - Administration & Governance Manager Karen Glover - Secretary, Patient Care & Safety Unit (Observer) CGC/12/063 – WELCOME AND INTRODUCTIONS. The Chair welcomed all present to the meeting. CGC/12/064 – APOLOGIES. Apologies were received from: Mr K Asaad, Mr H Rowe, Ms G Jones & Mr J Roberts CGC /12/065 – DECLARATIONS OF INTERESTS. There were no declarations of interest. CGC/12/066 – TO APPROVE THE MINUTES OF THE MEETING HELD ON Thursday 26th April 2012. The minutes of the previous meeting were approved following minor amendments. CGC 12/067 – MATTERS ARISING. Minute CGC/12/039 refers – Clinical Directorate Report The Committee received assurance that an action plan was in place and that both the Board Secretary & Director of Nursing receive regular updates and progress had been made. Director of Nursing informed the Committee of a planned visit on 31st August 2012 with representatives from the Community Health Council. This would ensure an independent view of progress. Holding to Account meetings continue with three Executives working with the Corporate Services department. Assurance was received regarding progress from Board Secretary/Corporate Director on the Governance Framework which is due to be completed August 2012. Minute CGC/12/052 refers – Mandatory Training An update on Organisational Training was received under Agenda Item 6.2 CGC/12/053 – 1000 Lives Plus Update-Transforming Care Initiative The Director of the 1000 Lives Plus programme visited 2 wards in Prince Charles Hospital and was pleased to see Transforming Care embedded into the organisation as well as complimenting the organisation on its very pleasing work. The 1000 Lives Plus Director has written to the Chief



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Executive to compliment the work and invite the organisation to showcase progress in some of the Workstreams. Care of Diabetes patients The ‘Think Blue Code’ campaign was discussed and the Director of 1000 Lives Plus advised that this approach will involve specialist staff and is an initiative being taken forward by Welsh Government on an All Wales basis. ACTION: Director of Nursing to request a written report on Transforming Care, identifying how many wards have embedded the initiative and how many to go, to the next Committee meeting. Agenda Items: CGC/12/068 – Action Log The Action Log was received by the Committee and it was noted that Action number 43-Escalation process for Estates work received no update and the Assistant Director of Nursing, Regulation & Legislation informed the Committee that a full report will be presented to the next Committee meeting. ACTION: Assistant Director of Nursing, Regulation & Legislation to provide a written report at Octobers meeting in respect of the Escalation of Estates work. CGC/12/069 - Presentation of a Patient Story. The Laboratory Manager, Clinical Biochemistry presented the Patient Story which outlined Outcomes and Benefits Realisation of the Cwm Taf Clinical Biochemistry Service following reconfiguration. A background to the service was presented together with the approach to improve service delivery. The information included the GP distribution throughout Cwm Taf and the way in which the sample collection was improved; this involved

• workforce re-design • Staff development • Health & Safety • Training • Quality Management • Analytical/clinical expertise/knowledge • Research opportunities

Together with the development of tertiary analytical services which include

• Income generation



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• £30K additional income(from income generation initiatives, specifically we are a tertiary referral site for Vitamin D, IGF-1 and Growth Hormone analysis for Betsi Cadwaleder LHB)

• Future developments The approach was to maximise analytical capacity and improve home service using pilot site approach and the 1st phase was implemented in April 2011. It was reported that 97.1% of GP work was automated by 6:30pm; this was achieved against a 90% target. Hub and Spoke model: In June 2010 the Clinical Biochemistry option appraisal concluded that a Hub and Spoke model would be the preferred option for future service delivery. It was decided following a benchmarking exercise that examined governance, service provision, affordability and analytical capacity that the Prince Charles Hospital laboratory would become the 'Hub laboratory' and the Royal Glamorgan Hospital laboratory would be designated the 'spoke laboratory.' The instruments at the Royal Glamorgan 'spoke' site were reduced in number to match the required capacity following the centralisation of all GP work at the Prince Charles 'hub' site. The main point which was delivered to the Committee was the redesign of the spoke was the 'standardisation of clinical platforms and reference ranges, reducing clinical risk with a seamless service across Cwm Taf LHB The aspects of the benefits realisation included:

• Sample collection for all GP practices • Reduced risk to practice staff transporting samples • Improved laboratory skill mix • Facilitate VER opportunities • Recurring savings • 10% increase in workload • Continued development of analytical services • Workforce development

Phase 2 – Redesign of Spoke This phase included the:

• Procurement of equipment at spoke (Royal Glamorgan Hospital) site to match required capacity

• Reduction from 6 instruments to 2 new instruments • Standardisation across both Royal Glamorgan Hospital & Prince

Charles Hospital o Same analytical platforms



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o Same Reference Ranges • Reduce Clinical Risk/Seamless service across Cwm Taf • Pre/post analytics-reduce handling sample and benefit across

disciplines (Biochemistry/Immunology/Microbiology) • Additional recurring savings on regent expenditure.

The presentation was well received and the Committee expressed their ‘pleasure’ with the improved service for both staff and patients and requested that this service change was highlighted as ‘Good Practice’. The Director of Therapies & Health Sciences informed the Committee members that Cwm Taf led the pathology programme across Wales with good integration with other Health Boards. An Independent member questioned whether as end users there has been any feedback from the GP’s and how we can evidence that the new service delivery is working for patients? The Head of Quality & Effective Practice responded it may be possible to see a reduction in incidents reported, which may be an indication of improved services. It was also asked if this has been explicitly discussed with the Local Medical Council (LMC)? The Director of Primary, Community & Mental Health Services gave assurance that this has been delivered through a number of GP CPD events. The Director of Nursing commended the unified approach for the whole of Cwm Taf. An Independent member enquired whether there are IT or confidentiality problems arising from the changes, the Laboratory Manager advised that in September there will be a new all Wales system. Adding that promoting electronic requests is in place however there are a few issues within the Outpatients department but that Secondary Care have overall good compliance. The whole team involved in this service redesign were thanked and commended by the Committee CGC/12/070 - Clinical Directorate Report. The Assistant Director of Nursing – Regulation & Legislation presented the Clinical Directorate report. The Committee were informed that this is an overarching report for the Clinical Directorates within the Health Board. It is quite a lengthy report however the themes were not new or a surprise to the Committee members and is also reflected in the Concerns and Incidents report. The Directorates face complex needs together with very real challenges. The Committee were assured that actions are in place to mitigate and manage the risks across the Directorates/Localities.



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The Chief Operating Officers team were holding an ‘away day’ to focus on its Governance Arrangements across the departments and will include additional work on identifying risks and associated risks. It is anticipated that a more comprehensive report will be reported at the next Committee meeting. The Director of Therapies & Health Sciences reassured the Committee that there are a number of work streams ongoing:

1. Acuity of Falls – these are more likely to be higher in some areas given the clinical conditions of the patients, some patients requiring a greater deal of nursing care than others and are therefore more susceptible to falls

2. Patient Flow – assurance was provided that work is continuing for both scheduled & unscheduled care groups

Critical Care and theatres are also part of the Transforming Care programme with a number of sub-groups such as enhanced recovery and pre-assessments, which also links in with the 1000 Lives Plus Workstreams. The Committee discussed the increasing numbers of patients requiring detoxification from alcohol as part of their acute episode of care and an Independent member queried the number of detox beds available. Assurance was given by the Director of Nursing and Director of Primary Community and Mental Health that whilst there were no dedicated beds, the acute beds were used flexibly and were assisted by the Outreach Services team for Drug and Alcohol who are based at Royal Glamorgan Hospital. The Director of Primary, Community & Mental Health Services advised the Committee of the strategic work which links to Falls and Dementia. Redesign work has commenced with the Older Peoples Strategic projects and the local work is to link with and join up on a number of initiatives by working with a number of colleagues. This was endorsed by the Board Secretary/Director of Corporate Services who further informed the Committee of the high volume of work ongoing strategically where there are specific actions against particular issues. There are a number of action plans which monitor the ongoing work. An Independent member requested that target dates are incorporated in the action plans for reassurance that the work is being progressed. The Director of Nursing advised that the work of the Director is to ensure mature reporting mechanisms and provide briefings on the work underway to mitigate risks; this allows all Directors to be familiar with the identified risks and all actions in place to minimise and eradicate the same. The Chair of the Committee enquired as to the lack of a specialist Tracheostomy Nurse and whether the organisation is looking to recruit to this post? The Assistant Director of Nursing Regulation & Legislation



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responded that where work is not covered by a Specialist Nurse there is Health Board wide work being undertaken to ensure skills across clinical areas. An Independent member raised concerns in respect of the inadequate cover in Maternity for Operating Department Practitioners Out of Hours and the Assistant Director of Nursing Regulation & Legislation advised that she would look into the details of this and report back at the next Committee meeting. The Director of Nursing advised that this point was discussed at the Board meeting and that it is in respect of the staffing levels and skill mix across both site. Services would form part of the broader South East Wales planning of services. An Independent member raised concerns over the inappropriate placement of patients due to the lack of bed capacity; the Director of Nursing responded that strategic work is ongoing looking at patient flow by ensuring that patients are in the right place and for the right amount of time to receive the care required. It is acknowledged that currently some patients are not on the specific ward immediately but that this should improve with the ongoing strategic work. The work on the Nursing Establishment has been completed and staff movements have already commenced with some Nurses being reallocated to short fall areas. It was noted that Cwm Taf are ahead of the All Wales work on Nursing Establishment. Lack of Laminar Airflow; the Director of Therapies and Health Sciences assured the Committee that all theatres will have laminar airflow once the refurbishment work has been completed in Prince Charles Hospital in 18 months time. Ophthalmology – it was noted that a task & finish group has been set up with its membership consisting of a Consultant and members of the Turnaround transformation team to address the issues. Lack of Junior Orthopaedic medical cover to support more recent consultant appointments. The Assistant Medical Director enquired as to the impact of this risk and the Director of Therapies & Health Sciences responded that the recent recruitment drive did not prove successful with 5 posts interviewed for , 3 offered and only 1 acceptance. The Clinical Director of Surgery & Orthopaedics is reviewing the service delivery and identifying any alternative options. This work is expected to be completed shortly. Action: The Committee RECEIVED the report.



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A comprehensive report to be provided at future meetings Target dates to be incorporated on all action plans Maternity cover to be identified CGC/12/071 - Adult Mental Health & CAMHS Directorate Report The Director of Primary, Community & Mental Health Services presented the report on behalf of the Assistant Director – Operations for Adult Mental Health & CAMHS. The report noted the integrated approach to Governance within both CAMHS & Adult Mental Health, and detailed the reporting mechanisms through to the Director of Primary Community & Mental Health. It highlighted the key areas of progress and lessons learnt. CAMHS Tier 3/4 services principal risk is the high level of vacancies however some posts have recently been appointed to and the service is looking at new models of working. The report also noted strategically there is a new policy direction in Wales to increase access to CAMHS services for 16/17 year old young people not in further education from 1st April 2012. Work is ongoing to identify a Consultant to work solely as a project post for a period of 2 years, further details on this matter to follow in future reports. Discussion is currently ongoing with Welsh Health Specialised Services Committee (WHSCC) on the commissioning of additional Tier 4 services to deal with the potential demand. A response is awaited in respect of the recent bid. Adult Mental Health Services It is envisaged that The Older Persons Strategic review planned for October will address the Mental Health Liaison service which currently poses significant problems for patients with complex physical and mental health needs. An Independent member raised concerns around the wording within the report and in particular the meaning of hope/might as these are open to interpretation. The Chair raised concerns over St Tydfils Hospital and the security issues however, the Director of Primary, Community & Mental Health Services responded that there are currently two wards still based there and both will move at the same time, one to Prince Charles Hospital and the other to Ysbyty Cwm Cynon . An Independent member raised concerns in respect of the Manchester report and the high numbers of suicide reported of people known to the service and the matter that no concerns have been raised through this Directorate report. The response to this report compiled by the Assistant Director (Operations) – Mental Health & Child & Adolescent Mental Health Services (CAMHS) was that exceptional rates are reported to Committee and the formal response to the report shared with the Committee members for information purposes.

Deleted: <sp>



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Action: The Committee RECEIVED the report and NOTED the ongoing work to minimise the risk. Assistant Director-Operations for Adult Mental Health & CAMHS to share response re: Suicide rate electronically prior to next Committee CGC/12/072 – Pharmacy Integrated Governance Annual Report April 2011-March 2012 The Chief Pharmacist presented this report to highlight the activity within the pharmacy directorate through the period April 2011-March 2012. The differences in the format of the report was noted and future reports to Committee will now be in correct format. The report contained an Executive summary of the Governance & Key Risks which were noted as:

• Workforce and sustainability risks due to sickness and maternity which continue to pose a risk across all sites

A contingency has been put into place in outpatients to direct resources appropriately to manage the risk together with cross site sharing of staff helping to manage the risk. Storage facilities are inadequate and cause an on-going risk in Prince Charles Hospital this is managed locally on an ongoing basis. The issue results in non-compliance with the fire regulations. The Board Secretary/Director of Corporate Services informed the Committee that the Fire Rescue Service are aware of the issues and reassured Committee members that this matter would not result in an enforcement notice for the organisation. The Director of Public Health enquired about the Discharge Advice Letter (DAL) which is to improve the transfer of medication information across interfaces of care provision. This is in print and is being trialled across both sites with an evaluation to include Primary Care feedback. The Committee requested the formal evaluation and audit be an agenda item for a future Committee meeting. Controlled Drugs The compliance audit is undertaken jointly on the wards and a steady improvement is recorded. All reconciliation checks are carried out by each ward, however currently there is no benchmark information available. All compliance information is available on SharePoint. The Director of Nursing informed the Committee that joint working has helped to raise compliance into the 90%’s however the aim is for 100%.

The LHB Chairman arrived

Action:



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The Committee RECEIVED and NOTED the report CGC/12/073 – Healthcare Inspectorate Wales (HIW) Unannounced Environmental & Cleanliness Inspection Report January 2012-Prince Charles Hospital The Director of Nursing presented the HIW report which provided an update to the Committee relating to the unannounced HIW visit to Prince Charles Hospital on 17th January 2012. The context of the visit was explained and the information updated with a report and associated action plan. The Director of Nursing raised concerns in relation to the understanding of some HIW representative in respect of capacity within South East Wales hospitals and the surge in demand for acute beds which resulted in the operationalisation of the Elastic Wards procedure to cope with the demand. Discussion took place in respect of a number of matters raised within the report and the Director of Nursing provided assurance to the Committee of the rationale behind HIW findings. It was noted that a number of comments in respect of this visit were published in the local press and subsequently the LHB Chairman and Chief Executive published a public response. The Committee were reminded that at the time of this unannounced visit the hospital and in particular the wards visited were due to be relocated as part of the Prince Charles Hospital refurbishment programme. However unfortunately there were unavoidable delays in the ward relocation and consequently the wards had packed ready for the move. The move took place ten days following the visit to newly refurbished wards having been postponed from the week of the visit. The final HIW report has been fully scrutinised and the Senior Nurse has taken responsibility for ensuring all actions within the subsequent action plan are implemented. Concerns were raised over the balance of the report and it was further noted that there is a large Infection Prevention & Control training programme in Prince Charles Hospital with a high staff uptake of 85/95% therefore it was a surprise to see the HIW findings, this raised concerns on the level of interpretation by staff. Action: The Committee NOTED the report and associated action plan with the progress on implementation CGC/12/074 – Managing Concerns-Quarter 4 Exception and Highlight report The Senior Manager for Investigations and Quality Improvement presented this report which provided a quarterly update on Concerns, to include reported Patient Safety Incidents, Complaints and Claims within Quarter 4. However due to the timing of the meeting, other information



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contained within the report for example inquests, were to an up to date position. It was noted that a total of 2,366 patient safety incidents were reported during Quarter 4 - a decrease of 3.1% over the previous quarter. These are reported to the National Patient Safety Agency (NPSA) on a monthly basis.

Of these, twelve were serious Patient Safety Incidents – these were also reported to Welsh Government as required. Regular and detailed updates on serious Patient Safety Incidents are provided to the Board.

From 1st April 2012 there has been a change in the ‘levels of harm’ to bring the organisation levels in line with those of the National Patient Safety Agency and other organisations, this being a reduction from 6 levels to 5.

The 6 most common occurring types of incidents being reported has not changed significantly over the last year. These are:

1. Slip, Trip & Falls 2. Pressure Damage 3. Delays 4. Admission/Transfer/Discharge 5. Patient Injury 6. Laboratory/Pathology Investigations

The Committee were reminded that it is now one year since the introduction of ‘Putting Things Right Regulations’ and that since April 2011 the Health Board has received an increase of approximately 50 new formal complaints per month, this being a significant rise of 60% compared with previous years. At present there are 122 open complaints ongoing. All complaints are fully scrutinised by the Concerns (Complaints & Redress) Scrutiny panel. The Director of Primary, Community & Mental Health services enquired as to how as an organisation we can proactively avoid complaints in these challenging times. A number of factors were considered which included:

o Increased scrutiny by Directorates and Scrutiny Panels o Work to support/reduce complaints within clinical areas o Actions/lessons learnt within clinical areas

The development of a newsletter to highlight lessons learned and share good practice is in place. It was further requested whether the Nursing staff can proactively support the work by managing the complaints at source in the clinical areas



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preventing them becoming formal complaints. The trends are discussed at ‘Holding to Account’ meetings, by monitoring and acting on the identified trends to ensure as an organisation we learn and improve to ensure that complaints/errors are not repeated. The Head of Clinical Education advised that through the Transforming Care initiative of intentional rounding this gave the opportunity to engage with the patient(s) who wishes to discuss aspects of care that are good and not so good. It also gives an opportunity to listen to the relatives/carers ensuring that the patients pathway is fully followed. The Assistant Medical Director for Clinical Audit and Effectiveness informed the Committee that communication with relatives/carers is key and that sometimes there is a misunderstanding of the practice/process which can result in a complaint. Therefore it is paramount to keep them informed and updated throughout the patients’ journey, allowing for discussion. An Independent member requested specific figures in respect of complaints which are received, but not dealt with. The Head of Quality & Effective Practice welcomed the discussion and informed the Committee that an action plan has been developed regarding the themes and trends. Work is ongoing to look at how we can use trends and themes to change culture and behaviour as well as further embedding ‘Putting Things Right’. The Assistant Medical Director for Education requested that the plan includes feedback with pre and post graduate education. The Board Secretary/Director of Corporate Services advised the Committee of some presentation points within the report and indicated the action plan is lengthy with over 100 actions. It was suggested that the key actions are highlighted to ensure scrutiny and support by the Committee. The Senior Manager for Investigations and Quality Improvement advised that there will be 2 streams from the action plan:

1. For the Operational group and 2. For the Clinical Governance Committee

An Independent member raised concerns why Complaints Training is still ongoing as this has been in place since 1993. This was responded to by the Director of Nursing who advised that lots of effort is put into feeding back results and trends to ensure learning for the workforce. These are challenging times for delivery of care and the culture to be adapted.



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However some issues are raised in respect of performance which requires addressing with the management.

Assistant Director (Operations) – Mental Health & Child & Adolescent Mental Health Services

(CAMHS) arrived The LHB Chairman informed the Committee of the unprecedented pressures currently being faced and the changes in service delivery which can be cause for complaints. There is a need to communicate more smartly and effectively, this is the professional responsibility of all staff. Currently the NHS is dealing with unprecedented numbers of patients and caring for an increasing number of elderly patients. Compassion is key and should be delivered as a driver for care. It was noted the Concerns team are involved with a number of movement groups informing them of trend data related to their specific area e.g. falls. An Independent member commented on how pleasing it is to see the new Coroner dealing with the high volume of backlog inquests and the Director of Nursing requested that future reports include the context of inquest activity. The Committee discussed the Patient Support Services and were informed that these now sit within the Concerns team and that there clearly is support provided with visits to ward areas and the supply of leaflets reminding patients and relatives of the service. Committee were informed of the process whereby if in the unfortunate event of a death, bereavement officers ask at the time of registering a death specific questions around the care of the loved one. Any concerns can be addressed them by the treating clinician. Action: The Committee NOTED the report.

1. Senior Manager for Investigations and Quality Improvement to ensure specific figures in next report in relation to the number of Complaints which following an initial review do not result in a complaint.

2. Assistant Director Clinical Education & Head of Quality & Effective Practice to meet to discuss inclusion of Trainees and to meet with Senior Manager for Investigations and Quality Improvement to further discuss legal claims seminar feedback & learning.

3. Senior Manager for Investigations and Quality Improvement to wrap context of the Coroner activity into future reports



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CGC/12/075 – Achieving Excellence -The Quality Delivery Plan 2012-2016 The Director of Nursing provided assurance that the Quality Indicators are scrutinised at the ‘Holding to Account’ meetings with the Directorates and the Finance & Performance meetings. Welsh Government ambition is to drive up the standards and sets out the actions which we need to take to ensure we deliver consistent excellence by 2016. The aim of the plan is twofold:

a. Quality Improvement – to do the right thing, and do it well b. Quality Assurance – to be able to continuously demonstrate positive

progress

It is noted in the plan that strong partnership working across all sectors will be crucial to its success. The Board Secretary/Director of Corporate Services informed the Committee following sight of the locally developed Quality Dashboard, Cwm Taf has been asked to assist Welsh Government in the National approach. The local dashboard for Cwm Taf will provide high level assurance and scrutiny for all Committees. This will also serve as a basis for the Clinical Governance Strategy (localised) which will be presented to the Committee in October 2012.

LHB Chairman leaves the meeting



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Action: The Committee NOTED the report Clinical Governance Strategy to be presented to the meeting in October for approval. CGC/12/076 – Organisation Mandatory Training Update The Head of Operational Health Safety and Fire, together with the Learning and Development Manager provided the Committee with an oral update on the current position of training throughout the organisation. The modules of Employee Self Service (ESS) were explained together with the 10 areas of mandatory training. Currently work is on going with the subject matter experts into changing the ethos around workplace learning. The PDR process was discussed. These are to be carried out on an Annual basis and ensure that the individuals have the competencies to undertake their duties. Concerns were raised by an Independent member in respect of the release of staff to attend training sessions as this has been identified as an issue. There was a discussion regarding what is ‘Mandatory’ training this needs to be concluded to ensure the right staff is receiving the relevant training in the relevant place. This may not always mean a classroom, however the type of delivery of training is currently being progressed. With the implementation of E-Rostering staff availability is identified up to 6 months in advance and therefore we are able to protect this time for ‘Mandatory’ training. The option of ‘E-Training’ was also discussed and this raised some concerns over how to assess competency levels. Action: The Committee thanked the team for the Oral update and requested a written report to a future meeting. CGC/12/077 – Healthcare Inspectorate Wales (HIW) – Review report of the Management of Patients with Diarrhoea & Vomiting 2009 The Director of Nursing provided an update on this matter and informed the Committee that a progress report has been submitted to HIW as part of their mandatory monitoring process. ACTION: The Committee NOTED the contents of this report



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CGC/12/078 – Uptake of Childhood Immunisation in Cwm Taf The Director of Public Health presented the report to inform the Committee of the uptake in relation to Childhood Immunisations. The report provided a level of assurance to the Committee that there are systems and processes in place to manage this area of service delivery. A few issues have been identified where some Practice Nurses within our surgeries refuse to immunise if the parents are not present. To minimise this matter and ensure that consent is adhered to a new consent form has been devised for Health Visitors to issue to those parents who are unable to take their child to clinic themselves. This will then be presented in clinic to the nurse identifying that the parents have given their informed consent for the vaccination to go ahead. A copy was presented to committee for information. As a Health Board we are proactive in the approach we take and work collaboratively to increase the amount of childhood vaccinations. A targeted approach is being taken to identify and resolve individual GP practices with lower performance. Action: The Committee NOTED the report and APPROVED the implementation of the new Parental Consent form. CGC/12/079 – Uptake of Influenza Vaccination in Cwm Taf The Director of Public Health delivered this report to inform the Committee of the Welsh Government (WG) influenza immunisation campaign which aims to minimise flu related morbidity, mortality, and hospital admissions. The report set out plans to increase uptake for all vulnerable groups including health and social care staff. Assurance was provided to Committee members that the Health Board’s vaccination and immunisation group develop, implement and monitor these actions. ACTION: The Committee NOTED the contents of the report and the work of the Vaccination and Immunisations Group. CGC/12/080 – Cwm Taf Smoke Free Environment Policy The Director of Public Health delivered this report and informed the Committee that there has been positive support and compliance from both staff and patients. A recent staff poll identified that from 149 responses 76% of staff are supportive of the policy.



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We have received many reports of staff successfully approaching people smoking to inform them of the policy, but the staff poll indicates that more work is required to encourage more staff to feel confident to do so. More work is also required to inform visitors of the policy.

The Executive Walkabouts and smoking hotline identified several issues that the Smoke Free Environment Policy Task and Finish Group will monitor and address and monitor policy implementation. ACTION: The Committee NOTED the contents of the report CGC/12/081 – Screening Programme update report for Cwm Taf The report was delivered by the Director of Public Health and highlighted the latest uptake of screening services in Cwm Taf by population eligible for the following screening programmes:

• Breast Cancer • Bowel Cancer • Cervical Cancer • Newborn Hearing • Antenatal • Abdominal aortic aneurysm

Screening is a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition.

An Independent member raised a query around consent for Ante-Natal screening and enquired whether patients are asked for consent as it is not disclosed exactly what tests are being carried out.

The Director of Nursing responded and assured the Committee that the consent process is fully adhered to and that patients are explained the full screening process by the midwifes.

ACTION: The Committee RECEIVED the report and NOTED the ongoing work

CGC/12/082 – Improving Outcomes for Fractured Neck of Femur The Director of Public Health presented this report and informed the Committee that Elderly patients with hip fractures are some of the most vulnerable we have. The report outlined the high mortality and morbidity rate and the numbers requiring long term care.



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An Independent member enquired if the reported Mortality data can be definitely linked to Fracture Neck of Femur (#NOF). The Director of Public Health responded that the data provided is reasonable compared with the National figures and that the Performance measures will be provided to a future meeting. This work is also linked to the Care Bundle work within the 1000 Lives Plus initiative which gives us specific measures and comparable data across Wales. ACTION: The Committee NOTED the report Director of Public Health to present a report containing the Performance Measures to a future Committee CGC/12/083 – 1000 Lives Plus Programme Workstreams The Director of Nursing delivered this report in the absence of the Assistant Medical Director-Clinical Governance and welcomed the attendance of the Assistant Medical Director for Clinical Audit and Effectiveness. It was reported that a significant amount of work has been progressed on both the 1000 Lives Plus Workstreams and the Standards for Healthcare Services in Wales. It was further noted that Education and Clinical Audit are critical aspects to both these areas of work. The Assistant Medical Director-Clinical Audit added that the link between Education and Clinical Audit is a reasonable process to help spread the information through evidence measurement and revalidation. Work is progressing in these areas to include trainees. The number of Workstreams (29) within the 1000 Lives plus campaign is evidence of the success in improving care and reducing harm. The next step is to streamline areas to build on previous success as well as maintaining and continuing to improve the delivery of care. ACTION: The Committee NOTED the contents of the report CGC/12/084 – Together for Health – South Wales Programme The Assistant Director of Nursing- Regulation & Legislation delivered this report to inform the Committee of the progress of Together for Health South Wales Programme in relation to developing a sustainable configuration of hospital services across South Wales. This work is being clinically led and regular updates will be presented to the Committee.



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ACTION: The Committee NOTED the contents of the report. CGC 12/085 – Clinical Governance Report The Director of Nursing informed the Committee of the development of the Clinical Governance Strategy which will incorporate the requirements of Achieving Excellence. The Quality Delivery Plan for the NHS in Wales 2012-2016 (Welsh Government, 2012), and be shaped by the principles of Improving Quality Reduces Costs – Quality as a Business Strategy (1000 Lives Plus, 2012).

It is proposed that the Heath Board's Clinical Governance Strategy will be based around the following framework:

1. Standards (in line with the Standards for Health Services in Wales) and Statutory obligations • Professional Standards • Clinical Standards • Infection Prevention and Control • Safeguarding

2. Structure • Committees, Directorate Governance Groups, Panels • Leadership

3. Systems, and processes • to measure, monitor and scrutinise • Policies and Protocols

4. Patient focus 5. Improvement initiatives

• Audit – national and local • 1000 Lives Plus programme areas • Learning from Concerns • Fundamentals of Care, Transforming Care

6. Education and Professional Development 7. Research & Development 8. Innovation An Independent member added that the Transforming Care programme which empowers frontline NHS staff across Wales to make changes to improve the patient’s experience of care, safety & quality of services in both hospitals and community are a fantastic achievement and staff are to be congratulated on all their hard efforts. This area of service change should be highlighted as Best Practice. There is further work to be done to ensure this is embedded across the organisation. ACTION: The Committee NOTED the contents of the report



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CGC 12/086 – Welsh Government Quality & Safety forum The Director of Nursing informed the Committee that either she or the Medical Director attends this meeting and the notes from which will be included for information in all future Committee meetings. Due to the timing of this meeting the notes will be circulated by email as soon as possible. ACTION: Welsh Government Quality & Safety notes for July to be circulated via email for this month and incorporated for information in all subsequent meeting papers. The Committee RECEIVED the oral update. CGC/12/087 – Revised Clinical Governance Terms of Reference The revised Clinical Governance Terms of Reference were agreed following minor amendments and it was noted that these would be reviewed at least on an Annual basis. The Board Secretary/Director of Corporate Services added that it may be beneficial to revisit the Clinical Audit section and add the work plan as an appendix to the Terms of Reference. ACTION: The Committee APPROVED the revised Clinical Governance Terms of Reference following minor amendments and further agreed that these will be reviewed at least on an Annual basis CGC 12/088 - Standards for Health Services in Wales This report was presented to inform the Committee on the suggested approach to undertaking this year’s Annual Self Assessment against the Standards for Health Services in Wales. The proposal consists of 4 elements:

1. Mapping existing work 2. Mapping to existing assessment 3. Corporate self assessment 4. Self assessment by Directorates/Services

This coming year it is proposed that the self assessment phase is completed by November 2012. To assist with timely completion, from Monday 2nd July 2012, Directorates/Services will be expected to self assess themselves against each of the 5 Core Standards on an incremental basis over a 20 week period. This approach will facilitate peer review for the completion of the self assessment. The Clinical Audit Team



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will support the directorates/services with the process and will also be responsible for escalating any issues of concern. ACTION: The Committee APPROVED the suggested approach within the report CGC 12/089 – Annual Report of Suicide Rate in Cwm Taf LHB Region The Assistant Director (Operations) - Mental Health & Child & Adolescent Mental Health Services (CAMHS) presented this report to highlight the current suicide rate in Cwm Taf region and benchmark to national data. Cwm Taf Health Board is responsible for primary and secondary care mental health services. Suicides of people in contact with services are reported to the Health Board, Welsh Government and the National Confidential Enquiry for Suicide. The National Confidential Enquiry into Suicide, hosted by The University of Manchester, also collates information from all other agencies of people not in contact with health services within one year of discharge or not in contact with services. The report presented data sourced from the Patient Care & Safety Directorate and the National Confidential Enquiry for Suicide. The national rate of suicide in Wales for men and women will have a range which will be above and below the norm. In Cwm Taf the actual numbers compared to the expected values are slightly higher, most likely linked to high areas of deprivation when compared to other regions. A significant investment is currently being made into Primary Care services as part of the new Mental Health measures which is expected to decrease the percentage figures for suicide related deaths. It was noted that within secondary care there are robust risk assessments in place and a tool which is ready to be implemented; therefore the Committee were asked to endorse the following:

1. To commence a 1000 lives project in CDAT to reduce unexpected deaths

2. Sharing this report with the Local Service Board as preventative strategies are wider-reaching than health board influence alone; for example, unemployment

3. Continue building a statistical analysis every year so we have the ability to examine data in 5 year cycles



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ACTION: The Committee NOTED the report and ENDORSED the above mentioned 3 points CGC 12/090 – Governance Statement 2011-12 The Board Secretary/Director of Corporate Services informed the Committee that this report was presented for information and that it has also been presented through the Audit Committee. ACTION: The Committee APPROVED & NOTED the Governance Statement CGC 12/091 – Organisation Readiness Self Assessment (ORSA) The Assistant Medical Director for Education presented the report and informed the Committee of the statutory requirement to implement a Medical Appraisal and Revalidation process within Cwm Taf LHB. The Health Board completed and submitted an ORSA to Welsh Government in June 2012. The assessment identified areas where further action was required. Concerns were identified as the appraisal rate in Cwm Taf LHB is lower than other LHB’s. The Revalidation Steering Group has identified that the current paperwork being used by the Health Board does not meet all the criteria requested. Therefore, it has been agreed that the NHS Appraisal Toolkit document is more in line with the requirements of GMC. The Medical Director has written to all medical staff requesting that this paperwork is used in the next round of Appraisals whilst waiting for the roll out of the Medical Appraisal and Revalidation System (MARS). This document will ensure readiness and availability of information for when the electronic system is implemented within the Health Board. Events have been arranged to advise and ensure that all Doctors are prepared for the revalidation. A total of 68 appraisers have been identified and it has been agreed that the Medicine Directorate will pilot the implementation of the system within the Health Board in September 2012. The Revalidation Officer is currently working on a training programme for both appraisers and appraises. Once the appraisals have been undertaken and an evaluation of the system completed a roll out plan will be agreed for all other Directorates and communicated via updates, emails, notice boards etc. ACTION: The Committee NOTED the contents of the report and the progress made CGC 12/092– Redesign of Medical Education Governance Structure



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The Assistant Medical Director for Education presented the report to provide an update on the streamlining of the Governance arrangements regarding Medical Education and training within the Health Board. The current medical education governance arrangements and board structure requires review in order to realign the quality and financial agendas to improve integration, efficiency and effectiveness. It has been recognised that intensive efforts are needed to reform medical education in order to meet the needs of the population. Pressure for changes to the organisation, content and delivery of both undergraduate and postgraduate medical education has greatly increased in the last two decades. The current structure does not differentiate between strategic and operational roles, potentially compromising the scrutiny, direction and efficiency of medicine education governance. The recommended streamline changes will allow for the:

• Review and rationalise medical education management related boards and their membership to deliver an integrated approach

• Differentiate operational and strategic roles, maximising development opportunities.

• Establish efficient ways of working • Establish clear and efficient communication processes

The proposed update of streamlining Governance arrangements for Medical Education have already received support of the existing committees which include Medical Director, Assistant Medical Director, Education and the Head of Clinical Education. The Head of Clinical Education extended her thanks & compliments to the whole Medical Education team involved in this work and the Board Secretary/Director of Corporate Services advised that this would strengthen the Committees to work top down as well as bottom up. ACTION; The Committee APPROVED the recommended changes to the Medical Education Governance arrangements. CGC 12/093 – Infection Prevention & Control Annual Report 2010-2011 The Assistant Director of Nursing Regulation & Legislation presented the annual report for information. Cwm Taf Local Health Board has made significant progress in reducing Health Care associated infections. The implementation of a systematic



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process of surveillance and swift action to prevent and control infections acquired in hospital has had a notable impact in reducing the number of infections ACTION: The committee NOTED the progress made and ENDORSED the Annual report 2010-11 CGC 12/094 – Clinical Governance Questionnaire 2010-11 The Assistant Director of Nursing Regulation & Legislation informed the Committee that there were varying views in the responses received. Constructive comments have been progressed and will form part of the work plan moving forward. ACTION: The Committee RECEIVED the oral information CGC 12/ 095 – Policies/Procedures for Approval: The following policies were presented for approval:

1. Incident Reporting procedure – this was well supported by the Board Secretary/Director of Corporate Services and following minor amendments to the terminology the Committee APPROVED the procedure

Director of Primary, Community & Mental Health leaves the meeting

2. Development of Anti-Ligature policy – the Committee were informed

that this policy is not required as the organisation is satisfied with its current position with all new builds being fully compliant. Future draft policies will go through the Mental Health & CAMHS reporting mechanisms for approval.

3. Management of Head Injuries – work on this policy is continuing as full sign up from all Clinicians has yet to be received. A meeting is scheduled between Primary Care & Secondary Care Clinicians; if no progress the Executive Board will be further informed. Once full sign up has been reached the policy will be presented to the Clinical Governance Committee.

Head of Quality & Effective Practice leaves the meeting CGC 12/ 096 – The following minutes from Sub- Committees/Groups were received for information:

1. Eating Disorder Group March & June 2012 2. Infection Prevention & Control Operational Group – May 2012 3. Infection Prevention & Control Strategic Group – April 2012



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4. Medicines Management Committee Minutes-May & June 2012 5. Children’s Safeguarding Operational Group May 2012 6. Adult Protection Committee – May 2012 7. Hospital Transfusion Committee – June 2012 8. Draft Immunisation Group – March 2012 9. Draft Research & Development Committee September 2012 10. Cancer Services Strategy group March 2012 11. DatixWeb Project Board January & March 2012

CGC 12/097 – Items/Newsletters for Information The following items were received by the Committee for information

1. HIW Newsletter May 2012 2. 1000 Lives Plus Newsletter June 2012 3. 1000 Lives Plus Summer Newsletter

CGC 12/098 – Any Other Business A.O.B. 1 The Committee were informed that at October’s meeting there will be 2 members of Welsh Government attending as Observers. A.O.B. 2 The Assistant Director (Operations) - Mental Health & Child & Adolescent Mental Health Services (CAMHS) raised concerns in respect of the requests being received through the Freedom of Information Act. A number of requests are being received for research purposes which could potentially cause a conflict through the Research & Development process. Once information has been provided there are no outcomes of the information received therefore no control over the data once it has been released. The Board Secretary/Director of Corporate Services responded and requested that the Health Board approach to Freedom of Information requests is followed and that any requests are put in writing to the Board Secretary/Director of Corporate services and The Assistant Medical Director for Research & Development. CGC/12/099 - DATE AND TIME OF NEXT MEETING. Thursday 25th October at 9.00am - Rhondda & Cynon Meeting Room, Ynysmeurig House, Abercynon. SIGNED: …………………………………………… Councillor Clive Jones, Chairperson

DATE: ………………………..

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