executive summary...2016/10/04 · executive summary report to: trust board date: tuesday 4 october...

Trust Board 4 October 2016 Quality Assurance Committee Draft Minutes 13 September 2016

Medical Director and Director of Nursing of 17 G:/Board Secretariat/Meetings/Board/Meetings/2016-17/04.10.16

EXECUTIVE SUMMARY REPORT TO: Trust Board DATE: Tuesday 4 October 2016 AGENDA NO: 2.2 AGENDA ITEM: Draft Minutes of the Quality Assurance Committee (Open) held on 13th

September 2016 SPONSOR: Andy Ibbs, Director of Strategy & Transformation

PREPARED BY: Lucy Parr, PA to Medical Director and Director of Nursing

PRESENTED BY: Tim Douglas-Riley, Non-Executive Director

Purpose

The purpose of this paper is to present the draft minutes of the Quality Assurance Committee (open) held on 13th September 2016.

Decision Approval Receive

Ratify

Key Issues

Key issues include:

R&D commercial income will stand outside central funding and a project is being undertaken to increase commercial income.

The internal reporting of child deaths is being reviewed.

The patient experience strategy is being developed.

The Trust is in breach of contract by not completing two national audits.

The Safeguarding Childrens Board annual report was received.

The patient experience annual report was received.

Supporting Information

The draft minutes are attached.

Controls and Assurance

The minutes of the meeting are considered by the Quality Assurance Committee for accuracy. Following discussion, amendments may be recorded as appropriate. The minutes are then formally approved by the Committee.

An accurate record of the proceedings of the meeting is required in order to ensure that the Board meets its duties in accordance with the Trust’s Scheme of Delegation, Standing Orders and Standing Financial Instructions. Copies of the Quality Assurance Committee minutes are presented to the Trust Board to note.

The Trust’s clinical governance management arrangements have been developed to meet the requirements of the Care Quality Commission standards (registration requirements 2012).

Impact Assessments Explanation

Quality

Equality and Diversity

Regulatory & Legal The legal and regulatory implications have been considered and none have been identified.



Finance

Potential Risk to the Organisation

If the minutes are not approved by the Quality Assurance Committee the Trust will be at medium risk of not acting in accordance with the organisation’s Standing Orders, Standing Financial Instructions and Scheme of Delegation.

Board / Committee Prompts

The Board is asked to RECEIVE the draft minutes of the open section of the Quality Assurance Committee held on 13th September 2016

References

None Strategic Objectives The Trust’s strategic objectives are reviewed by the Board on an annual basis. This paper supports the achievement of the following strategic objectives

We will deliver high quality care measured by effectiveness, safety and the person’s experience of care.

We will ensure access to a sustainable range of services that are delivered locally through partnerships and networks.

People will tell their story only once. We will deliver integrated health and social care, seamlessly to meet the needs of individuals.

We recruit and develop a flexible, fulfilled and multi-skilled workforce fully engaged in turning our vision into a reality.

We will efficiently and effectively run our services to benefit our local communities.

We will work in partnership with stakeholders to promote independence and well-being.

We will support individuals and communities to have more influence over how services are delivered and encourage others to do likewise.

Annual Corporate Objectives

This paper provides evidence to support the achievement of the following annual Corporate Objectives for 2016/17.

Does not contribute to this year's Corporate Objectives

Principal Risks

The Trust’s principal risks have been identified through the Trust’s risk management processes. They are updated as they are identified by the Risk Management Committee. This paper supports the mitigation of the following principal risks

Financial planning & management Clinical records management

Strategic & business planning Leadership & management

Workforce numbers Unsafe behaviour

Workforce skills External demands

Procedural management Partnership arrangements

Equipment & facilities arrangements Communication



MINUTES OF THE QUALITY ASSURANCE COMMITTEE Held in Chichester Boardroom, NDDH on Tuesday 13th September 2016 at 10.00am

PRESENT: Tim Douglas-Riley (Chair) TDR Non-Executive Director Linda Henderson LH Research & Development Manager Nicola Ryley NR Interim Director of Nursing Tony Neal TN Non-Executive Director George Thomson GT Medical Director Matt Kaye MKa Chief Pharmacist Helen Cooke HC Head of Physio & OT Hannah Jones HJ Clinical Audit and Effectiveness Manager Anna Brimacombe ABr Named Nurse, Safeguarding Children Charlotte Overney CO Divisional Nurse, Unscheduled Care Mandy Kilby MK Head of Corporate Governance Fiona Baker FBa Lead Nurse, IPC Nick Rudling NRu Safeguarding Adults Lead Donna Knight DK Divisional Nurse Andy Ibbs AI Director of Strategy & Transformation Andrea Bell AB Assistant Director of Nursing Chris Bowman CB Deputy Medical Director Becky Haynes BH Senior Governance Manager, Risks & Incidents

IN ATTENDANCE: Lucy Parr LP PA to Medical Director and Director of Nursing Andy Walder AW Consultant Anaesthetist Helen Hartstein HH Head of Communications

137/16 Apologies

Apologies were received from Di Walker, Toby Cooper, Sue Pilkington and Julie Poyner.

138/16 Minutes of the Meeting held on 12th

July 2015

The minutes of the meeting held on 12th July 2016 were approved.

139/16 Matters Arising Healthcare Videos Update AB advised that HK is the project lead and is line managed by SP as this fits with the quality portfolio. AB gave key headlines from the project, as follows.

23 patient and 2 staff videos have been implemented

Discussions are taking place In talks with Plymouth University re: formal evaluation

The business case for continuation of the project has been approved and



charitable funding for 6 months agreed

Objectives for the project have been set AB queried if the Committee are happy to receive quarterly updates. The Committee agreed. Organ Donation Committee AW attended the meeting to provide a briefing on organ donation within the Trust. AW advised that a detailed potential donor audit is carried out on all deaths in ICU and ED. This occasionally flags up potential donors but on review, there are issues with documentation, not potential organ donation. AW advised that the audit is very thorough and picks up patients that on paper have potential but on review do not. CB raised a concern that discussions took place with 4/5 families but there was no organ donation. AW advised that the Specialist Nurse had discussions with families and advised that in one case, a post mortem was requested and it was difficult to find a pathologist to confirm that the post mortem could be undertaken after organ donation, due to the discussions taking place out of hours. AW advised that in one case there was a delay between identifying potential organ donation and discussions taking place between the family and the organ donation team that resulted in the family not giving consent. TDR noted that having five potential donors but no actual donations caused this Committee to query the process. AW advised that all cases were reviewed by the Specialist Nurse and discussed with senior clinicians. AW noted that it is disappointing that individual obstacles occur but confirmed that three out of the five potential cases were not medically appropriate. The lack of organ donation was not due to lack of input. CB noted that balance is critical, noting that five families had been asked about organ donation before it was clear if the organs were appropriate for donation which potentially could have caused distress to the family. AW advised that it is recognised and documented that consent rates are best when the families are approached by the Specialist Nurse. AW advised that is very difficult, families want information about the process as soon as they know the patient can potentially donate but the time delay is a 12-14 hour wait, which is challenging. AW advised that initial responses are good but as time goes by, responses reduce. AW advised that this has been a focus of NHSBT. GT noted that the concern raised by this Committee was that organ donation is constrained due to geographical issues and queried whether there are any work rounds that would help to improve organ donation. AW advised that there are broader issues that NHSBT are trying to address. GT queried if the system is constraining organ donation. AW confirmed it is. GT queried what support can be given to the organ donation team. AW advised that reduction in Specialist Nurse time would be an issue. GT queried if benchmark data is available. AW advised that NDHT are averaging 2-3 organ donations per year which is similar to other Trusts of this size. TDR advised that the Committee need assurance that the processes in place are as good as can be, as is staff input. TDR noted that as chair of the Organ Donation Committee, he has this assurance.

LP



CB noted that there could be improvements and noted that access to the Specialist Nurse and time delays are issues and queried if there are options to explore that could make a difference. GT advised that he is willing to provide support that would improve patients / families wishes. AW advised that there are plans to improve family consent rates and advised that he will discuss support required at the next Organ Donation Committee. The Committee updated the outstanding actions on the action grid.

140/16 Safeguarding Childrens Board ABr presented the draft minutes of the Safeguarding Childrens Board held on 27th July 2016, highlighting key issues, as follows.

The 2016/17 safeguarding children and young people work plan and amalgamated action plan, as a response to serious case reviews, were approved.

The 2015/16 annual report was approved.

Progress against level 3 training was noted.

The risk of baby abduction from the Maternity unit has been added to the risk register following a test in the department.

Amendments to the paediatric element of the chaperone policy were approved.

The internal reporting of child deaths is being reviewed. MK noted that reporting of child deaths is important, advising that there is an established process in place externally but noting that these deaths should also be reviewed internally and concerns escalated correctly, with the internal process linking to the Child Death Overview Panel (CDOP). GT confirmed that the CDOP would find internal reports useful. HC queried what action is being taken re: poor compliance with level 3 training. ABr advised that there was a gap between the Named Nurse being in post and therefore level 3 training being delivered. ABr advised that she has put on monthly training sessions but not had good uptake. ABr advised that she is working with AC on a safeguarding training passport, which will need consultation. ABr advised that she is reviewing who requires the training and actively approaching these staff members. The Committee RECEIVED the minutes.

141/16 Research & Development Group LH presented the draft minutes of the Research and Development Group held on 1st August 2016, highlighting key issues, as follows.

Research participant recruitment figures in July have begun to decline due partly to the closure of the AFGEN study; several new studies which have had Operational management group (OMG) approval are moving into set up and should raise recruitment numbers. LH confirmed that the figures are still above target.

37% of recruits in July were into interventional studies, compared to department aspirational target of 20%.

Nathan Vernon (Clinical Research nurse) has taken the role of DRIVE champion, a South West initiative, and will be working closely with OMG.

The feedback from the Research and Development symposium held in June was presented. The feedback was very positive and a reflection of the day. The 2017 symposium will start to be arranged shortly to ensure the event can be advertised



with enough notice.

NIHR leadership Programme (Ashridge) is being undertaken by Linda Henderson, Research and Development manager and Roope Manhas, Research and Development Director. The 18 month programme includes an improvement project which will be to double commercial income by the end of 2017/18.

The patient experience questionnaire results were presented; the questionnaire was given to every research patient with an appointment during November 2015. The questionnaires are designed and managed by the CRN SWP (Clinical Research Network South West Peninsula). NDHT had a 65% response rate and feedback was positive. This will be shared with LPEG.

The Committee RECEIVED the minutes.

142/16 Research & Development Time to Target LH advised that the research and development time to target is a recruitment target that the Trust has to meet. LH advised that the national target is 80%. LH advised that until June 2016, 100% has been achieved however, this year 95% will be achieved as there is one study that is not expected to close within the time to target metric however, if the study is extended, the target will be met. GT asked LH to comment on regional issues re: time to target. LH advised of the South West position, in comparison to other regions. LH advised that it is unclear how funding is calculated, but advised that it has previously been calculated on overall recruitment however, it is expected that some funding to be based on time to target. GT noted that as a region he would not expect an increase in funding. LH has been advised that NDHT should expect a funding cut of 5%. GT noted the superb work being undertaken and how disappointing it is that funding will be reduced. MK advised that funding doesn’t seem to be based on a specific formula. CO advised that feedback from patients about research nurses is fantastic. LH advised that there is a funding model group who review how funding is given and the acute Trusts in the region are represented by Yeovil. LH advised that commercial income will stand outside central funding and a project is being undertaken to increase commercial income. GT suggested that this is highlighted to the Trust Board via the QAC minutes. The Committee agreed. The Committee RECEIVED the report.

TDR

143/16 TEP Audit Report SP presented the TEP audit report, highlighting key issues, as follows.

The number of patients who have Treatment Escalation Plans remains fairly constant which could mean that we are not identifying all patients in the last 12 months of life.

The Mental Capacity Question continues to challenge the clinicians.

The signature section completion is improving when the TEP is completed in the trust but patients that are admitted with a TEP are often not reviewed.

Documented discussion with patient and family is improving.



End of Life Lead and Safeguarding lead working together to ensure a clearer understanding of question on the form

GT clarified the MCA question, this is not being filled in but is taking place. TDR noted that discussions have taken place re: patients being admitted with a TEP and these being reviewed. NR advised that the Trust also need to ensure that patients admitted with a TEP are discharged with a TEP. This is work in progress. The Committee RECEIVED the report.

144/16 Midwifery LSA Audit Report NR advised that the LSA visited to sign off the LSA audit and assurance on the action plan is required. NR advised that external standards for supervision will cease next year and therefore will need to be managed internally. NR advised that there will be one last visit from the LSA before this infrastructure ceases. The Committee requested that the key highlights from the audit and action plan are presented at the next meeting, along with a briefing on the proposed management of supervision from 2017/18. NR to advise TC of what required. AI queried if the new process can be included in the CQC fundamental standards process. NR advised that this needs to sit outside as it is regulatory. TN queried if this action plan will be separate to the overarching maternity action plan. NR advised that the action plan will need to be reviewed prior to being merged into the overarching action plan.

NR /TC

145/16 Coding Report The Committee noted that the minutes from the Data Quality Group will be received at future meetings. GT advised that there is a false assumption that quality of coding should be monitored by the Mortality Review Committee however, this is wider than mortality.

146/16 Drugs and Therapeutics Committee MKa presented the draft minutes of the Drugs and Therapeutics Committee held on 21st July 2016, highlighting key issues, as follows.

The meeting was quorate

14 new NICE guidance were allocated leads

The SOP for Medication Incidents (update) was approved for use

There were no protocols and guidelines approved for use:

A medication safety report was received. This is a new report that will be presented 6 monthly. Overall, the report shows a reduction in medication incidents and harm associated with these. This report will tie in with the Trust performance data and previous CQUINs. Actions arising from this report will then be monitored through DTC

GT queried where medicines reconciliation data is reported. MKa advised that this will



be reported to DTC. CB noted that medicines reconciliation performance after the 24 hour target is poor and queried the difference in process for over 24 hours and within 24 hours. MKa advised of stages 1 and 2 and advised that these figures haven’t been reported before. GT noted that this is useful information and queried, as there are improvements to be made, whether there is an improvement plan / trajectory. MKa advised that there is action plan for the acute site which is being monitored. MKa assured the Committee that concerns can be escalated as this information is now being monitored on a monthly basis. GT & MKa to discuss reporting routes outside the meeting. The Committee RECEIVED the minutes.

GT & MKa

147/16 Infection Prevention & Control Committee FBa presented the minutes of the Infection Prevention and Control Committee held on 26th July 2016 and the draft minutes of the Infection Prevention and Control Committee held on 23rd August 2016, highlighting key issues, as follows.

There were no cases of trust attributed MRSA bacteraemia at North Devon District Hospital in June or July 2016. The HCAI limit for 2016/17 is zero MRSA bacteraemias acquired at NDDH, and there have been no cases since February 2015.

The committee received MRSA colonisation data from 2005 – 2016 noting that there had been year on year reduction in numbers over the last few years. The continuing steady decrease that has been observed correlates with a time period when there has been a constant (i.e. consistent / unchanged policy) screening policy, so there is reassurance that this is a real reduction in number of patients acquiring MRSA.

There were no cases of Clostridium difficile infection attributable to NDDH in June or July 2016. The HCAI limit for 2016/17 is a maximum of 7 Clostridium difficile infections to be attributed to NDDH. The total of cases attributable to the trust to date in 2016/17 is 4, so the trust is 3 cases under the limit. No lapses in care have been identified.

Compliance with MRSA emergency admissions screening was 93% in June and 94% in July 2016. Compliance with MRSA elective admissions screening was 94.2% in June and 94.8 % in July 2016, Non-compliant areas would be followed up by the divisions.

Blood culture contamination rate was noted to be 2.6% in June and 1% in July 2016. This was the lowest rate recorded to date at NDHCT - the national guidance advises a rate of no more than 3%.

Hand hygiene and Bare Below Elbow (BBE) compliance were both reported to be above the trust target of 95% in June and July 2016. Hand hygiene compliance observed by the IP&C team during 7 spot check audits of the inpatient areas was 78% in June and 85% in July 2016. Compliance with BBE was observed by ICNs as 94% in June and 81% in July. In the 7 outpatient areas that were spot checked in June and July 2016 the IP&C team observed hand hygiene compliance to be 100%, and BBE compliance was below target at 67% in June and on target at 95% in July 2016. Lapses were challenged at the time of the audit and the results sent to the divisional nurses, matrons, ward managers, and link practitioners.

The committee were advised that compliance with uptake of infection prevention and control mandatory training was above the trust compliance target of 85% for clinical staff in June and July 2016. Uptake of infection prevention and control training for non-clinical staff was below the target at 82.6% in June and July 2016.



This would be followed up by the divisions.

The committee noted the Hygiene Code briefing paper that had been submitted to QAC in July 2016 as requested by the Audit Committee

The committee received minutes from the Collaberative Operational Groups North and East (formerly Matron’s Charter Groups) and noted compliance with cleaning scores, and improvements identified on the Patient Led Inspections of the Clinical Environment visits (PLACE)

The committee agreed that the risk of not delivering the Hygiene Code actions could be closed on the risk register.

MK advised that issues with cannula documentation have been noted when MK and SP review SEAs and 72 hour reports. DK advised that this is being addressed and is progressing well. FBa advised that it is more difficult to audit cannula insertion. The Committee RECEIVED the minutes.

148/16 Mortality Review Committee GT presented the minutes of the Mortality Review Committee held on 19th July 2016 and the draft minutes of the Mortality Review Committee held on 16th August 2016, advising that there has been an increase in HSMR and SHMI. GT confirmed that both HSMR and SHMI are within the expected ranges but this is a concern as the increase is due to coding issues. GT advised that he is confident the processes put in place by the Information Governance and IM&T Committee will resolve the issues. GT advised that assurance has been gained that emerging CUSUM alerts are being tracked. GT advised that Paul Smith, NHSI re-attended the Committee and his feedback was very positive. The Committee RECEIVED the minutes.

149/16 Safer Care Delivery Committee NR presented the draft minutes of the Safer Care Delivery Committee held on 23rd August 2016, advising that she chaired the meeting on behalf of AD. NR advised that the function of the Committee has been reviewed to ensure duplication of reporting is avoided and to ensure there is a focus on improvement and safety. The Committee RECEIVED the minutes.

150/16 Learning from Patient Experience Group NR presented the draft minutes of the Learning from Patient Experience Group held on 21st July 2016, advising that the group is being restructured to ensure the focus is on patient experience. NR advised that the patient experience strategy has been delayed to allow engagement with the public and staff so the strategy will be meaningful. NR advised that there is a four month timeframe to complete the strategy.



NR advised that the membership of LPEG is being reviewed to ensure appropriate representation from all areas. NR advised that HC & CO will be giving a presentation on patient experience at the next meeting that will be shared with this Committee. HC noted that there are a lot of old actions. NR advised that these will be reviewed at the next meeting. The Committee RECEIVED the minutes.

NR

151/16 Clinical Audit & Effectiveness Programme Exception Report HJ presented the clinical audit and effectiveness programme exception report, highlighting key issues, as follows.

There are two National audits which form part of the Trust’s quality account which we are currently not participating in; IBD Registry; and BTS Asthma.

The National Dementia audit is underway, with approximately 30 cases to be submitted before the end of September. There are also staff and carer questionnaires that have been circulated to the appropriate staff and wards.

The has Trust volunteered to participate as a pilot site for the COPD audit, however, there being no resource to participate in the BTS Asthma audit, this should be raised.

MK queried if there is rationale for not participating in national audits. HJ advised that this is due to a lack of resource. MK noted that the Trust are in breach of contract by not completing the audits. GT requested that this is discussed further outside the meeting by GT, CB & HJ. The Committee RECEIVED the report.

GT, CB & HJ

152/16 NICE Standards Exception Report HJ presented the NICE standards exception report, advising that there are some standards still waiting assessment. These are being worked through and an action plan is being produced at time of assessment. HJ advised that the report format will be revised in order to make it more readable. The Committee RECEIVED the report.

153/16 NICE Guidance Exception Report HJ presented the NICE guidance exception report advising that the report has been put into a new format and is RAG rated. The Committee agreed that this report is much clearer and makes it easier to understand the Trust’s position. The Committee noted that there are a lot of pieces of guidance rated red. CB advised that this is due to the team are working through all pieces of guidance to ensure none are missed. CB advised that the team will work with divisions to improve compliance and will review the risks to the organisation to give an extra level of assurance. HJ advised that the team now need to go back through guidance to ensure all guidance relevant to Devon Cares is included as NDHT need to be assured that the



providers are compliant. GT queried if the team distinguish guidance by type. HJ confirmed they do. CO noted that a member of staff listed is no longer in post. HJ to update. The Committee RECEIVED the report.

HJ

154/16 Safeguarding Childrens Board Annual Report ABr presented the Safeguarding Childrens Board annual report, highlighting key issues. ABr advised that the Safeguarding Children Liaison Nurse post was approved at CSEC but not approved at vacancy panel. NR will take this forward outside the meeting with DA. MK noted that self-harm has significantly increased and queried if the Trust have resources to manage this or if additional support is required. ABr advised that a CAMHS audit is underway (Devon wide review) and is being discussed at the Safeguarding Childrens Board Operational Group. ABr advised that this is a small % of safeguarding activity and the data is immature. NR advised that this is a growing trend nationally and needs to be linked to national initiatives. The Committee RECEIVED the report.

NR

155/16 Patient Experience Annual Report HH attended to present the patient experience annual report. HH advised that this report shows how, by collecting and responding to patient feedback, Northern Devon Healthcare NHS Trust aims to embed a culture of continuous improvement within the organisation which will benefit patients, reward staff and enhance our reputation with commissioners and stakeholders. HH advised that patient experience features as the third element of the Trust’s quality strategy, therefore placing it firmly at the heart of the Trust’s continuous drive to improve the quality of services we provide. HH advised that this report details the activity carried out in 2015 by the Trust to capture patient experience feedback, understand it and improve in response to this feedback. Topics covered in this report are as follows.

Friends and Family Test – methodology and results

Additional patient experience questions that are asked and themes identified

Positive results from National Inpatient Survey

“You said, we did” report

Case studies of changes to food provision in neonatal and paediatric services and East Devon Stroke Unit at Ottery St Mary, following patient feedback

Communications deep dive

How we have used patient experience data to support transformation programmes

How we communicate the feedback

Governance systems that are in place HH highlighted key issues to the Committee, as follows.



The friends and family test has a target of 75% for “would recommend” score and advised that the Trust regularly exceed this target. HH advised that reaching the target for response rates is a challenge in some areas (20% target) and those that don’t achieve have an action plans developed.

The patient experience team continuing to increase the use of electronic data capture and use of volunteers.

The Trust scored higher in the national in-patient survey than the previous year and are in the top 5 Trusts for two areas. Areas for improvement have also been identified.

There were 21 specific pieces of “you said we did” activity.

A communications deep dive is taking place, this is included in the quality account.

Patient experience data is provided to support transformation programmes. HH advised of the priorities for next year, as follows.

Review of patient experience strategy

Redesign of LPEG

Increased electronic data capture GT noted that this report highlights outstanding results for community therapy teams and queried how this is being publicised externally. HH advised that the data is available on the website but noted that it is not easily digestible; this is being reviewed. CB advised that he is attending a meeting with the Overview and Scrutiny Committee and the CCG to help them understand the data and how it relates to quality, safety and effectiveness. TN queried if the data can be triangulated against other Trusts, noting that this would help to bust myths that the data is corrupt. AI queried use of SMS to collect friends and family data. HH advised objections were raised due to issues with domestic violence so this was put on hold but is being revisited. DK noted that the friends and family questions are included in the discharge procedure and staff have needed support with this. The Committee RECEIVED the report.

156/16 Safer Care Delivery Committee NR presented the Safer Care Delivery Committee compliance report for 2015/16, highlighting key risks discussed, as follows.

The correlation between agency usage and harm events.

Poor compliance with TEP in NDDH.

CQC inspection results.

Correlation between time of escalation and harm events. NR advised that attendance had been variable. As a result, the membership has been re-defined to ensure continuity in attendance. The Committee RECEIVED the report.

157/16 Patient Documentation Group



AB presented the Patient Documentation Group terms of reference and compliance report for 2015/16. Terms of Reference AB advised that a representative from medical records has been included in the group, in response to documentation incidents that have had an impact on quality of patient experience. AB noted that these meetings clash with an IM&T meeting that has shared membership. This is being reviewed in order to eliminate clashes. Compliance Report AB noted the key issues, as follows.

The Group met eight times in 2015-16

Eight meetings were quorate

The Group discharged its responsibilities in accordance with its Terms of Reference and received routine reports and approved key Trust documents.

The Committee RECEIVED the reports.

158/16 Prevention and Resuscitation Group AB advised that this group is undergoing review so the reports will be presented at the next meeting.

159/16 Emerging Issues DK advised that at CSEC it was agreed that the Trust would move to a paperless

approach for meeting papers, with colour printing ceasing for meeting papers. DK noted that there are a lot of colour paper copies of meeting papers at this Committee. The Committee noted for future meetings.

NRu thanked LP for the shared drive, advising that it is much easier to use to view papers.

160/16 Issues for Raising with other Committees There were no issues to raise with other Committees.

161/16 Review of Meeting There were no comments on the meeting.

162/16 Date and Time of Next Meeting Tuesday 11th October 2016 at 10.00am in Chichester Boardroom



ACTION GRID

NO MINUTE NO AGENDA ITEM ACTION DUE DATE COMMENTS LEAD OUTCOME

9th February 2016

51 033/16 Health and Care Videos

HK to present the evaluation report at the May meeting

10.05.16 12.07.16 13.09.16

May 16 – HK advised that the project has been extended until June. Therefore, the evaluation report will be presented at the July meeting. July 16 – HK advised that the project is still awaiting funding for the extension. An update will be provided at the September QAC. Sept 16 – on agenda

HK Closed

10th May 2016

66 075/16 Trust Compliance Report

AI to ensure that review of closed actions on the risk register is discussed with divisions

14.06.16 12.07.16 13.09.16

June 16 – no update available July 16 – discussed at CSEC. There will also be an internal audit looking specifically at this area. Sept 16 – action is underway, with divisions currently reviewing risks identified as closed.

AI Closed

69 086/16 Medical Devices Committee

FBi to discuss function of the Committee at CSEC

14.06.16 12.07.16 13.09.16

June 16 – FBi advised that he has been unable to get a slot at CSEC but so will address this at CSEC at the earliest opportunity. July 16 – meeting planned with the Chair of the Medical Devices Committee to discuss the CSEC proposal. An update will be provided at the September QAC Sept 16 – FBI has discussed with the

FBi Closed



NO MINUTE NO AGENDA ITEM ACTION DUE DATE COMMENTS LEAD OUTCOME MDC Chair and this will not be discussed at CSEC as the MDC has an Executive Director as Chair, is a long standing Trust Committee which carries out its duties as per the terms of reference, has overarching responsibility for the Trust use of medical devices, has a revised terms of reference which represents the current Trust, has an agenda discussing procurement, incidents, training, servicing and compliance with relevant guidance and standards, etc and will remain a separate Committee to give guidance and report on exceptions.

14th June 2016

74 095/16 Safeguarding Adults Board

NR to review longstanding actions at the next SAB

13.09.16 Sept 16 – action complete NR Closed

75 095/16 Safeguarding Adults Board

NR to formalise CAMHS risk and identify a lead

12.07.16 13.09.16

July 16 – no update available Sept 16 – action complete, Sharon Hinsley is leading

NR Closed

12th July 2016

84 117/16 Matters Arising GT, NR and MKa to discuss governance of medical prescribing

13.09.16 Sept 16 – MKa confirmed that pharmacy are undertaking an audit of medical prescribing

GT, NR and MKa

Closed

85 118/16 Research and Development Group

LH to present “time to target” data to QAC on a monthly basis and discuss monitoring of the RD&E action plan with RD&E colleagues

13.09.16 Sept 16 – on agenda LH Closed



NO MINUTE NO AGENDA ITEM ACTION DUE DATE COMMENTS LEAD OUTCOME 86 121/16 Trust Compliance

Report JP to provide GT with more information re: CQC smartcard access

13.09.16 Sept 16 – MK to follow up JP Ongoing

87 125/16 Infection Prevention & Control Committee

FBa to advise GT if MSSA bacteraemia attributable to another Trust can be removed from NDHTs cases

13.09.16 Sept 16 – FBa confirmed that cases cannot be removed as cases are attributed to the location the samples are sent from and there is no arbitration process. If an external target is set then the process will be changed.

FBa Closed

88 126/16 Maternity Services Patient Safety Forum

GT, NR & MK to discuss breach of confidentiality

13.09.16 Sept 16 – meeting being set up GT, NR & MK

Ongoing

89 126/16 Maternity Services Patient Safety Forum

TC to ensure there is a governance route for midwifery and medical staff

13.09.16 Sept 16 – no update available TC Ongoing

90 127/16 Mortality Review Committee

GT to request a coding report is presented to this Committee on a monthly basis.

13.09.16 Sept 16 – on agenda GT Closed

91 128/16 Hospital Transfusion Committee

MK & KW to review the terms of reference

13.09.16 Sept 16 – action complete MK & KW

Closed

92 129/16 Organ Donation Committee

DK to ask AW to provide a briefing at the next meeting

13.09.16 Sept 16 – on agenda DK Closed

13th September 2016

93 139/16 Matters Arising LP to agenda healthcare videos update quarterly

13.12.16 LP

94 142/16 Research and Development Time to Target

TDR to highlight actions being taken to increase commercial income to Trust Board

04.10.16 TDR



NO MINUTE NO AGENDA ITEM ACTION DUE DATE COMMENTS LEAD OUTCOME 95 144/16 Midwifery LSA

Audit Report NR to advise TC what is required to be presented at the next meeting

11.10.16 NR & TC

96 146/16 Drugs and Therapeutics Committee

GT & MKa to discuss reporting routes for medicines reconciliation performance

11.10.16 GT & MKa

97 150/16 Learning from Patient Experience Group

NR to share HC and CO’s patient experience presentation with the Committee

11.10.16 NR

98 151/16 Clinical Audit & Effectiveness Programme Exception Report

GT, CB & HJ to discuss participation in national audits

11.10.16 GT, CB & HJ

99 153/16 NICE Guidance Exception Report

HJ to ensure staff listed are correct

11.10.16 HJ

100 154/16 Safeguarding Childrens Board Annual Report

NR to discuss Safeguarding Children Liaison Nurse post with DA

11.10.16 NR

executive summary...2016/10/04 · executive summary report to: trust board date: tuesday 4 october...

Documents