south warwickshire nhs foundation trust meeting board of directors date 25 january

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

Meeting Board of Directors

Date 25 January 2018

Subject Board Committee Minutes

Enclosure R

Nature of item For information For approval For decision

Decision required (if any)

The Board is asked to receive and note the following public/open Board Committee Minutes: 1. Audit Committee on 11 October 2017; 2. Business Performance and Investment Committee on 19 October 2017,

and 3. Clinical Governance Committee on 8 November and 13 December 2017.

General Information

Report Authors 1. Colleen Tooze, Committee Administrator 2. Lindsey Cotterill, Committee Administrator 3. Lindsey Cotterill, Committee Administrator

Lead Directors 1. Kim Li, Director of Finance 2. Glen Burley, Chief Executive 3. Fiona Burton, Director of Nursing

Received or approved by

Meeting 1. Audit Committee 2. Business Performance and Investment Committee 3. Clinical Governance Committee

Date 1. 13 December 2017 2. 14 December 2017 3. 13 December 2017 and 10 January 2018

Resource Implications

Revenue Capital Workforce Use of Estate Funding Source

Applicable Quality Improvement Priorities

Integrated Care Normal Birth Rates Patient Experience – End of Life Leg Ulcer Healing Rates Patient Experience – Dementia Electronic Observations Patient Experience – Booking Medicines Management Delayed Transfers of Care

Freedom of Information

Confidential (Y/N) (if yes, give reasons)

No

Final/draft format

Final

Ownership

Trust

Intended for release to the public

Yes

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Open Minutes of the Audit Committee Meeting Held on Wednesday 11 October 2017 at 9.00am in the Brooke Suite, Warwick Hospital

Present: Rosemary Hyde (RH) Non-Executive Director (NED) and Committee Chair Tony Boorman (TB) NED (non-voting) Simon Page (SP) NED Bruce Paxton (BP) NED In attendance: Caine Black (CB) Anti-Fraud Specialist, CW Audit Services Chris Hart (CH) Manager, CW Audit Services Simon Illingworth (SI) Associate Director of Operations, Elective Division (Present from

Minute 17.129 until Minute 17.131) Helen Lancaster (HL) Director of Operations (Present from Minute 17.126) Kim Li (KL) Director of Finance Gus Miah (GM) Partner, Deloitte, LLP Sarah Swan (SS) Associate Director, CW Audit Services Colleen Tooze (CT) Committee Administrator There was no Governor Observer at this meeting. The Committee welcomed Caine Black, Anti-Fraud Specialist, CW Audit Services to the Audit Committee and introductions were made. MINUTE ACTION 17.123 APOLOGIES FOR ABSENCE

An apology of absence was received from the Acting Trust Secretary.

17.124 DECLARATIONS OF INTEREST No declarations of interest were made.

17.125 MINUTES OF THE MEETING HELD ON 13 SEPTEMBER 2017 – OPEN MEETING Resolved – that the Open Minutes of the meeting held on 13 September 2017 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

17.126 MATTERS ARISING AND PROGRESS MONITORING REPORT

17.126.01 Internal Audit Report – Strategic Internal Audit Workplan (Minute 17.100.02 refers) The Director of Finance confirmed that she had met with the new Head of Pharmacy and would pick up the topic of Clinical Procurement v Pharmacy as part of the Pharmacy Transformation Programme and Carter work. An update would be provided at the Board of Directors Workshop in December 2017. Resolved - that the position be noted.

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Open Minutes of the Audit Committee Meeting Held on Wednesday 11 October 2017

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MINUTE ACTION

17.126.02 Information Governance and Security Steering Group Quarterly Report (Minute 17.102 refers) The Committee Chair confirmed the Information Governance and Security Steering Group Quarterly Report had been added to the Schedule of Business. The Committee Chair also confirmed that there was an ongoing action relating to the reporting lines of the Information Governance structure which would be reviewed after 6 months to ensure appropriate level of assurance was being provided and unnecessary levels of duplication was avoided. Resolved – that the Audit Committee review the reporting lines of the Information Governance structure which would be reviewed after 6 months to ensure appropriate level of assurance was being provided and unnecessary levels of duplication was avoided.

RH RH

17.126.03 Internal Audit Progress Report (Minute 17.104 refers) The Director of Finance and the Associate Director, CW Audit Services confirmed that the large number of agreed actions left outstanding had been addressed. Resolved – that the position be noted.

17.127 SCHEDULE OF BUSINESS (UPDATE) The Committee noted the Schedule of Business (Update). The Committee Chair queried if the Gifts, Hospitality and Sponsorship 6 monthly report had been missed off the September 2017 meeting. The Director of Finance commented that the policy had just been ratified so the first report would be provided in February 2018. The Director of Finance added that the Single Tender Waiver Report had been added to the Schedule of Business but requested that the Committee reviewed whether or not it should be a quarterly report when discussed later in the meeting (Minute 17.141 refers). Resolved – that the Schedule of Business (Update) be received and noted.

17.128 INTERNAL AUDIT PROGRESS REPORT The Audit Manager, CW Audit Services presented the Internal Audit Progress Report and explained that work was on track and several chaser emails had been sent for an update on certain projects. The Audit Manager, CW Audit Services provided tabled copies of the agreed actions. The Committee Chair requested implementation of the outstanding items for the December 2017 meeting.


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MINUTE ACTION Mr Boorman (NED) queried on the actions for the Continence Service. The Audit Manager, CW Audit Services explained that he had spoken with the Managing Director, Out of Hospital Care Collaborative (OOHCC) in regards to the actions for the Continence Service and she was planning on performing a mini audit for December 2017 to determine if the Continence Service action plan could be fully implemented. Mr Paxton (NED) expressed concern around the response. The Director of Operations explained that there were significant challenges with the Continence Service and further work was required to identify the root of the problems. The Committee Chair requested that the Managing Director, OOHCC attend the next meeting to provide assurance on the status of recommendations and progress of the Continence Service. Mr Boorman (NED) suggested that the Managing Director, SWFT Clinical Services Ltd (SWFT CS) attends the next meeting in December 2017 as well. The Committee Chair observed that there were a number of End of Life Care action points that would need updating in December 2017. The Director of Operations suggested that the Director of Nursing would work with the Managing Director, OOHCC on the End of Life Care recommendations. Mr Boorman (NED) stressed that it must be the Trust’s emphasis to implement the highlighted recommendations. It was confirmed that the Managing Director, OOHCC managed End of Life Care but that the Director of Nursing was the Executive Lead. The Committee Chair requested that the Managing Director, OOHCC and the Director of Nursing attend the December 2017 meeting to provide the Committee with an update on End of Life Care. Mr Boorman (NED) sought assurance due to recommendations being 6 months old and requested that the debate on the topic be duly noted. The Director of Operations also suggested that it could also be noted on the action tracker. Resolved – that

(A) the Internal Audit Progress Report be received and noted; (B) the Managing Director, OOHCC provide assurance on the status

of recommendations and progress of the Continence Service at the December 2017 meeting;

(C) the Committee Administrator invite the Managing Director, SWFT CS to the December 2017 meeting, and

(D) the Director of Nursing and Managing Director, OOHCC provide an update on End of Life Care at the December 2017 meeting.

CT CT CT CT CT CT

17.129 INTERNAL AUDIT – BUDGET SETTING AND COST IMPROVEMENT PROGRAMME (CIP) The Associate Director, CW Audit Services presented the Internal Audit – Budget Setting and CIP report. Assurance was provided that the Trust’s budget setting was robust and that a moderate assurance level could be given on delivering the CIP target.


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MINUTE ACTION The Director of Finance explained that a joint CIP/QIPP Board had been created and the Trust was working actively with South Warwickshire Clinical Commissioning Group (CCG) on schemes in which things could be done differently in order to reduce costs and improve efficiency across the local health system. This included Carter work, the multi-hospital portal as well as looking at benchmarking data and liaising with the respective Divisions on moving CIPs forward. Progress was being made. The Partner, Deloitte, LLP sought clarification around whether the Trust or CCG would receive the benefit where the Trust implemented combined schemes. The Director of Finance responded that there was a “gain share” agreement. It was explained that the CCG had a list of schemes and that some items had been signed off and other proposals were being reviewed as the CIP/QIPP Board which was still in its infancy stage. Mr Paxton (NED) sought assurance on CIPs and the process of approval as he believed there were gaps in the CIPs signoff. The Director of Finance explained that there were Quality Impact Assessments completed for each CIP scheme. Mr Paxton (NED) suggested a change to the process in that Divisions were made functionally responsible for CIPs before they go to Management Board. The Director of Operations explained that she always challenged some CIPs even if they had been approved. Mr Paxton (NED) queried the timing of CIPs and if they could get approved earlier in the year. The Director of Finance commented that it was the Board of Directors’ and Chairman’s request but that they were being worked on and in progress. The Committee Chair responded that the key was to move to higher recurrent CIPs. The Director of Operations commented that it was difficult to identify CIPs for next year as Divisions were already feeling winter pressures. Mr Boorman (NED) suggested that there needed to be more of a strategic lead on CIPs. The Director of Operations added that with the re-design of pathways, a gain on resources could be realised. The Director of Finance explained that CIPs had been discussed at length at various Sustainability and Transformation Partnership (STP) workstream meetings and that progress had been slow. She would like to see re-engagement on a system wide approach and to have more transparency. Mr Boorman (NED) asked the Partner, Deloitte, LLP if there was any benchmark STP data. The Partner, Deloitte, LLP explained that it was best not to rely on any STP CIP data as there were structure reforms. It was suggested for the Trust to develop good relations with the CCG as a way forward and cautioned that if 60% CIPs were non-recurrent, it was not sustainable and should be of concern to the Trust. It was recommended that the Trust had 20% of CIPs as non-recurrent. Mr Paxton (NED) queried the number of budget holders as the last time it was mentioned, there was a large number and therefore suggested that the


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MINUTE ACTION number be reduced further. The Committee Chair concluded that the focus for the Trust should remain on CIPs. Resolved – that the Internal Audit Report – Budget Setting and CIP report be received and noted.

17.130 INTERNAL AUDIT – 18 WEEKS REFERRAL TO TREATMENT (RTT) OUTCOME RECORDING The Audit Manager, CW Audit Services presented the Internal Audit – RTT Outcome Recording Report. He noted that 120 records were reviewed over 6 specialties. The accuracy of RTT outcomes was reviewed with significant assurance achieved. Accuracy was rated as good, but there were issues around the timeliness of data recording. The Associate Director of Operations, Elective Division explained that outcome recording continued to be the Trust’s focus and that a RTT module was part of annual training for clinical staff. He highlighted that DNA was now below the Trust target of 7%. The Committee Chair queried if this report was the same as RTT Coding. The Audit Manager, CW Audit Services clarified that it was a different piece of work. The Partner, Deloitte, LLP queried that the external audit that took place last year suggested that RTT coding improvement would take 12 months to implement but was unsure on where it was with management. The Director of Operations explained that there had been some confusion with multiple action plans as a number of actions overlapped and that she had proposed an RTT Recovery Board to implement one action plan so that the Trust’s RTT position could be delivered. The Partner, Deloitte, LLP responded that RTT was the biggest area of data concern with pathways causing significant concern. The concern was around losing patients on the waiting list and commended the creation of the RTT Recovery Board. The Partner, Deloitte, LLP asked if the Trust was comfortable at a strategic level with its current RTT position. The Director of Operations responded that it was not going to be a quick journey and that a significant amount of work was required. The Associate Director of Operations, Elective Division provided assurance that there were now better processes in place. The Committee Chair requested that a more detailed presentation on the Trust’s RTT position be brought to the Audit Committee in December 2017 for assurance. Resolved – that

(A) the Internal Audit – RTT Outcome Recording report be received and noted, and

HL/SI


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MINUTE ACTION (B) the Director of Operations and Associate Director of Operations,

Elective Division provide a detailed presentation on the Trust’s RTT position at the next meeting.

HL/SI

17.131 EXTERNAL AUDIT PLAN 2017/18 (INCLUDING KEY PERFORMANCE INDICATORS (KPIS)) The Partner, Deloitte, LLP presented the External Audit Plan 2017/18 (including KPIs) report and highlighted the key points. Of particular note were the following points raised in discussion:

(a) the Director of Operations confirmed that an unannounced Care Quality Commission (CQC) visit would take place before Christmas with focus on 4 key areas. Challenges remained in Maternity and End of Life care;

(b) Mr Paxton (NED) noted that whilst there had been a number of positive internal audits; the CQC was down rating hospitals previously rated as “Good” for a number of reasons;

(c) the Director of Operations explained that the Internal Audit – Well Led report would be a significant piece of work for the Board of Directors and required a lot of preparation;

(d) the Partner, Deloitte, LLP advised that the way forward was working in partnership with the CCG;

(e) the Director of Finance had updated the Board of Directors around working in partnership with the CCG for an Accountable Care System and potential Superblock contract arrangement;

(f) the Partner, CW Audit Services indicated that most CCG’s were financially unstable and to ensure that the Trust had resources to mitigate risks. Also negotiating CIP/QIPP was important;

(g) the Director of Finance indicated that there was a risk on income due to the financial position of the CCG, she would continue to maintain tight controls over invoicing and negotiations to ensure that the Trust was paid for the activity undertaken;

(h) the Director of Finance confirmed that there was a cap on our A&E contract and was working with the CCG on demand management;

(i) the Director of Finance confirmed that the Trust accounted on an income and expenditure basis whereas the CCG operated on cash accounting which was fundamentally different. This created challenges in the agreement of financial positions at the year end;

(j) Mr Boorman (NED) enquired what the downside or risks might be if issues were not settled with the CCG. Mr Page (NED) sought clarification around whether the Trust was more concerned about the financial position this year than last. The Director of Finance provided assurance that the Trust would ensure the appropriate processes were in place and adhered to;

(k) it was reported that for Quality Accounts, RTT work was still a concern as well as Data Quality and that the level of on-going financial and operations challenge would continue year on year, and

(l) the Partner, Deloitte LLP commented that they were in the process of negotiating an audit fee with SWFT CS.


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MINUTE ACTION Resolved – that the External Audit Plan 2017/18 (including KPIs) report be received and noted.

17.132 NHS PROTECT – STANDARDS FOR PROVIDERS 2017/18 The Anti-Fraud Specialist, CW Audit Services presented the NHS Protect – Standards for Providers 2017/18 report and highlighted that the Trust was RAG rated green in each of the key areas, Strategic Governance, Inform and Involve, Prevent and Deter, and Hold to Account. There were two areas of action and amber RAG rated which were the level of staff awareness of the new Gifts, Hospitality, and Sponsorship Policy and the Trust-wide procurement processes currently under way. The Anit-Fraud Specialist, CW Audit Services tabled a circular from the Quality Assurance Group and explained that the Group assessed compliance with NHS Protect’s Fraud, Bribery and Corruption Standards for both provider and commissioner organisations. The Group had recently expanded in size and now involved members from a wide range of backgrounds. Assurance was given that there was a commitment to anti-fraud. The Committee Chair concluded that the Anti-Fraud Specialist’s, CW Audit Services insights would be beneficial. Resolved – that the NHS Protect – Standards for Providers 2017/18 be received and noted.

17.133

ANY OTHER BUSINESS No other business was discussed. Resolved – that the position be noted.

17.134 REFLECTION ON THE MEETING FOR THE OPEN MEETING There was no Governor Observer in attendance to offer any reflections for the Open Meeting. Resolved – that the position be noted.

17.135 APOLOGIES FOR ABSENCE – CLOSED MEETING

17.136 DECLARATIONS OF INTEREST – CLOSED MEETING

17.137 MINUTES OF THE MEETING HELD ON 13 SEPTEMBER 2017 – CLOSED MEETING

17.138 MATTERS ARISING AND PROGRESS MONITORING REPORT

17.139 INTERNAL AUDIT – CONSENT FOR SIGNIFICANT PROCEDURES


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MINUTE ACTION

17.140 ANTI-FRAUD PROGRESS UPDATE REPORT

17.141 SINGLE TENDER WAIVER REPORT

17.142 ANNUAL REVIEW OF STANDING FINANCIAL INSTRUCTIONS (SFI) AND SCHEME OF DELEGATION

17.143 FEEDBACK ON CHAIR

17.144 ANY OTHER CONFIDENTIAL BUSINESS

17.145 REFLECTION ON THE MEETING FOR THE CLOSED SECTION

17.146 DATE AND TIME OF NEXT MEETING The next meeting to be held on Wednesday 13 December 2017 at 9.00am in the Brooke Suite, Warwick Hospital.

Signed ______________________________ (Chair) Date 13 December 2017


Open Minutes of the Business Performance and Investment Committee Meeting Held on Thursday 19 October 2017 at 8.30am in the

Brooke Suite, Warwick Hospital Present: Simon Page (SP) Committee Chair Jayne Blacklay (JB) Director of Development Alan Harrison (AH) Non-Executive Director (NED) Helen Lancaster (HL) Director of Operations Kim Li (KL) Director of Finance Danny Roberts (DR) Chief Technology Officer Sue Whelan Tracy (SWT) NED In attendance: Simon Illingworth (SI) Associate Director of Operations – Elective Division (Present for

Minute 17.098 only) Matthew Statham (MS) Governor Observer Lindsey Cotterill (LC) Executive Assistant MINUTE ACTION 17.094 APOLOGIES OF ABSENCE

Apologies for absence were received from the Chief Executive and the Acting Trust Secretary.

17.095 DECLARATIONS OF INTEREST The Director of Development and the Director of Finance declared an interest in the Beauchamp Suite Update (Minute 17.101 refers) as they were both Directors of SWFT Clinical Services Ltd (SWFT CS). Resolved – that the position be noted.

17.096 MINUTES OF MEETING HELD ON 17 AUGUST 2017 – OPEN MEETING Resolved – that the Open Minutes of the meeting held on 17 August 2017 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

17.097

MATTERS ARISING AND ACTION UPDATE REPORT – OPEN MEETING

17.097.01 Stratford Health and Wellbeing Centre Business Case Update (Minute 17.073.03 refers) The Director of Development provided an update on the Keys Performance Indicators (KPIs) for the Health and Wellbeing Centre. Several Performance Indicators (PIs) had been identified rather than KPIs. These had been explained to staff involved. The Director of Development would circulate the PIs to the Committee. A meeting was scheduled with Warwickshire County Council (WCC) who had developed a set of KPIs regarding their Health and Wellbeing Centre and the Trust would consider adopting these. Resolved – that the Director of Development circulate the PIs relating to the Stratford Health and Wellbeing Centre to the Committee.

JB JB

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Open Minutes of the Business Performance and Investment Committee Meeting

Held on Thursday 19 October 2017

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MINUTE ACTION

17.097.02

Cost Improvement Programme Performance Against Plan (Minute 17.075 refers) The Director of Finance reflected on the action to provide the Committee with information on the number of single tender waivers produced and the identification of a KPI and decided that the more appropriate Committee was Audit Committee. The information had been presented to the last Audit Committee and the action would be removed from the Action Update Report. The Audit Committee has agreed to review the report on a 6-monthly basis. Resolved – that the position be noted.

17.097.03 Update on Business Case (Minute 17.077 refers) The Director of Development explained that the submission of a post implementation review of any business case over the £500,000 threshold to the Committee was an ongoing process. The first review would relate to the new ward block and this was being presented at the Programme Delivery Board. This would be a review against the Business Case. The Director of Development would circulate a list of cases awaiting review. Resolved – that the Director of Development circulate a list of business cases over the £500,000 threshold awaiting a post implementation review.

JB

17.097.04 2017/18 Divisional Objectives (Minute 17.032 refers) The introduction of patient feedback as a measure for appropriate objectives for the Elective Division would be considered as part of the divisional objectives when reviewed during November 2017. The objectives would be presented in February 2018. Resolved – that the Director of Operations present the divisional objectives to the Committee in February 2018.

HL HL

17.098 THEATRE PRODUCTIVITY UPDATE

The Associate Director of Operations (ADO) for the Elective Division provided an update of Theatre Productivity to the Committee. Discussion took place around the following key points: Recap of Activity The Trust currently had 4 Day Surgery theatres and 5 Main Theatres. The Theatre at Stratford was now fully opened and there was a local surgery unit at Stratford. One mobile theatre would remain in place until the end of the financial year. Overall the Trust had just over 11 main operating theatres and this provided 4,400 operating sessions per year. Performance Management The traditional means of monitoring theatre utilisation included start times,



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MINUTE ACTION finish times and utilisation rates. The Trust did well in relation to those targets. A company recently visited the Trust with the aim of maximising theatre productivity and the Trust was already doing as much as possible to maximise, although work would continue to do better. Over the last two years the Theatre Dashboard had been developed and it gave much more detailed information, including how many patients per list, the cancellation rate, the number of operations performed and actual time used against allocated time. The dashboard had helped the Trust to understand productivity. Work had been done with Wye Valley NHS Trust (WVT) to make additions to the dashboard as their dashboard provided information on each case that was booked into a slot. The Committee Chair noted that the measurements were quantative, and questioned the qualitative measurements. The ADO for Elective Care advised that the current focus was to increase numbers but the dashboard would be developed to measure qualitative data. Understanding Cancellations Short term cancellations had been investigated. One aspect related to the way in which the VR lists were organised with the aim of trying to overbook the list with complex VR work. Since reorganisation the cancellation rate had fallen; although there had been an increase in recent months due to sickness. The Trust had been able to set objectives which included more operations within the main operating theatres. This was now being monitored across specialities. Although the graph presented appeared to show less theatre cases during the current year than last, assurance was given that over the year this evened out. The differences occurred due to the reorganisation of the theatre list. Mrs Whelan-Tracy (NED) queried whether there were expectations and standards in terms of short term cancellations. Assurance was given that the Trust had very low numbers in terms of cancellations. Endoscopy was not counted within the main theatre figures. The Trust was on track to perform to the same level as the previous year. Key Performance Improvements The number of late starts was very small across all operating theatres, and this had been further reduced through better job planning for consultants. Job planning was a main reason for late starts as some plans stipulated 9am start, with the theatre list beginning at 8:30am. Bed availability also caused late starts along with patients arriving late. The dashboard indicated how late in minutes the late starts were and consultant trends could also be seen. Generally, there was a high number of small late starts rather than a few lengthy late starts. One cause was anaesthetists refusing to start until they physically saw the operating



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MINUTE ACTION surgeon, this was manageable through standardising job plans. Consequently, job planning would be monitored to determine whether this made a difference. The Committee acknowledged that in pushing for theatre productivity, the Trust had seen a rise in cancellations by booking more cases into theatre, if one overran, there was more proceeding clinics to be cancelled. The exercise as a whole had allowed for speciality objectives to be set. The Chief Technology Officer questioned the cross referencing of data sources, specifically in terms of the look back exercise and whether the information could determine why cases were cancelled. The Director of Operations explained that the reasons for cancellations were discussed three times a day, during bed state discussions, and determined in which division shortages were. However it was difficult to review why cases were cancelled in the past as the dashboard had not always been populated with the correct reasons for cancellations. Number of Overruns The number of overruns for Theatre 4 was 37%, although this had recently dropped to 30%, which was overall a 17% reduction in overruns. This did not relate to individual operations but rather the theatre list as a whole. This monitoring had provided an understanding of the physical space available and what was needed via timetabling. The Management of Safety was also considered, the Vanguard Theatre had an issue with infection rates and as such only orthopaedic cases could now be done in that theatre. The protracted use of the mobile theatre had helped the Trust to deliver the workload, however there was more overruns due to the need for a deep clean after each case. When the Vanguard Theatre overran the Trust was charged extra. There was no issue with overrunning as long as cases were not being cancelled. The Committee suggested putting longer cases within Vanguard. Continued Actions The Theatre Dashboard would be continued, along with the utilisation of productivity and the monitoring of cancellations and cases per list. A main focus would be job planning and aligning start times. Strategic Actions Consideration had been given to ways in which theatres could be made more efficient. Within ENT and Urology, the Trust had begun a project to look at Service Line Reporting (SLR). The surgeons were working with the team to analyse how this could streamline the Trust process. Using SLR would allow for the implementation of new techniques. The Booking Project was a key action to allow for effective list scheduling and make sure where are booking in good time to reduce the likelihood of a Did Not Attend (DNA). A plan would be developed for sustainable additional theatre capacity. The



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MINUTE ACTION Vanguard Theatre helps but ultimately is only a small gain. Staffing issues affected theatre performance. The Elective bed model utilised Beauchamp Suite and this had been useful. The Committee queried whether further opportunities could be found. The Trust had a target of 75% productivity of available time. The available time was set at 85% and therefore productivity would be 60% if working 100% of the time. There were 4,400 sessions available, and 93% is used. Of the 7% not used, 209 were related to the Local Surgery Unit, which could not be used, therefore, real usage of available theatre time was 97%. An additional 126 sessions were completed over the previous year, via the Vanguard Theatre and weekend sessions. There was a high overall pick up rate for theatres with little scope for completing anything more substantial within the current capacity. Sessions Vs Planned The Committee Chair requested that the ADO for the Elective Division return to the Committee in 6 months to discuss the actions and what the Trust was doing to improve theatre productivity. A report would be taken to Management Board detailing the constraints around theatres. Figures indicated that the Trust was approximately half a theatre short in terms of what was required substantively. A further piece of work was required to determine how the correct level of capacity was required moving forward. The Trust would require a whole extra theatre to meet and exceed targets. Theatre capacity over the next 5 years was a big strategic piece of work. Additionally, theatre staffing was a national issue. The Trust was investing in its own workforce to develop internal theatre staff. It was agreed that the ADO for the Elective Division would provide an update on theatre staffing at the next meeting. The Committee would see the strategic plan regarding theatres before the 6 monthly update. Resolved – that

(A) the Theatre Productivity Update be received and noted; (B) the ADO for the Elective Division provide an update to the next

Committee meeting regarding theatre staffing; (C) the ADO for the Elective Division provide an update in 6

months’ time as to how theatre productivity had improved against the actions, and

(D) the ADO for the Elective Division ensure the strategic plan regarding theatres be submitted to the Committee before the 6 month update.

SI SI SI SI SI SI



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MINUTE ACTION 17.099 COST IMPROVEMENT PROGRAMME (CIP) PERFORMANCE AGAINST

PLAN

The Director of Finance presented this plan to the Committee. A session had been held with the divisions on a model hospital and further sessions were planned to take them through SLR work and the Clinical Commissioning Groups (CCGs) list of QIPP schemes. The Trust was attempting to capture productivity and efficiency gains which would ultimately save on costs. Non-budget efficiencies were now being monitored and cost reductions captured. Divisions were being managed via control totals and are required to manage their bottom line. The focus was on CIP identification and planning for next year. The CCG work was more focused on change and the Director of Finance referred to a previous discussion at Audit Committee where members had challenged divisions to find medium term solutions. The Committee Chair queried developments within purchasing and pharmacy costs. The Director of Finance explained that the new Head of Pharmacy had commenced during the previous month. An initial meeting had taken place to understand the pharmacy transformation plan. The Trust would ensure that all was being done to reduce cost. The transformation plan would sit with the Director of Operations and a group would be created to identify and monitor the workstreams. The High Cost Drugs Group would be reconvened to look at issues. The Medical Director would be a member of this group. Once the first session had taken place an update would be bought to the Committee. The Director of Finance and Head of Procurement had reviewed the non pay spend. An external company had now been appointed to undertake further analytics work and secure opportunities. A Clinical Lead had also been identified who would chair a Medical Device Committee. Strong clinical engagement was now in place. Resolved – that

(A) the CIP Performance Against Plan Update be received and noted, and

(B) an update from the High Cost Drugs Group be bought to the Committee once available.

KL KL

17.100 QUARTERLY STATUS UPDATE REPORT

The Director of Development presented this report to the Committee noting the positivity and lack of red risks. There were a few amber risks which included theatre staffing. The Director of Operations acknowledged that Patient Experience was a complex area but there was confidence that a strong plan was in place and there would be successful delivery of objectives. This was a two-year project



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MINUTE ACTION to achieve the specified KPIs. The Committee Chair advised the Director of Operations to consider what the team intended to measure in terms of Patient Experience KPIs. There were qualitative measurements but also measurements of effectiveness, and these should be considered. Reassurance was given that effectiveness was measured but this was not articulated within the report. The Committee Chair queried the costs of the Midwifery Led Unit (MLU) and whether the actions to reduce costs would affect the overall aim of the unit. The Director of Operations explained that the unit had been reviewed and the cost had been reduced to just above what was expected. The key piece of work was consideration of staffing models and it was thought that there would be a strong gain in addition to the new Head of Midwifery. Resolved – that the Quarterly Status Update Report be received and noted.

17.101 BEAUCHAMP SUITE

The Director of Development presented an update on Beauchamp Suite. Three key elements were discussed. Firstly, after a year of running a review was completed. The patients loved the unit, however there was an inefficient staffing model in place and work was required to develop a simpler model. There had been an attempt to run the unit flexibly, however this resulted in the running of a half empty ward which was the least efficient staffing model. Therefore opportunities to extend services and use the facility to generate increased income were being considered by the Trust. Secondly, consideration was being given as to how the unit was run. At the moment the unit was run in partnership between the Trust and SWFT CS. This had been difficult as the Trust made the decisions, such as taking staff from the Beauchamp Suite when needed elsewhere within the hospital. SWFT CS had no control over this and at these times were unable to run the business. SWFT CS had been asked to formulate a proposal detailing how they would run the unit autonomously. Thirdly, a piece of work was ongoing on Guy Ward as part of the Front Door Redesign Programme. As a consequence, some bed capacity had been taken out meaning that Beauchamp Suite was not currently open for amenity work. The plan was to use half of Beauchamp Suite for ambulatory care until December 2017. Resolved – that the Beauchamp Suite Update be received and noted.



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MINUTE ACTION 17.101 ANY OTHER BUSINESS

17.101.01 Carter Review The Committee had previously requested that the Carter Review be presented to a wider audience. The Director of Finance confirmed that this would be taken to the Board of Directors Workshop in December 2017. James Cook from NHS Improvement (NHSI) had offered to present this to the Board which would be discussed with the Chief Executive. The Trust had compared itself to peers but had not sought comparison with the Sustainability and Transformation Plan (STP). The Committee agreed that the Trust should only take on-board actions that were valuable to itself, rather than all recommendations. Resolved – that the position be noted.

17.102 WHAT WORKED WELL, WHAT DID NOT AND WHAT CAN WE DO BETTER FOR THE OPEN MEETING?

The Governor Observer felt that the meeting had been positive, however concern was raised regarding the confidential items discussed and whether more could have been placed within the open meeting. The Committee Chair explained that it was difficult to get this balance right and, work and reflection would continue. The Director of Operations suggested further consideration at the end of the closed meeting as to whether any items discussed could have been placed within the open section. Resolved – that the position be noted.

17.103 APOLOGIES OF ABSENCE – CLOSED MEETING

17.104 DECLARATIONS OF INTEREST – CLOSED MEETING

17.105 MINUTES OF MEETING HELD ON 17 AUGUST 2017 – CLOSED MEETING

17.106 MATTERS ARISING AND ACTION UPDATE REPORT – CLOSED MEETING

17.107 OVERVIEW OF TRUST INVESTMENT PROFILE

17.108 KEY BUSINESS RISKS UPDATE

17.109 OUT OF HOSPITAL ELECTRONIC PATIENT RECORD (EPR) BUSINESS CASE

17.110 BUSINESS UNIT MANAGEMENT AND SERVICE LINE REPORT

17.111 ANY OTHER CONFIDENTIAL BUSINESS



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MINUTE ACTION 17.112 WHAT WORKED WELL, WHAT DID NOT AND WHAT CAN WE DO

BETTER FOR THE CLOSED MEETING

17.113 DATE AND TIME OF NEXT MEETING The next meeting to be held on Thursday 14 December 2017 at 12pm – 4pm, in the Brooke Suite, Warwick Hospital.

Signed ___________________________ (Committee Chair) Date 14 December 2017 Simon Page


Minutes of the Clinical Governance Committee Meeting held on Wednesday 8 November 2017 at 1pm in Room 1 John Turner Centre, Warwick Hospital

Present: Bruce Paxton (BP) Non-Executive Director (NED) (Committee Chair) Angela Brady (ABr) NED (present from Minute 17.246) Fiona Burton (FB) Director of Nursing (present until Minute 17.254) Rosemary Hyde (RH) NED Fraser Millard (FM) Associate Medical Director (AMD) for Governance (Deputising for the

Medical Director) Penny Smith (PS) Trust Governor In attendance: Vinodhini Clarke (VC) Chair - Women and Children’s Audit and Operational Governance

Group (AOGG) (present until Minute 17.247) Sarah Crawford (SC) Consultant – Emergency Medicine (present from Minute 17.259 until

Minute 17.264) Jennifer De Val (JDV) Principal Pharmacist (present from Minute 17.246 until Minute

17.248) Ruth Gibson (RG) Patient Safety Manager Sallie Green (SG) Safeguarding Adults Lead (present from Minute 17.253 until Minute

17.255) Anne Holland (AH) HSDU Operational Manager (present from Minute 17.256 until Minute

17.258) Linda Holland (LH) General Manager (GM) – Women and Children’s Division (present

until Minute 17.247) Jo Jennings (JJ) Orthogeriatric ACP (present from Minute 17.25 until Minute 17.260) Sarah Mitchell (SM) Clinical Audit and Effectiveness Manager (present from Minute

17.255 until Minute 17.257) Rosie McDonnell (RM) Head of Community Nursing (present from Minute 17.250) Lorraine Parsons (LP) Clinical Governance Midwife (present until Minute 17.247) Mark Rowlands (MR) GM – Hotel Services (present from Minute 17.56 until Minute 17.258) Karun Thaper (KT) Trust Assurance Manager Maggie Ward (MW) Lead Nurse – Safeguarding Children (present from Minute 17.253

until 17.255) Lindsey Cotterill (LC) Committee Administrator MINUTE ACTION 17.242

APOLOGIES FOR ABSENCE

Apologies for absence were received from the Medical Director, the Director of Operations, the Head of Governance, Dr Harrison (NED) and Mrs Whelan Tracy (NED). The Committee welcomed Mrs Penny Smith, Trust Governor.

17.243 DECLARATIONS OF INTEREST

No Declarations of Interest were made.

17.244 MINUTES OF PREVIOUS MEETING HELD ON 11 OCTOBER 2017

Warwickshire, Solihull and Coventry Breast Screening Service Update

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 8 November 2017

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(Minute 17.229 refers) Page 10, fourth paragraph, first sentence, this be amended to read: “The AMD for Governance requested that the Committee reflect on the challenges they put to report submitters…” Resolved – that subject to the above amendment and correction of several typographical errors, the Minutes of the meeting held 11 October 2017 be confirmed as an accurate record of the meeting and signed by the Committee Chair.

17.245 MATTERS ARISING AND ACTIONS UPDATE REPORT

17.245.01 Actions Listed as Complete All Actions listed as Complete or On the Agenda on the Actions Update Report were noted and would now be removed from the report. Resolved – that the position be noted

17.245.02 Warwickshire, Solihull and Coventry Breast Screening Service update (Minute 17.229 refers) The Director of Nursing had liaised with the Director of the Breast Screening Service for Warwickshire, Solihull and Coventry, and received assurance that the service provided was safe, however an annual report would not be available until February 2018, at which point the previous 2 years would be reported on. The Committee agreed to this as there were minimal governance concerns, but rather a request to improve the structure of the report. Resolved – that the position be noted.

17.245.03 Infection Prevention and Control Monthly Report (Minute 17.233 refers) The Director of Operations was not present to provide an update on the missing data for quarter 3 Surgical Site Infection Surveillance. An update would be provided at the December 2017 Committee meeting. Resolved – that the Director of Operations provide an update on the missing data for quarter 3 Surgical Site Infection Surveillance at the December 2017 Committee.

HL HL

17.245.04 Internal Well Led Audit Report (Minute 17.234 Refers) Mrs Hyde (NED) had raised the Well Led Audit at Audit Committee in terms of the inaccuracies and questioned the sign-off of recommendations. It was explained that this was signed off by the Chief Executive. The Committee Chair explained that it would be useful to schedule self-reflection for the Committee. This would be considered further under Any Other Business (Minute 17.265.01 refers). Resolved – that the position be noted.

17.246 WOMEN AND CHILDRENS AOGG REPORT

The Chair of the Women and Children’s (W&C) AOGG Report provided an updated report to the Committee, noting that the Executive summary had


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been elaborated since the previous submission in October 2017 (Minute 17.224 refers) The following points were highlighted:

(a) the level of incidents within the division had not increased, with all incidents being low or no harm;

(b) there were no new claims; (c) there were 6 new complaints and most related to communication

issues; (d) the audit system was robust; (e) the safety thermometers showed good results, and (f) mandatory training was continually reviewed and worked on as

compliance was slightly lower than it should have been across the specialties.

Updates were given relating to each of the divisions: Maternity The Maternity division had a good reporting system and were conscious of the risks relating to clinical capacity. The perinatal mortality had improved. Acute Paediatrics A good audit and governance programme was in place. Community Paediatrics Concern had been raised regarding staff shortages and stress levels. This was being addressed within the speciality with the relevant manager. A locum had been appointed along with a permanent member of staff but further details were not available to the Committee. Gynaecology Good Friends and Family Test (FFT) Results had been received. There had been one incident with moderate harm; no other major issues were reported. Paediatric Therapy Incidents The main concern was the lack of access to the Electronic Patient Record (EPR) system. This was being worked on with the IT department. Mrs Hyde (NED) queried the value of the financial claims to the division and whether managers were aware of the figures as these were not specified within the report. The GM for Women and Children’s’ division explained that claims were discussed at a speciality level and due to the nature of the division the claims tended to be large. The Director of Nursing had liaised with the Head of Midwifery and requested that she meet with the Clinical Director for Obstetrics to review any themes drawn from claims. The Committee Chair noted that birth claims could be on going for 25 years. The GM for the Women and Children’ Division highlighted that the division focused on learning from claims and circulating this to staff. There was always an in-depth review of incidents. The Trust Assurance Manager requested clarity on the mandatory training figures following a Care Quality Commission request. It was confirmed that


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these figures related to quarter one figures and therefore there had been an improvement since report submission. Ms Smith (Trust Governor) queried the obstetric ultrasound capacity, especially with regards to the Midwifery Led Unit (MLU) and requested further information on the issues and planned resolution. The Clinical Governance Midwife explained that there was a capacity demand issue within obstetric radiology which dovetailed into the capacity demand issues within obstetrics and consequently several workstreams were ongoing to consider clinical care pathways and would consider how women could be seen more appropriately with more prioritisation. With regards to obstetrics clinic capacity, the risks were improving, and the control measures were having an impact. Dr Brady (NED) queried the staffing and support to MLU and whether an update would be provided in the January 2018 report. The Chair of the W&C AOGG explained that a business case had been prepared and submitted and would help the paediatric cover. Work was being done regarding neonatal staffing and this was on the risk register within the maternity division. The Committee Chair confirmed that both staffing considerations were being worked into business cases. The Committee Chair thanked the Clinical Governance Midwife for her contribution to the Committee as she would now be moving to a new role. Resolved – that the Women and Childrens’ AOGG report be received and noted.

17.247

DRUGS AND THERAPEUTICS COMMITTEE (DTC) QUARTERLY REPORT

The Principal Pharmacist presented this report to the Committee in the absence of the newly appointed Head of Pharmacy. The progress of the committee in terms of their approval of central guidelines and processes within the Trust was going well The antibiotic CQUIN would be achieved following the implementation of the guidelines for IV to oral switch for antibiotics in the hospital. Endocrinology guidelines had been implemented regarding electrolytes. The September DTC meeting had to be cancelled as there was no chair available. This was a one off. Quoracy issues had also been resolved. It was acknowledged that on occasion work had to be delayed to the following meeting due to lack of quoracy. CD incidents had shown nothing out of the ordinary. The Principal Pharmacist was impressed with the improvements of some areas in terms of their CD audit compliance. There were 9 locations that did not meet the 90% target but only 4 were underperforming for the second time, which was an improvement on previous. With regards to critical care, focus work had been completed and they had improved during quarter 3. This was a sustained improvement. The Patient Safety Manager supported this


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statement; there had been substantial discussions at AOGG meetings re this. The Terms of Reference were due for consideration with an update relating to the Patient Safety Medication Group. This group was working well, but more time was needed to establish the group. The Terms of Reference would be renewed in January 2018. Dr Brady (NED) acknowledged the good activity portrayed in the report. CCU had continued to improve and this was very impressive. The Director of Nursing noted an increase in controlled drugs incident within Maternity relating to tinzaparin. The Principal Pharmacist explained that a new pharmacy service had commenced to Maternity and therefore this was a new stream of work that was highlighting previously unreported issues. Mrs Hyde (NED) queried Feldon Ward who had dropped from 100% CD compliance to one of the lowest. No further information was available relating to this and the Principal Pharmacist would investigate this further and provide an update to the Committee within the February 2018 Report. The Director of Nursing thanked the Principal Pharmacist for her hard work during the previous months. Resolved – that

(A) the Drugs and Therapeutics Committee Quarterly Report be received and noted;

(B) the Drugs and Therapeutics Committee Terms of Reference be presented in January 2018 following discussion with the head of Governance, and

(C) the Principal Pharmacist investigate the drop in CD compliance on Feldon Ward and provide an update within the February 2018 DTC Report.

JDV JDV JDV JDV

17.248 INFECTION PREVENTION AND CONTROL MONTHLY REPORT

The Director of Nursing presented this report to the Committee. The Trust had met all of its previous annual targets and was on track to meet the current ones. There had been an increase in C.diff reporting and these were being investigated although the Trust remained below the maximum ceiling target. Assurance was given that all infections were investigated. Mrs Smith (Trust Governor) queried the hand hygiene audit and why some wards had received more visits that others. The Director of Nursing explained that additional visits were completed to Wards that had a low level of compliance or where concern had been raised. The Committee Chair queried how the Trust was performing in relation to the specific issue of washing hands after being in touch with a patient’s surroundings. This was an ongoing issue but the campaign was being noticed by members of the public.


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Resolved – that the Infection Prevention and Control Monthly Report be received and noted.

17.249 PATIENT EXPERIENCE MONTHLY REPORT

The Trust Assurance Manager presented this report to the Committee noting that it was an abridged version of the quarterly report that had been presented to the Board of Directors. The Trust had a consistent volume of complaints during the month, with no clear trends or areas of concern found. No complaints received had been rated as red. Two complaints had been referred to the Parliamentary Ombudsman and one report had been received back from the Ombudsman. Findings and actions were in place to ensure the Trust met the recommendations of the Ombudsman. In terms of feedback, the Trust was below the target range for response rates for FFT, predominately in A&E but there was also fluctuation in other areas. With regards to A&E, this has been raised as a formal performance notice by the CCG, however this related to collaborative working to devise a revised process. The agreed trajectory would be presented to the Committee once available. Additionally, the local action plan had been include as an appendix to the report. With regards to complaint 4378, feedback had been received from the Patient Experience Team that all actions were completed and no theme had been identified. It was a follow up of appointment that caused the issue, rather than a follow up of the care. With regards to the iPad that would be used to capture patient experience, this Committee discussed how this could be highlighted to the public. The positioning of the iPad would be considered. The Director of Nursing assured the Committee that with regards to the patient surveys and CCG Patient survey, the Trust was noted as providing good care and received good results. Resolved – that the Patient Experience Monthly Report be received and noted.

17.250 PATIENT SAFETY MONTHLY REPORT

The Director of Nursing presented this report to the Committee, apologising for the lateness of the paper, but reiterating that this allowed for the most up to date information to be presented. With regards to the medication incidents with harm, as previously indicated the increase in incidents related to an increase in services provided. The unavailable staffing data suggested that there was a 7% gap in October. Every option to improve this via leadership and rostering on the ward was being considered. The fill rate of bank and agency staff and the


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recruitment and retention of staff was also being considered. Overall a good level of safety performance continued. The Committee Chair noted the strong recruitment efforts and the importance of nurse care indicators. Dr Brady (NED) noted assurance in the continued improvement in the sepsis of deteriorating patient figures along with the persistent ratio of the peri arrest. It had been difficult to embed to the NEWs work and it was assuring to see this work reflected in the data. The Critical Care Outlook team had been expanded to cover 24 hours a day which aided with the sickest patients. The Committee Chair noted that care bundle usage had fallen since April 2017. This related to acquired pneumonia within the community and the AMD for Governance noted that there was difficulty with this bundle and how its use was captured. The Director of Nursing explained that an electronic NEWs system (SEND) was being was being implemented which may cause an increase in reporting of failure to escalate NEWs or a failure to calculate NEWs but this would not represent a deteriorating position but rather more issues were now being accurately gathered. This would improve patient safety but could appear as a dip in performance. Dr Brady had queried with the Board the best practice for Fractured Neck of Femur and noted that it was not clear where this fell within Clinical Governance or alternatively within Patient Safety or an AOGG. The Director of Nursing explained that dialogue took place with the Elective Care AOGG and the Committee could track this through the AOGG report. Mrs Hyde (NED) queried the falls data, specifically relating to Squire ward where a fall with moderate harm was reported. This incident highlighted an increase in patients within Squire Ward, although this had previously been reduced. The Director of Nursing explained that in early 2017, bed capacity modelling was completed and suggested a reduction in the number of elderly care beds. This was not sustainable due to the increase in activity across A&E. Therefore, the bed numbers had been increased. This may be reduced again in the future. The AMD for Governance noted that the Critical Care Group worked extremely hard and completed valuable work on the deteriorating patient agenda. Dr Brady (NED) suggested that this would be a useful subject to present at the Board of Directors workshop. The Committee Chair noted, that with regards to mortality reviews, a definition was needed as to what standard the Trust was adhering to when reviewing the non-essential review of deaths. The wording would be amended to reflect more appropriately the work completed. Resolved – that

(A) the Patient Safety Monthly Report be received and noted, and (B) with regards to mortality reviews, a definition was required as

FM


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to what standard the Trust adhered to. The AMD for Governance would ensure that this appropriately reflected the work completed.

FM

17.251 SERIOUS INCIDENT (SI) ACTION PLAN TRACKER

The Patient Safety Manager presented this tracker to the Committee. The report detail all the actions that had arisen from SIs from 1 April 2016 that had been closed. The oldest action related to consent and the relevant AOGG was monitoring this and this was expected to the closed by December 2017. A second action awaiting closure related to the neuro observation chart. This related to replacing a chart which would be superseded by electronic system. Discussing was taking place in relation to this. A third action relating to radiology and review of scans had been completed and an update was awaited. The Tracker was in a very positive position and was fulfilling its purpose. Resolved – that the SI Action Plan Tracker be received and noted.

17.252 CQUIN REPORTING QUARTERLY EXCEPTION REPORT

The Trust Assurance Manager presented this report to the Committee. In terms of Quarter 1, the CCG confirmed that the Trust had met all requirements. There had been significant progress in relation to sepsis with 100% of patients being screened and treated within the timescale. Work was ongoing with the CCG in relation to the audit process and what could be improved further. All CQUINs were on track for quarter 2 with the exception of CQUIN 8a which includes one element that was linked to Lorenzo and was part of a national project relating to discharge summaries. The CCG was aware of national slippage. All community CQUINs were on track and the Trust was meeting continuously with the CCG and Community Leads to ensure a channel of communication. The report also contained reference to the monitoring of assurance process. The report to the Committee focused on the risk and assurance that mitigations are in place. The financial aspect was considered at the Finance and Performance Committee. Community CQUINs were agreed on reputation and previous success, rather than financial reward. Resolved – that the CQUIN Reporting Quarterly Exception Report be


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received and noted.

17.253 OUT OF HOSPITAL CARE COLLABORATIVE AOOG REPORT

The Head of Community Nursing presented this report to the Committee. The divisional audits and SI Tracker were all on track and the CD audit was meeting the threshold. There had been an increase in safeguarding incidents which reflected good reporting and most related to verbal aggression from relatives. Staff were escalating and dealing with these issues appropriately. There had been an increase in incidents relating to lost notes and Information Governance was concerned with the number of lost notes within the community. This would be rectified once electronic records were implemented. Additionally, records that were kept in folders within the patients’ homes were being highlighted with stickers instructing that they were not to be thrown away. The CCG had done an unannounced inspection of the Nicol Unit with positive results. Infection Prevention had also visited and raised issues with broken blinds and the state of the cleaning cupboard. The cleaning would continue to be monitored. The CCG had performed an unannounced inspection at Castle Brook Lodge and the Trust Commissioned beds were found to be excellent. It was explained that the contract with Castle Brook was a yearly contract. HomeFirst continued as usual working alongside reablement. The Trust had received the Solihull 0 – 19 services, and the Trust had put out a tender for the 0 – 5 services within Warwickshire and the Coventry 0 -19 services. End of Life care had an updated CQC Action Plan and the CW Audit Plan continued to be updated. A new strategy had been launched and the Care of the Dying Care plan, ReSPECT, continued to be embedded. The Codes survey had been launched within the community and feedback was assuring. During the previous week the contract had been signed for the Out of Hospital services. The Governance Structures would now be formulated. The expected outcomes of the contract was under review due to the overlap with other contracts. Tissue Viability had been shortlisted for a Nursing Times Award in the Community. Community Services had presented at the Annual Trust Conference. The Committee Chair highlighted that 81% of the community team had achieved more than a year without pressure ulcers. The Director of Nursing noted the good presentation of the report that


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clearly relays the information. Mrs Hyde (NED) queried how well the ReSPECT papers were being utilised by community nurses and GPs. The GPs were running low on forms and queried how to order more. The Director of Nursing noted that there was some resistance to completion of the form within the community that put extra pressure on teams, however this had improved over the previous month. The Committee Chair queried the work at Millbrook. The Head of Community Nursing explained that concerns had been raised regarding the decontamination and cleaning process of community beds. This was flagged to Warwickshire County Council (WCC) who completed an inspection. The Trust then completed an unannounced inspection and found issues. Staff were not wearing gloves or aprons when cleaning returned equipment. The area was small, and a large amount of equipment was processed. Mattresses were stacked on top of each other which then meant that some were unable to be cleaned and had to be removed from service. Housekeeping arrangements and processes needed to be amended. All actions that were given were acted upon and this was confirmed by a reinspection. The CCG was present for the latter inspection and although further improvement was required, as Millbrook were working with the Trust on improvements, the CCG was happy for the Trust to continue to use them within the decontamination process. Resolved – that the Out of Hospital Community Care AOGG Quarterly Report be received and noted.

17.254 COMBINED QUARTERLY (1&2) SAFEGUARDING REPORT

The Safeguarding Lead for Adults presented the first part of the report which related to quarters 1 and 2. The main points highlighted were as follows:

(a) the division had had very complex safeguarding issues raised which had been successfully dealt with using various approaches;

(b) the adherence to the DOLS policy and the MCA processes was improving; however, a risk had been raised as an incident report was not always received from the Wards and therefore there was a lack of confidence that accurate information was received regarding the DOLS applications across the Trust. Work was underway with the DOLS lead to ensure that information would be sent to the Safeguarding Leads for Adults regarding DOLS referrals received in order for this to be cross checked. A risk assessment for this issue was included within the papers and would be discussed at the Corporate Risk Group during the following week. An update on this would be included within the February 2018 Committee Report;

(c) The AMD for Governance highlighted that the issue did not relate to the DOLs process but rather the recording of the process and the Director of Nursing explained that the best practice would be for the ward to know who was on a DOLS within their ward and the least restrictive care plan was consequently given. The Trust should have a central record of how many people were on a DOLS within the

SG


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hospital, and (d) another Risk Assessment related to the lack of substantive

employment of the Safeguarding Lead Role. The role was now out to advert.

Dr Brady (NED) queried the Multi Agency Safeguarding Hub (MASH) position and assurance was given that this had been recruited to and employment checks were currently taking place. The Committee Chair queried the Deprivation of Liberty area had previously been ambiguous, but assurance was given that this was resolving and more was being done to achieve compliance. Maggie Ward presented the Safeguarding Children Section of the report noting the following main points:

(e) incident reporting relating to data collection revealed that the highest number of incidents were reported from A&E and related to whether or not a child protection referral was made. This was reassuring as it showed the Trust was recognising when children were vulnerable and were taking the appropriate actions;

(f) the witness statements created a lot of work for the safeguarding team and the policy has been reviewed and relaunched. There were difficulties with practitioners understanding the process and the correct format to follow. There was a successful sharing of learning event with clinical leads. From this practitioner engagement with safeguarding evolved along with a commitment to form a group of champions across the acute and community;

(g) training at all levels had seen an increase in compliance; (h) the Solihull 0 – 19 Out of Hospital Collaborative would require a lot

of work and would be further mentioned within February 2018 Committee Report

(i) the Safeguarding Operational Committees that had combined the acute and community was working well and introduced two way sharing and receiving feedback from the areas;

(j) with regards to child protection supervision, the policy would be reviewed and made relevant to practitioners across the Trust;

(k) there were difficulties in relation to staffing, with vacancies, long term sickness and maternity leave. This combined with the increasing workload coming from Solihull was a pressure.

The Committee Chair queried who was responsible for the Out of Hospital Care and what was the risk associated with this. This had been discussed with the Head of Governance and the Trust had strong processes relating to this. An update was requested detailing how the Committee could understand the subcontractor organisations and their essential standards and responsibilities and what the Trust is responsible for. Resolved – that

(A) the Combined Quarterly (1&2) Safeguarding Report be received and noted;

(B) the February 2018 Committee Report contain an update on the DOLS risk assessments following discussion at the Corporate Risk Group during the following week;

MW RM / ABu SG


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(C) the Solihull 0 – 19 Out of Hospital Collaborative would be further considered within February 2018 Committee Report, and

(D) the Head of Community Nursing would liaise with the Head of Governance to determine the governance arrangements regarding Out of Hospital Services.

MW RM / ABu

17.255 CLINICAL AUDIT COMMITTEE – QUARTER 2 REPORT

The Clinical Audit and Effectiveness Manager presented this report to the Committee noting the following main points:

(a) there had been development towards the Quality Improvement (QI) and clinical audit projects;

(b) all national audits were on track for 2017/18. The majority of audits are in progress or completed;

(c) Dr Brady (NED) queried the Terms of Reference (ToR) and noted that the team would benefit from the QI programme. It was requested that the ToR contain an explicit link as to where the work linked with the Trust strategy and consideration given as to whether the current observation was clear.

Resolved – that,

(A) The Clinical Audit Committee Quarter 2 Report be received and noted, and

(B) the Clinical Audit Committee Terms of Reference contain an explicit link as to where the work of the QI programme linked with the Trust strategy and consideration given as to whether the current observation was clear.

SM / KT SM / KT

17.256 CHKS PATIENT SAFETY INDICATOR REPORT

The Clinical Audit and Effectiveness Manager presented this report to the Committee. Many of the actions had been processed and the Trust was doing well in comparison to peers, the Trust was in a good position. Dr Brady (NED) acknowledged the well written report and was happy to see that falls all rated as green. With regards to birth injury and whether the Trust was transparently reporting or over reporting. The Committee Chair requested a maternity view on this within the Women and Childrens AOGG Report in January 2018. Although the peer group had recently changed, this was now based on the size of the organisation rather than the demographic. Resolved – that,

(A) the CHKS Patient Safety Indication Report be received and noted, and

(B) The January 2018 Women and Childrens AOGG Report contain a maternity view on birth injury and whether the Trust was transparently reporting or over reporting.

VC VC


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17.257 HSDU DECONTAMINATION ANNUAL REPORT

The General Manager for Hotel Services presented this report to the Committee noting the following key points:

(a) mandatory training had been improved, including the technical specification training for staff;

(b) with regards to mattress decontamination, there had been an increased target of 120mins;

(c) the division had been asked to request ideas for improvement via the satisfaction survey and this had been included. This addition had highlighted that more clarity on invoices was required, notice of when the regular driver was on and an improvement with regards to tears and wraps of internal trays;

(d) 22 incidents were seen between September 2016 and September 2017. 2 of these had led to operations being cancelled and one of those led to an IMR as a set had been used late at night and HSDU were not aware that it was ready for collection and cleaning; it was then needed and not available. The actions from this related to more training and awareness. It had also been agreed with theatres that a call would be made to HSDU to identify any trauma kits that came late at night;

(e) indicator 6 related to tears in trays and further trials had been done in relation to this. There were issues with how the trays were being stored within theatres. A different tray would be considered which would be more robust.

(f) The number of trays produced had decreased from 61,000 to 52,000 which came from a loss of external businesses as they moved to single use. The Vanguard was keeping the productivity up;

(g) Indicator 8 related to maintenance and the good working relationship with the Estates team was noted. Daily and weekly inspections were taking place;

(h) Indicator 10 related to the Trust’s certification. There had been 2 during the current year. A scheduled inspection had taken place and the Trust had received one major and one minor non-conformance but these had no effect on the accreditation;

(i) the management of the decontamination of mattresses had transferred to the EBME Manager as there was additional space next to the equipment store. These report figures would be monitored via the Support Services AOGG Report to the Committee;

(j) the 2 hour turnaround KPI had been considered an the Trust was achieving 67 minutes;

(k) a five year development plan was now in place, working closely with the Capital Manager. The plan was to develop the clean room with a new air handling unit. The flow of staff through the department would also be considered.

(l) the report contained detail on Scantrack, and the options that were being considered. £50,000 had been allocated from the software team to acquire software and hardware;

Mrs Hyde (NED) queried the issues previously raised in relation to Community decontamination and whether this was a business stream that


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the Trust could pick up. However the Trust may struggle with the quantity that would flow through. The Committee Chair queried the weekly tests with results of 100% and 96% and received clarification that this related to first time tests. Resolved – that the HSDU Decontamination Annual Report be received and noted.

17.258 MORTALITY SURVEILLANCE COMMITTEE QUARTERLY REPORT

The AMD for Governance provided this report in the absence of the Medical Director. The three indices for overall deaths revealed a positive picture. The HSMR graph showed a closing gap with peers and it was hoped that this would be reflected in SHMI. The Trust had tried to establish links with the local CCG to try and examine how deaths were reviewed within 30 days. There were now drivers to share learning across Trusts and the West Midlands Mortality Leads meeting were now sharing learning between Trusts. The National Guidance on Learning from Deaths had key themes of identifying the concerns of carers and their relatives and making sure deaths are reviewed. A Mortality Surveillance Policy was now available on the intranet and highlighted the reporting of deaths at Board level. Whilst the Trust was compliant with national guidance, a debate had arisen within the Trust as to how to move forward and an AMD had been appointed to lead on this. A National Medical Examiner system was proposed, however this was not a success so consideration would be given to developing these processes internally and establish an elite group of clinicians who were trained in mortality reviews. The Committee Chair thanked the AMD for Governance and the Head of Governance for inviting him to a number of events which would add assurance to the statement that the Trust complied with NHS guidance and was working to improve. The Committee discussed the national debate regarding whether it was useful to identify deaths as preventable. There was no nationally recognised definition of preventable. The guidance indicated all deaths that required an SI review should be reported, additionally a sample of deaths is recommended. Resolved – that the Mortality Surveillance Committee be received and noted.

17.259 QUALITY FACULTY PROGRESS REPORT

Ms Jennings (Advanced Clinical Practitioner) presented this report to the Committee noting the following key points:


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(a) the Quality Improvement and Operational Group had been established and was now up and running on a fortnightly basis;

(b) an email address had been set up ([email protected]) for people to submit their quality and improvement projects;

(c) a proposal form had been created and piloted; (d) the Quality and Improvement Hub had been established with

ongoing work in relation to membership; (e) the only risk was that the work on establishing the group began in

August 2017 rather than April, but it was thought that the Trust would catch up and meet all Key Performance Indicators (KPIs) by March 2018.

The Committee Chair noted the benefit of having an initiative of continued improvement. The Trust Governor noted that Trust Governors were not mentioned within the report; however they were the interface with the public and would be very happy to be involved. A discussion would take place at the next Council of Governors meeting as to whether the Governors Concerns form remained a useful tool or whether the QI hub could suggest something more constructive. Additionally the hub’s links with Deloitte were queried. Dr Brady (NED) praised the continued dialogue of where clinical audit sat within QI. The AMD for Governance queried the best practice for Fractured Neck of Femur and where this sat. Concern was being raised that patients were not receiving a geriatrician review. Clarification was given that less than 1% did not have an ortho-geriatric review of their fractured neck of femur. Thee 18% that were not meeting the best practice during the previous month were not getting to theatre on time, either because theatres were full, organisational issues or medical issues. Resolved – that,

(a) the Quality Faculty Progress Report be received and noted, and

(b) the Trust Governor would liaise with the Ms Jennings (Advanced Clinical Practitioner) to determine how the Patient Care Committee could be further involved with the QI Hub.

PS PS

17.260 ANY OTHER BUSINESS

There was no other business.

17.261 CONFIDENTIAL MINUTES FROM THE MEETING HELD ON 11 OCTOBER 2017


17.263 SERIOUS INCIDENT 2017/21610/6653

17.264 SERIOUS INCIDENT 2017/23158/6670

mailto:[email protected]


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Signed Date 13 December 2017 (Chair of the Clinical Governance Committee)


17.266 DATE AND TIME OF THE NEXT MEETING

The next meeting would be held on Wednesday 13 December 2017 at 12:30pm in the Brooke Suite, Warwick Hospital.


Minutes of the Clinical Governance Committee Meeting held on Wednesday 13 December 2017 at 12.30 hours in the Brooke Suite, Warwick Hospital

Present: Bruce Paxton (BP) Non-Executive Director (NED) (Committee Chair) Charles Ashton (CA) Medical Director (present until Minute 17.273 and from Minute 17.279) Angela Brady (ABr) NED (present from Minute 17.274) Fiona Burton (FB) Director of Nursing Alan Harrison (AH) NED Claire Hinds (CH) Associate Director of Operations (ADO) – Support Services (present

from Minute 17.279 until Minute 17.280) Rosemary Hyde (RH) NED Simon Illingworth (SI) ADO - Elective Care (present from Minute 17.279 until Minute 17.280) Helen Lancaster (HL) Director of Operations Fraser Millard (FM) Associate Medical Director (AMD) for Governance Penny Smith (PS) Trust Governor Sue Whelan Tracy (SWT) NED (present from Minute 17.281) In attendance: Neil Anderson (NA) Director of Coventry and Warwickshire Pathology Services (present

from Minute 17.280 to Minute 17.282) Pablo Garcia de Paso

(PGP) Chair of the Emergency Care Audit and Operational Governance Group (AOGG) (present from Minute 17.280 until Minute 17.284)

Ruth Gibson (RG) Patient Safety Manager (present from Minute 17.275) Dipa Parekh (DP) Quality and Improvement Manager (present from Minute 17.280 until

Minute 17.282) Sean Ramcharan (SR) Chair of the Elective Care AOGG (present from Minute 17.280 until

Minute 17.281) Val Ross-Gilbertson (VRG) The Hospital Based Coordinator for Coventry & Warwickshire

Cervical Screening Programme (present from Minute 17.280 until Minute 17.283)

Sumara Parvez (SP) Head of Pharmacy (present from Minute 17.283) Lindsey Cotterill (LC) Committee Administrator MINUTE ACTION 17.267

APOLOGIES FOR ABSENCE

Apologies for absence were received from the Head of Governance, the Trust Assurance Manager and the Hospital Transfusion Practitioner.

17.268 DECLARATIONS OF INTEREST

No Declarations of Interest were made.

17.269 CHAIRS NOTE

17.269.01 Resignations The Committee Chair acknowledged the departure of the Committee Administrator and the Head of Governance. The December 2017 Committee meeting would be their last, and thanks were given for their hard work. Resolved – that the position be noted.

SOUTH WARWICKSHIRE NHS FOUNDATION TRUST Minutes of the Clinical Governance Committee Meeting Held on Wednesday 13 December

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17.269.02 Flu Vaccinations

Committee members were encouraged to receive their flu vaccination and to promote this throughout the organisation. The Trust was hoping to achieve a higher number than the previous year. Resolved – that the position be noted.

17.269.03 Care Quality Commission (CQC) Visit The Committee Chair expressed disappointment in the hand wash non-compliance that was noted within the Emergency Division during the CQC visit throughout the previous week. Thanks were given to all who were involved with the inspections. Resolved – that the position be noted.

17.270 MINUTES OF PREVIOUS MEETING HELD ON 8 NOVEMBER 2017

The Committee highlighted several typographical errors, and these would be amended. Resolved – that subject to the typographical amendments, the Minutes of the meeting held on 8 November 2017 be confirmed as an accurate record of the meeting and signed by the Committee Chair.


17.271.01 Actions Listed as Complete All Actions listed as Complete or On the Agenda on the Actions Update Report were noted and would now be removed from the report. Resolved – that the position be noted

17.272.02 Patient Experience Monthly Report (Minute 17.174 refers) The Director of Nursing was to explore the option to resolve the grading issue of complaints. The grading of an incident when initially recorded often changed during investigations. This was explained as normal as an initial view may seem simple, but investigations could uncover complex causes Additionally, some complaints were multi-faceted with only some aspects being upheld. This could cause confusion. The Committee queried whether the gradings, therefore, reflected the seriousness of the complaint. The Director of Operations explained that the Patient Experience Team were considering ways that the end grading and wording could more clearly reflect the initial complaint, however there would always be slight mismatches due to the nature of investigations. Resolved – that the position be noted.

17.272.03 Quality Faculty Progress Report (Minute 17.259 refers) Ms Smith (Trust Governor) would liaise with Ms Jennings (Advanced Clinical Practitioner) to determine how the Patient Care Committee could be


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further involved with the Quality Improvement (QI) Hub. Ms Smith (Trust Governor) explained that this meeting would take place in approximately 6 months’ time once the work had been further embedded. Resolved – that the position be noted.

17.273 INFECTION PREVENTION AND CONTROL MONTHLY REPORT

The Director of Nursing presented this report to the Committee. The main point of note was that the report was missing the hand hygiene results for A&E. This was an error on the team’s part. This would be included in future reports. Hand hygiene audits had been completed in January and June 2017 and indicated that the results were improving. Dr Harrison (NED) queried why Farries ward appeared to acquire more infections than other wards. The Director of Nursing explained that Farries ward dealt with haematology patients, with many being neutropenic and therefore more susceptible to infections. The Committee Chair queried the Total Knee Replacement graph and any trends that were shown. The Director of Nursing would liaise with the Infection Prevention Team to determine why the Trust was off-kilter with the trend line. Resolved – that

(A) the Infection Prevention and Control Monthly Report be received and noted, and

(B) the Director of Nursing enquire as to the varying figures against the trend line within the Total Knee Replacement Graph.

FB FB

17.274 PATIENT EXPERIENCE MONTHLY REPORT

The Director of Nursing presented the report noting that Friends and Family (FFT) results were the main concern. There was a constant struggle to achieve the desired A&E FFT response rate. The Trust had received a performance notice from the Clinical Commissioning Group (CCG) and consequently the Trust Assurance Manager and the CCG had met with the A&E team to work through a different methodology which included an agreement to focus on FFT for one week out of each month to focus attention. The Committee Chair queried whether the electronic tablet was back in use. There was no update available for this. With regards to Maternity Services, a disappointing decline in response rates had been seen; the division usually achieved the response rate target. Initial explanation for this decline was that the maternity admin clerk had left the Trust which led to a break in process. However, it was later determined that the division had ran out of cards and there was a delay in replenishing these. The maternity processes would be refined.


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Ms Smith (Trust Governor) queried a complaint which involved a patient taking several hours to get transferred to the University Hospitals of Coventry and Warwickshire (UHCW) even though they had a previously ruptured aneurism. It was queried whether such patients would be taken directly to the UHCW once all stroke patients were taken there. The Director of Nursing explained for patients with subarachnoid haemorrhage, if the surgeon had accepted the patient and surgery was planned, then the patient would be transferred to UHCW. Ms Smith (Trust Governor) queried why elderly patients were having to wait for a substantial time in A&E. Other Trusts had placed a consultant within A&E to assist with triage and allow patients to be immediately sent for a scan The Director of Nursing explained that the trust did have a consultant in A&E 7 days a week who worked flexibly between triaging patients and treating the most complex and sick patients. The Director of Nursing went on to explain that the Trust had a Frailty Unit and patients that had been seen by a GP were referred directly to the Frailty Unit rather than via A&E. Dr Harrison (NED) queried the 1 star NHS Choices comment and asked whether there was any interest in the complainant meeting Trust staff to discuss issues further. The Director of Nursing explained that this patient had contacted The Patient Advice Liaison Service (PALS) who had asked the division to investigate and respond. The division concluded that treatment given had been appropriate and had tried to contact the complainant to feed back. However the family was non-contactable and therefore the issue was closed and consultants agreed that the episode followed good practice. Resolved – that Patient Experience Report be received and noted.

17.275 HOSPITAL TRANSFUSION COMMITTEE 6 MONTHLY REPORT

In the absence of the Transfusion Practitioner, the Director of Nursing presented this assuring report. One area of noncompliance with sample validity was highlighted which was noncompliance with the revised British Society for Haematology (BCSH) guidance. This was due to a delay resulting from the upgrade of the Laboratory Information Management System (LIMS). This had been implemented on 4 December 2017 and the Committee requested an update on this implementation within the June 2018 Committee Report. Dr Harrison (NED) queried risk 1197, which related to increased wastage of blood within the Trust’s blood bank due to an increased amount of stock requested by Nuffield Private Hospital. Once all contractual payments had been received, the working agreement would be reviewed. The ageing blood storage equipment was discussed and whether this would be reviewed. The Director of Operations explained that this was a recognised risk, however replacements parts remained available for the equipment and the Trust was confident that the machines were fit for

SS


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purpose and could be repaired when needed. Dr Brady (NED) queried the Anti-D incidents which were listed as a service achievement and whether this was correct as it indicated good reporting. It was felt that the placement of this information as an achievement was an error. Resolved – that

(A) the Hospital Transfusion Committee 6 Monthly report be received and note;

(B) an update on the implementation of revised British Society for Haematology (BCSH) guidance be included within the June 2018 Committee report, and

(C) the Hospital Transfusion Committee Terms of Reference be presented to the January 2018 Committee meeting.

SS SS

17.276 PATIENT SAFETY MONTHLY REPORT

The Patient Safety Manager presented this report to the Committee. The Director of Nursing queried why medication incidents had increased in terms of their grading with harm. The Drugs had Therapeutics Committee had reviewed this and believed it related to an increase in maternity reporting due to raised awareness. The incidents with low harm did not suggest significant harm to patients. The division was working towards a stretch target of 8%. The Director of Operations requested that future reports contain narrative relating to the patient safety graphs within the Executive Summary Dr Brady (NED) queried the Central Alerting System (CAS) and the ongoing alert on the restricted use of open systems for injectable medication. The deadlines had been missed and mitigation was queried. A national fix was awaited for this issue; however there was no timescale for this. The Director of Nursing queried the incident and medication data and enquired as to any themes that could be seen from this. The data showed the number of incidents reported was stable, with the frequent categories being pressure ulcers, falls and medication. The Patient Safety Manager would liaise with the Director of Nursing to determine the usefulness of the data and whether all was required within the report. The Committee Chair queried the medication incidents and noted a high level of insulin incidents. Clarification was given that the “patients’ homes” category covered the whole of the community throughout Warwickshire and this was where most incidents occurred. This was not high considering the number of community patients. Commentary was requested within the report as to why these incidents occurred and determine whether the number of insulin related incidents were beginning to increase. With regards to the deteriorating patients’ data relating to sepsis, the significance of the completion of care bundles was questioned as the

RG RG RG


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completion was 55%. The Deteriorating Patient Committee completed a regular audit to see if the bundles were being used and whether they were being used well. Patients were identified as having sepsis and a care bundle was allocated, however checks were then needed to determine whether actions requested had been actioned and the outcome this had on patient care; consequently, this was a complex measurement in checking each stage. The completing of the bundle figures related to whether actions had been initialled, not that they had been actioned. The Committee discussed the consistent definition of post-partum haemorrhage. The Maternity safety thermometer defined this as more than 1000ml, however the Elective Care AOGG defines it as 1500ml. It was explained that Maternity had their own set parameters and was measured at different levels, this was therefore not an inconsistency. The Committee Chair queried the Patient IT ongoing alerts with a deadline due in December 2017. There was no update relating to cardiology and a fix for the national systems, however no completion date was available. The Committee requested comment on this within the January 2017 report. The Director of Nursing acknowledged the extensive amount of work that the Patient Safety Manager and Patient Safety Team completed in order to form this report for the Committee. It was hoped that an automated system would soon be in place. The Committee gave their thanks. Resolved – that

(A) the Patient Safety Monthly Report be received and noted; (B) future reports would contain narrative for the graphs within the

Executive Summary; (C) the Patient Safety Manager would liaise with the Director of

Nursing to determine the usefulness of the data and whether all was required within the report;

(D) the January 2018 Committee report contain further information in relation to the insulin incidents and determine whether these were beginning to increase again;

(E) future reports contain commentary on the high number if insulin medication incidents within the community, and

(F) the January 2018 Committee report contain comment on the Patient IT cardiology fix.

RG RG RG RG RG RG

17.277

SERIOUS INCIDENT (SI) ACTION PLAN TRACKER

The Patient Safety Manager presented this SI Action Plan Tracker to the Committee. The Care Plan incident had now been closed. The consent incident was now moving forward. Dr Harrison (NED) noted the strong progress of the Tracker and acknowledged its usefulness to the Committee. Resolved – that the SI Action Plan Tracker be received and noted.


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17.278 CLINICAL PRACTICES GROUP ANNUAL REPORT AND APPROVAL OF

THE TERMS OF REFERENCE

The Director of Nursing presented this report to the Committee in the absence of the Head of Governance. The report showed an assuring picture of all of the guidelines and procedures that had been approved through the Committee and during the previous year the Clinical Practices Group and the Patient Information Group had been combined. There had been no significant changes to the Terms of Reference and the Committee agreed approval. Resolved – that

(A) the Clinical Practices Group Annual Report be received and noted, and

(B) the Clinical Practices Group Terms of Reference be approved and ratified.

17.279 SUPPORT SERVICES AOGG QUARTERLY REPORT

The ADO for Support Services presented this report to the Committee The Committee had previously queried the national audit that had rated amber (Minute 17.209 refers). This was confirmed as the National Parkinson’s Audit; however the action plan had now been received. The following key points were noted:

(a) within podiatry there was an increased demand for complex wound care and diabetic foot care had stretched the service. Concentration focused on the most urgent which must be seen with 48 hours. However, by meeting this target, there had been an increase in waiting times for follow up appointments for routine care. This was further impacted with the increase in diabetic patients. The audit indicated that GPs were monitoring patients for longer, meaning that at the time of referral they were noted as complex cases;

(b) podiatry was leading the way in piloting totally paperless Lorenzo clinics. The Allied Health Professionals were keen to do this. This was working in conjunction with Rugby clinics. This process included the emailing of appointment information. Within orthotics, information was sent digitally to suppliers via a secure network. These had been presented as models for Trust wide use and the aim was to roll these out throughout 2018;

(c) with regards to AHPs, there were 3 areas where LocSSIPs were being used; Speech and Language, Physiotherapy and Podiatry. The services had implemented these successfully and were also implementing auditing compliance;

(d) there had been two incidents within the Outpatient clinic service. On occasion patients had been sent to Outpatients to wait for services such as a taxi or appointment without an assisting member of staff. These patients had complex needs and learning had been


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highlighted from these incidents, and (e) within the Health Records Scanning Bureau a system had been

implemented to minimise the amount of loose filing within inpatient records, by collecting these from wards and scanning these into patient records. This would reduce the likelihood of it being misplaced or misfiled.

Dr Brady (NED) queried the wheelchair service and what was being done to mitigate the high waiting times. The ADO for Support Services explained that the sickness level within the team had been high, however improvement had recently been seen. Additionally, there had been an increase in demand and complexity of the patients. An action plan had been formulated to aid in the management of the service, and work would be done with the CCG on the matter. Resolved – that the Support Services AOGG Quarterly Report be received and noted.

17.280 ELECTIVE CARE AOGG QUARTERLY REPORT

The Chair of the Elective Care AOGG presented this report to the Committee, following acknowledgement from the Committee Chair of the clear, refreshing style of the report. Additionally, praise was given for the WHO checklist performance. The safety performance of the division was pleasing for the previous quarters. Challenge was found in recruitment; particularly in oncology, ophthalmology and urology. The urology position was due to go out for advert in the new year and there had been interest in this. With regards to General Surgery and Breast, the workload had increased, and flow issues had been considered to keep services flowing. Consideration was being given to the creation of a Surgical Assessment Unit. Within Gastroenterology, a new lead nurse had been appointed. However, there were concerns with regards to sustaining the on-call rota; specifically, with regards to having a service for upper gastrointestinal (GI) bleeds. This had been added to the risk register. There had been issues with Endoscopy, specifically regarding the scopes that had been purchased during the previous year. The picture quality was not up to the desired quality. The suppliers were doing extensive investigation into the mechanics of the scope to determine the cause of the issue. It was noted that other users of the same scopes throughout the country had not reported issues. An update would be given within the March 2018 Committee Report. Patient risk would not be measurable for the next few years. With regards to Oncology haematology, the Director of Development and

SR


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the Chief Executive were due to meet with UHCW to discuss the issues with regards to medical recruitment for the specialities. This issue related to how Stratford Hospital was staffed. Issues had arisen with regards to Dermatology capacity and consultant shortages. However, the Trust had acquired two new locums which would alleviate some of the problems. There were no concerns with regards to complaints, mortality, incidents and the safety thermometer. There had been a few information governance breaches; however there was no trend to the breaches. The division had queried whether Local Safety Standards for Invasive Procedures (LocSSIPs) was sustainable in the long term as it was unclear as to what the data would produce on a national level and whether this would be kept on a local level. LocSSIPs were in place for the prevention of harm to patients and acted as a safety checklist to limit the number of incidents and never events for patients having local or minor procedures. The Trust had discretion to make it fit for purpose throughout the organisation and ensure that the LocSSIPs were focused on reducing harm, as such a low risk procedure could have a very simple LocSSIPs. The Committee noted that the LocSSIPs would benefit from streamlining. There had been an improvement with regards to controlled drugs audit, however further culture change was required for further and sustained improvements. Main Theatres had attained 96% compliance which was praised by the Committee. Dr Harrison (NED) queried whether the Committee should be concerned regarding the mortality reviews which were over performing in some areas and underperforming in others. The Mortality Review process was being reviewed and to align this with Trust levels, a job plan review would be required. Additionally, the Grand Rounds could be utilised for shared learning, once every three months. The national guidance on learning from death stipulated that all unexpected deaths were to be reviewed. By definition, deaths within the Elective division are unexpected and therefore all were reviewed. The difference between over and under-performing areas was related to how data was recorded. Dr Brady (NED) queried complaint 4015, which related to the Central England Rehabilitation Unit (CERU) and management failure. This was now graded amber with a reply due in April 2017. The ADO for the Elective Division explained that this was now closed and could be removed. The complaints table had yet to be updated with several of the complaints closed and removable. Complaint 4828 was the only one which remained open upon the first page. The Committee Chair queried the learning that was disseminated from mortality reviews and the checks that took place to determine whether this had been connected to practice. This would be considered in accordance with inter-speciality learning. The Director of Nursing explained that this would be monitored via the QI Hub. These themes would be fed in and


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divisions would be encouraged to cascade the learning and embedding checks through divisions. The Director of Operations explained that many issues were small issues rather than any major concerns. Doctors were asked during their appraisal how they had contributed to quality improvement; consideration of mortality review learning could be a part of this. Resolved – that

(A) the Elective Care AOGG Quarterly Report be received and noted;

(B) the March 2018 report contain further information on the Endoscopy Scopes and the investigation into the quality of the images produced

17.281 COVENTRY AND WARWICKSHIRE PATHOLOGY SERVICES 6

MONTHLY REPORT

The Quality and Improvement Manager presented this report to the Committee. There had been several issues in phlebotomy regarding staffing arrangements and the availability of a third cubicle on a regular basis. There was now a full complement of phlebotomists who had been through a full consultation phase in order to introduce seven day working to bring added robustness to the system. The new rota was now live and Swift Queue, the Electronic Patient Management System, had been introduced. This had gone very well, and patients were waiting no longer than 15 minutes. Positive patient experience feedback had been received. The Quality and Improvement Manager would work with the patient forum to gather further patient feedback in the future. Mrs Whelan Tracy (NED) queried how the new phlebotomy service processes would be communicated with patients and GPs, especially those that were not IT literate. The service had been liaising with Primary Care to promote the service and communicate the changes. It was believed that this had gone well and most patients appeared to be booking successfully. It was noted that phlebotomy was not considered to be a robust system and Dr Brady (NED) queried how this was measured across the network. The electronic system was going live across Stratford in January 2018 and was already live within the Trust. This system would allow for domiciliary visits to be managed and for flow to be monitored. The Director Coventry and Warwickshire Pathology Services noted the many GPs perform their phlebotomy services within their practice and when overwhelmed created an overflow. This was now able to be controlled. The next step would be to liaise with the CCG as to how to work with GPs on their current Local Enhanced Service (LES) agreement. Work was ongoing with outpatient clinics to secure slots for specific areas and there was availability for walk in patients, although they may have to wait for a longer time. The new system would allow for waiting time statistics to be gathered.

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With regards to external audits, there has been a UCAS inspection. They had reviewed the phlebotomy, haematology and transfusion services had they had retained accreditation. In addition the UHCW blood bank was inspected by the Medicines and Healthcare products Regulatory Agency (MHRA) and had received 8 findings, none of which were critical and the service had until 5 January 2018 to propose plans as to how this would be resolved. This was a type two letter meaning that the service would work in conjunction with MHRA. There had been challenges in achieving the blood sciences Key Performance Indicators (KPIs) for coagulation. Audits had been undertaken and indicated that if an add-on test was requested on an existing episode, it artificially calculated the turnaround time from the original sample received dated. Secondly, there was IT connectivity issues. Work was ongoing to highlight this with the Trust IT team and UHCW’s team. It was hoped that collaboration with IT would fix the issue. The network had staff employed on all sites and staff engagement was a focus to aid understanding of staff needs. Line managers would be empowered to build robust relationships with staff and influence proactive behaviour at a local level. Listening events had commenced across the Network and these were effective sessions resulting in beneficial actions. Dr Harrison (NED) queried the blood bank storage for Warwick Nuffield and it was confirmed that the Trust is awaiting a letter to be served to Nuffield. Payment was awaited before the letter was sent. Resolved – that

(A) the Coventry and Warwickshire Pathology Services 6 Monthly Report be received and noted, and

(B) the Quality and Improvement Manager would work with the patient forum to gather further patient feedback on the improved phlebotomy service.

DP

17.282 CERVICAL SCREENING SERVICE – 6 MONTHLY REPORT

The Hospital Based Coordinator for Coventry & Warwickshire Cervical Screening Programme presented this report to the Committee, which was primarily an update on the previous Quality Assurance (QA) visit in March 2016. The report had also been considered by the Women and Childrens AOGG for sign off before submission to Public Health England. When a reply was received in July 2017, out of 10 items, 7 were complete and 3 were outstanding. Since then one has been signed off. The two remaining were proving difficult. Firstly, the Colposcopy Unit should provide administration cover for the service, which is done, however there was no cover in times of annual leave or sickness. This was difficult to solve due to the extra hysteroscopy clinics which required further staff. The Director Operations noted that further resources may be required for the Colposcopy/Hysteroscopy service. Secondly, the Colposcopists were required to attain a minimum of 50% attendance at Colposcopy MDTs, only


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3 out 6 Colposcopists’ were meeting this target. Clinicians were struggling to meet target due to clinical clashes. The department was investigating whether the clinics on the MDT day could be shortened to allow for lunch time attendance. The Committee discussed whether future reports would be minuted as public or confidential following a previous Freedom of Information request from the press regarding the screening programme. The Committee Chair reminded presenters that reports should be anonymised before presentation. The Report would now be taken via the Women and Childrens AOGG who would report any issues to the Committee via their quarterly report. Resolved – that the Cervical Screening Service 6 Monthly Report be received and noted.

17.283 END OF LIFE UPDATE

The Chair of the Emergency Care AOGG presented this report to the Committee for the first time. The End of Life Group had been completely remodelled with a change to the membership, vision and framework of the group. There had been strong attendance to the first reorganised End of Life Group meeting. The challenges for the future were found in the communication and documentation of plans and escalation. However, reassurance was given that the Trust’s care of dying patients was caring, kind and compassionate in the last days of life. Challenge was found in the time before the final days. Consequently the group has been remodelled with a focus on internal staff and procedures. Previously the group had a lot of influence from external organisations, which was appreciated, however the Trust required a group that worked within the organisation and met the needs of the service. An additional risk related was the lack of a permanent Palliative Care Consultant. This issue would be tackled through use of the county network of palliative care consultants. An interim process would be discussed with the Director of Nursing and the Medical Director. An advert and job description for the post had been released. Quarterly End of Life updates would be presented to the Committee and Dr Brady (NED) had agreed to sit on the Group as a Non-Executive representative. The Director of Operations queried the engagement of other stakeholders with the group, such as the Macmillan Hospice who support the organisation with different models of care and facilitating the end of life care pathway. The Chair of the Emergency Care AOGG explained that representatives are welcome to attend the group but it was not a requirement. The Director of Nursing queried how the Trust had oversight of the End of Life incidents, complaints, themes and issues following questioning from the CQC. This oversighted needed to be built in to the End of Life Group. The


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Group would receive each AOGGs Minutes which would provide an overview of any issues per division. Additionally audits would also take place along with the national End of Life Care audit. Mrs Whelan Tracy (NED) queried whether the End of Life Group was prioritising any of the audits. The Group was prioritising a change of culture in order to gain influence in ward rounds and meetings to allow wards to take ownership of those that die. A sequence would be established to screen patients to recognise those that were at risk of dying over the coming year and then this would be flagged to the receiving team, if patients’ deteriorated during their stay then the holistic care plan for the dying patient would be initiated. The group would aim to make the Trust compliant with the National Institute for Health and Care Excellence (NICE) guidelines regarding End of Life, as the Trust was currently only partially compliant and action plans were in place to rectify this. The Trust Governor expressed previous concern from the Governors Forum at the lack of progress of the End of Life Group, and acknowledged the good work that was now on-going and the advancement of the group. The Chair of the Emergency Care AOGG was welcome to attend the Patient Care Committee and the Community and Hospital Information Exchange Forum (CHIEF) to speak about the work of the group. Resolved – that the End of Life Update be received and noted.

17.284 ASEPTIC EXTERNAL AUDIT REPORT AND ACTION PLAN

The Committee welcomed the new Head of Pharmacy who presented the report and noted that moving forward any external audits or visits to the Pharmacy unit would be relayed to the Committee in advance of visits being arranged. The Aseptic Audit had been positive and had moved the unit from high risk to low level of risk. This has been due to the Trust investment into the new unit, as the old unit was failing. There was a comfortable level of assurance. A few areas that required work were identified by the audit but these were mostly low risk and the Department therefore had 18 months to resolve the issues. The department was already aware of some of these and plans had been put in place to address and actions have already been rectified. These audits occurred every 18 months. An action plan had been submitted to the auditor as part of the Trust’s response, with all issues being addressed. One concern related to risks associated with injectable medications. This was not classified as a major risk however this would be reviewed as a risk for the whole of the Trust. A new way of completing the risk assessment was being designed via the regional Medication Safety Officer Network. Following creation of this documentation the injectable medications audit would take place at SWFT with a view to completion by November 2018.


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Signed ______________________________ Date: 10 January 2018 (Chair of the Clinical Governance Committee)

Dr Harrison (NED) noted the positivity within the report and queried the completion dates of some actions and assurance was given that actions were finalised before the November 2017 Submission. A new cold storage unit had been installed and was identified in the audit as needing a Service Level Agreement (SLA) over time frames for response in case it broke down. It was agreed that this was a departmental responsibility. Resolved – that the Aseptic External Audit Report and Action Plan be received and noted.


Thanks to the Committee The Committee Chair thanked members for their hard work over the previous year and wished all well for the festive season.

17.286 CONFIDENTIAL MINUTES OF PREVIOUS MEETING HELD ON 8 NOVEMBER 2017


17.219 DATE AND TIME OF THE NEXT MEETING

The next meeting would be held on Wednesday 10 January 2018 at 12:30pm in the Brooke Suite, Warwick Hospital.

south warwickshire nhs foundation trust meeting board of directors date 25 january

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