Meeting of the
Quality & Clinical Governance Committee
Thursday 19th November 2015, 2:00-4:30 pm
In the Nightingale Conference Room, Nightingale House
Present:
Godfrey Allen
James Gillgrass
Nnenna Osuji
Michael Fanning
Mike Bailey
Jayne Black
Non-Executive Director (Chair)
Non-Executive Director
Medical Director
Director of Nursing, Midwifery and AHPs
Non-Executive Director
Chief Operating Officer & Deputy CEO
(GA)
(JGi)
(NCO)
(MF)
(MBa)
(JBl)
In Attendance:
Helen Astle
Katherine Falkner
John Goulston
Julieanna Kotey
Mary Twagira
Marcia Marrast-Lewis
Ann Morling
Director Quality Assurance & Governance
Assistant Director of Nursing
Chief Executive Officer
Senior Infection Control Nurse [for item 12]
Consultant Clinical Microbiologist and Infection Control Doctor
Committee Secretary (minutes)
Director of Midwifery
(HA)
(KF)
(JG)
(JK)
(MT)
(MML)
(AMo)
Apologies
Azara Mukhtar
Michael Burden
Michael Bell
Director of Finance
Director of Human Resources and OD
Chairman
(AM)
(MBu)
(MBe)
1.
Apologies
1.1
The Chair called the meeting to order welcoming Members. Apologies were
received from Azara Mukhtar Director of Finance, Michael Burden Director of
Human Resources and Organisational Development and Mike Bell Chairman.
2.
Meeting Quorate
It was noted a quorum was present.
3.
Declaration of Interests
No new interests were declared.
4.
Minutes of the previous meeting
The minutes of the meeting held on 14th October 2015 were approved subject
to textual amendments.
5.
Action Tracker and Matters Arising
5.1
Progress updates were given against outstanding actions:
Item 7 from 14 October 2015 – it was agreed at that meeting that all committee
report cover sheet should be completed properly to include information relevant
to the Equality Impact Assessment where required, HA and MML to ensure that
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this was actioned
Item 14 and 17 from 14 October 2015 – HA confirmed that a standard annual
report template was circulated to the Chairs of all of the Board committees for
completion and submission to the Trust Board in December.
Quality & Assurance
6.
6.1
6.2
6.3
Quality Experience & Safety Programme Update
HA provided a progress update of the Quality Experience & Safety Programme
(QESP) reminding the Committee that a response together with action plans
for the 4 ‘Must do’s’ and 31 ‘Should do’s’ was ready for approval by the Trust
Board prior to submission to the Care Quality Commission (CQC). The
committee considered the overarching action plan and noted that completed
milestones would be removed once management had signed them off. The
Committee noted that 2 outstanding action plans required approval by Lisa
Chesser the Director of Planning & Information which related to integrated
hospital and IT systems as a shared care record. It was noted that this action
plan would be signed off in readiness for approval by the Trust Board on 9th
December 2015. It was agreed that outstanding milestones would be RAG
rated to facilitate monitoring by the Committee and the Trust Board and that the
QESP Delivery group would oversee action plans, look at evidence and track
progress.
MBa queried CQC 7 – “continue to recruit to vacancies” asking if there was any
conflict with the financial recovery plan and the recruitment freeze. JG
explained that there was no conflict in relation to the recruitment of clinical staff
as increased recruitment of clinical staff would reduce the need for temporary
bank and agency staff. However a review of non-clinical posts was in progress
to reduce pay costs and the first draft of the report would be ready for review
by the Financial Recovery Board by the end of the year. The plan assumed
that 40% of non-clinical vacancies would not be filled and 60% would be risk
profiled. It was suggested that the action should be reworded to reflect that
“the Trust would continue to recruit to all clinical and clinical support
vacancies”.
MBa also queried CQC 12 ‘continue meetings’ noting that this was not really an
action that would implement the required change. JG suggested that the
action should include an implementation plan for clinical documentation in the
Emergency Department with action 4 agreeing an ‘implementation date’. MBa
also queried CQC 16 Outpatients – “extend consultant notice period” notice to
take annual leave without cancelling clinics. NCO explained that an annual
leave system was to be implemented as well as a monitoring system to look at
activity could be cancelled when consultants took annual leave. Therefore the
action should ensure that sufficient notice to take annual leave is given. JG
confirmed that some progress was made on the IT issue of integrating
community adult information as there was an options appraisal coming to the
Informatics Board in January 2016 for implementation by March 2017. JBl
noted that Directorate quality reports would also contain progress of CQC
actions where relevant. The Committee noted the progress of the QESP to
date and agreed that the proposed action plan be submitted to the Trust Board
for approval.
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7.
Quality Strategy
7.1
MB talked through the Quality Strategy advising that it had been considered at
the Quality & Oversight EMB on 2 separate occasions as well as Business
Planning EMB. MB explained that the Strategy was based on the 5 CQC
domains with clearly set out quality outcomes within the document detailing
how the outcomes would be monitored. MB talked through the medium and
long term goals needed to transform the Trust’s rating from “requires
improvement” to “good”.
JG suggested that quantifying the level of
improvement from the current date should be the next step in terms of
monitoring implementation of the Strategy. MB explained that a dashboard
could go alongside the Quality Strategy, and in addition the Quality Account
would provide the evidence needed to demonstrate the implementation of the
strategy. JGi asked how the various elements of the Strategy would be
reported to their respective committees for assurance. MB explained that more
emphasis on the role and importance of the Quality Report would satisfy this
issue. AMo suggested that more detail on staff training or core skills should be
included in the strategy. MF agreed stating that this could be expanded under
safe staff levels, skills mix and safety.
7.2
The Committee agreed that subject to amendments the Quality Strategy would
be approved for submission to the Trust Board and then refreshed and
appended to the Quality Account for 2015/16. The Committee approved the
Quality Strategy.
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Directorate Quality Report Integrated Adult Care
8.1
JBl introduced Kate Falkner the new Associate Director for Nursing who talked
through the Q2 report for the Integrated Adult Care directorate highlighting
areas of work currently in progress in the directorate. Areas of focus included:

Work to reduce the number of complaints and improve response times
in the directorate.

Ensuring that the workforce was empowered, motivated, skilled and
Core Skills Training (CST) compliant to ensure that senior teams can
lead the way and provide good examples of effective working in the
Directorate.

KF noted the on-going issues with e-learning which had hindered core
skills training compliance and assured the Committee that a
concentrated focus on e-learning was in progress so that these issues
were addressed.

In terms of the Friends & Family Test (FFT) response rates KF advised
a general decline in responses in the Emergency Department (ED).
The recent decant and implementation of the new interim facilities was
attributed as the main cause of the decline. It was noted that the ED
also had the lowest PDR compliance.

KF noted that in terms of responsiveness the ED breach in waiting
times during Q2 highlighted the wait for medical beds as the main
reason. However the Edgecombe Unit which was opened at the
beginning of November 2015 is expected to impact positively on waiting
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times in Q3.

In relation to nursing KF confirmed that a further analysis of falls and
pressure ulcers would take place to determine any themes or trends
and implement actions as necessary to reduce numbers.
8.2
JGi asked if the Friends and Family Test had been implemented in the
Community. MF confirmed that the Community was the last part of the
organisation to implement FFT for patients. JGi queried performance on 2 day
GP referral. JBl explained that the Trust achieved trajectory in October
particularly in Gastro Intestinal pathways where performance has improved
with the appointment of 2 gastroenterology consultants. In relation to repeat
attenders in the Emergency Department, JGi asked if plans have been
developed to look at reasons for re-attending. KF explained that this issue was
discussed at their monthly quality review where it was agreed that some
analysis should be carried out to gain an understanding of the reasons for reattending.
8.3
MBa queried the impact of the recruitment review on the recruitment of clerical
and administrative staff in Referral to Treatment Times (RTT) pathways. JBl
assured the Committee that this issue would be addressed by the cancer team
to ensure that all pathways are working and that measures are put in place to
mitigate the impact of the recruitment freeze.
8.4
JG noted that the number of incidents reported appeared to be low given the
size and complexity of the directorate. However the Trust was currently
trialling anonymous reporting to see if this would affect the level of incident
reporting throughout the Trust. NCO added that there were a number of
different strands of work underway to improve incident reporting. GA noted
that despite the low levels of incidents reported, the Directorate had reported
21 serious incidents with 8 that were overdue. JBl advised that the directorate’s
performance meeting reviewed these incidents as well as the number of risks
with their corresponding mitigations. JBl confirmed that future reporting of
Directorate Quality reports would include a progress update on their CQC
actions.
8.5
HA advised that an increase in the number of investigators was being
considered and root-cause analysis training would be offered to existing
investigators. GA queried the average time for patients to be triaged noting it
was close to the national average, JBl advised that the Directorate was asked
to review the data capture process to ensure that data was accurate. [KF left
the meeting]. The Committee noted the report
9.
Trust Quality Report
9.1
MF summarised the Trust Quality Report which covered the period September
2015 advising that the Matron’s Quality Rounds continued to take place which
has highlighted the Emergency Department as an area of focus for immediate
action which will be addressed by the Associate Director of Nursing. MF
attributed historical issues related to the recruitment of senior nurses in the ED,
which have now been filled, as well as distraction as a result of the decant. JG
stated that the Executive Quality Rounds regularly took place which would
provide some oversight in the department if the Matron’s Rounds were not
carried out. AMo confirmed that an executive round was carried out before the
ED decant at the beginning of November. MF acknowledged that the lack of
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matron rounds in the ED was disappointing particularly as matrons have been
given time and assistance to carry out their Quality Rounds. MF agreed to flag
the ED as an issue with Matrons. AMo added that a CQC peer review was
scheduled to take place within the next 2 weeks which would provide a further
layer of oversight particularly as the new matrons have been in post for 2 or 3
months which should show a positive impact on the department.
9.2
9.3
9.4
9.5
9.6
9.7
MF explained that Quality Rounds were having a positive impact in other areas
of the hospital and that areas of good practice were being demonstrated on the
wards. It was expected that progress would continue particularly in those
areas RAG rated red.
Under ‘the Well led’ domain, MF advised that the Trust continued to report well
against national data for safer staffing, but that there was variability in the
number of red flags on wards. However this is mitigated by the movement of
staff on wards to ensure that safe staffing levels are maintained. The Trust
also continued to perform well in relation to the key Safety Thermometer
indicators. MF noted the ongoing work with the Integrated Adult Care
Directorate regarding falls prevention. MF also highlighted the increase in
pressure ulcers in ED and as a result further work in the validation process has
been undertaken to determine where pressure ulcers were acquired e.g. Under
the care of the Community, home or care homes.
In relation to the Friends & Family Tests (FFT), it was noted that the maternity
department reported a decrease in the postnatal response rate. AMo stated
that response rates were expected to improve as FFT cards are provided in
discharge packs, and this should encourage prompt completion and return.
MF noted that the area of complaints continued to make good progress.
JBl queried the methodology employed to calculate safe staffing levels at the
Trust particularly in areas where there were issues of staff shortage. MF
explained that safer staffing levels were calculated on all areas in the Trust not
just in areas of greatest need or where there was a reduction in staff. He
confirmed that levels were monitored vigilantly to ensure that safe staffing
levels were maintained. MF added that guidance on safer staffing received
from Monitor/TDA still allowed for a certain degree of flexibility as to how
individual Trusts would manage staffing levels.
JG suggested that Quality Rounds should be undertaken by Community
Nurses. MF agreed stating that this was under discussion to explore how this
could be carried out. Currently electronic Quality Rounds were going to be
tested and matrons would be given tablet devices to record data and which
could also be employed in the Community.
NCO presented the mortality data advising of a data aberration which
compromised the accuracy of the Trust’s mortality reports. As a result this
showed patients to appear better than they actually were so that the number of
expected deaths was lower than they should have been. In view of the error
NCO was able to confirm that there was not a problem with mortality at the
Trust as there were no red flags or outliers up to when the issue occurred and
since then mortality has remained within the expected levels. The Mortality
Review Group also examines the Trust death rate in real time to understand
when deaths are expected and undertakes deep dives to provide further
assurance. NCO confirmed that the incorrect data was now in the public
domain without any caveat or redress, as the Health & Social Care Information
5
Centre (HSCIC) who provides the data; do not allow submitted data to be
refreshed past the freeze point. This leaves the Trust with a reputational
management issue. The Trust Regulators (CQC and Monitor/TDA) are aware
of the data corruption.
9.8
9.9
9.10 Action
NCO presented the Venous Thrombo Embolism (VTE) compliance figures
confirming they were accurate. JGi asked for further detail in relation to the
reasons for the data corruption of mortality. NCO explained that this was
following a software upgrade to the data warehouse facility by an external
company which had a negative effect in the way the data was submitted by the
Trust. JGi also asked if the HSCIC who publish the data are doing so
knowingly. NCO confirmed that there was on-going communication between
organisations and HSCIC. MBa asked in terms of reputation management
what steps were taken to manage the press or any negative feedback. NCO
confirmed that the Quality report would be placed in the public domain via the
Trust Board (Part 1) and that the Trust was prepared with a reactive statement
in the event that the data was queried by the public. NCO advised that an
independent report on neonatal mortality was received which reported the
exemplary performance of the Trust.
NCO also highlighted the additional work in the area of acute bronchitis, which
had been previously flagged as a mortality outlier. The work has revealed a
problem with coding which has yet to be rectified. However the CQC has
requested a repeat of the review of a more recent timeframe which is currently
in progress. It was agreed that the MBRRACE (Mothers and Babies: Reducing
Risk through Audits and Confidential Enquiries) Report, a yearly report on
perinatal mortality is submitted to the Committee in January 2016. (Note for
forward plan). The Committee noted the report and approved its submission
to the Trust Board in December 2015.
Report to the Committee on the development of quality rounds in the
Community.
Consider MBRRACE Report at next Committee meeting following
consideration at the Patient Safety Committee.
10.
10.1
10.2
Quality Accounts – Recommendations & Lessons Learned
HA presented the paper acknowledging that the paper should have been
presented to the Audit Committee prior to consideration at the Quality &
Clinical Governance Committee. HA gave a brief overview of the history
regarding the Quality Account (QA) for 2014/15 stating that the Chair of the
Audit Committee had not been satisfied with the process for 2014/15 and
requested that a report be submitted to the Audit Committee detailing the
process and lessons learned from delivery of the 2014/15 Quality Account. HA
talked through the key learning points:
 The process should have started earlier but could not due to staffing
issues.
 Patient priorities required improvement as well as allowing sufficient
time for external stakeholder scrutiny;
 External audit were not afforded sufficient time to review the Quality
Account and the process in connection with data quality;
In relation to the process for the current Quality Account, HA confirmed that
additional milestones have been added to allow sufficient time for the Audit
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Committee’s consideration. Additional time for stakeholder engagement would
also be incorporated particularly with the Local Authority to ensure review of
the QA is factored into their timescales in line with the Overview and Scrutiny
Committee. In relation to key priorities HA advised that the Audit Committee
suggested a second check in relation to patient involvement which could take
place through the Improving Patient Experience Committee and the Patient
Conversation Listening into Action group.
10.3
JGi sought assurance that the new timetable would provide sufficient time to
complete, review and approve the Quality Account in accordance with agreed
governance processes acknowledging the tight schedule. HA agreed that the
schedule was tight and that the process could be challenged further if the
schedule is altered when guidance is released by NHS England. The
challenge therefore lay with the Team to adhere to timescales as closely as
possible and monitor progress through QESP. JG suggested that directorate
Quality reports could adopt the style of the Quality Account which would assist
with the collating of information at the year end. The Committee noted the
report.
10.4 Action
Directorate Quality reports to assume the format of the Quality Account
during the year end period to support the collating of information for the
substantive Quality Account.
11.
VTE Maternity
11.1
AMo presented the paper advising that it detailed the improvements made in
compliance with maternity VTE performance. AMo talked through the history
associated with maternity VTE noting that this was the primary cause of
maternal deaths. The number of maternal VTE assessments has significantly
increased since the roll out of Cerner into the maternity department in April and
the aim is to achieve 100%. NCO confirmed that the Cerner alert not only
provides a check but also a prompt to take action. The Committee noted the
report. [MT and JK entered the meeting]
12
Nurse Revalidation
12.1
MF talked through the report which summarised the decision of the Nursing &
Midwifery Council (NMC) to introduce a process of Nurse Revalidation from
April 2016. MF talked through the key implications for the Trust with the main
aim being to ensure that all nursing staff are engaged and comply with the new
requirement. MF confirmed that a draft NMC Revalidation policy had been
written and was undergoing the process of approval. It was noted that the first
cohort of registrants due for revalidation from April 2016 have been identified
through the Electronic Staff Records (ESR) system. JGi asked what the
implications would be for the Trust when the revalidation process was
implemented. MF explained that all locum staff acquired through the London
Procurement Programme (LPP) will be required to have revalidated status in
place but for individual interims the expectation from the Trust is that
revalidation would be part of the governance process. In relation to the time
given to staff for revalidation it is expected that staff would combine this with
formal learning time and their own time. The Committee noted the report.
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13.
Infection Control
13.1
MT introduced the new Senior Infection Control Nurse Julianna Kotey. MT
presented the Infection Control report noting that the paper was amended
since it had been considered at the Quality & Oversight EMB. MT talked
through the amendments highlighting changes to the recorded number of
Clostridium Difficile (CDif) deaths at the Trust, advising that following a serious
incident review the C.Dif death recorded in April 2015 was downgraded to a
secondary cause of death rather than primary. The report also included the
details of hospital acquired e-coli bacteria and the likely causes as well as
expanded on the detail in relation to wards in special measures.
13.2
JGi asked about the progress on the recruitment of infection control nurses to
rebuild the team that had recently left the Trust and the impact on the Trust’s
capacity to provide high quality infection control advice. MT explained that
recruitment was progressing well, two Band 6 nurses have been appointed
together with one health care assistant who will take up their posts in
December 2015 and January 2016. The infection control team underwent a restructure to take into account the difficulty recruiting band 7 nurses. MT
assured the Committee that the team had worked very hard to give appropriate
and adequate advice and that standards were maintained while coping with the
shortage of nurses in the team. MF expressed his thanks to the team noting
that core members of the team had stepped up to take on more responsibility
during the transitional period. The Committee were informed that a further
Band 7 nurse had recently resigned which would bring additional challenges
while a replacement was recruited. MF added that discussion with the TDA
had taken place with the view of securing additional support during the
recruitment phase.
13.3
NCO assured the Committee of the Infection Control team’s presence and
contribution throughout the organisation noting that assistance and support
were always available when needed. JG raised the issue of the wards in
special measures, noting that Purley 1 was particularly problematic but none of
its problems could be attributed to a staffing issue. MT explained that there
were some concerns regarding Purley1, stating that a recent mattress audit on
the ward revealed that 3 out of 12 mattresses were damaged. There was also
concern with the frequency of mattress audits and MF confirmed that feedback
from the senior nurses had assured him that audits would be properly
addressed with additional training if necessary. MF expressed his confidence
that improvement to the wards would be made evident shortly as processes
and systems were improved. MT confirmed that the organisation had now
reached its C.Dif trajectory but an action plan was now in place to address the
management of any further increase. The Committee noted the report.
14.
Infection Control Committee Terms of Reference
14.1
MT talked through the main changes to the Terms of Reference, advising the
main change included adding a Non-Executive Director to the membership.
JBl suggested that the deputy Chief Operating Officer was also added to the
membership. AMo suggested maternity and paediatric representation should
be added to the membership. The Committee agreed that subject to the
8
amendments discussed that the Terms of Reference were ratified.
15
15.1
Committee Reports/Minutes (for information)
None
16
Committee Annual Report
16.1
GA presented the Quality & Clinical Governance Committee’s Annual Report
for the period 1 April 2014 to 31 March 2015 which discussed the Committee’s
key areas of work in accordance with the approved Terms of Reference for the
period. The Committee approved the report subject to the minor amendments
agreed.
17
Committee Forward Plan (for noting).
17.1
The Committee received and noted the forward plan.
18.
Any Other Business
18.1
None
19.
Date of Next Meeting
19.1
Wednesday 14th January 2016, 2:00-4:30pm in the Conference Room
Nightingale House.
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