Quality & Safety Committee
Minutes of the Meeting held on Thursday 5th June 2014
in Ysbyty Gwynedd, Bangor
Present:
Ms J Dean
Rev HM Davies
Dr P Higson
Cllr E Roberts
Dr C Tillson
Independent Member (Chair)
Independent Member (part meeting)
BCUHB Chairman
Independent Member
Independent Member
In Attendance:
Dr M Adke
Mr N Bradshaw
Mr D Harries (DH)
Mrs J Hughes (JH)
Mrs A Hopkins (AH)
Mr I Howard
Miss L James (LJ)
Mr M Joyce
Mr A Jones
Mr G Lang (GL)
Mrs G Lewis-Parry (GLP)
Mr T Lynch (TL)
Prof M Makin (MM)
Mr I Mitchell (IM)
Mrs V Morris (VM)
Dr B Tehan (BT)
Mr A Thomas (AT)
Ms S Utley
LNC Representative (part meeting)
Interim Director of Capital & Estates (part meeting)
Head of Internal Audit
Staffside Representative
Executive Director of Nursing, Midwifery & Patient Services
Head of Strategic Analysis & Development
Head of Corporate Affairs
Member of the public (observing)
Associate Chief of Staff, Nursing, MHLD (part meeting)
Acting Chief Executive
Director of Governance & Communications
Interim Chief Operating Officer
Executive Medical Director and Director of Clinical Services
Interim Chair, Healthcare Professionals Forum (HPF)
Interim Director of Quality Assurance (part meeting)
Assistant Medical Director (Secondary Care)
Assistant Director of Therapies and Health Science
Wales Audit Office (observing)
Agenda Item
Action
By
QS14/73 Declarations of Interest
Mr I Mitchell declared an interest in agenda item QS14/79.1, in his capacity as
Clinical Director of Therapies, linked to actions in the Hergest Unit.
QS14/74 Apologies for absence
Mrs V Nelson, Mrs H Stevens, Mr A Jones and Mr H Owen-Jones.
QS14/75 Patient Story
QS14/75.1 Mrs V Morris presented this agenda item. She played a patient story DVD
in which the wife of a patient described the unsatisfactory care her husband had
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received. The Committee agreed that the film was uncomfortable to watch and had
highlighted unacceptable standards of care. Ms Dean asked if the staff involved had
seen the DVD. Mrs Hopkins confirmed they had and outlined the actions taken. Dr
Higson asked what had been done to prevent a recurrence of the events described.
Mrs Hopkins explained the proactive approach being taken with the work of Mrs
Morris and her team to triangulate quality metrics and complaints. Prof Makin stated
that the development of quality metrics was about working together, and he outlined
work undertaken on behaviours and systems for compassionate care.
QS14/75.2 Rev Davies suggested conducting research to ascertain if the case
presented in the film was a one-off, or whether it was part of a theme of complaints.
Cllr Roberts asked if the patient’s wife had been kept involved in the concerns
process. Mrs Morris confirmed that she had, and that she had been supported
throughout the process. Dr Tillson queried, in respect of the generic skills of nurses,
whether the nurse referred to actually possessed the skills to flush the patient’s line,
or whether she simply did not wish to carry out the procedure. Mrs Morris responded
that she believed the case illustrated an attitude, rather than a skills, issue. Dr Tillson
wondered whether the nurse had been appraised. Ms Dean reiterated that the main
reason for presenting patient stories of this nature was to elicit an emotional reaction
that Committee members would then hold for the rest of meeting.
QS14/76 Patient Safety Item: The prescription and administration of sedative
medication to patients who have dementia
It was noted that this item had already been reviewed and approved by the Board.
QS14/77.1 Trusted to Care – An independent review of the Princess of Wales
Hospital and Neath Port Talbot Hospital at Abertawe Bro Morgannwg University
Health Board, by Prof June Andrews and Mark Butler.
Mrs A Hopkins presented this report and described the actions to be taken in
response. Dr Higson reminded the Committee that the Minister’s spot checks would
commence in mid June, focusing on the four priority areas highlighted in the report.
BCU would also be conducting its own testing. Dr Tillson noted that some of the
recommendations covered issues such as 24/7 working and other important points to
be addressed. He queried if these would be mentioned in the response sent to the
Minister. Dr Higson explained that there would be a broader Board response to the
report and its recommendations, in addition to the initial response required by the
Minister. Following discussion, the report was noted.
QS14/77.2 Concerns Report
QS14/77.2.1 Mrs A Hopkins presented this report, stressing the importance of
learning lessons from concerns to negate the need for further complaints. She led the
Committee through the key points of the report, drawing attention to the commitment
to deal with the legacy of overdue complaints. Rev Davies asked Mr Lang to confirm
the investment in staff that had taken place following receipt of the critical external
reports. Mr Lang confirmed that the internal business case quoted a sum of £1.3
million as the required investment in Concerns. However, due to differences of
opinion regarding the appropriateness of the proposed structures, it was
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subsequently agreed to provide in excess of £300,000 to cover secondments and
external recruitment. Following further questioning from Rev Davies seeking
assurance, Mr Lang reiterated that the sum was not necessarily believed by everyone
to be a correct estimate. Mrs Hopkins stated that it was not simply about building the
central team; she pointed out that a substantial amount of money had been invested
already, but a major part of what needed to be done was about embedding and
assessing the benefits of new team members. She added that external recruitment
was taking place, and that in a few months time, this issue would be the subject of a
further review paper to assess progress against addressing the legacy issues.
QS14/77.2.2 Ms Dean pointed out that addressing people management issues was
crucial in order for an organisation to learn. She highlighted risks to the organisation
from personal injury claims, drew attention to the need for more load handling
mandatory training, and also highlighted the risk of length of time taken to undertake
investigations. It was noted that the Workforce & OD department had an additional
resource that CPGs could purchase in order to secure help with investigations. Mr
Lynch confirmed that performance on concerns would feature as part of the
Performance Framework triangulation. Ms Dean also queried the embedding and
auditing of changes to practice, and asked how assurance could be provided on this.
Mr Thomas confirmed that this would be built into the Audit Plan, as would
Ombudsman Report issues. Ms Dean asked for further thought to be given to
assurance coming back to the Committee and exception reporting. She was pleased
to observe progress made and the commitment to dealing with legacy issues, and
thanked everyone involved. The report was noted.
QS14/77.3 Quality Improvement Strategy (QIS)
QS14/77.3.1 Mrs Morris presented this strategy. She described its content, principles
and processes. She pointed out that CPGs would now need to produce their own
plans to underpin the strategy, which would be closely monitored. Mrs Morris asked
for comments. Mrs Hopkins stated that the strategy was still a working document; the
final version would contain a number of amendments and corrections. She invited
feedback from the Committee in order that members’ views could be reflected in the
final QIS to be submitted to the Board. Mr Mitchell commended the document, and
suggested the addition of more measures. Mrs Morris responded that tier 1 and CPG
priorities were reflected in the QIS. Mr Mitchell commented that any percentages
used must be robust. Dr Tillson welcomed the document and stated that the
percentages must be accurate. He added that monitoring must tie in with the clinical
audit programme. Mrs Morris explained how monitoring would work.
QS14/77.3.2 Rev Davies queried the aspirations beginning on page 7 of the
document, and suggested they should be worked through on page 30. He suggested
adding a cross-reference to show the journey that BCU was on, and how the aims will
be achieved. Mr Thomas welcomed the paper. Mrs Lewis-Parry advised that certainty
was needed on where data would come from and what the baseline was. Mrs
Hughes commended the document and suggested that the patient environment
action team could benefit from having a Health & Safety (H&S) representative. She
added that the NHS Leadership Academy had appropriate online courses that all staff
could access. She reminded the Committee that patient waits in radiology needed to
be built into any metrics adopted. Mrs Morris responded that a H&S representative
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would be useful, although the team referred to was mainly concerned with the
performance and accountability framework.
QS14/77.3.3 Dr Higson commented that the document was very helpful, though he
felt it was not sufficiently ambitious, as some of the actions listed were things that
BCU should be doing already. He queried whether the Welsh Government ‘givens’
were sufficiently clear, and stressed the need for clarity on which targets were to be
achieved. He also reminded colleagues that the Strategy must knit together with the 3
Year Plan, for synchrony and synergies. He observed that the document was mainly
concerned with secondary care, and should also include primary and community
care, as well as public health inputs. In respect of measures, Dr Higson pointed out
that hitting a target did not mean that quality had been achieved, as processes were
not proxies for quality. Referring to governance, he suggested more thinking through
of how the Quality Assurance Executive (QAE) was reporting to the Q&S Committee,
then on to main Board. He reminded those present that the purpose of the
Committee was simply to seek assurance.
QS14/77.3.4 Mrs Morris agreed that the 3 Year Plan and tangible public health
objectives needed to be included in the Strategy. In respect of primary care, she
reported that she had discussed the Strategy with the Primary Care Support Unit and
relevant Assistant Medical Directors, with a view to drafting a more integrated
document. Dr Higson noted that one of the recurring themes was that patients could
not secure a GP appointment and so attended their A&E Department. Cllr Roberts
asked how measures linking to Local Authorities would be incorporated into the
document. Mrs Morris responded that the Local Partnership Forum and Stakeholders
Reference Group had Local Authority members and had been consulted on the
Strategy, however she asked Cllr Roberts for further advice. Cllr Roberts offered to
work with Mrs Morris outside the meeting. Ms Dean noted the tight timescale for
commenting on the Strategy. Dr Higson suggested deferring submission to the
September Board, to give Q&S more time to contribute to the final draft. Ms Dean
suggested holding a workshop to further develop the QIS, but stressed that quality
improvement actions must continue in the meantime. Mrs Hopkins stressed that the
improvement objectives needed to be broadly approved. Dr Higson added that the
measures needed to feature in the Operational Plan, and Mr Lang confirmed that
they had already been incorporated. Ms Dean noted that key areas contributing to
quality were missing from the Strategy, including maternity, child health and specific
outcomes for staffing and the workforce. She suggested the number of babies solely
breastfed up to 6 months of age as an example of a population health indicator that
could be utilised. It was agreed that the QIS workshop would be held as part of the
July Q&S Committee meeting. Members and those in attendance at the Committee
were asked to send comments on the QIS to Vicky Morris within the next 3 weeks.
The Strategy was noted.
QS14/77.4 Mandatory Training Update
Mr Lang presented this item. He described the key points of the update and the
planned reporting arrangements relating to the forthcoming mandatory training
review. It was noted that the Q&S Committee would monitor this, and a report would
be submitted in September. Rev Davies asked if the review would cover sanctions for
those refusing to be trained. Mr Lang indicated that the piece of work was not about
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that aspect – which would become a competence or disciplinary issue – rather, it was
about the journey BCU needed to go on in order to support staff and hold them to
account if necessary. Dr Higson wondered whether risk assessments should be
incorporated, in relation to what the consequences would be if mandatory training
was not undertaken. He stressed the need for the right training for the right people.
Ms Dean stated that recommendations 4 and 5 in Trusted to Care should be built into GL
the mandatory training review. Cllr Roberts would like to see more of BCU working
with its partners. The update was noted.
QS14/78.1 Quality & Safety Report
QS14/78.1.1 Mr T Lynch introduced this item. In response to questioning from Dr
Tillson, Mrs Morris gave further information regarding falls, and suggested providing
the underpinning set of questions in the appendix. However, she stressed that the
dashboard drew attention to all the key issues, of which falls was one. Dr Higson
pointed out that the banding relating to Wrexham Maelor Hospital should also be
coloured red. Mrs Morris explained that she had picked up different triggers, and she
stated that further refinement and work on consistency was required. Mr Mitchell
observed, in relation to primary care, that the small 3% increase in access to dental
health services was perturbing in light of the Oral Health Strategy. Mr Lang
commented that the picture needed to be enhanced by drawing other elements into
the report. He confirmed that a breakdown by age could be shared if the necessary
data was available. Ms Dean noted that access was lower in the west, and she
suggested also providing a breakdown by locality.
QS14/78.1.2 Cllr Roberts reported that many staff had informed her that they were
not able to access e-learning. Ms Dean concurred. Mrs Hopkins commented that elearning would never be a panacea, as it was simply one approach, to be balanced
with other types of training. Dr Higson observed that BCU was an outlier on
readmission rates, and he asked what constituted an acceptable rate. He stated that
the report should set out that which BCU was striving to achieve. It was noted that, on
page 27, on-the-spot concerns coding was ambiguous and Mrs Hopkins advised that
this was to be revisited.
QS14/78.1.3 Prof Makin updated on the mortality review conducted by Prof S Palmer.
He reminded Board colleagues that Prof Palmer had been commissioned by the
Welsh Government to review hospitals with an above-average risk adjusted mortality
index (RAMI). He had been tasked to look at systems in place for reviewing mortality,
and to examine the maturity of the mortality review culture. Prof Palmer had
concluded that, although Wrexham Maelor Hospital had a score higher than the
Welsh average, the RAMI had been skewed by factors related to rehabilitation
facilities being located within the hospital. BCU had been able to demonstrate a
culture of mortality review and to illustrate how staff responded to deteriorating
patients. Prof Palmer had concluded that there was no need for a more targeted
investigation into mortality in Wrexham. It was noted that current standards should
ensure the review of 100% of death certificates and 100% compliance with stage 2
reviews.
QS14/78.1.4 Returning to the dashboard, Ms Dean stated that she knew that each
ward held its own dashboard for the purposes of drilling down into more detailed
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information, but she queried how the Committee could be made aware of this
information. Mrs Hopkins explained that the data was aggregated up, avoiding
misinterpretation of information, and she described how assurance would be provided
to Q&S via the Quality Assurance Executive (QAE). Mr Lang added that there was a
need for the Executives to drive through improvements, as the report was on the
verge of becoming something far more sophisticated, linked to Trusted to Care. Ms
Dean asked if the next report could highlight a trends analysis in the narrative. The TL
report was received.
QS14/78.2 Infection Prevention & Control Report
QS14/78.2.1 Mrs A Hopkins presented this report. She highlighted that Dr D Jenkins
would start work shortly as Lead Infection Control Doctor, and he would bring
important leadership. She highlighted assurances against the Duerden report, graphs
on national cleaning standards, the spike in April of MSSA bacteraemia cases, and
the rigour now in place for better root cause analysis. She described steps taken to
conduct further work in respect of peripheral venous catheters, including
implementation of the care bundle.
QS14/78.2.2 Mrs Hopkins reported that pseudomonas colonisation had been
detected in the neonatal unit in Ysbyty Glan Clwyd. This had first come to light
through routine screening. Mrs Hopkins stressed that all babies in the unit had
remained well, control measures had been implemented, and close communication
had been maintained with the parents. She drew attention to links to infection control
messages that Prof Duerden had presented to the Board earlier in the week. Prof
Makin re-affirmed his support for the work led by Mrs Hopkins, and he pointed out
that the key message was that infection prevention and control should be everyone’s
concern.
QS14/78.2.3 Dr Higson queried the whereabouts of the all-Wales figures. He stated
that he sensed BCU had made progress, but remained an outlier. It was noted that
staffing issues had been resolved. Dr Adke commented that venflon insertion was
extremely important, and he suggested targeting junior doctors joining BCU in
August, via their induction packs. Ms Dean queried decontamination risks. Mrs
Hopkins responded that the all-Wales work was ongoing, and she suggested bringing
an assurance report back to the Committee in September. Ms Dean commented that AH
she had the feeling that the situation had improved in the organisation. Dr Adke
mentioned the need to increase isolation space on wards. Mrs Hopkins provided
assurance that Prof Duerden had looked at this and was pleased to note that single
cubicles had been brought back into use, together with a risk-based approach. Mr
Lynch stated that there was a need to decide if isopods would be rolled out. Mrs
Hopkins responded that this would happen, and a formal report would follow in due AH
course. Rev Davies re-joined the meeting. Dr Adke reiterated the importance of handwashing. The report was noted.
QS14/79.1 Mental Health Services Update
QS14/79.1.1 Mr Lang introduced this item. Mr A Jones was also in attendance. Mr
Lang explained the content of the report and action plan, adding that a draft
Healthcare Inspectorate Wales (HIW) inspection report had now been received. He
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described the next steps to be taken in response. Ms Dean clarified that the Q&S
Committee’s role was to scrutinise the action plan and report back to the Board. Mr
Jones described the work underway to implement the action plan. In response to Ms
Dean, Mr Lang stated that engagement from therapies and medical staff had
improved, though this should still be viewed as being on a journey. Mr Jones
concurred and explained in more detail the inputs from staff groups other than
nursing. Discussion ensued on the approach taken to moving improvements forward.
Rev Davies recounted positive feedback from a family related to a Tawel Fan client,
but added that he had visited Hergest and noted that there were not many activities
for clients. He queried how the Committee could assess what it feels like to be a
Hergest patient. He stated that he sensed that clients were not being stimulated, and
he sought objective assurance. Mr Jones agreed that this was a theme that had been
identified, and he explained that more therapies coordinators were being invested in
as a result. Rev Davies emphasised the importance of learning lessons.
QS14/79.1.2 Dr Higson stated that he was pleased to see progress being made on
previously ingrained issues. He asked when all necessary actions would be
completed. Mr Jones replied that there was further work to do and there were
scheduled away-days taking place throughout 2014 in order to engage different
groups of staff. Dr Higson stated that there was need for a sense of when closure of
the action plan could be estimated, as the additional monitoring would have to stop at
some point. Further consideration would need to be given to determining at which
point ‘business as usual’ would be achieved. Dr Higson requested a wider strategic
document on mental health services, to include information on the role of an acute
psychiatric unit. He commented that the external environment at Hergest was looking
a little careworn. He also reminded colleagues that action plans needed to be backed
up with an evidence file. Mr Jones assured the Committee that evidence files were
available.
QS14/79.1.3 Mr Mitchell declared an interest in this agenda item in his capacity as
Clinical Director of Therapies. He explained steps taken, including the fact that the
Head of Occupational Therapy (OT) now sat on the CPG Board, the introduction of
stronger governance structures enabling colleagues to view therapy notes via a web
browser, and a significant amount of personal development taking place in OT. He
stressed the need to work with colleagues and Local Authority partners to ensure an
effective discharge strategy. Mr N Bradshaw joined the meeting. Ms Dean pointed out
that the action plan should indicate an expected outcome, to give something to
measure against. She also stated that the evidence file should be referenced in the
plan, as should arrangements to monitor the embedding of changes to practice. This
would enable the Committee to identify when business as usual had been achieved.
In respect of staff morale, she asked if anything objective was being used to assess
improvements eg pulse surveys.
QS14/79.1.4 In respect of the anti-ligature assessment, Ms Dean asked if the
business case had been agreed and if so, when the work would be done. Mr
Bradshaw replied that an architect had been commissioned and submission of a bid
to Welsh Government would be necessary, though this was not expected before
Autumn. Mr Jones explained steps taken to mitigate risks in the interim. Discussion
ensued. Mrs Hopkins suggesting adopting the all-Wales assurance matrix. Dr Higson
asked if the building as it stood presented a risk. Mr Bradshaw replied that there had
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been mitigation, but more work was needed. Ms Dean summarised that the Q&S
Committee would report back to the Board on the mental health update, as
requested. She also reminded colleagues of the need to decide when business as
usual had been achieved. She asked that the next mental health update be amended
to reflect this, with a recommendation on the expected completion timescale. It was
agreed to incorporate this into the July Q&S Committee CPG meeting, as part of the
mental health agenda item. Mr Lang agreed that the HIW report and a refreshed plan
should be discussed at the next meeting, with a fuller report prepared for a future
Board. The update was noted and Mr Jones left the meeting.
The following item was taken out of sequence on the agenda
QS14/79.4 Ysbyty Glan Clwyd Redevelopment Project
QS14/79.4.1 Mr Bradshaw and Mr I Howard presented this report and updated the
Committee on the opening of the Emergency Quarter. Mr Bradshaw led the
Committee through the main points of the report, drawing attention to safe decanting,
capacity and the bed stock net decrease of 2 spaces to increase the number of single
rooms available for infection control purposes. He explained that false fire alarms had
caused some concern as Ysbyty Glan Clwyd was not fully compliant with fire
protection standards, therefore a heightened approach was being adopted. Mr
Bradshaw gave an assurance that fire protection was being resolved and that safety
was improving, but the fire alarm issue remained in the transition stage. Mr Bradshaw
added that the car parking challenges continued, and he described a number of
strategies employed to alleviate the problem.
QS14/79.4.2 Ms Dean thanked Mr Bradshaw and Mr Howard, and stated that she
took assurance from the report. Dr Adke emphasised that the fire alarm was a key
issue, and he advised that outputs could be affected should the situation continue. Dr
Tehan commented from the Hospital Management Team (HMT) perspective,
explaining that the team was working hard to minimise false alarms and to look at
how to respond to them. However, he stressed that people could not be permitted to
ignore the alarms. He also commented on the work ongoing regarding car parking.
The use of fire marshalls was discussed. Dr Adke reiterated the risk of fire alarms
being ignored. Ms Dean asked Dr Tehan and the HMT to look into this matter again.
BT
Dr Higson stated that there was a need to have a plan with dates in order to tackle
parking issues. Mr Bradshaw agreed that a more managed parking approach and
zoning would help. Dr Higson added that the neonatal unit development would
constitute another major capital project, therefore a wider site development plan
could be needed, incorporating consideration of what activity could be taken off site.
QS14/79.4.3 Prof Makin raised the issue of beds and decanting. He noted that
systems were more geared to ‘assess to admit’, and he added that the narrative
needed to give assurance that future care would not simply be about the same style
of medical intervention. Discussion ensued. Dr M Adke left the meeting. Mr Bradshaw
concurred that the change model was an important concept to communicate. Ms
Dean stated that hospital redevelopment sometimes led to deterioration in patient
outcomes. She asked for assurance that the risk mitigation was working, and queried
how this was being monitored. Prof Makin responded that the QAE report could
address this. Mrs Morris added that indicators were being developed to measure
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impacts on patients and staff. It was agreed that Ysbyty Glan Clwyd redevelopment
should be reported to Q&S on a quarterly basis. The paper presented was noted, and
Mr Bradshaw and Mr Howard left the meeting.
QS14/79.2 Together for Health – Ophthalmic Health Delivery Plan
Ms Dean stated the Committee’s terms of reference did not permit the approval of
plans. Mrs Lewis-Parry explained the logistical and practical problems for all Health
Boards in Wales due to the need to approve all 14 national plans. Mrs Morris left the
meeting. Discussion ensued on building the plan into the performance and assurance
reporting framework, WG timescales, fit with the operational plan, equality impact
assessment, evaluation and sustainability of the plans. Dr Higson stated that it may
not always be appropriate to be driven by an all-Wales approach. He asked that the
plan be deferred until such time that it could be submitted to the Board with the
necessary coversheet. He added that the Executives would need to provide an
appraisal of the plans and their implementation in practice. Mr Lang explained that
there was a debate taking place at national level regarding the points raised. Mr
Lynch confirmed that work was ongoing on the Board paper and underpinning
pathway. It was agreed to defer the plan until the July Board meeting.
TL
QS14/79.3 Heart Disease Delivery Plan progress report
Ms Dean asked Prof Makin to comment on primary percutaneous coronary
intervention (PCI) and mortality. Prof Makin responded that he intended to share the
results of the RAMI audit when available, and he added that a Royal College of
Physicians review of the cardiac delivery plan had been commissioned to ensure its
fitness for purpose in North Wales. National clinical audits were also carried out. Mr
Thomas updated on the heart failure audit. Dr Tillson asked if the plan was
mandatory or on a ‘moving towards’ basis. Following discussion, it was agreed to
receive the update as a progress report, noting those areas requiring further work as
highlighted by Prof Makin and Mr Lynch. The progress report would become part of
the July Board paper referred to during discussion of the preceding agenda item. Dr
Higson reminded colleagues of the need for progress to be part of the monthly
performance report on a ‘one plan, one report’ basis.
TL
QS14/80.1 Quality Assurance Executive (QAE) Report
QS14/80.1.1 Prof Makin presented this update. He stated that the QAE had made
great progress, but was still bedding-in and logistic processes were being worked
through. He described in more detail the checkpoint report provided. Ms Dean
observed that the Committee was still not sighted on some elements, such as
safeguarding, even though this featured on the risk register. Dr Tillson welcomed the
pulmonary rehabilitation report but asked if QAE was also functioning as a
commissioning group. He stated that there was a need to clarify responsibilities. Mr
Lang, taking the respiratory work as an example, explained how matters were dealt
with using the programme management office (PMO) arrangements and tracked via
the performance management framework. Dr Higson stated that more time would
need to be given to see how everything would fit together and be reported back. He
pointed out that the QAE could not be accountable to the Q&S Committee; rather, its
purpose was to be used by the Executives as a vehicle for providing assurance to the
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Committee.
QS14/80.1.2 Mrs Lewis-Parry explained the background to the establishment of the
QAE, which was designed to cover the functions of the original 5 Q&S subcommittees. These groups now fed into the QAE, although further work was required
in respect of the way the risk sub-group would fit in. Dr Higson reiterated that the
Committee could have a view, but could not approve management structures. It was GLP/AH
agreed that Mrs Lewis-Parry and Mrs Hopkins would give further consideration to the
points discussed. Dr Higson suggested this could be looked at as part of Board
Development on the role of the Board. Mr Thomas suggesting providing issues of
significance cover-sheets from the sub-groups in future, to give additional assurance.
The report was noted. Rev Davies left the meeting.
QS14/80.2.1 Annual Quality Statement (AQS) and Healthcare Inspectorate
Wales (HIW) Update
Mrs Hopkins presented this agenda item and explained the process for meeting AQS
publication timescales. To improve the Q&S Committee’s engagement with the AQS,
it was agreed that an AQS workshop would be held as part of the July Committee
meeting. Mr Harries pointed out that he would also need to give an opinion on the
AQS, therefore timescales were very challenging. The final version would be
submitted to the September Board meeting. The update was noted.
QS14/80.2.2 Standards for Health Services in Wales Update
Mrs Hopkins supported by Mrs grace Lewis-Parry presented this item. It was
proposed that changes were made to the Star Chamber scrutiny process with
Standard 1, being dealt with as part of a Board workshop. Dr Higson noted that
annual reports on performance against the Standards were not currently being
produced. He also noted some low scores in the self-assessment, and discussion
ensued. Mr Harries emphasised that the Standards should not be seen as an annual
event; rather they should be embedded within day to day processes. Mrs Hopkins
suggested that a position statement might be helpful. Mr Lang reminded those
present that the Board had previously received score summary reports as part of
annual reporting. It was agreed to retrieve these previous reports and review them as
part of a workshop during the July Q&S meeting. Ms Dean asked that aspects
scoring less than 3 should be specifically noted, and should have justification and an AH
action plan in place. Mrs Hopkins agreed to look into this. The update was noted.
QS14/81.1 Minutes of the meetings held on 3.4.14 and 8.5.14
The minutes were approved. Ms Dean stated that she had raised issues from the
primary care report discussed on 8.5.14 at the last Board meeting. It had been
recommended that the Board needed to decide what information it required on
primary care. Future primary care reporting would involve a suite of reports.
QS14/81.2 Matters arising and summary action plan
Each entry on the summary action plan was discussed and updated accordingly.
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QS14/81.3 Committee Annual Report 2013/14
It was agreed to delete the action related to Trusted to Care, as this had been
reserved to the Board. The Committee’s self-assessed amber status was noted, as
an indication that not all objectives had been achieved, but plans were in place.
Subject to the required amendment, the Committee agreed the Annual Report, LJ
including the terms of reference.
QS14/81.4 Corporate Risk Register
It was noted that the register was not presented for approval, as this was not within
the Committee’s remit. However, the Committee could recommend changes to the
Board. Following discussion, it was agreed that there was no justification for
amending any of the risks. The mental health rating may reduce in due course. Mrs
Hopkins indicated that she intended to give further consideration to ligature points AH
outside the meeting. The register was noted.
QS14/81.5 Cancer Delivery Plan Update
Mr Lynch presented this update, which was noted. Ms Dean suggested that uptake
of human papilloma virus (HPV) immunisation could be added, as an important part
of the prevention agenda.
QS14/81.6 Issues of Significance to be reported to the Board
To be agreed with Committee Chair.
QS14/81.7 Any Other Business
None.
QS14/81.8 Date of Next Meeting
3.7.14.
Signed:
(Chairman)
Date:
BCUHB Quality and Safety Committee minutes 5.6.14 V0.03 draft
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