enc. 1 quality & safety committee held on 18 may at 9:30 … · 2017-07-21 · page 1of 14...

of 14Quality & Safety Committee meeting APPROVED minutes – 18 May 2017

Enc. 1Minutes of a meeting of the

QUALITY & SAFETY COMMITTEEHeld on 18th May at 9:30 am

Syndicate Room 9, SECC, Royal Shrewsbury Hospital, Shrewsbury.

Present: Rolf Levesley, Non-Executive Director & Committee Chair (RL)Mike Ridley, Chairman (MR))Dr M Ganesh, Medical Director (MG)Steve Jones, Non-Executive Director (SJ)Alison Trumper, Associate Director of Quality (ATr)Julie Thornby, Director of Corporate Affairs (JT)Sally-Anne Osborne, Deputy Director of Operations (SAO)Paul Devlin, Deputy Director of Operations - (PD)Rita O’Brien, Chief Pharmacist (ROB)Jo France, Head of Nursing & Quality – Children (JF)Angela Cook, Head of Nursing & Quality – Adults (AC)Andrew Thomas, Head of Nursing & Quality – Adults (AT)

Apologies: Jan Ditheridge, Chief Executive (JD)Steve Gregory, Director of Nursing and Operations (SG)Nuala O’Kane, Non-Executive Director (NOK)

Minute taker: Jayne Williams, PA to Director of Nursing & Operations (JW)

Guests / Sarah Yewbrey, Practice Education Facilitator (SY)Presenters: Sara Hayes, Head of HR (SH)

Peter Foord, Corporate Risk Manager (PF)Mark Donovan, Patient Experience & Engagement Lead (MD)

Minutenumber:

Agenda Item title Action

2017/05/01 Declarations of Interest (Agenda Item 3)None.

2017/05/02 Minutes of the Previous Meeting held on 20th April 2017 (AgendaItem 4)

The minutes of the last meeting held on 20th April 2017 were agreedand approved by the Quality & Safety Committee as an accuraterecord of the meeting.

2017/05/03 Matters arising not covered by the rest of the Agenda (AgendaItem 5)

Action Log MonitoringThe action log was discussed and updated.

2017/05/04 Quality Performance Report (Agenda Item 6)

The Quality & Performance executive summary was presented byAC/JF and outlines the Trust’s performance for April 2017 and isaligned to the CQC domains of quality – caring, responsive,effective, well-led and safe services.


Caring:Key Messages: The key messages discussed

Claims for Compensation: MR asked for more detail on thecompensation claim; JT responded to say this was an ongoing claimfrom 2009 relating to Health Visiting; JT to provide MR with moredetail outside of the meeting.

Responsive:Key Messages: The key messages discussed

DN Response Times: The data inputting is now identified atindividual level. CSM has instructed the individuals and teams torelook at this. This indicator is on an improving trajectory.

Delayed Transfer of Care (DTOC): Nationally DTOC targets havebeen revised with a trajectory for our Trust to achieve 3.5% inSeptember 2017. Red 2 Green to re-launch in June followingdevelopment of SOP, following an internal audit report.

SAO informed the Committee that the re-launch of Red 2 Green willre-focus staff; we will hold each other to account to progressdischarges; this re-launch reflects what’s happening nationally.

ICS: We continue to work with Commissioners; the indicators for theHealth element of ICS have not been agreed with theCommissioners for this year yet. We will continue to report whilst werefine.

SJ spoke about the Executive and Non-Executive visit which tookplace recently to the ICS team at Bridgnorth. The visit highlightedthe issues our staff are experiencing and the extra work they take on,particularly at weekends - providing both Health Care and the SocialCare (It seems the Local Authority are only providing Social CareMonday to Friday in Bridgnorth); our staff are picking this up atweekends and shouldn’t be. SAO said ICS is one of the key areas offocus for the A&E Delivery Board (SAED) and it is also beingdiscussed weekly at the COO meetings.

RiO was successfully rolled-out into the MIUs; congratulations wereextended to all staff for managing to maintain all their targets despitethe roll-out.

Patients waiting > 18 Weeks: TeMS

MR asked how long we will continue to send patients to theNuffield Hospitals; PD responded to say that the NuffieldHospitals at Shrewsbury and Wolverhampton are long termpartners and are now part of the model. The Nuffield chargelower rates that SaTH and additional podiatry has beensourced internally non-recurring.RJ&AH currently offer us Rheumatology services but goingforward will be providing spinal surgery capacity as SaTH nolonger provide this service.


We will also be moving diagnostics, this will greatly reducethe waiting lists; the service will be provided via mobile unitsat Euston House. Long term we will be looking at a modularbuild to co-locate CT and MRI at Euston House.

Audiology RTT:SAO reported that this situation has occurred as a result ofSaTH not receiving income and therefore ceasing to seepatients referred from the RWT Audiology Assessment Clinic.They did initially see long wait patients as an exception.

The position was reported at the monthly CCG Service andPerformance Forum and the Clinical Quality Review meeting(CQRM) requesting the CCG to escalate the issue to SaTH intheir respective contract and clinical quality meetings toresolve.

Changes in commissioners followed with no resolutionreached. As a result our internal processes have continued to‘discharge’ patients off our patient lists but the patients havenot then transferred across to SATH and as such have notbeen monitored in their numbers of patients waiting. Thereare 42 patients who have been identified in this category. Asa result of this the patients were not reported as breachingthe 18 week RTT pathway or the 52 week wait.

We have agreed a temporary solution for the patients withoutstanding audiology needs which includes weekend clinicsat Bridgnorth for all of the patients commencing 14th May2017. SAO confirmed that SaTH staff are running theseclinics at Bridgnorth and picking up the costs and that allpatients will have been assessed by the end of May 2017.

Further discussions are being held with SaTH for theprovision of the pathway new patients referred for audiologytreatment.

Effective:Key Messages: The key messages discussedNo questions were raised or comments made on this domain.

Well-Led:Key Messages: The key messages discussed

Information Governance Requirements:ATr explained to the Committee that she is working withOrganisational Development to look at the mandatory trainingstatistics and how the data is reported. Currently when a newmember of staff joins the Trust that member of staff immediatelyshows ‘red’ on their mandatory training statistics. We are looking ataltering this to exclude new starters to the Trust from the monitoringdata for a short period of while they complete their CorporateInduction and IG Training, thus avoiding the ‘negative’ well-led


performance data. We are also looking at possibly including IGtraining at Corporate Induction.

Mandatory Core Requirements:A discussion took place around training and how we know which ofour frontline staff have not completed their Mandatory Training. JTsaid that weekly data is analysed but we are still having some issueswith the ESR. CPR Training was discussed in particular; ATr wasactioned to identify which frontline staff have never completedtheir mandatory CPR training or are 6 months or more overdue.

Consistent non-compliance is being monitored and actions put inplace to address through emails and phone calls to the individualsand their managers.

Safe:Key Messages: The key messages discussed

Pressure Ulcers:Grade 3 & 4 pressure Ulcers – zero this monthGrade 2 pressure Ulcers reduced to 6 this month. All inpatient gradetwo reported in service in hospitals are reviewed at the IncidentReview group.

E learning for all staff has been identified to support face to facetraining and is being rolled out across all services. Communityservices aim to achieve 100% in training compliance in April 2017 -Compliance is currently at 200 staff out of 240.

Percentage of admissions screened for MRSA:Bridgnorth - 4 missed MRSA screeningsWhitchurch - 3 missed MRSA screeningsLudlow - 3 missed MRSA screeningsBishops Castle - 0 missed MRSA screening

There have been inaccuracies noted in the inputting of specimenform data in the lab. Times of collection from the CH’s not the timesthat the specimens were taken has been noted and also the missinglocations, times and other details. A breakdown of all the missedscreenings and incorrect information on the lab reports have beensent to the individual ward managers for action. Ludlow have beenasked to identify and rectify issues that have arisen with the missedscreenings being attributed to catheter specimens of urine not beingobtained within 24 hours of admission. Anomalies in the inputting ofdata from specimen forms in the lab at SaTH have been noticed anda DATIX has been completed.

Infection Control - CDif and MRSA has been outstanding throughoutthe year – this was acknowledged by the Committee.

Serious Incidents:2 reported this month, both fractures. RCA’s being done.The Incident Group will be sharing the learning; the emphasis andculture of this group will be changed ; ATr and PF are workingtogether on this.

ATr


Falls:Falls reported are slightly lower than the previous month; Bridgnorthhas required the additional supervision of patients who have hadmultiple falls.

Safety Thermometer Data: Harm Free CareWe achieved slightly below the 95% target for harm free carealthough new harms is a relatively high score of 98. 6%. Of the 5.4%harms, 3.70% is for pressure ulcers and catheter associated UrinaryInfections is at 1.29%. We have introduced the Safety Thermometerto measure and improve care; this is discussed at SDG Q&Smeetings and goes into detail in any areas in particular that lowerperformance.

Action: ATr to look into Capturing Safety Thermometer Data andto confirm we have systems in place to ensure we are capturingall ‘harms’.

CQUINSSAO advised the Committee that the Q4 has been submitted andthat we didn’t meet Q3.

The Clinical Qqality Review Meeting in June will discuss the Q4submission; we are expecting some questions to be raised aroundthe Local CQUIN – Improving Hospital Discharge.

The Quality & Safety Committee discussed and accepted theQuality Performance report noting the actions.

ATr

CARING & RESPONSIVE2017/05/05 Draft Quality Account (Agenda Item 7)

AT presented this report, the purpose of which was to provide theQuality and Safety Committee with a draft of this year’s qualityaccount so far for discussion and amendment.

There are some areas within the quality account (highlighted red)which require some clarification.

The Committee were unanimous in their feedback; there are someissues with the language used in the Quality Account; this is goinginto the Public domain. AT assured the Committee that he would beworking with the Communication Team to undertake a complete editand proof read for the final draft and that a table of acronyms will beappended to this document.

The final draft of the Quality Account will be presented to the Quality& Safety Committee in June for Approval and then to the Board.

The Quality & Safety Committee discussed the Quality Accountand noted the actions being taken prior to the final draft.

2017/05/06 Equality & Diversity – Everyone Counts Report (Agenda Item 8)JT presented this report, the purpose of which was to provide theQuality and Safety Committee with an update relating to the Trust’swork on equality and diversity since the last report presented to the


Committee in November 2017.

The key messages discussed: Inspiring people Equalities Event – a very successful event

for staff and partners was held at Shrewsbury Town FC onJanuary 26th 2017

Equalities themed visit involving protected characteristicgroups at community hospital.

Hearing loops developments corporately and locally. LGBT - pilot training course in end of life care took place in

January Accessible Information Standard update. Disability Awareness Course/s planned for summer 2017 for

receptionists and other front line staff. Local Health Economy partnership work update. HR related activities: including staff survey, ENABLE,

WRES

JT informed the Committee that the team are working with volunteersfrom protected characteristics to carry out equality themed visits toour key services, in order to get their experience and insight into howthe service and buildings feel for them, specifically from theperspective of for example, someone with hearing or sight loss. Theconcept is basically a hybrid of the ‘Observe and Act visits & PLACEassessment’ which will give us new insights from people fromequality protected characteristics.

The Quality & Safety Committee discussed and accepted thereport.

2017/05/07 Complaints and PALS Annual Report (Agenda Item 9)

This report was deferred until June 2017.

2017/05/08 Patient Experience Report (Agenda Item 10)JF presented this report, the purpose of which was to provide theQuality & Safety Committee with information about patientexperience for Quarter 3 2016 and Quarter 4 2017 alongside currentand future developments.

The highlights from the report: We have maintained a Friends & Family Test (FFT) result of

between 94% – 97.8% who would recommend our servicesfor quarter 3 and 4.

Patient Carer Panel (PCP) volunteers monitor FFTinformation for each of the three Service Delivery Groups(SDG’s) and present their reports and findings to theFeedback Intelligence Group and the SDG’s.

27 Observe & Act’s that took place during Quarter 3 and 4with the vast majority of observations being very positive withsome areas for development.

We are seeing more ‘You said - we did’ actions as a result offeedback from FFT’s, patient/carer stories and Observe andAct.

Community Orthopaedics (MSK/Pain Management) Podiatry


Services, CAMHS and ICS have led to the most PALSenquiries for quarter 3 and 4.

There have been 17 formal complaints and 119 Complimentsreceived during quarter 3. During quarter 4 there were 22complaints and 81 Compliments.JF said they are working on more alignment between thepatient experience team and complaints team.

Electronic Tablets – MR asked for an update on the roll-out of theelectronic tablets; JF updated the Committee. 30 tablets are currentlyout in practice and are increasing the FFT uptake. We are looking toorder a further 30; Andrew Crookes is looking into this.

Environmental issues are still a strong theme within patientfeedback within the Trust. In particular the Committee asked aboutWellington Health Centre (Diabetes Service). This issue seems to bethat patients are unclear where to go when arrive; consequentlyappointments are running approximately 50 minutes late.Noticeboards need updating, door signage not helpful and accessproblems for pushchairs and wheelchairs. A suggested action was aletter sent out to explain in more detail where to go.

Podiatry Service; patients reporting some issues trying to contactthe podiatry team, this seems to have been an issue since RiO but isnow being addressed.

The Quality & Safety Committee discussed and accepted thereport.

EFFECTIVE2017/05/09 Service Delivery Groups Quality Dashboards (Agenda Item 11)

All three SDG dashboards are structured around the five CQC keylines of enquiry; caring, responsive, effective, well-led and safe. Theaim is to provide visual assurance in relation to our quality and safetycompliance measures, with additional detail by exception, to thecommittee.

A safer staffing review concludes the report; with additional detailanalysis and exception reporting.

The dashboard will be analysed at monthly SDG meetings and moreaccessible for service managers to share at team level.

Children and Families: JF presented this report.Highlights from the report:

Friends & Family Test % recommend – 97.5% CQC Action Plan - CAMHS CQC actions have been handed

over to South Staffordshire and Shropshire NHS Trust. Thiswas a very tight timescale but successful handover wasachieved within a month.

Mandatory Training – 96.2% Information Governance – 97.7%

Medicines Incidents within Children’s and Families; ROB raiseda question that there are never any medicine incidents reported in


the Children and Families dashboard; is this because there aren’tany or is it merely a reporting issue? JF responded to say that PF isworking with the C&F teams on reporting of incidents and alsolooking at a simplified/shortened process. JF told the Committee thatshe was confident that no harm was being caused.

Risks – The risk relating to the suction machine demand within theCommunity Children’s Nurses team has been updated as per AprilQ&S Committee. The CCN team are now ordering additionalequipment to reduce the risk.

Community Hospitals and Outpatients: AT presented this report:Highlights from the report :

Friends & Family Test % recommend – 97.4%Only 13 F&F tests (electronic) received which is very low.Overall 45 responses received (paper and electronic).

CQC Action Plan - Service level action plans in place.Nineteen compliance or must do / should do actions with 17actions completed and working toward assurance. Scheduleof Quality assurance visits underway.The main unresolved issues are staffing establishments forWards and MIU to be agreed and recruited to.One main action, recruitment of a clinical lead is underway. Afurther acuity of inpatient audit is underway and theadmissions policy has been updated, for discussion withMedical Advisors on 19th May.

Mandatory Training – 89% Information Governance – 87.39% Level 2 Adult Safeguarding Training –a new mandatory

training requirement from 1st April 2017 – at the time of thereport this stood at 17%; AT reported at the meeting that thisis now at 43% and he is estimating that we will achieve targetin a month – AT will continue to monitor.

ZERO Grade 3 or 4 Pressure Ulcers. High level of vacancies remain at Ludlow, Bishops Castle and

Whitchurch – recruitment underway

Duty of Candour - MR asked AT whether we acknowledge thesemistakes in writing to the patients; AT responded, yes, we make anapology to the patient if the analysis shows that we have caused anyharm; this apology would be given either verbally or in writing.ATr said that the process needed to be strengthened; she felt thatwe are not capturing all duty of candour and that there are probablya lot more that go unreported. JT responded to say that there aremore incidents reported as duty of candour which probably shouldn’tbe; so would not be included within these reports.

Safer Staffing Incidents – A discussion took place around theclosure of Ludlow MIU where the unit closed early on two days dueto staffing levels and the inability to source agency cover to safelyrun the unit. SAO backed up the decisions made to close the unit


saying that it would not have been safe to keep this unit open onboth of these occasions. The Quality & Safety Committee are notcurrently sighted on MIU closures. Action to SAO/AT - MIU closuredetails/figures to be included in the Q&S SDG dashboard

Community Services: AC presented this report.Highlights from the report:

Friends & Family Test % recommend – 99.15% - highestcompliment received for this service in the patient experiencereport.

CQC Action Plan - All must do’s completed with validationunderway for assurance relating to clinical supervision andoutcome measures.

Mandatory Training – 92.3% Information Governance Training – 91.5% Sickness Absence Rate – 3.24% Sickness absence reasons - hotspots identified:

o Short-term sickness: Gastro problems Cold and Flu Back Problems

o Long-term sickness: Anxiety/stress/depression and other Pregnancy related disorders MSK problems

Pressure Ulcers in Service – 8o 6 in service Grade 2’s , 2 ungradable.

No Grade 3 or 4 pressure ulcers.There is a decline in pressure ulcers this month due tothe CSMs introducing some eLearning and othereducational resources.

Medication Incidents increased for the 3rd month in a row.Primarily attributed to insulin; omitted insulin’s, wrong dose,and missed insulin’s attributed to scheduling errors onLorenzo. ROB and AC are doing a piece of work on this andwill be launching a news brief shortly. There has been noreported harm as a result of the medication incidents but ACsaid that there would be some peripheral harm.

Vacancies – all positions have been advertised.

The Quality & Safety Committee discussed and accepted thecontent of the SDG Dashboards and noted the actions.

SAO/AT

WELL-LED2017/05/10 Pre-Registration Update (Agenda Item 12)

SY presented this report the purpose of which was to raise the profileof Pre-registration education placement provision and high qualitymentorship within the Trust and to provide assurance to the Quality& Safety Committee regarding placement quality and compliancewith Health Education England and professional body requirements.

Key points from the report: The Trust is actively engaged in the provision of clinical


placements in accordance with our LDA agreement withHealth Education England West Midlands (HEE WM), integralto the preparation of future practitioners

The Trust is compliant with professional body requirementsregarding mentorship and the maintenance of a database ofactive mentors

Quality of placement provision is monitored as per EducationCommissioning for Quality (ECQ) expectations andprofessional body requirements

The Committee discussed the benefits to the Trust of supportingpractice placements. As a provider of high quality placements, theTrust will be considered a viable employer in a highly competitiverecruitment marketplace. During the period April 2016 – March 2017,the Trust has supported a total of 23 newly qualified nurses throughour Preceptorship programme, 19 of whom studied at StaffordshireUniversity, 2 at Wolverhampton and 2 at Chester.

SY informed the Committee that every student we support we getsome funding back. Our main partner is Staffordshire University.We have received fantastic feedback from their lecturer.

RL asked SY if there were any downsides with supporting thestudents on their placements; SY said that the feedback she hasreceived was that students welcome this opportunity but our staffhave fed back that it does put a pressure on them at times buthaving the senior students has proven very beneficial on our wards;with students spending 50% of their time out on placements.

The Committee welcomed this report and found it interesting to readand very informative; RL felt that this would be of interest to theBoard; MR agreed. It was agreed that this report would come to theQuality & Safety Committee annually. AT to add Pre RegistrationUpdate to the Quality & Safety Committee work plan; annually.

SY said the Freedom to Speak Up Guardian is scheduled to speak tonew staff and she has also offered to go into the universities. ATsaid we have 240 mentors currently live on the register which isfantastic and where possible if we have additional capacity tosupport students we proactively contact the universities to let themknow.

The Quality & Safety Committee discussed the accepted thecontent of the report

AT

2017/05/11 Sickness Absence Update (Agenda Item 13)SH presented this report the purpose of which was to make theQuality and Safety Committee aware of our organisational sicknessabsence as at 31st March 2017, consider our approach to managingsickness absence and staff health and wellbeing, and considerwhether there is anything else we could do to reduce sicknessabsence and improve the health and wellbeing of our staff.

Key points : The report considers our organisational sickness absence

rate as at 31st March 2017, and provides analysis based onthat information.


It uses Staff Survey results to triangulate against WorkforceMetrics (available from ESR).

It provides an update on the pilot Deep Dive approach takenwith our Ludlow Inpatients team to reduce their sicknessabsence

It provides a summary of our performance against the2016/17 Health & Wellbeing CQUIN

It sets out the revised 2017-19 targets Presenteeism is considered in the light of our Staff Survey

results and against a backdrop of informal West MidlandsNHS benchmarking

It provides an update on actions completed to improve theHealth and Wellbeing

It provides an action plan to reduce the sickness absence ofour staff in the last 6 months

It provides a summary of actions planned for coming months.

First Pilot - Ludlow In-Patient Deep Dive has concluded; this wasidentified as one of the top five teams with the highest levels ofsickness absence. Two patterns were identified the first being duringthe year of 2016 long term sickness was the predominant cause ofsickness absence and the second being that every month throughout2016 the top three reasons consistently were (in the same orderevery month):

Anxiety/stress/depression Back problems MSK problems

Actions were identified and carried out based around these twopatterns.Following the Deep Dive the sickness levels in 2017 have shown asignificant reduction but it is difficult to ascertain whether thereductions are all attributable to the Deep Dive.

A Second Pilot is underway with the Health Visiting team, and isexpected to report shortly.

Once the second Deep Dive is concluded we will take a view as towhether the Deep Dive process has added any value and should becontinued.

The 2017/2019 Health & Wellbeing CQUIN is very challenging; toachieve a 5 percent point improvement in two of the three NHSannual staff survey questions:

1. Does your organisation take a positive action on Health andwell-beingSH reported that Health and Wellbeing champions have beenappointed to address these areas.

2. In the last 12 months have you experienced MSK problemsas a result of work activities

3. During the last 12 months have you felt unwell as a result ofwork related stress

SH updated the Committee on the Staff FFT software; this is nowavailable from Meridian with the first figures being analysed now.This will tell us what staff think; not what patients think.


Return to Work Interviews are being reviewed for any commonfactors; none identified. Are all Managers filling their responsibilitiesin line with Policy? Action to SH to look at return to workinterviews and compliance with policy.

AC suggested we look at agency use and the impact on the teams.The inconsistencies in teams for the substantive staff and impact onthese members of staff when there is a high turnover of agency staffused. Is this contributing to higher levels of sickness absence?

SH reported that currently 8% of our workforce is off work due tolong-term sickness absence but no reason for absence wasattributed. Action SH to work on this to ensure they all have areason for absence given.

The Quality & Safety Committee discussed and accepted thereport noting the actions.

SH

SH

SAFE2017/05/12 Getting to Good Dashboard (Agenda Item 14)

ATr presented the dashboard, the purpose of which was to make theQuality and Safety Committee aware of the current position inrelation to our CQC action plan.

ATr reported that we have 3 actions off-track but in progress – theseare all around the staffing establishment.

All amber rated actions will finish by the end of May; the red ratedactions will go over target with an estimated completion date of theend of June.

The Quality & Safety Committee discussed and accepted thecontent of the Getting to Good and Beyond Dashboard andnoted the status of the actions.

2017/05/13 Mortality Report (Agenda Item 15)MG presented this report the purpose of which was to provide theQuality and Safety Committee assurance that Shropshire CommunityHealth NHS Trust (SCHT) has a robust internal mortality reviewprocess that ensure patient safety, clinical effectiveness and userexperience form the core practice and principles of services.

Summary of key points: Assurance that the Local Mortality Review processes are

being carried out and appropriate reporting of both expectedand unexpected deaths is taking place and is beingmonitoring by the Mortality Group in collaboration with theAdult Service Delivery Group and Community HospitalMedical Advisors Group

The Mortality Group continue to monitor and review nationalguidance and reports relating to mortality investigations,learning and reporting to ensure our processes are kept up todate.

No expected deaths reviewed by the Mortality Group raisedany concerns regarding their management whilst they were in


the Community Hospitals.

MG reported that there have been two unexpected deaths since thelast report to the Quality & Safety Committee.

Child deaths have decreased; a brief discussion took place inrelation to the recent child suicide; JF was involved in theinvestigation and reported that there was nothing that ShropshireCommunity Health Trust could have done to prevent the death.

MR asked whether we as a Trust know, of the 121 expecteddeaths; how many of these patients would have preferred tohave died at home. AT responded; 70-80% of patients choose tostay in hospital but the information MR is asking for was not availableat the time the report was produced. AT will forward thisinformation onto MR.

The Quality & Safety Committee discussed and noted thecontent of the report.

2017/05/14 Adults Safeguarding Report (Agenda Item 16)MG presented this report the purpose of which was to provide theQuality and Safety Committee with an overview of the workundertaken by the Safeguarding Team and assurance in relation toSafeguarding activity.

Summary of key points: Safeguarding activity and compliance with relevant guidance

is evidenced. National recommendations are considered to strengthen our

assurance on the protection of people at risk Shropshire Community Health Trust continues to make

safeguarding everyone’s business

Since this report was written the Adult safeguarding Level 2 trainingis now at 42% (not 17%).

No questions were raised by the Committee on the content of thisreport.


2017/05/15 Policies (Agenda Item 17)for Noting:

Management of Norovirus and other Gastro-intestinalInfections Policy

Patient Access Policy

The Quality & Safety Committee noted the above policies.for Approval:

None

Items for Information: Terms of Reference Revision – Adults and Children Service


Delivery Groups Quality & Safety Meeting

The Quality & Safety Committee noted the above Terms ofReference. Final draft to include an issue and review date.

2017/05/15 Risks/Assurances: (Agenda Item 17)Risks: (new or different)

None

Assurances: Reporting of medication Incidents Sickness Absence Policy

2016/05/16 Any Other Business (Agenda Item 18) Governance Guardian for Safe Working

This was requested by JD at the Board; this will go to thenext Board and is presented here for information only.

EOL - The Committee were informed that our CQC Rep,Aimee Everett is spending two days with the End of Life team– this is an informal visit.

Clinical Leads will be attending the Quality & SafetyCommittee rotationally – the Chair agreed one Clinical Leadper meeting.

Ofsted CQC SEND inspection; Telford for Looked afterChildren is due to take place Monday 22nd May to Friday 26th

May – staff have been briefed.The criteria for the inspections is:o data about initial and health review assessments for

children looked after who have or who may have specialeducational needs and/or disabilities.

Date and time of next Meeting (Agenda Item 19)

Thursday 15th June 2017, 9:30am – 12:30pm, K2, William Farr House.Themed Review:

Pressure Ulcers – Joy Tickle Transition of Care – Jo France/C&F Staff

Forthcoming Themed Reviews:12th July

Dementia Care – Andrew Thomas / Julie Rogers

17th August Impact of the Productivity Review – Yvonne Gough

of 13Quality & Safety Committee meeting APPROVED minutes – 20th April 2017

Enc. 1Minutes of a meeting of the

QUALITY & SAFETY COMMITTEEHeld on 20th April at 9:30 am

Board Room, Haughmond View Medical Practice, Severn Fields Health Village,Sundorne Road, Shrewsbury. SY1 4RQ

Present: Rolf Levesley, Non-Executive Director & Committee Chair (RL)Mike Ridley, Chairman (MR))Jan Ditheridge, Chief Executive (JD)Steve Gregory, Director of Nursing and Operations (SG)Alison Trumper, Associate Director of Quality (ATr)Julie Thornby, Director of Corporate Affairs (JT)Nuala O’Kane, Non-Executive Director (NOK)Sally-Anne Osborne, Deputy Director of Operations (SAO)Paul Devlin, Deputy Director of Operations - (PD)Rita O’Brien, Chief Pharmacist (ROB)Jo France, Head of Nursing & Quality – Children (JF)Angela Cook, Head of Nursing & Quality – Adults (AC)

Apologies: Andrew Thomas, Head of Nursing & Quality – Adults (AT)Dr M Ganesh, Medical Director (MG)Steve Jones, Non-Executive Director (SJ)

Minute taker: Jayne Williams, PA to Director of Nursing & Operations (JW)

Guests: Ros Preen, Director of Finance (RP)Liz Watkins, Head of Infection Prevention and Control (LW)Diane Davenport, PA to CEO & Chairman (DD)Chris Panayi, Quality Team (CP)

Presenters: Andy Matthews, Service Delivery Group Manager, CHOP (AM)

Minutenumber:


2017/04/01 Declarations of Interest (Agenda Item 3)None.

2017/04/02 Minutes of the Previous Meeting held on 16th March 2017(Agenda Item 4)

The minutes were accepted as a true and accurate record with oneamendment to page 3, under DTOC, paragraph three – amend thewording to make it clear that the investment into Social Care is alocal investment not money solely being invested into SCHT. Thewording in the paragraph currently could be misleading.

The minutes of 16th March 2017 were Approved by the Qualityand Safety Committee.

2017/04/03 Matters arising not covered by the rest of the Agenda (AgendaItem 5)

1. Action Log MonitoringThe action log was discussed and updated.


2017/04/04 Quality Performance Report (Agenda Item 6)The Quality & Performance executive summary was presented byAC/JF and outlines the Trust’s performance for March 2017 and isaligned to the CQC domains of quality – caring, responsive,effective, well-led and safe services.

Caring:Key Messages: The key messages discussed

% of in patients extremely or likely to recommend the wardthey were treated in. We have seen a small improvement inperformance to 84.8%. Results and comments have beensent to relevant ward manager. Despite the low percentageout of all 35 comments for Whitchurch and Bishops Castlewho had the lowest %, all but four comments were positive.

AT explained to the Committee that there has been a dip involunteers who collect this information and also reminded theCommittee that these figures only pertain to patients whohave completed the survey.

The roll-out of tablets into the community is underway withmore tablets being ordered also one of our patientrepresentatives; Julie Southcombe is gathering feedbackfrom discharged patients by telephone.

The Committee are very keen to see the figures from theCommunity as currently they only see inpatient figures.

Responsive:Key Messages: The key messages discussed

DTOC is improving but not in line with the trajectory; weshould be at 6% and are currently at 15% 20/4/17 and wereat 10% on 19.4.17. The new trajectory for our Trust is 3.5%by September 2017.

SAO explained why she thought there had been a dip indemand this month

o Less demand in the systemo Escalation levels lowero Flow is bettero More beds availableo ICS interim support

Shropshire is still using ICS as a stop gap to provide caresupporting patients discharge. Telford has better access tocare – can we learn anything from Telford!

JD questioned how we have done this and whether we needto do a mini deep dive/RCA to re-visit the recovery plan andlook at why there has been a dip in demand. SAO to look atany learning over the past month and report backverbally to the Committee in May.

DN Response Times within 24 and 48 hoursStill shows under performance. CSM reports that datavalidation and recording of response times is the main issue


and although some improvement has been seen, thecompliance date of February has been missed and staff needfurther support to understand their responsibilities to recordresponse times accurately on Lorenzo.

SAO was confident that RiO would resolve these issues. TheDN visits are happening; it’s the recording of those visits thathas not been happening. Action: Figures for 24 and 48hours should be available before RiO. Ros Preen andSAO agreed to discuss with the performance team andprovide an update to the May meeting.

Urgent Care – JD and SG agreed to share the presentationdelivered by the A&E Delivery Board on 20.4.17 with boththe Quality & Safety Committee and the Board. Action toSG to circulate.

Effective:Key Messages: The key messages discussed

Data timeliness (2 days)Slight deterioration of position in relation to this indicator,compliance date not achieved. We continue to monitorRecovery plan being reviewed to ensure compliance.Compliance in some areas will not be achieved prior to theimplementation of the electronic patient record.

This is currently recorded on Lorenzo. We shouldn’t rely onRiO to rectify this problem! This is part of NMC registrationand we will be targeting non-compliant teams. JD suggestedthat once the teams are identified, an Exec and a NED visitthe teams to offer support.

SAO doesn’t anticipate that we will not be on track to meet100% by May 2017.

Well-Led:Key Messages: The key messages discussed

As discussed earlier as part of the action log monitoring; SG saidthat we need to be clear about the impact of the ‘reds’ in the well-leddomain in terms of governance. SG agreed to take this forward todefine from a governance point of view and will also have adiscussion with RF in relation to the performance. Our positionhas improved and the CQC would see this if they came in today,but the statistics would still remain red. We are reluctant at thisstage to go down the route of revising our targets.

Total shifts exceeding NHSI capped rate180 breaches out of the 220 are CHOP in-patient wards andMIU's (179 RN and 1 HCA) with the remaining 40 beingChildren’s & Families medical staff. SOP continues to befollowed so that breaches are minimised. Highest usage is atOswestry MIU (45), Ludlow Ward (43) and Stoke HeathPrison (38). High RN vacancies exist within these serviceareas. Feedback on in-patient and MIU services nursing

SAO/RP

SG

SG


establishments expected on 3rd May at the safer staffingMeeting. Centralised bank booking the shifts and sourcingalternative agencies if main provider can only offer paybreach shifts.Active recruitment being undertaken in affected areas.

SG stressed the safety issues in relation to staffing, inparticular the need to go out of framework to safely staff theMIUs. The alternative would be to close the MIU which couldpotentially put patients at risk.

Information Governance requirementsResults have risen to 94.19%, against the target of 95%.This figure has been shared with the services. We wereapproximately 13 members of staff short of achieving target.Children’s Services rose to 97.4%, Community Services to93.55%, CHOP rose to 90.94%. TeMS rose to 85.3%.

Emails and phone calls were made in the month to contactnon-compliant staff and their managers to encouragecompliance. Performance actions will be put in place forconsistent non-compliance.

JD asked how many staff had never done their IG trainingand what were the consequences of them not completing thistraining in terms of safety? SAO responded to say thatcurrently she does not have that data but agreed that it needsaddressing as patients and teams are at risk if individualshave not completed their IG training; these individuals shouldbe held to account. We are exposed as a Trust and so arethose individuals who have never done their IG training. Nomember of staff can undertake their RiO training if they havenot completed their IG training.

Action to SG/SAO to identify those individuals who havenever completed their IG training and feed thisinformation into the recovery plan. Considerconsequences for non-compliance.

Safe:Key Messages: The key messages discussed

Percentage of admissions screened for MRSAThe IPC team validated the VTE from data that has beensubmitted, a breakdown of which is provided below:

o Bridgnorth had 2 missed MRSA screeningso Whitchurch had 3 missed MRSA screeningso Bishops Castle had 1 missed MRSA screeningo Ludlow had 7 missed MRSA screenings

The above missed screenings have resulted in the monthlyMRSA screenings achieving a 91.10% success. The overallscreening percentage for 2016/17 was 96.01% against atarget of 97%. The Committee felt that the target should beraised to 100% and that that the Committee should havemore regular sight of these figures.

SG/SAO


LW confirmed that an action plan is in place. LW saidcurrently the Nurse in charge role is not in place. MRSAscreening falls with the responsible person on rota on theday. This needs addressing and should be looked at in termsof tasks to include MRSA screening. ATr said this will beadressed as part of safer staffing. All Community Hospitalshave been asked to review the missed screenings and tocomplete a DATIX. Ludlow has been asked to identify andrectify issues that have arisen with 6 of the missedscreenings being attributed to catheter specimens of urinenot being obtained within 24 hours of admission.

Anomalies in the inputting of data from specimen forms in thelab at SaTH have been noticed and a DATIX has beencompleted. A meeting was held between the IPC team andSaTH to stress the importance of correct data capture.

In service pressure ulcersGrade 2 pressure ulcers remain at 11 in the month. Thenumber reported is the same as the previous month. Thelevel is indicative of the problem, e. g. non-compliance. Allinpatient Grade 2 reported in service in hospitals arereviewed at the Incident Review Group.

E learning for all staff identified to support face to facetraining and is being rolled out across all services.Community services aim to achieve 100% in trainingcompliance in April 2017.

Some focus work is being done at Bridgnorth where Grade2’s are still high. Joy Tickle continues to work with the teams.

The Quality & Safety Committee discussed and accepted theQuality Performance report noting the actions.

CARING & RESPONSIVE2017/04/05 Developing the Quality Priorities in our Quality Account (Agenda

Item 7)AT presented this report, the purpose of which was to provide theQuality and Safety Committee with an overview of what has beenidentified as quality priorities for the forthcoming year at astakeholder engagement event held in March 2017, and to seek theCommittees agreement, thoughts and amendments to our prioritiesto be outlined in the Quality account.

ATr informed the Committee that the identified priorities for 2017-2018 have been discussed and agreed with members of our Patientand Carer Panel, other local organisations, our staff and the Board.The priorities are clinically driven and link closely with our strategicpriorities and values.

A brief summary of the four priorities the Committee were asked toconsider:

Priority One Continue our Work to be a provider of good oroutstanding Caring, Responsive, Effective, Well Led and Safeservices for patients using Quality Accreditation and


Assurance Tools. Priority Two Improving the Discharge from Hospital

Experience. Priority Three Transition of Care: Ensuring patients transfer

from one service to another, safely, easily and withoutdisruption or gaps in service provision.

Priority Four Sign up to Safety: Putting Safety First - Safercare of the deteriorating patient. Recognising and respondingto deterioration and promoting successful recovery from an illhealth.

Comments/feedback from the Committee: MR asked for a summary/briefing of the Quality Assurance

and Accreditation Scheme (QAAS); ATr agreed to brief MRoutside of the meeting on the QAAS scheme.

JD asked whether EPR/Audit/Service redesign and changecan be built into this; for example: auditing the impact ofMeridian or how did our services respond to a big servicechange (these were just two examples)

Use of acronyms in this report; explain what these are, forexample: EWS, ILS

The Quality & Safety Committee discussed the four priorities,noted the actions and accepted the report.

EFFECTIVE2017/04/06 Service Delivery Groups Quality Dashboards (Agenda Item 8)

All three SDG dashboards were presented for a second time in arevised format for February 2017. The revision was structuredaround the five CQC key lines of enquiry; caring, responsive,effective, well-led and safe. The aim is to provide a visual assurancein relation to our quality and safety compliance measures, withadditional detail by exception, to the committee.

Community Hospitals and Outpatients: AC presented this reporton behalf of AT.Highlights from the report :

F&FT – 95.4% Children’s Safeguarding Level 2 Training – 85% Sickness Absence – 5.2% Pressure Ulcers In Service – 2 MRSA Screening – 2 missed screenings at Bridgnorth Safer Staffing - Vacancy %

o Ludlow – 22.6%o Bishop’s Castle – 32.7%o Bridgnorth – 16%

Community Services: AC presented this report.Highlights from the report:

F&FT – 98.4% Clinical Audit (Page 3)

o Clinical record keeping Audit - Admiral Nursing,start delayed.

o Audit of NICE CG161 on falls prevention in


community nursing and IDT, start delayed.o Clinical record keeping audit in community

nursing/IDT, start delayed.o Clinical record keeping audit in respiratory

team, start delayed.o Clinical record keeping audit in Tissue

Viability, start delayedAC informed the Committee that due to lack ofresources the above audits have been delayedprimarily due to the EPR work taking precedence.The reports themselves are very long; maybe look atreducing the reports; condensing them. There is avery limited amount of resource available in theClinical Audit team to undertake these audits andproduce these lengthy reports. Ros Preen gave theCommittee some feedback on a recent clinical visitshe did and discussions she had with staff relating toa clinical audit on record keeping; the feedback shereceived was that the results were very slow incoming back to the teams.

Sickness Absence – 3.7% Pressure Ulcers In Service – 13 (9 Grade 2’2, 4 un

gradable – South Shrewsbury reporting the highestnumbers) AC informed the Committee that these were notdeveloped due to our care but reported in our services.

Staff Incidents – 3 Physical assaults one of which wasreported under the RIDDOR regulations. Details of theassaults: 1 thumb fracture, 1 strike by patient, I strikewhilst breaking up two patients fighting. All three physicalassaults made on staff were made by dementia patients.

SG should be made aware of all RIDDOR reportedincidents. He was not aware of this incident. Followingthe reporting of a RIDDOR incident SG would ensure thata plan was then put in pace to support the member ofstaff.

Safer Staffing - Vacancy %o North East IDT – 15%o South Shrewsbury IDT – 14%

Children and Families: JF presented this report.Highlights from the report:

F&FT – 95.8% Increase in Patient Incidents – 29

Health visiting and School Nursing were the highest reportersfor patient incidents relating to communication betweenindividuals and organisations predominantly relating tosafeguarding.

Missed Birth notifications – 3 this month but with new systemchanges in place to rectify this we should see less missednotifications, if any. MR has raised concerns previously inrelation to missed birth notifications, MR said he is nowreassured that this is under control.


Increase in Staff Incidents – 27 - Largest reported wasSchool Nursing relating to workload. Telford team is due tohigh safeguarding numbers; the SNs are picking up socialworker roles which should not be happening. JF informed theCommittee that this has been raised with the Commissionersand the Safeguarding Board.It is crucial that we can safely support children with theresources that we have. We have not received a responsefrom the Commissioners. Action to JF/SG to raise in theappropriate forums and escalate to Commissioners togain assurance for the Quality & Safety Committee thatwe are working within the contract and that we areproviding safe care to children with the resource wecurrently have.

SG said that we need to work within the contract but that wewill find that staff will always go the extra mile purely becauseit’s safeguarding.

Shrewsbury team have seen a reduction in WTE due tosecondment and staff long term sickness absence.Additional hours have been offered to support backfill.

The Telford SN team will receive an Executive and Non-Executive visit from SG and NOK on 27th April.

CAMHS Waiting List; 50 children who are under 8 years arebeing seen by Community paediatricians. A recovery plan isin place to reduce the waiting lists and the new provider issighted on these with additional funding and support hasbeing provided by the CCG.

Riskso Suction Machines in CCN team: JF assured the

Committee that these machines are serviced annuallyand deemed safe for use by EBME; this is on the riskregister as a projected risk only.The Committee would like to see the descriptoragainst this risk amended to say that thesemachines are not dangerous and are safe to use.Action: JF to amend the wording on the riskregister and to explore the possibility ofreplacement machine being purchased throughCharitable funds.

The Quality & Safety Committee discussed and accepted thecontent of the SDG Dashboards and noted the actions.

JF/SG

JF

2017/04/07 TeMS Report (Agenda Item 9)PD presented this report the purpose of which was to make theQuality and Safety Committee aware of the current status of theTeMS Service describing key interventions put in place to minimisethe risk to patient safety or quality of life due to avoidable delays inreceiving care. It also provides assurance of RTT performance.

Highlights from the report: Achieved 92.49% RTT against a target of 92.00% w/c 20th

March as per recovery plan and we have maintained this


Alternative spinal activity been sourced and scheduled Alternative accommodation identified and taken forward for

Admin Booking Hub Consultant booking horizons reduce to 5 weeks EPR go live for TeMS delayed - a solution will be identified

week commencing 17th May 2017

The report outlines the key actions currently underway to improveperformance and an update on critical actions.

TeMS continues to outsource a proportion of medical typing;remaining part of the plan to sustain 92% RTT performance. Thetarget is one week for all latters to be produced following anoutpatient appointment. PD expects to be at that one week target ina fortnight’s time.

Comments from the Committee: Congratulations extended to the TeMS team on achieving

RTT. Action: SG to write to the TeMS team to say ‘thankyou’ for all the hard work and their contribution toachieving the RTT target of 92%.

MR expressed concerns over the SaTH backlog; PDresponded to say that we are diverting surgical activity awayfrom SaTH to both the Nuffield Hospitals in Shrewsbury andWolverhampton and the Robert Jones & Agnus HuntOrthopaedic Hospital. PD said that he is confident that wecan reduce the surgical activity to SaTH by 80%. A revisedtrajectory for SaTH is due in the next few weeks.

JD asked how confident PD was that we have a long term fix.PD responded to say that he is confident that the new way ofworking is sustainable.

The Quality & Safety Committee discussed and accepted thecontent of the TeMS report and noted the actions.

SG

WELL-LED2017/04/08 Culture Working Group (Agenda Item 10)

JD Presented this report the purpose of which was to inform theQuality & Safety Committee on the current progress of the CultureWorking Group and its sub-groups.

Current progress:The CWG has been focussing on our sustainability agenda and thecultural impacts that this will have on our staff. Most recentlyfocussing attention to:

CQC & Clinical Supervisions Staff Survey

The Committee raised no particular questions in relation to thisreport.

JD said that the Intention to continue/or not with the Staff Away Dayswill be an agenda item for the CWG and will also be a discussed atthe Board.

The Quality & Safety Committee discussed the accepted thecontent of the report and noted the Implementation Plan.


SAFE2017/04/09 Getting to Good Dashboard (Agenda Item 11)

The Dashboard was presented by SG.

SG informed the Committee that all actions are on track for End ofMay.

SG and MG have an allocated slot on the Board agenda on 27th Aprilto go through the critical actions with the Board.

The Quality & Safety Committee discussed and accepted thecontent of the Getting to Good and Beyond Dashboard andnoted the status of the actions.

2017/04/10 Medicines Management Report (Agenda Item 12)ROB presented this report, the purpose of which was to provide theQuality and Safety Committee with an overview of current safety andcontrol measures implemented by the Medicines Management team.

Drug Procurement: The Highlight of the report was the successfulprocurement of a new drugs supplier which went live on 1st April. Itappears so far, to have been a smooth and very positive transition;feedback has been very good.

Stoke Heath Prison: ROB confirmed that Stoke Heath Prison withits (350 prisoners) will be ‘Smoke-Free’ by September 2017.

A Controlled Drugs Issue: The incident occurred in a communityhospital where an unexplained loss of controlled drug was reported.This necessitated a report to West Mercia Police, the NHS Englandregional Accountable Officer for Controlled Drugs (CDAO), andSCHT Counter Fraud and Security specialists. The investigationshowed several areas for improvement, as there was non-conformance to legal requirements for record keeping and policy.

The SCHT CDAO has written to every registered nurse in thathospital and a Lessons Learned Bulletin will follow to the remaininghospitals. The main confounding issue was that on three separateoccasions the legal record was completed as 9 ampoulesdiamorphine present. Two nurses had declared that quantity waspresent, and these nurses confirmed this in their statements. On thenext day, the level was counted as 7 ampoules present.Root Cause conclusion: The nurses did not check independently andalso made assumptions that cartons were full and did not check thecontents.

Action: ROB to include a risk register as part of this report;include for the next presentation of this report to the Quality &Safety Committee.


ROB

2017/04/11 Infection prevention and Control Report (Agenda Item 13)LW presented this report the purpose of which was to provide theQuality and Safety Committee with a summary of the activitiesundertaken by Shropshire Community Health NHS Trust to comply


with the Health and Social Care Act 2008: Code of Practice on theprevention and control of infections and related guidance (RevisedJuly 2015) in the period 1 January 2017 – 31 March 2017.

The report outlines current performance of Shropshire CommunityHealth NHS Trust against 2016/17 MRSA bacteraemia, Clostridiumdifficile infections and MRSA screening targets.

Summary of Key points:• The Trust achieved zero MRSA bacteraemias in 2016-2017• In 2016/17 the Trust has had zero post 72 hour Clostridium

difficile against a target of no more than two cases for theyear

• In 2016/17 the Trust had achieved a 96.01% thresholdagainst the 97% target MRSA screening threshold

• 1 outbreak of influenza like illness at Whitchurch• 2 outbreaks of diarrhoea and vomiting at Bridgnorth• Legionella continues to be detected in the water supply at

Whitchurch and work continues with SSSFT estates to tryand eradicate this. LW informed the Committee that PublicHealth are aware that we are not causing harm or carryingany risk in relation to the Legionella detected in the watersupply at Whitchurch.

• The IPC team 2016-2017 annual programme was completed• The IPC team 2016-2017 audit programme was completed• Infection Targets 2017 – 2018

Comments made by the Committee:This level of detail in this report is not required for the Quality &Safety Committee; the Committee only need to know what level ofrisk we have or are carrying.

Successful recruitment of a Band 6 IPC Nurse.


2017/04/12 NMC Revalidation Compliance (Agenda Item 14)JF presented the NMC Revalidation Compliance report, the purposeof which was to provide assurance that Shropshire CommunityHealth Trust is compliant with employer NMC revalidationresponsibilities and provide an update on how this has impacted onstaffing levels.

Since writing the report JF was able to provide some figures for theCommittee; of the 635 Registered Nurses employed by the Trust,261 have been through revalidation since 1st April 2016.

The requirement for revalidation is every 3 years; everyone will havegone through the process of revalidation by 2019 based on thiscohort. Nationally every Registered Nurse will have revalidated by2019.


The Quality & Safety Committee have asked to see this reportquarterly.

Action: JT was tasked with; what would a workforce report looklike? JT agreed to produce a first draft in line with the nextpresentation of this report to the Quality & Safety Committee.


JT

THEMED REVIEW2017/04/13 Safer Staffing in the Community Hospitals (Agenda Items 15)

Andy Matthews and ATr presented a review of Safer Staffing in theCommunity Hospitals to the Quality and Safety Committee.

A copy of the presentation is appended to the minutes.

2017/04/14 Policies (Agenda Item 16)

for Noting: Control of Contractors Policy Medical Gases Pipeline Systems Management Policy Permit to Work: Standard Operating Procedure Fire Policy Use of Personal Digital Technology by Service Users Policy

The Quality & Safety Committee noted the above policies withthe exception of the Use of Personal Digital Technology byService Users Policy.

Action: Ros Preen to take through internal approval processesbefore it is re-presented to the Quality & Safety Committee forapproval.

for Approval: None

Items for Information:New staffing guidance for Community Teams and mental Health

https://improvement.nhs.uk/resources/safe-staffing-district-nursing-services/

https://improvement.nhs.uk/resources/safe-staffing-mental-health-services/

R Preen

2017/04/15 Risks/Assurances: (Agenda Item 17)Risks: (new or different)

Assurances: Missed birth notifications

2016/04/16 Any Other Business (Agenda Item 18)

Audiology RTTSG brought to the attention of the Quality & Safety Committee; aparticular issue which had come to light this week in Audiology. Anumber of individuals seem to have been lost in the system. We


assumed these individuals had been referred but apparently now itappears that their referrals had not been accepted. Theseindividuals (9 people with >52 week waits) have now been identified.Action: SAO to produce a RCA for the Quality & SafetyCommittee detailing the lessons learned.

SAO

Date and time of next Meeting (Agenda Item 19)

Thursday 18th May 2017, 9:30am – 12:30pm, Syndicate Room 9, SECC.

Forthcoming Themed Reviews:15th June

Pressure Ulcers – Joy Tickle Transition of Care – Jo France/C&F Staff

12th July Dementia Care – Andrew Thomas / Julie Rogers

17th August Impact of the Productivity Review – Yvonne Gough

Minutes of the Audit Committee Meeting 4th April 2017 Page 1 of 10

Minutes of the Audit Committee meetingheld on Tuesday 4th April 2017 at 13:00 pm

in meeting room K2, William Farr House

Present : Peter Phillips (Chairman) Non-Executive DirectorNuala O’Kane Non-Executive DirectorRolf Levesley Non-Executive DirectorSteve Jones Non-Executive DirectorRos Preen Director of FinanceJulie Thornby Director of Corporate AffairsPeter Foord Corporate Risk ManagerAllison Rhodes External Audit – Grant ThorntonGrant Patterson External Audit - Grant ThorntonAlex Hire Internal Audit – RSMAndy Turnock Head of Management Accounting (observer)

In attendance: Anita Bishop Minute Taker

MinuteNumber


2017/04/99 Welcome from the Chairman (Agenda Item 1)The Chairman welcomed everyone to the meeting.

2017/04/100 Apologies (Agenda Item 2)Apologies were received from Lisa Randall.

2017/04/101 Declarations of Interest (Agenda Item 3)None were declared.

2017/04/102 Draft Minutes of the Audit Committee meeting held on 6th January2017 (Agenda Item 4 )

CORRECTION: Page 3, 3rd Paragraph – The underlined section has beenadded to the following paragraph. “Ros Preen advised that this procedurerelated to Directors On-Call process of approval, whereby staff telephonethe on-call director and gain verbal approval to authorise emergency coverif there is a critical safety issue, however, there is no record of thetelephone conversation, which is a gap that could be closed.The matter regarding telephone conversations not being recorded, wouldbe followed up by the Internal Audit plan. All the ‘off-framework’ shifts arerecorded.”

Subject to the above amendment, the minutes of the meeting wereapproved as being a true and accurate record. Agreed by all present.

2017/04/103 Matters Arising from the meeting held on 6th January 2017Agenda Item 5)

Audit Committee Annual Report (Agenda Item 5.2) – It was agreed thatthe Audit Committee Annual Report would be presented at the AuditCommittee meeting scheduled for 4th July 2017, and it would then bereferred to the Board meeting later in July. Agreed by all present.

Benefits of Sponsorship - Diabetes Service (Agenda Item 5.3) – PeterFoord advised that he had met with Catherine Chaplain, Clinical Educator,to discuss potential for services more wisely to benefit from sponsorship asdiabetes does, however, recently new national guidance had been issuedregarding ‘Conflicts of Interest’, and the Trust was waiting to receive


further National Guidance prior to issuing information to staff relating tosponsorship. This would be issued as soon as it became available.Overdue Action Tracking regarding Bank and Agency Staff - Alexadvised that the entry had been reopened and further details would bepresented as part of the Internal Audit report later in the meeting.

Deferred Clinical Audit Reports (Agenda Item 5.4) – A number of clinicalaudits had been planned and then were deferred. Julie had passed on thedetails of the report to the Quality and Safety Committee. There was nowa stronger process in place, and clinical audits were being prioritised bythe Quality Leads and their progress was being tracked.

Trust’s Car Lease Policy (Agenda Item 5.5) – Julie advised that a newrobust sign-off process was now in place, and regular meetings were beingheld with Payroll Services. A discussion took place regarding the Trust’slease car arrangement. The Trust had approximately 170 lease cars, thebase value of a car being around £11,000. Staff had been given theopportunity to choose a car of higher value, but they have to pay thedifference in the lease rate. The lease agreement takes intoconsideration the use of lease vehicles for private mileage, and earlytermination of the contract. If staff exceed their maximum private milesthey become liable for the excess payment. It was noted that there were30 – 40 staff who had not fulfilled their predicted business mileage in theirlease car, and this issue is currently being worked on, with a view tochanging them to a more cost effective arrangement. Nuala noted that itwas important that staff had access to reliable transport in order to carryout their duties. The committee members asked to be kept up-to-date withthe investigation, and a report should be brought to a future meeting.

JulieThornby

NEW ITEMS2017/04/104 Managing Conflicts of Interest (Agenda Item 6.1)

Peter Foord advised that the draft NHS England consultation document fornew Conflicts of Interest Guidance had been presented to the Board on30th March 2017. As soon as the model policy was received, a comparisonand amendments would be made to the existing draft document. Thecommittee agreed to approve the policy, via e-mail, in order to meet the1st June 2017 implementation date.

PeterFoord

2017/04/105 Annual Governance Statement (Agenda Item 6.2)The statement was a part of the end of year process. Guidance had beenreceived from NHSI. Other than further guidance on the inclusion of thedata quality of waiting times, there are no significant changes.

A draft copy of the Annual Governance Statement was circulated to thecommittee members, and the final document would need to be submittedwith the annual accounts at the Extraordinary Audit Committee. Adiscussion took place about the type of significant issues that would needto be included in the document.

A change of wording was agreed, page 8, half way down the page, shouldread: “Following RCA investigations all these incidents have or will bereviewed by an Incident Review Group, which looks at the circumstances,the quality of investigation, lessons learned and how these lessons can beshared across the organisation.”

Julie asked the committee members to consider if there were anyadditional items that they thought should be added, and asked them torefer them to Peter Foord via e-mail, after the meeting. The statement Committee


would be kept under review, and the final statement would be signed off on31st May 2017.

It was agreed that consideration needed to be given as to whether theincidents posed a risk to the strategic objectives of the trust, as this was akey definition.

The committee members approved the draft document, subject to theabove amendment, and would consider if any further changes needed tobe made.

Members

2017/04/106 Trust Annual Report (Agenda Item 6.3)Peter Foord advised that he had received an update from Andy Rogers,Communications & Marketing Manager: The document is currently in draftform and the first draft of the report will be shared with the Board memberson 13th April 2017, the Auditors on 26th April 2017, and the final version willbe presented to the Audit Committee on 31 May 2017.

It was noted that there would a tight turnaround time to achieving the finaldraft and Audit Committee and Board members were reminded that theyneeded to respond promptly via e-mail to enable the final draft to beapproved.

2017/04/107 Local Security Management Specialist Update Report (Agenda Item 6)6.4.1 Changes to NHS ProtectTerry Feltus and Ian Gingell attended the meeting to discuss the content oftheir reports. There had been further changes with NHS Protect since thereport had been written. NHS Protect are going to continue to overseeCounter Fraud work, and as from 3rd July they will be re-branded as NHSCounter Fraud Authority, and reporting will continue via the NHSStandards targets on an annual basis. Quality inspections will alsocontinue on an adhoc basis. NHS Protect Security work has changed, andthey will no longer provide an overall management and control for securitywork, although at a local level this will continue as usual. The body thatwill oversee security management is still to be decided; possibly NHSEngland. Terry and Ian advised that they would continue to produce thereporting regarding security standards, although it was unclear at presentwho would be taking over the management work.

The committee members noted the content of the report, and no questionswere asked.

2017/04/108 6.4.2 Security Management Update Report Bladder Scanners (tracking medical devices)Terry advised that a meeting had taken place with the Clinical Servicesmanager to discuss the loss of the bladder scanners, and it was noted thatthere was now a system in place to monitor the location of bladderscanners and ensure that they are serviced regularly. A periodic audit ofthe scanners would take place in the coming year. Terry noted that otherexpensive equipment was also being considered to add to the monitoringprocess. Discussions were also taking place with local recycling centres incase they received any NHS equipment that could be reused. Adiscussion took place regarding the recording of equipment issued topatients, and the importance of reducing waste.

2017/04/109 Root Cause Analysis (RCA) UpdateTerry advised that an RCA had been carried out to fully investigate some


threats made to staff in a particular incident, however, there had beeninsufficient evidence to pursue the matter further. Staff safety and incidentreports would be monitored by Trust’s Safer Working Group, on a monthlybasis, which then reported into the Quality & Safety Committee.

Terry had met with Alison Trumper to discuss plans for staff to receiveMAPA training in the near future. A discussion took place about the safetyrisks staff experienced whilst carrying out their duties. It was agreed thatthe Trust could not mitigate for all eventualities, and the risk was onlyslightly increased. Additional training would help staff to identifybehavioural warning signs when entering patient’s homes, but the greatestrisk to staff safety was road traffic accidents rather than assault. Over thelast 12 months the number of assault incidents had reduced from 86 to 79,of which 5 incidents related to dog bites.

It was noted that the total number of physical assault incident on staff werelow, and that assaults were mainly related to patients with dementia inCommunity Hospitals. MAPA training would become part of staffmandatory training and all front-line staff would attend conflict resolutiontraining.

The committee members noted the content of the report.

2017/04/110 Internal Audit Contract Period (Agenda Item 6.5)The committee members gave their approval for the Internal Audit contractto remain with RSM for another year, and the matter would be reviewedagain in 6 months time. Agreed by all present.

ACCOUNTS POLICIES2017/04/111 Progress Report (Agenda Item 6.6)

6.6.1 Consolidation of Charitable FundsA discussion took place about the use of charitable funds, and the impactthe monies had on patient care. Nuala advised that some of the monieswould be spent on the installation of WiFi in community hospitals, whichwould enable better communications for patients and their families, whichshould then ease the pressure on nursing staff needing to contact patient’sfamilies.

Ros advised that the Trust’s charitable funds were not material andtherefore did not require consolidation. The committee members approvedthe proposal, agreed by all present.

2017/04/112 6.6.2 Approval of Trust Accounting PoliciesRos advised that only minor changes had been made. The policies werebased on those in the model Department of Health accounts. Thecommittee members noted the content of the report and gave theirapproval. Agreed by all.

2017/04/113 6.6.3 Going Concern ReportThe Trust accounts for the period 2016/17 had been prepared on a ‘going-concern’ basis, although it was acknowledged that the Board hadannounced that they viewed the Trust as ‘not being sustainable’ over thenext 2 years and consultations would take place with the ‘SustainabilityBoard’.

It was noted that to-date the Community Trust was one of feworganisations to take this particular route, and the Board members


considered the route to be pro-active and essential in order to maintainand develop community services.

A discussion took place regarding the conclusion scenarios that could beused, detailed under item 4.1. It was agreed that scenario 2 would beused, which stated: “The Trust is a going-concern but there areuncertainties regarding future issues which should be disclosed in theaccounts to ensure the true and fair view.”

The committee approved the ‘Going Concern Assessment’ subject to therequired disclosures. Agreed by all present.

INTERNAL AUDIT2017/04/114 Progress Report (Agenda Item 7)

7.1 Progress ReportAlex advised that the reports being presented today were the finalprogress report for the 2016/17 plan. The audit work had been completedas at 31st March 2017 and 4 audit reports were presented; PerformanceManagement, Safeguarding Arrangements for Adults and Children,Assurance Framework and Risk Management and DischargeManagement. It was noted that Safeguarding Training had beencompleted, and there were processes in place for those staff who havebeen unable to complete the training. The Quality and Safety Committeewould review the matter again at their meeting, and additionally therewould be a follow-up by internal audit to check that recommendations hadbeen implemented and sampling had taken place to check that themeasures had been fully implemented.

A discussion took place regarding the status of items on the action tracker(4Action). There had recently been a problem where notifications to staffhad failed to be sent, however, this had now been resolved. Peter Foordnoted the importance of closing the ‘Action’ and being clear about thewording used to make the entry relevant. The dates for implementation ofthe actions also needed to be realistic.

Discharge Management Audit – The audit report relating to DischargeManagement had been supplied as a draft report and had been finalised inthe last few days. An opinion of ‘partial assurance’ had been given, asthere was no ‘clinical discharge of patient’s policy’ in place at the time ofthe audit. Recommendations had been made to improve the audit trail andto record why decisions had been made. The Chairman noted that thiswas the third audit that had received a ‘Partial Assurance’ rating, whichhighlighted the importance of ensuring that the actions andrecommendations were implemented. Best practice had been evaluatedat 2 community hospitals and a policy was now being rolled out.

A discussion took place regarding the use of Red and Green Bed DayForms, and the importance of their consistent use to determine patientdischarge.

2017/04/115 7.2 Draft Audit Annual Report and HOIA OpinionAlex noted that after the meeting she would issue the final annual reportwhich should be considered when reviewing the Trust’s AnnualGovernance Statement. The audit work had not identified any significantinternal control weaknesses. However, the work had identified furtherenhancements to the framework of risk management, governance andinternal control to ensure that is remains adequate and effective.


2017/04/116 7.3 Annual Internal Audit Plan 17/18 (Enclosure 14b)The audit plan showed the strategy from 2016/17 to 2017/18. The annualplan for 2017/18 reflected the decisions made by the Board. The keypriorities for the future audit work had been discussed by the executiveteam. There was a large element of contingency included in the AuditPlan, therefore, there was flexibility to bring forward any recognisedpriorities.

There had been a recent presentation at the Board regarding Cyber Fraud,which had been organised by internal audit, and had been veryinformative. The Chairman enquired about the subject of ‘data retention’and if the Trust had a policy in place. It was noted that there were differentrules for different types of data. It was not known when the last recordsretention audit took place. The Chairman asked if there could beassurance for compliance with regards to data retention, not necessarilythe need for an audit. It was noted that the Trust did have a RecordsManager, who supported people with the implementation of the policy.Ros recommended the pulling together of key facts regarding DataProtection and data retention, and these should be reviewed at a laterdate.

Steve Jones highlighted that on Appendix B, page 15, the report CostImprovement Programme (CIP) had been marked as ‘deferred’, and thatthis needed to be a priority. It was noted that the process for CIP was inplace but not the content. A discussion took place regarding the auditprocess, monitoring and outcome reporting. It was agreed that this wouldbe reviewed and debated at the next Resource and Performance (R&P)meeting.

All present approved the Internal Audit Plan, subject to further debate atthe next R&P meeting.

AlanFerguson

Ros PreenSteveJones

EXTERNAL AUDIT2017/04/117 External Audit (Agenda Item 8)

8.1 Audit Plan 2016/17Grant advised that the plan had not changed fundamentally since lastyear. The committee were asked to review the summary on page 4,Understanding your business and key developments’ to ensure that it wasa correct reflection. It was noted that the Trust would be reviewed as a‘going concern’, in the light of the Board’s decision to resolve that the Trustwas not sustainable.

Page 5 of the report showed a reduction of 1.75% of the Trust’s overallmateriality level, this being adjusted due to the Trust’s intention to beacquired by a larger organisation.

The significant risks identified were similar to that of last year.

Page 8, paragraph 2, it was agreed that the statement should be changedto read as follows: The Trust Board has resolved that the Trust is notsustainable in the medium to long term (clinically and financially) and isworking with NHS Improvement to find a sustainable solution for the future,which may include formally joining another organisation.

The Value for Money Conclusion (VFM) – an initial risk assessment hadbeen completed which looked at financial sustainability and how the Trustresponded to the CQC inspection. It was expected that the findings wouldconcluded that there were adequate arrangements in place.

GrantPatterson

AllisonRhodes


2017/04/118 8.2 Informing the Risk Assessment 2016/17The committee were asked to consider the responses to ensure that theywere consistent with their understanding.

The committee members unanimously approved the report.

GOVERNANCE2017/04/119 Workplan (Agenda Item 9.1)

The committee members noted the content and no questions were asked.

2017/04/120 Board Assurance Framework (Agenda Item 9.2)Peter Foord advised that there had been very few changes to the reportsince the committee last reviewed them, therefore members were asked toreview the risks to determine if the committee were happy with the level ofassurance.

A discussion took place regarding the entry Ref: 7-2014 Changing Culture,and the Culture Working Group, it was agreed that a representative of thegroup would be invited to attend the next meeting to provide assurance tothe committee.

The committee members would review the risk and assurances again atthe April Informal Board meeting.

JanDitheridge

2017/04/121 Corporate Risk Register (Agenda Item 9.3)Peter Foord advised highlighted the main points of his report.

A discussion took place regarding Risk 1438 – Compliance with dataprotection legislation, and the risks to the Trust, as our services reliedheavily on personal sensitive data. It was agreed that the Committeeshould have sight of recent data protection incidents and Alan Fergusonwould be invited to provide assurance to the committee at its’ next meetingin July.

The members noted the content of the report.

AlanFerguson

2017/04/122 Directorate Risk Register – Community Services (Agenda Item 9.4) Child and Family DivisionJo France joined the meeting to answer any questions that the committeemembers wished to raise about the risk register.

Jo confirmed that the risk register had been reviewed, and that all riskswith a rating of 12 and above were reviewed on a monthly basis at theQuality and Safety Committee and the Children’s and Family ServiceDelivery Group. Every service manager had an understanding of theirservice risks and continued to monitor them.

Two risks had been added recently this month, as a result of discussionthat the Quality and Safety Committee. These related to the CAMHS, withregards to waiting lists and the service tender.

Steve Jones enquired about the level of Safeguarding training for frontlinestaff. Jo confirmed that a process was in place, however, the system wasnot a smooth process. A meeting was planned for Julie Harris, NamedNurse for Safeguarding, Jo France and the Organisation and Developmentteam to review the system so that staff compliance could be recorded


more easily. The current modular method involved staff recording theirown training on the system, and then a manager approving the entrybefore the details were included in the statistics. Jo advised that shebelieved the level of compliance to be higher than the reported statistics.

The Quality & Safety papers had reported that there was 91% ofcompliance with regards to Level 3 safeguarding. Concerns had beenraised that some staff were dealing with patients who were not compliantwith their training requirements. Jo noted that the ‘hotspots’ related toCAMHS and Community Children’s Nurses (CCN’s) as a result of staffsickness, vacancies and transition to the new services. It was noted thatSara Hayes, Head of HR and Workforce, was currently drafting a letter toall practitioners about their responsibility within mandatory training to keeppatients safe, and if training was not taken up then staff would then betaken through a performance management process.

It was noted that there was no evidence to suggest that there was anypoor safeguarding practice. Jo noted that she felt confident that the teamwere suitably qualified to deliver a high quality service and the staff whohad not attended training were either off sick leave or maternity leave, anddue to the small size of the team, the percentage compliance currentlyshows a RED.Steve Jones asked for assurance about the young patient who recentlycommitted suicide; Jo France advised that the young man was in contactwith CAMHS and she was confident the correct arrangements had been inplace.

A discussion took place regarding entry Risk ID: 2748, High Levels ofdomestic violence notifications. Jo advised that there had been a recentchange in the system for the notification of domestic violence. The childhealth notifications used to be screened and then be forwarded out to theteams. Now the notifications are coming direct to the School Nursingteams, and the small teams are challenged to deal with many notificationsin the course of a week with no admin support. It was noted that from14th May 2017, when RIO came online, the task would be easier to dealwith as the notifications would be receive electronically. The concern hadbeen flagged to commissioners. The committee discussed the need toprotect the staff involved and also the need to protect children. Questionswere asked if similar risks were being experienced by other teams.

Risk ID: 1101 Dental Decontamination – compliance with best practice.This risk required an update to establish the residual risk, however, it wasnoted that no incidents had occurred as a result of the currentdecontamination processes.

The Chairman thanked Jo providing assurance about the directorate riskregister.

2017/04/123 Single Tender Approvals (Agenda Item 9.5)The committee reviewed the details of the report. It was noted that thetender relating to catering equipment was the first purchase through theSouth Staffordshire and Shropshire Healthcare NHS Foundation Trust(SSSFT) process.

2017/04/124 Loses and Compensations (Agenda Item 9.6 )There were none.


2017/04/125 Review reports from Regulatory and other external bodies (AgendaItem 9.7)The committee members noted the content of the report. No questionswere asked.

2017/04/126 Risks from other committees (Agenda Item 9.8)The risks had been circulated to the lead directors, and no changes hadbeen made.

The Chairman noted that MSK underachievement was not reflected on therisk registers. Peter Foord would raise the matter with Steve Gregory.

All present approved the content of the report.

PeterFoord

2017/04/127 Emergency Planning Report (Agenda Item 9.9)Pete Old attended the meeting to provide assurance and an update aboutthe Trust’s performance against the 2016 National Core Standards foremergency planning. The report was a retrospective analysis of last year’swork. It was noted that the Trust was significantly compliant, however, thecriteria is changed annually which makes it difficult to achieve. Training forstaff and senior managers was underway. The Trust’s self-assessmentshowed that the Trust was compliant with 37 out of 43 criteria, with 6areas where full compliance couldn’t be evidenced at the time, but all hadpart compliance now and further work was planned. Pete Old advised thatNHS England had advised that they believed the Trust was in a betterposition than the reports actually indicated, and that some of ourprocedures are ahead of other trusts. Ins the self-assessment, althoughthere are 6 areas that we were not fully compliant with, our services do notprovide frontline care in the event of disaster response.

Workshops had been held regarding business continuity, to encouragestaff to change their culture and to build business continuity into the core oftheir services.

The committee noted the content of the report and approved the actionplan. Agreed by all present.

2017/04/128 BoardPad Archive of meetings (Agenda Item 9.10)The committee members noted the schedule for archiving meetings onBoardPad. Archiving the meetings would result in the meeting papersbeing removed from Trust ipads, therefore any documents withannotations would need to be saved to a reading room, if they needed tobe kept for the future. All those present approved the planned archivedate of 28th April 2017.

RISKS & ASSURANCES IDENTIFIED2017/04/129 Risks and Assurances Identified at the meeting (Agenda Item 10)

Child Safeguarding Training Data Protection Mandatory Training – inclusion of Safeguarding.

MINUTES FROM THE QUALITY & SAFETY COMMITTEE2017/04/130 Minutes from the Quality & Safety Committee (Agenda Item 11)

The content of the reports were noted for information. No questions wereraised.


ANY OTHER BUSINESS2017/04/131 Any other business (Agenda Item 12)

Risk Management Policy – Peter Foord advised that a minor changeneeded to be made to the Risk Management Policy, this related to the RiskEscalation Chart; the rating had been changed to ‘Current Rating’. Thecommittee noted the change.

DATES OF FUTURE MEETINGS2017/04/132 Dates for future meetings (Agenda Item 13)

Weds 31st May 2017 - Extra Ordinary Meeting to Approve the Accounts,09:30 – 12:30 in the Meeting Room A, William Farr House

Tue 4th July 2017, 13:00pm - 17:00pm, Room K2, William Farr HouseTue 3rd October 2017, 13:00pm - 17:00pm, Room K2, William Farr House

Approved by: ………………………………………………………………………………… Date: ………………………

Mr Peter Phillips, Chairman

Minutes of the Extra Ordinary Audit Committee Meeting 31st May 2017 Page 1 of 3

Minutes of the Extra Ordinary Audit Committee meetingheld on Wednesday 31st May 2017 at 9:30am

in meeting room A, William Farr House

Present : Peter Phillips (Chairman) Non-Executive DirectorJan Ditheridge Chief Executive OfficerRolf Levesley Non-Executive DirectorSteve Jones Non-Executive DirectorRos Preen Director of FinanceNorman Pryce Financial Accounting ManagerJulie Thornby Director of Corporate AffairsPeter Foord Corporate Risk ManagerAllison Rhodes External Audit - Grant ThorntonGrant Patterson External Audit - Grant ThorntonTess Barker External Audit - Grant Thornton

In attendance: Anita Bishop Minute Taker

Apologies: Nuala O’Kane Non-Executive DirectorDiana Owen Head of Financial Accounting

MinuteNumber


2017/05/12 Welcome from the Chairman (Agenda Item 1)The Chairman welcomed everyone to the meeting.

2017/05/13 Apologies (Agenda Item 2)Apologies had been received from Nuala O’Kane and Diana Owen.

2017/05/14 Declarations of Interest (Agenda Item 3)None were declared.

EXTERNAL AUDIT2017/05/15 Audit findings and Value for Money report (Agenda Item 4)

External Audit thanked Ros and her team for the high quality informationthey had supplied, which had resulted in a smooth audit process for theaccounts.

Grant highlighted the main points of the report.

The draft financial statements for the year ended 31st March 2017 resultedin a retained surplus of £2,534k. No adjustments had been identified,however, a small number of amendments were recommended to improvethe presentation of the financial statements.

There was also a misclassification of intangible assets for the purchase ofIT equipment (for the EPR project) a value of £600k. It was noted that thishad no effect on the total non-current assets shown on the Statement ofFinancial Position, but would be more appropriately classified as anintangible asset. It was proposed that this would not be adjusted in thisyears’ statements, as none of them were deemed to be significant, but itwould be reconsidered for the 2017/2018 accounts. Agreed by all present.

A discussion took place regarding lease agreements. Page 16, InternalControls, the ‘Update on actions taken to address the issue’ stated –“Formal lease agreements are not yet in place. We understand the Trustare not actively pursing lease agreements with NHS Property Services at


present.” It was agreed that an amendment would be made to read“Formal lease agreements are not yet in place. This is in progress.”Agreed by all present.

The accounts were duly signed.

Value for Money Statement – The Trust had proper arrangements inplace with regards to the economy, efficiency and effectiveness in its useof resources.

Following the CQC inspection an action plan had been developed andcompliance had been reached as at 31st May 2017, however, it was notedthat it was difficult to close down the piece of work, as the Trust would notbe re-inspected by the CQC in the same way again, but all action plansthat the Trust had identified, had now been completed. The matter hadbeen discussed at a recent Board meeting, and due to the way futureinspections would be conducted, the Trust was not sure if they would beable to attain a status of ‘good’ even though all identified actions had beencompleted.

An unqualified opinion had been given on the Trust’s financial statements.

AllisonRhodes

2017/05/16 Letter of Representation (Agenda Item 5)Allison Rhodes advised that an unadjusted statement had been provided.The matter regarding intangible assets and the acceptance of thecommittee members not to adjust the changes to the accounts would beincorporated with the letter.

All those present agreed with the content of the letter of representation,and the letter was duly signed by Jan Ditheridge and Ros Preen.

ANNUAL ACCOUNTS 2016/172017/05/17 Annual Accounts for approval (Agenda Item 6)

It was noted that the Trust Board had formally delegated authority to theAudit Committee to approve the Trust Annual Accounts.

Page 14 of the report, item 1.17 Clinical Negligence Costs, Peter Phillipsquestioned the provision made for clinical negligence costs and whetherthis was sufficient or there were other known costs that should be takeninto account. Norman Pryce/Peter Foord reported that there was a smallprovision and this related to the excess for non-clinical claims. For clinicalnegligence the costs are met fully under the Clinical Negligence Schemesfor Trusts (CNST).

Peter Phillips questioned the Trust’s liability in relation to pension costs,and in light of the Trust looking to transfer to another provider. Rosadvised that the pension scheme was consistent with all other trusts aspart of the NHS.

FINANCIAL MONITORING & ACCOUNTS FORMS2017/05/18 Financial monitoring and accounts for discussion (Agenda Item 7)

Those present noted that the spreadsheets provided the technical detailsbehind the accounts. Allison Rhodes confirmed that the spreadsheetswere consistent with the accounting statements.

No questions were asked.


ANNUAL GOVERNANCE STATEMENT2017/05/19 Annual Governance Statement for approval (Agenda Item 8)

It was noted that the Annual Governance Statement had been discussedat the recent Board meeting. It had been concluded that there were nosignificant issues, and the Trust had an adequate and effective system ofinternal control. Two minor amendments were made to the statement.This was agreed by all present.

The statement was duly signed by Jan Ditheridge.

PeterFoord

DRAFT ANNUAL REPORT2017/05/20 Draft Annual Report for approval (Agenda Item 9)

It was noted that the Trust Board had formally delegated authority to theAudit Committee to approve the Trust Annual Report.

The committee approved the Annual Report with no amendments.

ANY OTHER BUSINESS2017/05/21 Any other business (Agenda Item 10)

There was none.

DATES OF FUTURE MEETINGS2017/05/22 Dates for future meetings (Agenda Item 11)

Tue 4th July 2017, 13:00pm - 17:00pm, Room K2, William Farr HouseTue 3rd October 2017, 13:00pm - 17:00pm, Room K2, William Farr House

Approved by: ……………………………………………………………………….. Date: ………………………………….

Mr Peter Phillips, Chairman

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