1. business and industrial
2. company
3. annual report

Agenda item: 24
GOVERNING BODY MEETING – TUESDAY 11 NOVEMBER 2014
MINUTES TO BE RECEIVED
Title of Meeting
Date of Meeting
Quality Improvement, Governance and Engagement
Committee
23 September 2014
Status (ratified/draft)
Ratified
CCG Representatives
A Janjua, K Toole, I Stewart.
Summary of key issues discussed:
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NWAS update
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Update on Patient and Public Engagement activity
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Updated Complaints Policy accepted and agreed by the Committee
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Medicines optimisation documentation accepted and ratified by the Committee
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Safeguarding update provided by the Head of Safeguarding
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Sub Group minutes accepted by the Committee
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Project management Office (PMO) highlight report
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Ophthalmology Pre-PEAR Assessment reviewed and ratified
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Quarter 4 final delivery dashboard was noted; the report included the following:
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report against Assurance Domains for quarter 4
the Delivery Dashboard received from NHS England
the annual assurance letter
the Assurance Guidance issued for 14/15
Issues requiring action:
Details:
By whom:
Timescale:
All actions are identified within the minutes.
Recommendation:
The Governing Body is asked to review and note the contents of the minutes.
Jennifer Aldridge
Chief Nursing Officer
Quality Improvement and Governance Committee Chair
Minutes of the Quality Improvement and Governance Committee meeting
held on Tuesday 23 September 2014 in the Grasmere meeting room, Wesham
Present:
Jennifer Aldridge, Chief Nursing Officer (Chair)
Adam Janjua, GP and Elective Clinical Lead
Peter Tinson, Chief Operating Officer
Tracy Riddick, Senior Integrated Governance Officer
Amanda Bate, Community and Engagement Manager
Kevin Toole, Lay member for Patient and Public Engagement
Ian Stewart, Secondary Care Doctor
Alice Marquis-Carr, Designated Nurse and Head of Safeguarding
Fiona O’Donoghue, Safeguarding Manager
Nick Medway, Quality and Clinical Governance Manager
Stephanie Betts, Performance and Quality Manager, CSU
Julie Lonsdale, Medicines Optimisation Manager
Dr Vasudev, Board member Healthwatch Lancashire/Retired Histopathologist
Tony Naughton, Clinical Chief Officer
Julie Pennington, Executive Assistant/Minute Secretary
Justine Howe, (Item No 7 only)
Pippa Hulme, (Item No 14 only)
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Apologies for absence:
Apologies for absence were received from K Greenwood, Z Atcha, C Lewis
2
Declarations of Interest
There were no declarations of interest.
3
Minutes of the last meeting held on 229 July 2014
The minutes of the meeting held on 29 July 2014 were approved as an accurate record.
4
Matters Arising
There were no matters arising from the minutes of the meeting held on 29 July 2014.
5
Action sheet from meeting held on 24 June 2014
The action sheet was updated accordingly.
6
Any other urgent business
None.
7
Update on NWAS
7.1
NWAS Update
Justine Howe was present for this agenda item and provided an update to the Committee, highlights of
which included:
Current NWAS performance had dipped due to an increase in demand.
Resilience funding had been given to NWAS, a breakdown of use is awaited.
Performance currently being discussed and addressed included: (1) Increase in Community First
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Responders; (2) Review of man-made spikes, ie shift patterns and hand overs; (3) Review of general
commissioning intelligence, ie falls made up 14% of calls to 999, 65% of which were being conveyed.
Discussion took place on what types of falls were being conveyed and whether an audit had taken place
on specific falls patients and whether GPs were alerted to such falls. J Howe advised that she would
seek responses on these queries and report back to the QI & GC in the future.
J Howe advised that NWAS would be undertaking a Pilot Scheme in relation to provision of Advanced
Community Paramedics. J Howe said that although Fylde and Wyre were not piloting this scheme, she
would be working closely with NWAS and would obtain a report in due course.
P Tinson reported that, following an additional £15m investment, NWAS would be putting a recovery plan
in place with particular emphasis on First Responders. This appraisal would be taking place on a North
West wide basis.
J Howe accepted an invitation to attend future QI & GC meetings to provide further updates.
7.2
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NWAS Update Report – non urgent transport services
This document was circulated with the agenda for information.
Patient and Public Engagement
8.1
Healthwatch Collaboration
Dr Vasudev reported that the new Chief Executive of Lancashire HealthWatch had been appointed,
namely Gill Brown; Ms Brown is a bio-medical scientist with 40 years’ experience of working for the
NHS. She has worked in various Merseyside NHS Trusts including the Royal Liverpool and
Broadgreen Hospitals. She is at present serving as the Director of Corporate and Research
Governance at the Walton Hosiptal. Ms Brown would be taking up post on 3 November 2014. He also
reported that a Communications Officer and Website Designer had recently been appointed.
Three focus groups had been held by HealthWatch Lancashire; A Bate agreed to speak to Dr Vasudev
in order that the CCG could glean messages from those sessions and continue to work towards joint
forums in the future, where appropriate.
J Aldridge asked Dr Vasudev to pass on thanks to HealthWatch Lancashire for their involvement in the
forthcoming Stroke Pathway deep dive visits.
8.2
Sub Group Update
K Toole provided an update from the recent PPE Sub Group meeting advising that Dr Tony Naughton
attended the September meeting to talk through the five year strategy. Dr Naughton’s attendance was
well received by the Group.
Mark Britton had recently been appointed as Communications Manager; M Britton would be working
closely with K Hurry and would primarily be driving the CCGs communication strategy around social
media and web development.
The Fleetwood Neighbourhood Team now had an established engagement committee forum.
T Naughton would be attending the next meeting to present the five year strategy to this group.
K Toole advised that HealthWatch Blackburn with Darwen had recently commissioned Travers Peter to
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carry out research into the experience of the LGB & T community in Blackburn with Darwen in relation
to access to health services. (Travers Peter works for Lancashire County Council on the Isaac Hitchen
project.) K Toole asked if a similar exercise should be undertaken by Fylde and Wyre. K Toole agreed
to liaise with Dr Vasudev about the current streams of work HealthWatch Lancashire have on in
relation to this subject.
I Stewart asked the question as to how the PPE Group engaged with elderly groups, as the majority of
people in this group may not have access to computers. K Toole advised that notice boards within GP
surgeries was a good method of reaching out to such groups; A Bate said that the PPE Group
recognised it was difficult to reach out and engage with the elderly, however, she assured the
Committee that there were strong community links which assisted in reaching this particular group. The
CCG also linked in with Jules Walls, Head of Equality Diversity and Human Rights who was based
within the CSU Delivery Assurance Team who also helped reach out to this Group.
K Toole referred to the forthcoming Quality Assurance Visits – Stroke Pathway, and reported that three
Listening Events had taken place around the Stroke Pathway, with Stroke Association representatives
leading the events. The events were extremely well attended with over 80 members of the community
participating. Once the full report was received from the Stroke Association it would be shared with the
Committee.
Quality Assurance Visits – Stroke Pathway: J Aldridge reminded the Committee that two visits
would be taking place around the Stroke Pathway, the first would be on 14 October in the Community
and the second would take place on 21 October at Blackpool Victoria Hospital. She advised that a
considerable amount of work had been carried out to-date and that the visits were a very complex
operation. She reminded the Committee that these visits were not about inspection but to gain
assurance.
8.3
9
Complaints Policy
The updated Complaints Policy was circulated with the agenda. A Bate advised that the Policy had
been adopted from the old PCT Policy with minor amends made to reflect Fylde and Wyre CCG
requirements. A Janjua commented that he thought the Policy was a very good document. The
updated Policy was accepted and agreed by the Committee.
Clinical Effectiveness
9.1
Medicines Optimisation
9.1.1
Relvar Ellipta for COPD and Asthma
Amended policy circulated with the agenda was accepted and ratified.
9.1.2
Certolizumab for AS
Accepted and ratified by the Committee.
In order to provide assurance, J Aldridge reminded the Committee that the Medicines Sub Group
consulted and considered medicines prior to them being referred to the QI & GC for ratification.
J Lonsdale also advised that the medicines were also consulted and considered at Lancashire level.
9.2
Quality Reports
S Betts referred to the Quality Report circulated with the agenda, a summary of highlights were:
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Diagnostic waiting times: Indicator not achieved for July 2014, the main issue being backlog of
cystoscopy patients at BTH. P Tinson advised that a recovery plan submitted in June 2014 stating
that the Trust would achieve target by August 2014 had not been achieved.
Mixed Sex Accommodation: 1 x breach reported due to bed availability.
Referral to Treatment Waiting Times: Not achieved. The Trust has been asked to develop a plan
for achievement of the target at speciality level from September 2014 onwards. P Tinson advised
that NHS England had since extended the amnesty to end November 2014.
Never Events: 1 x event in July involving a dermatology patient at Clifton Hospital.
Post meeting: It was originally believed that the patient was a Fylde and Wyre CCG patient,
however, since the Report had been compiled and circulated it had been noted that the patient was
a Blackpool CCG patient
Health Care Associated Infections: 3 x new cases had been apportioned to the Trust. It was
noted that the Trust had breached the quarterly target and was currently reviewing its action plan.
Cancer 62 Days - % of patient receiving first definitive treatment: 12 x admitted and 3 x nonadmitted patients have breached the 62 day wait target for receiving first definitive treatment at
BTH. Admitted patient breaches were attributed to complex pathways for 5 patients, patient choice
for 3 patients, late referrals for 2 patients and delay of one week for one patient in MDT due to the
unavailability of a radiologist. The non-admitted patient breaches were attributed to patient choice,
delay in treatment for one patient for ‘medical reasons’ and a complex pathway for one patient.
In response to a query from I Stewart, S Betts confirmed that she and C Lewis were currently looking
at the format of future reports and that complaints would be included in reports going forward.
T Riddick raised concern that actions were coming out of the main Lancashire AT QSG meeting and
being delegated to the Lancashire AT QSG Primary Care Sub Group, however the QSG Lancashire AT
Primary Care Sub Group had not met for quite some time. J Aldridge agreed to raise this point at the
next QSG meeting.
9.2.1
9.3
Governing Body Dashboard
This report had not been submitted for circulation with the agenda. S Betts agreed to address
this and to ensure the report was submitted to future meetings.
Learning Disability Annual Self-Assessment Framework Return
In C Lewis’s absence, this item was deferred to the October meeting.
10 Patient Safety
10.1
BVH Mortality Update
A Janjua that BVH Mortality Board meetings were now held every two months; a meeting had been held
in August however no new validated data had been presented at that meeting. A CCG Mortality
Surveillance Group would be held on 29 October.
10.2
Safeguarding Update
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10.2.1 Safeguarding Dashboard
A Marquis-Carr updated the Committee on recent developments within Safeguarding both at
local and national level; a summary of highlights from the report follows:
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Audit of Safeguarding Arrangements is nearing completion for 2013/14. Where
appropriate action plans are in place progress is being monitored through contact
from the team thus ensuring arrangements are robust.
Safeguarding Internal Audit Report: a review of the CCGs safeguarding
arrangements had been undertaken by Mersey Internal Audit Agency (MIAA); although
some weaknesses in the design and/or operation of controls were identified, either their
impact would be minimal or they would be unlikely to occur. Overall the level of
assurance was deemed significant.
Safeguarding Network: All CCGs across Pan Lancashire have agreed to the
collaborative approach for safeguarding. Areas of work currently being developed
under the collaborative include a revamp of the safeguarding assurance process for
commissioned services; review of safeguarding policies and training framework; MCA
and DoLs as a direct result of the Cheshire West Judgement; guidance for GPs re
safeguarding training ; commissioning of named GP functions and the health
contribution to Lancashire's multi-agency safeguarding hub (MASH)
CQC pending inspection: work continues in ensuring all health organisations are
prepared for the unannounced inspection of safeguarding and CLA services.
Multi-agency mock inspection by LCC: health agencies across Lancashire recently
took part in a multi-agency case file audit as part of LCCs preparations for a pending
Ofsted inspection of local authority services for children in need, protection, early help
and children looked after. Initial feedback from the process is that health were
commended for their swift turn around in getting relevant information into the inspection
process and early indicators are that cases have been well managed from a multiagency perspective.
10.2.2 MCA/DoLS
A Marquis-Carr reported that a huge amount of work was being undertaken across Lancashire
in light of the Cheshire West Judgement. She referred to the report circulated with the agenda
which provided more in depth information in relation to activity to date, next steps and
recommendations.
J Aldridge and A Marquis-Carr agreed to meet outside of the meeting to discuss individual risks
in more detail. J Aldridge agreed to update I Stoddart on anticipated financial implications.
10.3
National Peer Review Programme : In C Lewis’s absence, this item was deferred to next meeting.
10.4
Outlier Alert: In C Lewis’s absence, this item was deferred to next meeting.
10.5
Patient Safety Alert: In C Lewis’s absence, this item was deferred to next meeting.
10.6
AQUA: In C Lewis’s absence, this item was deferred to next meeting.
11 Items to be noted from or escalated to Quality Surveillance Group
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There was nothing identified for escalation to the Quality Surveillance Group.
12 Sub Group updates and minutes
12.1
Patient and Public Engagement Group
The minutes from the meetings held on 14 August and 11 September 2014 were noted and
ACCEPTED.
12.2
Assurance Group
The minutes from the meeting held on 10 September 2014 were noted and ACCEPTED.
12.3
Contract Performance and Quality Group
The minutes from the meeting held on 12 September 2014 were noted and ACCEPTED.
12.4
Medicines Sub Group
The minutes from the meeting held on 29 July 2014 were noted and ACCEPTED.
12.5
Safeguarding Assurance Group
There was no meeting in August, therefore no minutes were available for distribution.
12.6
Mortality Surveillance Group
There was no meeting in August, therefore no minutes were available for distribution.
12.7
Primary Care Quality Improvement Group
There was no meeting in August, therefore no minutes were available for distribution.
13 Corporate Governance
P Hulme was in attendance for this agenda item.
13.1
Project Management Office – highlight report
P Hulme referred to the Project Performance Dashboard and Annual Commissioning Plan and advised
that the purpose of the report was to provide members with the updated Programme Dashboard for the
period 25 August – 12 September 2014 and present the reformulated Annual Commissioning Plan. The
report was a snapshot in time position statement covering all of the projects underway in Year 1 of the
Programme work plan, underpinning the delivery of the CCGs five year strategy. The report also
provided a proactive transparent and visual representation of the projects which was continually updated
on a weekly basis to reflect progress and change and will be reported monthly.
The report was noted and accepted by the Committee.
13.2
Pre-PEAR Assessments Review and Approval
The Committee reviewed and ratified the Ophthalmology Pre-PEAR Assessment. The request to
delegate authority for the Quality Sub Group to approve Pre-PEAR Assessments for further projects
was approved.
13.3
Quarter 4 Final Delivery Dashboard
The Q4 Final Delivery Dashboard was circulated to the Committee for audit purposes only. The report
summarised the following:
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report against Assurance Domains for Quarter 4
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the Delivery Dashboard received from NHS England
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the annual assurance letter
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the Assurance Guidance issued for 2014/15
The report was noted.
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14 Dates and times of future meetings:
Tuesday 28 October 2014 – 10.00 am : Patient Engagement Workplan (KT) / Insight (NM)
Tuesday 25 November 2014 – 10.00 am
Tuesday 16 December 2014 – 10.00 am : NWAS Recall / Provider & Quality Schedule (CL)
Tuesday 27 January 2015 – 10.00 am
Tuesday 24 February 2015 – 10.00 am : Nursing Homes (NM & JH)
Tuesday 31 March 2015 – 10.00 am
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