ENCLOSURE U
Paper WL1797
WEST LONDON MENTAL HEALTH NHS TRUST
QUALITY & RISK COMMITTEE
Minutes
Thursday 11th February 2010 (draft)
Present:
Mrs Ann Chapman
Dame Sally Powell
Dr Elizabeth Fellow-Smith
Mr Ian Kent
Ms Maria Harrington
Ms Gail Miller
-
Non-Executive Director (Chair)
Non-Executive Director
Medical Director
Deputy Chief Executive
Associate Director Clinical Governance
Associate Director Risk & Violence Reduction
Attending:
Mr Peter Cubbon
Miss Abby Fadina
-
Chief Executive
Board Secretary (minutes)
-
Non-Executive Director
Director of Nursing & Patient Experience
1.0
1.1
APOLOGIES FOR ABSENCE
Ms Lisa Harrington
Mr Steve Trenchard
1.2
The Board Secretary agreed to ensure that Miss McGee, Director of High Secure Services
is informed that she is a member of the Committee, so that she is present at future
meetings.
Action: Miss Fadina
2.0
MINUTES OF THE PREVIOUS MEETING FOR APPROVAL
2.1.1
Subject to the following amendments the minutes of the meeting held on Thursday 17th
December 2009 were agreed to be a correct record:(para 3.2) new Trust structure, SDU governance arrangements and structure
Members of the committee were informed that Mr Cubbon had presented a report to the
Board in October that encompassed a revised structure, and this would be further
discussed at the Operations Board.
(para 4.3.3) Functions of the Committee
Remove the words and SUIs.
(para 9.2) Outline of 2009/10 Quality Account
Ms Miller said that instead of using the PMVA Breakaway mandatory training figure under
“Improve update of mandatory training” it would be best to use the Non Physical
Intervention mandatory training which is externally monitored.
3.0
3.1.
MATTERS ARISING
The Committee’s Action Schedule was noted; the following updates were provided:
22.10.09 3.2 Remitted to F&P Committee; closed
22.10.09 3.3 Completion date to be June 2010
22.10.09 3.9 Completion date now February 2010 – on agenda
22.10.09 3.12 Completion date now April 2010
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17.12.09 4.2 To be taken to March Service User Forum for nominee to committee
17.12.09 4.3.2 Revised ToR to come to committee in April 2010 to note
17.12.09 6.7 Action completed
17.12.09 8.1 Declaration published; complete
17.12.09 9.3 Revised indicator agreed; action complete
17.12.09 9.4 On agenda
17.12.09 10.2 Completion date to be February 2010
17.12.09 14.1 Update – Mr Corlett had assured Ms Miller that ligature risks are considered
when patients are moved
17.12.09 16.1 On agenda
17.12.09 17.1 On agenda
4.0
4.1.
LIAISON PSYCHIATRY SERVICE (Adult)
Mr Kent’s reported detailed the current provision for the liaison psychiatry service in the
Trust’s 3 local SDUs; Ealing, Hammersmith & Fulham and Hounslow. He informed the
Committee that same report was being presented to the Ealing Interface Group to
stimulate joint working discussions.
4.2
In response to Mr Cubbon’s question Mr Kent agreed to inform him about the volumes of
the contracts between the Trust and three acute hospitals (Ealing, Charing Cross and
West Middlesex)
Action: Mr Kent
4.3
The Committee noted the opportunities that will be pursued to make improvements to the
Liaison Psychiatry Service, if funding is made available; which included senior nurses
available to provide assessments in acute trusts, the investigation of medically unexplained
symptoms targeted at frequent A&E attendances, psychology/brief interventions and
increased provision of support to liaison nurses from more senior medical staff.
5.0
5.1
PHYSICAL HEALTHCARE STRATEGY AND IMPLEMENTATION PLAN
Dr Fellow–Smith presented the physical healthcare strategy, which will support the delivery
of improved primary care to inpatients and also improve delivery of physical health and
health assessments. The strategy addresses issues raised in the CQC report and
contributes to the Trust’s service improvement agenda to support service improvement in
clinical practice.
5.1.1
The Committee noted that the strategy had previously been presented to the Operations
board in November 2009 and approved as a working document during a short period of
consultation. Dr Fellow-Smith said that since then the strategy had been shared with the
Trust wide Clinical Leads, PCT Directors of Public Health and Directors of Commissioning
and their comments had been received and noted to formulate the strategy being
presented.
5.2
The Committee endorsed the Physical Healthcare Strategy and its implementation plan.
6.0
6.1.
WLMHT HIGH LEVEL RISK REGISTER
The Committee received for review the Trust’s High Level Risk Register and agreed that it
would retain oversight of all of these, rather than splitting this between the Quality & Risk
Committee and the Finance & Performance Committee.
6.2.
Dr Fellow-Smith explained that the register presented was from an ‘old’ paper system
which was being replaced by a new electronic risk register; that would be less
cumbersome, which would be better matched to Executive Directors’ portfolios, would
allow for automatic archiving and which would be ‘live’ at all times. Dr Fellow-Smith said
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that the Executive Directors would make a decision as to whether the Trust would use an
external electronic system by Datix or an in-house system developed by the Risk
Department.
6.3.
The Committee reviewed the red and amber rated risks and Dr Fellow-Smith agreed to
ensure that her Executive Director colleagues updated their actions on the current risk
register. The Committee agreed to review the revised Risk Register at its next meeting.
Action: Dr Fellow-Smith
6.4.
The Committee confirmed its agreement that all possible risk mitigation actions had been
identified and accepted the residual risk levels recorded and as amended at the meeting.
The Chairman agreed items 10 and 11 would follow so that Ms Miller could then attend another engagement
10.0
10.1.
QUARTER 2 INCIDENT REPORT 1st July 09 - 30th Sept 09 and QUARTER 3 INCIDENT
REPORT 1st Oct 09 to Dec 09
The Committee received and noted the corrected Quarter 2 Incident Report and received
the Quarter 3 report in a proposed revised format for discussion.
10.1.1 The discussion about the Q3 (and future) report focused on the content, style and
graphical data that the Committee required to assure the Board that action was being
taken to reduce incidents in the Trust. The Committee agreed the following:
 Detailed quarterly incident data would be presented to the Operations board to
consider the underlying causes of the incidents and identify actions that are to be
taken.
 The Committee would receive an analysis of the quarterly incident report, with
information on key issues, trends and actions as well as commentary generated from
the Operations board
10.2
The Committee identified and discussed the following key themes from the Q3 report:
10.2.1 There is evidence of a good reporting culture in the Trust – shown in the number of
recorded incidents in (2) Community patient deaths (3) Assault to patient and (4)
Medication error.
10.2.2 There was 1 In-patient death recorded in Q3 as an in-patient suicide – this was significant
as it is one of the Trust’s Never Events
10.2.3 The number of Community patient deaths within the category of natural causes has
started to increase. Mr Kent said that now the Trust was collecting this data there needed
to be an agreement as to what was done with the data collected. Dr Fellow-Smith added
that the SHA had now set up a quarterly observatory and under the Medical Director the
SHA had been asked to look into this.
Mr Kent and Dr Fellow-Smith agreed to check
why the number of deaths by natural causes in the community was increasing.
Action: Mr Kent, Dr Fellow-Smith
10.2.4 The number of RIDDOR reportable incidents has been increasing. The Committee noted
that this was being investigated by the Health, Safety and Welfare Group.
Mr Cubbon left the meeting
11.0
11.1
REVIEW OF INCIDENT REPORTING AND MANAGEMENT
Dr Fellow-Smith’s paper presented a summary of the findings and proposals following the
review of the Incident Reporting and Management Process Policy. Her paper included a
summary of the findings from 4 other NHS Trusts (3 of which are FTs) about their serious
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incident review and reporting process and procedures, researched by Timandra Dyer of
the Risk Reduction Team.
11.2
Dr Fellow-Smith highlighted that the Trust had not been successful in recruiting 2 Incident
Review Facilitators, whose roles would have been as a specialist in root cause analysis to
assist the Chair in writing the Level 1 / 2 report and also to provide family liaison support.
Dr Fellow-Smith explained that recruitment had been difficult because the skills needed for
both roles were unique and no one individual had so far combined both qualities. She
proposed that the roles be split and the separate jobs re-advertised. The Committee
agreed.
Acton: Dr Fellow-Smith
11.3
Dr Fellow-Smith drew the Committee’s attention to other amendments to the revised Policy
which included changes to ensure that policy met revised NHSLA standards and the areas
within the policy that required Non Executive Director involvement.
11.4
The Committee agreed to recommend to the Board the following process, with effect from
the March Board meeting, for gaining assurance regarding level 1 reviews:
 The Chief Executive’s Report will inform the Board of an incident;
 A level 1 report and action plan will be presented to the Board;
 A thematic analysis of level 1 incidents will be presented to the Committee with the
incident analysis report
 Key items will be highlighted to the Board through the Committee Chair’s report.
This process will be adopted following agreement by the March 2010 Board.
11.5
The Committee welcomed the inclusion of Appendix 4 of the revised Policy to assist with
checking the quality of Level 1 reports as well as to provide benchmarking data from the
SHA and agreed that it would be renamed ‘toolkit’.
11.6
The updated Incident Reporting and Management Policy will be presented to the Board in
March 2010 for approval.
Action: Dr Fellow-Smith
Ms Miller left the meeting
7.0
7.1.
PERFORMANCE SCORECARD, QUALITY INDICATORS
Dr Fellow-Smith presented for review the performance scorecard linked to Corporate
Objective 1 - To further develop and measure safe and high quality care - as at December
2009, and the Trust’s Quality Indicators.
7.1.1
Enhanced patients with no 6 month review – Ms Harrington said that the apparent increase
(figure of 941) for December 2009 was being reviewed by the CPA Steering Group, it was
likely that this was a data error in the recording via RiO.
7.1.2
The Committee noted the links between the Quality Account and the Indicators, particularly
the focus on improving accommodation and employment status compliance. Whilst
compliance has improved to 66% at December 2009, this remains ’red’ RAG rated
because the Trust’s target is 95%.
7.1.3
The Committee noted that a minor was admitted in an adult ward for 1 night in a crisis.
7.1.4
The Committee agreed to monitor the Average Length of Stay statistics as this had
fluctuated in its RAG status.
7.2
The Committee recognised the progress that has been made towards achievement of the
Trust’s Quality Account targets and noted that the Trust further aspires to exceed these
targets.
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7.3
The Committee agreed that the review of the Integrated Performance Report would be
undertaken by the Board, with review of the C01 Balanced Scorecard undertaken by the
Committee.
8.0
8.1
QUALITY ACCOUNTS 2009-2010 AND 2010-2011
Dr Fellow-Smith presented the Department of Health circular concerning Quality Accounts,
which clarified that Quality Accounts were to be shared with Commissioning PCTs, LINks
and Local Authority Overview and Scrutiny Committees (OSC) before they are published in
June. Dr Fellow-Smith said that this impacted on the Trust’s timescales as it meant that
the Quality Account 2009-10 would need to be completed by the end of April so that it can
be shared with the organisations listed above and their comments returned to the Trust.
The Committee noted that Mr Trenchard had already contacted the Borough LINks to
inform them that their comments would be sought.
8.2
Dr Fellow-Smith updated the Committee on the actions undertaken to improve
performance against the mandatory training targets.
8.3
The Committee agreed to approve the final Quality Account 2009/10 at its April meeting.
Dr Fellow-Smith agreed to work with the Communications Team on its presentation format.
Action: Dr Fellow-Smith
8.4
Dr Fellow-Smith highlighted that the proposed Quality Account priorities for 2010-11 would
need to be agreed by the Trust in consultation with PCTs, LINks and OSCs. The
Committee agreed the measures and targets proposed for next year, subject to further
detail.
Mr Kent left the meeting
9.0
BOARD VISITS
9.1
9.1.1
Board Visit Feedback form
The Committee received the Board members’ feedback forms from visits in January 2010
to the John Conolly Unit and Lakeside Mental Health Unit as well as feedback from the
Finance Department following the receipt of a Board visit in November 2009 and feedback
from the H&F Memory Clinic following the receipt of a Board visit in December 2009.
9.1.2
The feedback form was discussed and changes were suggested which would assist to
make it more relevant; including adding a section to complete what was good about current
practice observed, what staff are proud about at their work place, what the concerns are
and the rotation of key themes every six months for Board visits to be focused upon (i.e.
for the next 6 months the focus would be on cleanliness). Dr Fellow-Smith and Miss
Fadina agreed to revise the feedback forms.
Action: Dr Fellow-Smith, Miss Fadina
9.1.3
The Committee agreed that that feedback forms must be completed following all visits by
Board members so that responses to areas that are identified for follow up may be audited.
9.2
9.2.1
2010 Board Visit Programme and visits arranged (for info)
The Board Secretary agreed to circulate this to Board members. Non Executive Directors
were reminded that they may attend any visit on the Board Visit Programme by
arrangement.
12.0
12.1
ANNUAL REPORT TO THE MARCH AUDIT COMMITTEE
Mrs Chapman agreed to compile this report detailing the key areas of work of the Quality &
Risk Committee, outcomes, changes it has affected and assurances provided to the Board.
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Action: Mrs Chapman
13.0
13.1
CLINICAL RISK REVIEW SUB COMMITTEE
The Committee received and approved the terms of reference of the Clinical Risk Review
Sub Committee and noted the contents of the draft minutes of its first meeting held on the
13th January 2010.
14.0
14.1.
Q&R COMMITTEE CHAIRMAN’S REPORT TO FEBRUARY 2010 BOARD MEETING
The Committee agreed the contents of Mrs Chapman’s chair’s report. Mrs Chapman
agreed to write her report. The Committee noted that the draft minutes of this meeting
would not be completed in time to meet the February Board paper agenda.
Action: Mrs Chapman
15.1 SUMMARY UPDATE FOLLOWING CQC HCAI UNANNOUNCED VISIT
15.1.1. The Committee received Mr Trenchard’s paper which provided an overview of the actions
taken following the CQC HCAI unannounced visits in November 2009 and the proposed
future reporting arrangements to the Committee.
15.1.2 Contrary to the proposal in the report the Committee agreed that the minutes of the
Infection Control Group meeting should be submitted to the Clinical Standards Sub
Committee and the minutes of the latter presented to the Quality & Risk Committee. The
Committee agreed Chair’s action to approve the terms of reference of the Clinical
Standards Sub Committee because the Quality and Risk Committee would not meet again
until 22nd April and did not wish to delay the approval process for the terms of reference of
the groups reporting into the Sub Committee.
Action: Mrs Chapman, Mr Trenchard
15.2 SLIDES FROM PRE BOARD SEMINAR PRESENTATION
15.2.1 January 2010 Board: none. The Board discussed the CQC Registration and Trust
submission.
16.1 Terms of reference of the Quality & Risk Committee
16.1.1 For information. These were approved at the January 2010 Board meeting
16.2 INTEGRATED GOVERNANCE CHART
16.2.1 For information. This was approved at the January 2010 Board meeting.
17.0
17.1.
ANY OTHER BUSINESS
Mrs Chapman requested that an annual work plan be prepared to inform the Committee’s
agenda planning.
Action: Dr Fellow-Smith, Miss Fadina
17.2
DATES OF FUTURE MEETINGS: 0930HRS – 1230HRS
Thursday 22nd April 2010
Thursday 17th June 2020
Thursday 19th August 2010
Thursday 21st October 2010
Thursday 16th December 2010
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