Minutes of the meeting of the Integrated Governance Committee (IGC) Held on the 19 January 2012 Trust Headquarters, Springfield University Hospital

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1 Minutes of the meeting of the Integrated Governance Committee (IGC) Held on the 19 January 2012 Trust Headquarters, Springfield University Hospital Present: Professor R Horton Non-Executive Director (Chair) Ms M Broadhurst Non-Executive Director Mr I Wilson Interim Chief Executive Dr R Allen Director of Social Work Ms K Goddard Director of Nursing and Operations In Ms C Alexander Clinical Governance Manager Attendance Mrs A Attah Director of Corporate Affairs Ms J Cantelo Facilities Manager Ms C Vander Patient Safety and Quality Assurance Manager Ms D Adams Chief Pharmacist Mrs T Philpott Minutes 59/11-12 Apologies for Absence 59.1 Apologies were received from Ms J Wilson, CEO and Dr B Nereli, Medical Director 60/11-12 Minutes of Meeting held on 3 November 2011 (IGC/11-12/33) 60.1 The minutes of the meeting of the Integrated Governance Committee held on 3 November 2012 were received and agreed as an accurate record. 61/11-12 Action Checklist and Matters Arising (IGC/11-12/34) 61.1 All items on the action checklist scheduled for January 2012 are on the agenda Mrs Broadhurst stated that the revised minutes of the IGC held on 8 th September 2011 had not been received by members. Ms Alexander would ensure these were circulated Mrs Broadhurst also reported that the Safeguarding Rights of Informal Patients leaflets were not on the Carer Group agenda for that evening s meeting. Dr Allen said that she would table the leaflets at the meeting. 62/11-12 Medicines Management Strategy Progress Update (IGC/11-12/35) 62.1 Ms Adams presented the Medicines Management Strategy Progress report which describes the constraints and progress to date on the strategy. A number of items were highlighted Medicines safety Mrs Broadhurst asked whether it would be helpful if Pharmacy reviewed all serious incidents. Ms Adams responded that she is on the circulation list for serious incidents and assesses the relevance of medication in each incident Mrs Broadhurst asked whether the Board should be concerned that medication error reporting rates remain low and if so, what can the Trust do to support and encourage people to report. Ms Goddard responded that national benchmarking figures indicate that the Trust is very good at high level reporting and that the implementation of the e-reporting system would improve lower level reporting. 1

2 Medicines cost-effectiveness A 50% drop in items dispensed per month for Wandsworth and Sutton & Merton was highlighted. Ms Adams congratulated teams for their work and achievement, in particular the Balham, Tooting and Furzedown CMHT. Ms Adams reported very few complaints from GPs It was agreed that congratulations are sent from the Board to the Balham, Tooting and Furzedown CMHT. Action: Ms Adams to contact Communications to send out this good news message Finance Reports Ms Adams would report back to IGC on the work to rationalise cost centres and improve reporting by replacing consultant cost centres with ward cost centres. Action: Ms Adams to provide a report to IGC on progress of the finance reports Communication Ms Adams described the Choice and Medication system recently purchased and explained that service users are able to access the website from their homes as well as on the wards. Posters are provided on the wards for guidance on using the website Dr Allen asked whether patients rights in relation to medication were accessible on the website and Ms Adams undertook to look into this. Action: Ms Adams to explore accessibility of patients rights on the Choice and Medication system and report back to IGC Explanatory leaflets on the Choice and Medication system to be made available on wards and in CMHTs were tabled. Mrs Broadhurst and Dr Allen would take examples of these to the Carer Group meeting Ms Goddard reported that she had approved the proposal made to the service directors on their behalf for the pharmacy savings to be realised from savings in the directorate drug budget It was agreed that the IGC is kept informed of progress E-learning Mrs Broadhurst asked whether guidance in the medicines management e-learning package was risk assured. Ms Adams was able to give limited assurance to which Mrs Broadhurst requested that this is investigated further Action: Ms Adams undertook to look into investigate risk assurance in the E-learning package further Ms Goddard highlighted Item 21 in the Medicines Management Action Plan and explained that remedial works in clinical rooms had been implemented and audited making this Amber. Once the new build is finished this can go Green Mr Wilson pointed out that consent and capability did not appear anywhere in the report. Ms Adams responded that the work of the Mental Capacity Act and Consent to Treatment task group would identify issues to be addressed in relation to medication. The action plan would be revised accordingly Mrs Broadhurst raised a discussion regarding carers concerns when those they care for stop taking their medication. Ms Goddard responded that she would ask Christine Kapopo, 2

3 Associate Director of Nursing, to attend a carers meeting to help address their concerns Action: Ms Goddard to ask Christine Kapopo to attend a carers meeting Mrs Broadhurst requested information of all meetings that carers have had an involvement and this was agreed Action: Ms Adams to come back to the IGC to report on progress with the strategy and the above actions in July /11-12 Crisis Line Review Update (IGC/11-12/36) 63.1 Ms Goddard updated the IGC on the recent review of the Crisis Line and described how it would be operated. The Crisis Line would go-live at the end of March. Ms Goddard would report back to IGC the evaluation and comments from users of the Crisis Line The IGC noted the Crisis Line Review Update 64/11-12 CQC Moderate Concerns Update (IGC/1112/ Ms Alexander updated the IGC on the progress of the CQC Moderate Concerns to date. Ms Alexander stated that the majority of the actions would be completed by the end of March and that monitoring would continue a. Care Planning Group Action Plan (IGC/11-12/38) 64.3 Ms Goddard updated the IGC of the progress of the Care Planning Action Plan to date Mrs Broadhurst queried whether carers would be able to access training and education programmes provided by the Recovery College Ms Goddard undertook to ensure that it is made explicit that carers can access education programmes at the Recovery College Assurance was given that the target numbers of community service users on CPA with two recover goals would continue to be increased The IGC noted the Care Planning Group Action Plan b. Capacity and Consent Group Action Plan 64.9 Dr Allen tabled the Capacity and Consent Group Action Plan and described the 3 projects detailed within it. Dr Allen stated that the main actions would be completed by the end of March. The CQC had noted signs of some improvement on some wards also that the Mental Health Act Office was working well Mr Wilson was concerned that incomplete actions leave the Trust vulnerable if the CQC make an unplanned visit and emphasised the need complete the actions swiftly It was agreed that the IGC would be provided with regular updates The IGC noted the Mental Capacity and Consent to Treatment Planning Action Plan 65/11-12 NHS London Gateway Review Update 65.1 Ms Goddard updated the IGC on the NHS London Gateway Review. The Executive Team would present a progress report to the CEO on his return from annual leave. 66/11-12 Draft Quality Strategy (IGC/11-12/39) 3

4 66.1 Ms Goddard presented the draft Quality Strategy to the IGC for approval prior to ratification by the Trust Board Ms Goddard explained that the revised format is to ensure that lay people can read and understand the Trust s Quality agenda. Comments were invited Attention was drawn to page 2 safe care delivered in a manner that minimises risk of harm to the service user. Mrs Broadhurst considered that this should read risk of harm to anyone and this was agreed. The document would be amended accordingly Action plans are to be put in place to monitor delivery of the objectives The IGC approved the Draft Quality Strategy /11-12 Serious Incidents Q Report and Performance Notice Update (IGC/11-12/ Ms Alexander informed the IGC of the reported Serious Incidents in the quarter and progress in completing Root Cause Analysis reports Ms Alexander reported that the Trust has written to the SW London Cluster seeking to have the performance notice lifted in light of the progress made with outstanding serious incidents. Processes have been put in place to prevent a backlog of SIs occurring in future Mr Wilson congratulated Ms Alexander and all involved in achieving this outcome The IGC approved the Serious Incident Governance Group Q3 Report 68/11-12 Claims Q Report (IGC/11-12/41) 68.1 Ms Alexander introduced the Claims Q3 Report Ms Alexander apologised for the limited amount of information in this first report and explained that a similar system for claims to that of serious incident reporting is being developed, along with a process of disseminating the learning from such occurrences. More detail would be provided in subsequent claims reports Mrs Vander suggested separating incidents involving staff and patients and Ms Alexander agreed to look into this Action: Claims report to be brought back to IGC July The IGC approved the Claims Q3 Report 69/11-12 Integrated Governance Committee Policy List: Clinical Policies (IGC11-12/42) 69.1 Ms Alexander presented the list of Trustwide Clinical Policies and provided an update on progress since September Clinical policies are reviewed and updated by relevant groups and actively managed by the Clinical Governance Committee It was agreed that Ms Alexander would include exception reports in future reports to the IGC Action: To be brought back to IGC in April The IGC noted the IGC Policy List: Clinical Policies 70/11-12 Reporting Groups (for noting): Clinical Governance Minutes (Oct 2011) 70.1 The IGC noted the Clinical Governance Minutes for October

5 71/11-12 Hot Topics None raised. 72/11-12 Any Other Business None raised. 73/11-12 Next Meeting 73.1 It was confirmed that the next meeting of the committee was scheduled for Thursday 16 th February 2012 from pm in Meeting Room 1, Trust Headquarters, Springfield University Hospital 5

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