Committee: Trust Board Meeting Date: 25 June 2015 This paper is for: Assurance and Information Title: Clinical Governance and Workforce Committee Summary Report Purpose: The purpose of this report is to provide the Trust Board with a summary of the Clinical Governance and Workforce Committee meeting. Summary: The inaugural meeting of the Clinical Governance and Workforce Committee was held on 10 June 2015. Draft Terms of Reference were presented and discussed. It was noted that specific elements were still to be added, due to the expansion of the Committee s remit to include workforce issues. This would be completed ahead of the next meeting. It was agreed that Committee meetings would take place on the second Wednesday of each month, in order for the Trust Board to receive a summary report and any escalation of concerns within the same month. It was agreed that the key purpose of the Committee would be to provide assurance that high quality care is delivered throughout the Trust and to assist in this delivery through resolution of escalations. Exception reports and items of note were received from Governance and Risk, and Corporate Medical and Nursing Directorates. The Committee also received a verbal update on the report of Sir Robert Francis QC, entitled Freedom to Speak Up [written summary attached as Appendix 1]. Items of note: Capacity issues continue within the Governance and Risk Directorate but the new structure is approved and adverts will be placed in June. Some interim support has been secured. A remedial action plan to deal with the complaints response backlog has been developed and implemented; this is already having a positive impact on performance. A system of monthly review of in-hospital mortality has been implemented, to audit the care provided pre-mortem. This will identify any shortcomings in practice and/or communication, to identify areas for targeted improvement. A proposal for an initial immediate review of any unexpected death was also discussed and agreed. Implementation of an integrated risk management software system has been delayed, with a potential to impact on the Trust s ability to demonstrate compliance with Regulations 16 and 17 of the Health and
Social Care Act 2008 (Regulated Activities) Regulations 2014: Mitigating actions had been identified and were in progress. A review of clinical governance presentation sessions was underway, to improve the dissemination of clinical audit findings and increase the impact of projects. There are current staffing risks within Radiology, with the impending departure of key staff. A substantive Consultant Microbiologist would commence in July 2015. The first Joint Safeguarding Committee with stakeholders was to be held on 12 June 2015. The Trust currently has no Equality and Diversity Lead but this is being addressed. The significant challenge in respect of the recruitment of nurses was highlighted, as was the current concern in respect of substantive midwifery levels. The Committee was updated on the findings of unannounced visits undertaken on behalf of the Special Measures Oversight Group. The content of a whistleblowing letter was discussed and the Committee apprised of actions taken in response. External stakeholders had been notified of the letter and the Trust s actions and an internal investigation had commenced, which would report through external routes. The NED Chair of the Committee agreed to provide independent review of the investigation, on behalf of the Trust. Quality concerns in respect of the Pathology Partnership were discussed and would be a standing agendum for future meetings until resolved. The Committee received the draft Quality Account, which has been shared with external stakeholders. There were two indicators [of 93] with elevated risk scores highlighted in the CQC s Intelligent Monitoring Report. These were discussed; one indicator used 2013/14 data but 2014/15 data shows that the Trust is not an outlier, and the other reflects the Trust s Special Measures status and financial position. The Dr Foster Mortality Summary report continued to show the Trust as statistically within the expected range. Two clinical conditions flagged as potential outliers were due to low numbers and case-mix and did not indicate poor outcomes. The Trust has not been identified by the CQC as an outlier. It was a recommendation of the Committee that a repeat audit of palliative care coding should be scheduled, to provide assurance of accuracy. It was noted that the well led domain of the CQC s hospital inspection programme would likely include a review of value for money and efficiency, but details and timelines have yet to be confirmed. Prepared by: Frances Carey Director of Governance and Risk Presented by: Chris Welsh Non-Executive Director Recommendation: The Trust Board is asked to note the summary report from the Clinical Governance and Workforce Committee.
Appendix 1 FREEDOM TO SPEAK UP; a report by Sir Robert Francis QC Published 11 February 2015 Background Following the Mid Staffordshire NHS Foundation Trust Public Inquiry, Sir Robert Francis QC made a number of recommendations to further embed a culture within the NHS that is patient focused, open and transparent. He was subsequently commissioned by the Secretary of State to undertake an independent review of progress because of continuing problems with regard to the treatment of staff who raise genuine concerns about safety and other matters of public interest, and the handling of those concerns. In February 2015, the report, entitled Freedom to Speak Up, was published. This paper provides a summary of the report findings and sets out next steps for the Trust. Summary The Freedom to Speak Up review sets out principles and actions that are intended to create the right conditions for NHS staff to speak up about concerns, share learning and provide redress when things go wrong. Fundamentally, this means actively seeking and encouraging the provision of feedback from patients, visitors or staff and being willing to listen, to learn and to reflect on the criticisms and compliments received. The report acknowledges that the NHS is working hard to promote a culture of openness and learning. It also recognises the capacity challenges in finding time and resource to deal sensitively and intelligently with issues; however, the evidence received during the review from across the country underlines an urgent need for system-wide action to build a stronger culture in which staff feel safe to raise concerns. In too many instances, staff who raised concerns became the subject of disciplinary or other punitive actions, and some reported experiencing suicidal thoughts as a result of these negative reactions. The evidence also suggests that some groups of staff are more vulnerable to punishment than others, such as agency and locum staff, students and trainees, BME groups and those working in primary care. Five key themes are highlighted within the report and set out the need for: culture change improved handling of cases measures to support good practice particular measures for vulnerable groups extending legal protection The Freedom to Speak Up review makes two key recommendations, one of which is for all provider organisations to implement the principles and actions applicable to them and the other is for the Secretary of State to review, and report to Parliament, at least annually the progress made. Of the 46 actions set out in the report, 28 require providers to act.
Next steps At Hinchingbrooke Hospital, we have already taken steps to encourage and celebrate those staff who act as patient safety champions by raising concerns but we recognise there are further actions we need to take to embed the culture we desire. The Director of Governance and Risk has assumed the role of Freedom to Speak Up Guardian, with Medical, Nursing/Midwifery and HR Executives also identified to staff as safe havens. The Freedom to Speak Up Guardian role will receive Non-Executive Director support, challenge and oversight from the Chair of the Clinical Governance and Workforce Committee. The rate of near miss and no harm incidents reported by the Trust [2 nd highest rate compared with 140 acute trusts] is indicative of a positive safety culture although capacity challenges have limited the extent to which the Trust currently reviews and acts on near miss data. There also continues to be a low number of anecdotal accounts of staff attempting to raise a concern and being overruled by managers or subjected to criticism for incident reporting. The revised Stop the Line procedure, launched earlier this year, makes it clear that the Executive will view any such action dimly and, where necessary, will consider disciplinary action against anyone who inappropriately prevents a colleague from raising a concern. A gap analysis against the 28 provider actions is currently underway and an update will be presented to the Trust Board in July 2015, along with specific recommendations for the Trust. Frances Carey Director of Governance and Risk June 2015
REF# ACTION 1.1 Boards should ensure that progress in creating and maintaining a safe learning culture is measured, monitored and published on a regular basis. 2.1 Every NHS organisation should have an integrated policy and a common procedure for employees to formally report incidents or raise concerns. In formulating that policy and procedure organisations should have regard to the descriptions of good practice in this report. 3.1 Bullying of staff should consistently be considered, and be shown to be, unacceptable. All NHS organisations should be proactive in detecting and changing behaviours which amount, collectively or individually, to bullying or any form of deterrence against reporting incidents and raising concerns; and should have regard to the descriptions of good practice in this report. 3.3 Any evidence that bullying has been condoned or covered up should be taken into consideration when assessing whether someone is a fit and proper person to hold a post at director level in an NHS organisation. 4.1 Employers should ensure and be able to demonstrate that staff have open access to senior leaders in order to raise concerns, informally and formally. 5.1 Boards should consider and implement ways in which the raising of concerns can be publicly celebrated. 6.1 All NHS organisations should provide the resources, support and facilities to enable staff to engage in reflective practice with their colleagues and their teams. 7.1 Staff should be encouraged to raise concerns informally and work together with colleagues to find solutions. 7.2 All NHS organisations should have a clear process for recording all formal reports of incidents and concerns, and for sharing that record with the person who reported the matter, in line with the good practice in this report. 8.1 All NHS organisations should devise and implement systems which enable such investigations to be undertaken, where appropriate by external investigators, and have regard to the good practice suggested in this report. 9.1 All NHS organisations should have access to resources to deploy alternative dispute resolution techniques, including mediation and reconciliation to address unresolved disputes between staff or between staff and management as a result of or associated with a report raising a concern and/or repair trust and build constructive relationships. 10.1 Every NHS organisation should provide training which complies with national standards, based on a curriculum devised jointly by HEE and NHS England in consultation with stakeholders. This should be in accordance with the good practice set out in this report. 11.1 The Boards of all NHS organisations should ensure that their procedures for raising concerns offer a variety of personnel, internal and external, to support staff who raise concerns including: 11.1.a 11.1.b 11.1.c 11.1.d a person (a Freedom to Speak Up Guardian ) appointed by the organisation s chief executive to act in a genuinely independent capacity a nominated non-executive director to receive reports of concerns directly from employees (or from the Freedom to Speak Up Guardian) and to make regular reports on concerns raised by staff and the organisation s culture to the Board at least one nominated executive director to receive and handle concerns at least one nominated manager in each department to receive reports of concerns
11.1.e a nominated independent external organisation (such as the Whistleblowing Helpline) whom staff can approach for advice and support. 11.2 All NHS organisations should have access to resources to deploy counselling and other means of addressing stress and reducing the risk of resulting illness after staff have raised a concern. 12.2 All NHS organisations should actively support a scheme to help current and former NHS workers whose performance is sound to find alternative employment in the NHS. 13.1 All NHS organisations that are obliged to publish Quality Accounts or equivalent should include in them quantitative and qualitative data describing the number of formally reported concerns in addition to incident reports, the action taken in respect of them and feedback on the outcome. 13.2 All NHS organisations should be required to report to the National Learning and Reporting System (NLRS), or to the Independent National Officer described in Principle 15, their relevant regulators and their commissioners any formally reported concerns/public interest disclosures or incidences of disputed outcomes to investigations. NLRS or the Independent National Officer should publish regular reports on the performance of organisations with regard to the raising of and acting on public interest concerns; draw out themes that emerge from the reports; and identify good practice. 13.3.a 13.3.b 13.3.c CEOs should personally review all settlement agreements made in an employment context that contain confidentiality clauses to satisfy themselves that such clauses are genuinely in the public interest. All such settlement agreements should be available for inspection by the CQC as part of their assessment of whether an organisation is well-led If confidentiality clauses are to be included in such settlement agreements for which Treasury approval is required, the trust should be required to demonstrate as part of the approval process that such clauses are in the public interest in that particular case. 14.1 Employers should ensure that staff who are responsible for, participate in, or permit such conduct are liable to appropriate and proportionate disciplinary processes. 14.2 Trust Boards, CQC, Monitor and the NHS TDA should have regard to any evidence of responsibility for, participation in or permitting such conduct in any assessment of whether a person is a fit and proper person to hold an appointment as a director or equivalent in accordance with the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014 regulation 5. 14.3 All organisations associated with the provision, oversight or regulation of healthcare services should have regard to any evidence of poor conduct in relation to staff who have raised concerns when deciding whether it is appropriate to employ any person to a senior management or leadership position and whether the organisation is well-led.