BOARD COMMITTEE SUMMARY SHEET NAME OF COMMITTEE: Governance Committee DATE OF COMMITTEE MEETING: 14 February 2014 KEY POINTS TO DRAW TO THE BOARD S ATTENTION WEBSITE AND INTRANET UPDATE a) Website The structure and aesthetics of the website were updated at the end of 2013 3 written concerns were received in the first three quarters of the year that the website was not up to date Actions taken include new processes to ensure information is up to date and consideration of decentralisation of responsibility for web content b) Intranet New intranet site planned and currently in contract negotiation to go live 1/5/14 Committee proposed that these changes should in future be reported direct to Board in the regular Media and Membership Report. LOCALITY GOVERNANCE BRIEFINGS Herefordshire Locality Briefing Issues reported included: Difficulty in accessing all the functionality of Datix due to the separate server in Herefordshire hosted by Hoople as part of the contractual arrangements There will be more focus on ensuring the learning from complaints occurs and is shared with staff The health Learning Disability Services have undergone an internal assurance CQC inspection and will be developing an action plan The CCG has undertaken assurance visits to Jenny Lind and Mortimer Wards All wards in the Stonebow Unit have been visited by the Royal College of Psychiatry AIMs accreditation team. The feedback has been positive and formal notification is awaited. Gloucestershire Localities Briefing Issues raised included: There was no meeting in held in January. The recent focus has been on the use of the risk register in the localities which has been included in a recent PWC internal audit. Gloucestershire Countywide Locality Briefing Issues reported included: A recent audit of emergency responses within the in-patient units has been undertaken, with the identification in some areas of improving response times. This information will come to the Governance Committee. A review is taking place within Hollybrook on response to emergency situation and the use of staff from the individual patient units. A recent focus on assessments for VTE and Falls assessment has demonstrated some variable practice in some areas which is being addressed Page 1 of 8
Risks that remain a concern include high bed occupancy, the Eating Disorder Waiting List, Linen Store at Wotton Lawn. A number of risks have been closed as the actions have been completed and the risk mitigated. Gloucestershire Children and Young Peoples Service Briefing Issues raised included: Continued focus upon the risk register, and mitigating actions Suicide and self harm prevention work continues in partnership with other partners organisations in the county There has been positive contribution and feedback on a Quick Read document for the new Assessment and Care Management Policy. It is felt that the approach in the new policy is much more appropriate for the service A recent Peer Review of the service led by the Royal College of Psychiatry was positive. The final report is awaited. EXPERT REFERENCE GROUPS EXCEPTION REPORT Points to note from the Expert Reference Groups include: Organic: Gloucestershire Memory Assessment Service has been accredited by the Memory Service National Accreditation Programme. The national trend to shift diagnosis of dementia from secondary to primary care was noted. Functional: work plans are being developed Physical health: work progressing on CQUIN for physical health and a review of the ECG policy for inpatients has taken place Forensic and complex care: There has been a focus upon the pathway with other agencies for people with a personality disorder in both counties. Work in place regarding GP services for unregistered patients in longer term hospital care (e.g. Montpellier Unit ). Substance misuse: exploring joint work with Nelson Trust regarding the provision and support of detox beds in Herefordshire. There is planning taking place for a conference focussed upon the use of Legal Highs. RISK POLICY AUDIT The new Risk Policy was ratified by the Governance Committee on 11 th October 2013 and involved a considerable shift in emphasis from previous practice to a more proportionate approach to risk assessment, with the most complex risk assessment requiring robust documentation and risk formulation. Update training commenced immediately after ratification of the policy. This audit was planned to assess progress during this period of change. At the time of the report 550 staff had received update training and this increased to 732 at the time of the Governance Committee. The audit only considered the care offered by staff that had completed the training. The quantitative audit data (provided by the Information Department) looked at the current risk assessment status. Of the current community case load 43% had a risk assessment and of current inpatients 66% had a risk assessment recorded, as recorded in the correct Risk section on RiO. Practice continues where clinicians record risk assessment in the RiO progress notes which is not in line with policy. The qualitative audit looked back on the risk assessment and documentation of 10 patients (5 community and 5 in-patient patients). The qualitative audit demonstrated a lack of consistency in the assessment of risk and the recording of such between clinicians and across teams. Page 2 of 8
Key observations from the 10 records reviewed included: Notable practice one risk assessment identified 12 risks demonstrating detail and clarity Core assessments one was appropriate, 6 partially completed and 3 had no core assessment Reviews of care- wide variation in frequency and quality Risk levels 10/10 risk levels were documented Risk assessment 8/10 patients had a risk assessment, 4/10 were using the new risk policy template. Observations recommended more details being recorded in the risk assessment Risk assessment review these were taking place; however there were times when it would have been indicated and had not occurred. The Committee concluded that: Greater assurance is needed in relation to the assessment and recording of risk assessment. The new Risk Assessment Policy remains appropriate to the current needs of the Trust and offers opportunities to provide a basis for identification of and subsequent improvement in quality of risk assessment for the future Over 400 staff still require training and a plan is in place to deliver this. Whilst training is of significant importance, other practices to implement the new policy also need attention. Actions were identified to support the implementation programme. There needs to be communication with staff of the need for more detailed risk assessment. Feedback of the key themes to staff should be given through News in Brief and Team Leaders A monthly qualitative audit should be performed by team leaders of 5 cases with summary feedback (rota of team leaders to review cases) and for this information to be reported to the Governance Committee quarterly. PATIENT SAFETY / SERIOUS INCIDENT REPORT 4 papers were considered by the Committee: a) Preventing suicide in England: One year on. First annual report on the cross-government outcomes strategy to save lives. Jan 2014. This notes that sadly for the first time since 2007 the national suicide rate has risen. It gives details of 6 key areas for local services to work together to promote suicide prevention. b) National statistical data relating to suicide. January 2014. This notes: The increase of suicides by people in contact with mental health services ( in 12 months prior to death) Increase in deaths involving helium poisoning. c) Suicide & Self Harm in Gloucestershire. January 2014. By Public Health Department and presented to Health and Care Overview and Scrutiny Committee. Key messages include: Suicide and self-harm on rise nationally The suicide rate in Gloucestershire is marginally higher than the rest of the South West, but in Gloucester and Cheltenham is significantly higher than the national rate 64% of Gloucestershire deaths by suicide occur in the home. Other hotspots include river / canals, multi-storey car parks and railway tracks/stations 2/3rds of the persons involved did not have any known previous contact with mental health services In comments offered by the Coroner, 72% were not considered to be related to mental Page 3 of 8
health but to social, financial, physical health and lifestyle issues Unemployment may be contributing Wider fallout of recession has potential to have negative impact on emotional health and wellbeing Increased demand for the range of services that respond to children and young people are being explored The varied and complex nature of the causes of suicide required wide ranging interventions from families, friends, communities, professionals, schools and other organisations Intervening at an individual level is more challenging d) Quarter 3 Patient Safety and Near Miss Report. Points to note include: Comparable trend in Serious Incident Reporting with known historical trend Number of reported serious incidents reported to date less than previous 2 years The Trust Quality Indicator Target for 2013/14 regarding serious incident rate per 1000 case load is that this should fall below an average of 0.2 incidents per 1000. The current average rate is 0.19 incidents per 1000 case load. Number of patient deaths resulting from Serious incidents lower than 2011/12 =32, falling to 21 in 2012/13. The 2013/14 figure has shown a slight rise, being 23 at end of quarter 3. This is above the Trust stated target. RISK MANAGEMENT REGISTER AND DASHBOARD a) Risk dashboard to provide a snapshot of how the Trust is performing in key areas of risk through the use of Key Risk Indicators. This demonstrates areas of assurance. Areas where full assurance is not provided include Project management Better for Less - Efficiency Savings. Risk increased due to shortfall in meeting 2013/14 target Datix incident management system - see Datix section of this summary Risk management standards ( formerly NHSLA) see NHS Litigation Authority section of this summary Safeguarding data capture around referrals and Children subject to a Child Protection Order Staff absence sickness levels Information Governance incidents Health and Safety Annual Inspections progress b) Risk register a list of the Trust s risks presented in order of risk score within each category. The Trust s highest scoring risks were reviewed by the Committee together with mitigating actions. These include: Serious Incidents Requiring Investigation External financial environment RiO contract Accessing Children and Young Peoples Services inpatient facilities Efficiency Savings risk of failing to achieve Actions to address the concerns raised above (a and b) were reviewed by the Committee. Page 4 of 8
NHS LITIGATION AUTHORITY CLAIMS QUARTER 3 REPORT There are 2 areas of claims: Clinical (Clinical Negligence Scheme of Trusts)- commonest cause of claims relates to self harm during 24 hour care Non-clinical (Risk Pooling Schemes for Trusts) This includes Liabilities to Third Parties Schemes for Trusts (commonest causes relate to slips, trips and falls and assault of a member of staff by a patient) and Property Expenses Scheme There are a total of 13 open claims (8 x Clinical and 5 x Non-clinical) which is an increase of 4 since last quarter (5 new claims and 1 closure). There is a gradual increase in the number of clinical claims in the past few years (2009-2011 2 per year, 2011-2013 4 per year). On a national scale the NHS LA Director of Claims has advised Trusts that there has been an unprecedented number of new claims in the past 6 months. 2 new non-clinical claims have been received through the new Portal system which aims to deal with non-contentious lower value claims and benefits from fixed legal costs if agreement to settle can be achieved within strict deadlines. However, the Trust s defence was considered robust enough to deny liability and therefore falls out of the Portal system. The Trust s CNST financial contribution has benefitted this year from an overall reduction in its contribution based on the last 5 years claims record, however it is anticipated that this trend will not continue. Lessons learnt from claims are included in the system for Continuous Improvement process and reported in the Aggregated Learning paper reported to Governance Committee. Issues arising are managing violence and aggression, suicide prevention, slips trips and falls, and supervision/escorted leave. HEALTH AND SAFETY STAFF INCIDENTS REPORT The overall number of incidents reported has shown a slight decrease. Incidents of violence and aggression to staff remains the highest category. There were 4 RIDDOR incidents (Reporting of Injuries, Diseases, and Dangerous Occurrences Regulations) in the reporting quarter. All involved staff. Two had trapped their fingers in doors, one stumbled when standing from a kneeling position in staff training and one was a result of violence and aggression. The Committee noted the progress made and the actions being taken to reduce the likelihood of future incidents. ASSESSMENT AND CARE MANAGEMENT POLICY (CARE PROGRAMME APPROACH) The stated purpose of The Assessment and Care Management Policy (Incorporating the Principles of the Care Programme Approach) is: To provide a clear framework for assessment, care planning, care coordination and overall care management within the Trust. It complies with the National CPA guidance as well as providing a framework for the provision of services not covered by the CPA guidance. This policy outlines how these principles will be applied within the Trust, and provides benchmark for monitoring practice against standards Features of the new policy include: Applies the principles of the Care Programme Approach Is person centred Is of a generic nature which is easily applied to all Trust Services Service Users assessed in line with presenting needs Page 5 of 8
Clinicians and staff empowered to use clinical judgement skills Proportionate recording of Service User information The Committee agreed: Ratification of the new Assessment and Care Management Policy The proposed Trust wide training programme and implementation plan A Trust wide audit of the Assessment and Care Management procedures in July 2014 CARE QUALITY COMMISSION COMPLIANCE The paper outlined that the last Quality Risk profile was released on December 2013 and reported to January Governance Committee January 2014. A verbal update was provided at the meeting on the latest QRP which was released on 11 th February and it continued to demonstrate an overall low risk. There have been no inspections by the CQC undertaken since the last report in January 2014. Following a CQC review of the Trusts 2012/13 Mental Health Minimum Data Set (MHMDS), the Trust was asked to examine the data collection on assaults, self harm, seclusion, AWOL (absent without leave) and deaths, which had historically not been reported via the MHMDA. Testing of this data is planned over the next few weeks. The Trust will then need to establish a robust system to collect date, report, and act on the routine quality checks that will need to be undertaken. QUALITY REPORT The third quarter review of the Quality Report was reviewed by the Committee. Progress was noted in terms of quality, targets and objectives. Actions planned on those targets not yet met were reviewed. The Committee approved sharing of the report with partner organisations, commissioners and governors. It would also be presented to the Trust Board for information MEDICAL PROFESSION UPDATE REPORT Points to note include: Doctors continue to submit their appraisals via SARDJV (Strengthened Appraisal & Revalidation Database, Joint Venture) and there is evidence of increased registration on the system with 68.9% online appraisal engagement. Current compliance with appraisal is 70.3% 20.3% are shown as non-compliant and 9.5% as compliance unknown. These figures includes those doctors who have not yet entered data onto SARD and those who are unable, at the present time, to complete due to be absent from work or completing a phased return to work. There are 4 doctors who are scheduled to have complete revalidation by April 2014. There are currently no doctors due for revalidation that are deferred or identified as not cooperating There are no open cases for the GMC regarding medical workforce. Issues relating to the failure to apt an Occupational Health Consultant were noted. A further attempt to appoint will be started shortly. DATIX REPORT Datix is the Trusts online incident reporting system which is used by staff to report incidents, errors or near misses. In December 2013, Price Waterhouse Cooper (PWC) undertook an audit of Datix and produced a report which identified a number of issues and risks which were rated Page 6 of 8
from critical" to medium. In addition, an incident occurred in 2013 when access to Datix was temporarily lost as a result of an IT failure. The resilience of the system is therefore being considered as part of a wider IT resilience action plan. The Committee reviewed: The PwC internal audit report on the use of Datix within the Trust. Proposed action plan to address the concerns Issues identified by the PwC report included: Incidents are not actioned in a timely manner Errors identified in the incident record Database configuration issues No clear processes learnt form incidents which do not meet the threshold for serious incident. The Committee noted: Significant concern of the current status of the Datix programme and the need for further assurance The most up to date version of Datix has now been installed Information re the identification of handlers has now been cleansed. Issues relating to training are not yet resolved but actions are being taken to resolve. Administration support to the Datix programme is being addressed. An action plan to address the identified issues in the Datix programme was agreed. A progress report on delivery of the action plan will be presented to the Governance Committee in 3 months. Awareness of possible impact of the Datix programme current deficits will be communicated to Locality Governance teams in order to heighten sensitivity to risk issues. FALLS ASSESSMENT PATHWAY REVIEW A revised Falls Assessment Pathway was considered by the Committee. This pathway was agreed for all patients within in-patient services. CLINICAL POLICIES The Committee received an update on the Care Practice policies being monitored, reviewed, consulted upon and ratified. An update was provided on the progress made on reviewing the total number of Care Practice Policies (in excess of 200) with the purpose of integrating policies where possible, and the removal of policies that could now be considered excess to requirements. INFORMATION GOVERNANCE POLICIES As a result of a number of information governance breaches the Information Government policies have been revised. These were presented to the Committee. The following policies were approved subject to amendments agreed at the Committee: Information Security Policy Changes made strengthen guidance given at the end of the previous version and translate the policy into requirement. These changes relate to the use of personal IT devices in conducting Trust business, the use of personal e mail apps on ipads, strengthening requirements around the storage of person identifiable data and the use of a PO Box number as return address rather than 2gether specific addresses. Portable IT equipment policy Changes made to bring consistency with revised Information Security Policy and provisions regarding ipads. Page 7 of 8
These changes will be communicated to Trust staff and John McIlveen will provide greater detail to board members. ACTIONS REQUIRED BY THE BOARD The Board is asked to note the content of this report. SUMMARY PREPARED BY: Martin Freeman ROLE: Committee Chair DATE: 15 February 2014 Page 8 of 8