Mid Highland CHP
Clinical Governance & Risk Management Group
Wednesday 2 December 2009 (2.00 pm - 4.30 pm)
The Board Room, Larachan House, Dingwall
PRESENT: Mrs Gill McVicar General Manager
Mrs Ann Bethune Non Executive Director, NHSH Board
Mrs Kate Earnshaw Clinical Services Development Manager,
Skye & Lochalsh, Ross, Cromarty & West Ness
Mrs Alison Phimister Locality General Manager, Skye & Lochalsh,
Ross, Cromarty & West Ness
Mr Colin Shields CHP Health & Safety Manager
Mr Findlay Hickey CHP Lead Pharmacist
Mrs Alison Hudson CHP Lead Nurse
Ms Margaret Moss CHP AHP Lead
Mrs Cath Melville CHP Hotel Services Manager
Mr Alastair McKenzie Estates Manager, NHSH
Mrs Tracy Ligema Acting Locality General Manager, Lochaber
Ms Hazel Smith Community Hospitals Team Leader, Ross &
Cromarty
Ms Sue Scott-Dickins Integrated Community Nursing Team Leader
IN ATTENDANCE: Mrs Fiona Matheson Business Support Manager
Mrs Jackie Jefferson CHP Administrator (Minutes)
APOLOGIES: Dr Angus Venters CHP Clinical Director
Mr Bill Reid Head of eHealth, NHSH
Mr Tom Slavin CHP Head of Finance
Dr Lesley-Anne Smith Head of Clinical Governance, NHSH
Mrs Theresa James NHSH Community Care Manager/CHP Mental Health & Emergency Planning Lead
1 / WELCOME AND APOLOGIESMrs McVicar welcomed everyone to the meeting. Apologies were noted as above.
2 / MINUTES OF PREVIOUS MEETING
Ms Smith (HS) had given her apologies for the meeting on 9 September. The minutes were otherwise approved.
3 / MATTERS ARISING
3.1 Steam Cleaners
Mrs Melville (CM) confirmed that training in the use of the three new steam cleaners will be taking place shortly at Raigmore Hospital and will be cascaded down appropriately.
3.2 MacKinnon Memorial Hospital
Further to Item 5 in the previous minutes, Mrs McVicar (GMcV) confirmed that she had visited the hospital with Douglas Seago and Mrs Hudson (AH). There were still areas of great concern although AH reported that progress had been achieved in de-cluttering. The Chief Executive made a further visit last week. GMcV acknowledged that although the premises were not ideal, there was still a great deal that could be done by staff to improve matters. Mrs Earnshaw (KE) noted that there were issues which were affecting staff morale although work was ongoing to resolve these.
3.3 Guidance for Keyholders/Lone Working Issues
Mr Shields (CS) was unable to attend the NHSH Health & Safety Committee so was not in a position to provide an update. He undertook to follow up on the issues raised and report back at the next meeting. GMcV indicated that this matter should be escalated.
Action:
CS to follow this up and report back to next CHP CG&RM meeting
3.4 Visit by NHSH Infection Control Manager
AH indicated that Morag Greenshields will be unable to attend a CHP meeting as she is stepping down from this post.
3.5 IT Access in the Community
A full update was not available as Mr Reid was not present. Ms Scott-Dickins (SSD) reported that training is being cascaded down at Invergordon.
3.6 New NMC Guidance on Record Keeping
AH confirmed that the annual audit will be published soon. Training issues have been discussed to identify who would be most suitable to take this forward. No feedback has been received from Dr Smith (LAS) around the role of the Clinical Effectiveness Team. It is hoped that an education programme can be set up for early next year, once the results of the 2009 audit are available.
3.7 Falls Strategy/Falls Co-ordinator
Mrs Moss (MM) indicated that she had submitted a paper to CHP Management Team that morning. The Delivery Framework for Adult Rehabilitation was presented at the previous Management Team and MM sought support for the implementation of the action priorities identified in this. The Framework includes a set of evidence-based standards around which QIS will be publishing a report soon. This should provide a detailed action plan which can be adapted for use in NHSH and the CHP.
The CHP Falls Group has now met twice. It has representation from across the professions and from Highland Council. It is currently focussing on falls prevention training for hospital staff and care homes and has acknowledged that there are huge issues around education and awareness-raising in the wider community. Attendance at hospital staff training sessions has been low and MM is seeking support from LGMs to move this priority area forward. There is also a joint proposal by Age Concern & Help the Aged Scotland/NHS Highland for a local awareness-raising and self-management project, possibly in Ross & Cromarty.
Management Team supported the implementation of the priorities outlined in Mrs Moss's paper, particularly around falls prevention training, and the development of a CHP action plan for falls prevention and bone health.
3.8 Medicines Management
Mr Hickey (FH) indicated that he had still not had sight of the reports on Medicines Safety and Medicines Incident Management (referred to under Item 3.9 of the minutes for the meeting on 11 March) and undertook to follow this up. MM has attended one meeting of the Medicines Safety Sub Group but regular attendance at future meetings is in doubt as they take place on the same day as CHP Management Team. GMcV suggested that a deputy (who is not a member of Management Team), possibly one of the Prescribing Support Pharmacists.
3.9 'Do Not Attempt Resuscitation' Status
GMcV did not have the opportunity to raise this issue at the Ambulance Liaison meeting as planned. This is due in part to the ongoing restructuring within Scottish Ambulance. She will follow this up at the next meeting in January. KE confirmed that, having reviewed the situation in S&L she is comfortable that the guidance is being applied appropriately. HS indicated that she was clear on the policy and had no specific concerns. This item will now be removed from the agenda.
Action:
GMcV to raise issue of DNR status at next Ambulance Liaison meeting
3.10 CHASE - NHS Internal and H&S Audit Project
CS indicated that the first pilot has taken place. The results were as anticipated and there is an expectation that the number of questions will be reduced. The new system should prove very helpful and full roll-out will commence during 2010.
3.11 Theatre Washer at MacKinnon Memorial Hospital
KE indicated that this is an ongoing problem and is in fact an issue Highland-wide. Following an earlier Critical Incident Review, it was agreed that Medical Physics would act as co-ordinators in the event of future problems. Although the washer has malfunctioned since then, the new procedure for dealing with problems has worked well. KE has raised the issue with Maimie Thompson as the issue could potentially impact on the 18 Weeks RTT target.
4 / CLINICAL GOVERNANCE STANDARDS UPDATE
A full update could not be given as LAS was not present. GMcV noted that the Quality Improvement Scotland visit is planned for March.
5 / FINANCIAL RISKS
GMcV highlighted the significant financial risk around achieving the third tranche of cash releasing savings. A £259k overspend is projected at year-end but the CHP is currently reporting a £375k overspend to date i.e. for the last 7 months. This is unacceptable to the Board who have indicated that the CHP must break even. NHS Highland has however guaranteed that they will not allocate Raigmore's overspend to CHPs. GMcV indicated that she has been unable to confirm to the Board of NHSH that a break-even position will be achieved.
6 / RISK REGISTER
At the previous meeting, it was agreed that all action owner updates should be sent to CS or JJ by end September 09. CS was concerned to note that some information is still awaited, and the next review is due in March 2010. He reiterated his request for all outstanding data to be with him by 31 December 09. The Group was asked to consider if all key risks were noted in the register. In light of recent HAI issues, AH undertook to review the Control of Infection section. Following discussion it was agreed that this document would be reviewed in detail at the next meeting.
7 / INCIDENT REPORTING
The Incident report for the quarter July-September 09 was circulated prior to the meeting. The DATIX web-based incident reporting management system continues to develop. An analysis of the "free access" categories of incident (Personal Accidents, Fire, RTA, Security and Slips, Trips and Falls) for the first 6 months of this year compared to the last 6 months of the previous year shows that there has been a doubling of reported incidents at Belford Hospital.
Some "teething problems" within the system have been identified. These have been acknowledged by the Project Lead and steps are being taken to resolve them.
Slips, trips and falls remain the major issue. Figures for disruptive, violent and aggressive behaviour chiefly relate to Fyrish Ward, as do data for absconding/missing patients. CS recommended that some levels of risk be treated with a degree of caution. For example, the consequences of a slip, trip or fall may not actually be significant but because the likelihood of recurrence was great, it would appear as High Risk.
GMcV highlighted the need to encourage reporting of Near Misses.
8 / COMPLAINTS
The Complaints reports for September 09 were circulated prior to the meeting. GMcV noted that complaints for the CHP were fairly small in number but were complex and targets were not being achieved. She suggested that if there were capacity issues managers should be encouraged to highlight this as quickly as possible.
The Group reviewed specific incidents to ensure that potential learning points were identified and acted upon.
9 / PANDEMIC INFLUENZA
Mrs McVicar congratulated all those concerned in the staff vaccination programme. Mrs Hudson noted that uptake for H1N1 vaccination has been good in Mid Highland with approximately 70% of Mid CHP staff having been immunised.
She highlighted risks around the At Risk categories where the vaccination programme is not yet complete. There are also risks around children under 5 because although they have now been identified an Enhanced Service has not yet been agreed with Primary Care to deliver vaccination. This is a national issue. FH anticipates that completion of the At Risk category patients will not be completed until Christmas.
Community Nursing Teams were managing the programme well and any issues have been dealt with locally.
FH highlighted the fact that email communications to GP practices often did not appear to be reaching the intended recipients. GMcV acknowledged that this was an issue for concern noting that the majority of communications were now via email. FH noted that Public Health now use email routinely because of the speed and efficiency of this method. Following discussion it was agreed that this issue would be taken to the Chairman’s Group in the meeting prior to the GP Sub Committee.
FH reported that incidences of milder flu-like illnesses being seen in Primary Care appear to be decreasing. In terms of the more severe hospital cases, incidences appear to be lessening although the situation remains fluid.
GMcV confirmed that there had been 70% uptake for staff vaccination although she was disappointed to note that the figure was lower for most hospitals, particularly Skye and Fort William. Unfortunately some negative and unhelpful messages have been circulating at local level advocating against vaccination. It was agreed that Drs Venters and Tracey, Mr Hickey and Mrs Hudson will develop information to counter this for circulation prior to mop-up sessions in these areas.
Action:
GMcV to refer issues around email communication with GP practices to Chairman’s Group prior to GP Sub Committee
AV, DT, AH & FH to develop response to negative messages in hospital settings about vaccination
10 / CONTROL OF INFECTION ISSUES
Report to the Chief Nursing Officer Directorate by Health Facilities Scotland
'The Patient Environment in Relation to Control of Infection'
GMcV referred to a letter from Dr Kevin Woods, Director General Health and Chief Executive NHS Scotland which was issued to all NHS Boards following the inspection reports from the Healthcare Environment Inspectorate (HEI). She emphasised that this was an extremely high profile issue, the importance of which should not be under-estimated.
The Health Facilities Scotland report to the Chief Nursing Officer Directorate "The patient environment in relation to the control of infection" has now been circulated and GMcV confirmed that Mid Highland is already addressing most of the recommendations relating to NHS Highland's Caithness Hospital, Wick. These are contained in the CHP draft action plan developed by AH (circulated with the meeting papers), together with any gaps which have been identified. This was reviewed and discussed.
Environmental issues at MacKinnon Memorial Hospital
Although MacKinnon Memorial Hospital (MMH) was being used as an example in this instance, GMcV emphasised that all hospitals in the CHP must take cognisance of this. Action plans are required for each individual site and these will feed into an overall CHP plan which will inform both the CHP Management Team and this Group.
GMcV highlighted concerns around the need for staff to better understand their role in Control of Infection and prevention of HAI and be motivated and empowered to make changes that are within their control. Although clutter is still an issue, AH indicated that staff have done an enormous amount of work on this and the improvements had been acknowledged by the Chief Executive and Director of Nursing following their visit. Mrs Melville (CM) expressed her concern that her staff were unable to do their jobs properly because of clutter.
The front corridor and Outpatients are still areas of great concern and KE outlined some of the options that are available. These were discussed. Part of the issue is around fire safety and it was agreed that a fire report should be obtained in the first instance. If the Fire Officer is satisfied, further discussions can place around cosmetic work to the clinic rooms to make it more user-friendly. Mr McKenzie (AMcK) will contact the Fire Officer.
Action:
AMcK to contact Fire Officer regarding clinic rooms at MMH
Clostridium difficile cases at MMH
AH referred to her report on Clostridium difficile cases at MMH between June and November 09. There were 6 cases at the hospital, only one of which was acquired at the unit in question. In accordance with guidance from HPS and 'triggers' for action developed by Dr Andrew Hay, a CDI Severe Case Analysis was undertaken by Jo Watt, Infection Control Nurse. A Critical Incident Review will also be required. The matter was also reported to the Scottish Government and enhanced surveillance commenced.