PUBLIC
Minutes of the Integrated Governance Committee, 12 February 2014
Integrated Governance Committee
[DRAFT] Minutes of the meeting held on12 February 2014 at 09:00in the Boardroom, Chancellor Court, Oxford OX4 2GX
Present:Martin Howell / Trust Chair (Chair of meeting) (MH)
Ros Alstead / Director of Nursing and Clinical Standards (the DoN/RA)
Stuart Bell / Chief Executive (the CEO/SB)
Anne Grocock / Non-Executive Director (AG)
Mike McEnaney / Director of Finance (the DoF/MME)
Clive Meux / Medical Director and Director of Strategy (the MD/CM)
In attendance:
Tehmeena Ajmal / Head of Quality and Safety (TA)
Deborah Humphrey / Head of Nursing – Mental Health (Older Adults) (DH) part meeting
Sukh Lally / Clinical Director – Specialised Services (SL) part meeting
Pete McGrane / Clinical Director – Community Services (PMcG)part meeting
Eddie McLaughlin / Divisional Director – Mental Health Services (EMcL)
Rosie Shepperd / Clinical Director – Children and Families (Oxfordshire & Buckinghamshire) (RS)
Wendy Woodhouse / Clinical Director – Children and Families (Wiltshire & BANES) (WW)
Hannah Smith / Assistant Trust Secretary (Minutes) (HS)
1. / Welcome and Apologies for absence / Action
a / Apologies for absence were received from:Yvonne Taylor, Chief Operating Officer; Mike Bellamy, Non-Executive Director (MB); Justinian Habner, Trust Secretary; Rob Bale, Clinical Director – Mental Health (Adults); Brian Murray, Clinical Director – Mental Health (Older Adults); Peter Crabb, Head of Internal Audit – CEAC; and Helen Ward, Quality and Clinical Standards Manager – Oxfordshire Clinical Commissioning Group.
2.
a
b
c
d
e
f
g / Minutes of the meeting held on 13 November 2013
The Minutes were approved as a true and accurate record of the meeting.
Matters Arising
Item 2(d) Patient experience – dimensions being measured
The DoN reported that the dimensions of patient experience which the Trust would measure were being developed through the new Patient Experience Group and these would be reported on in the future.
Item 2(g) Safe and secure use of controlled drugs
The DoN reported that although daily checks of controlled drugs had not yet been implemented, these were being planned. This was relevant across Divisions. The CEO requested that the DoN report back on the timescale to implement daily checks of controlled drugs.
Item 3(d) Incidents subject to web holding
TA confirmed that these were included in the report on Serious Incidents Requiring Investigation (SIRIs) on the agenda at item 4 and noted that the number of such incidents had reduced.
Item 4(b) Including ethnicity and gender in reporting on physical restraint and seclusion
The DoN noted that the report on Physical Restraint and Seclusion on the agenda at item 5 included reporting on gender but also discussed issues with reporting ethnicity. The CEO requested that reporting include ethnicity to provide reassurance that there were no issues with disproportionate restraint of ethnic minorities.
Item 16(e) Reporting on staffing issues
The Chief Executive noted that staffing issues could be a potential indicator of quality issues and requested that the DoF look into including a digest of any such issues as part of the reporting from the HR Quality Improvement Committee to this Committee or HR reporting to the Board.
The Committee confirmed that the rest of the actions from the 13 November 2013 Summary of Actions had been actioned, completed or were on the agenda for the meeting: 2(b); 2(c); 2(f); 2(i); 3(e); 3(g); 7(d); 9(c); 10(c); 13(b); 15(c); and 16(d). / RA
RA
MME
QUALITY IMPROVEMENT, PATIENT EXPERIENCE AND PERFORMANCE
3.
a
b
c
d
e
f / Report on progress on implementing the recommendations from the second Francis report
The DoN presented Paper IGC 02/2014 which set out the Trust’s progress on implementing the relevant recommendations from the second Francis report.
The Chair noted that MB had submitted a question in relation to section 3.7 in the report and had asked whether sufficient resource was being committed to the development of multidisciplinary teams given the number of frontline teams. The DoN confirmed that the resourcing was sufficient. The CEO added that the Trust had the capacity to promote the development of multidisciplinary teams and that this had been appropriately linked with the work on Productive Wards. However, the test of the effectiveness of this would be the extent to which quality improvement work became a part of teams’ daily routines.
AG referred to the action plan in the spreadsheet attached to the report which set out the Trust’s response and actions to the relevant recommendations from the second Francis report. AG asked how the action plan would be taken forwards. TA replied that the Trust would report on progress against the relevant Francis recommendations to the appropriate commissioning groups, as part of the Trust’s contractual requirements. The Quality Account had also been developed to incorporate and respond to the main themes from the Francis report and quarterly updates against progress on the Quality Account were provided to this Committee and to the Board.
PMcG, SL and DH joined the meeting.
The Chair noted that MB had submitted a question in relation to section 4.1 in the report on the need for strong Board engagement with, and oversight of, the safety and quality of care being delivered. MB had asked whether the section should be expanded to delineate between: (i) the actions of the Board; (ii) the actions of its principal sub-committees, such as this Committee; and (iii) the actions of individual Board members in assessing quality through, for example, involvement in front line visits, complaints and SIRI reviews. The CEO added that the Trust, through its work in mental health services in particular, provided more opportunities for Board and Director engagement with safety and quality than might be found in the acute sector and that this should be documented in more detail in the report. The Chair added that recording visits at Executive Director, Divisional Director and senior manager level may also be helpful. The DoN replied that this was already picked up through the work on Safer Care and Productive Wards and that Executive Director visits were regularly reported into the Executive meetings.
The Committee noted that a final version of the report should be made available on the Trust’s website and that the DoN should provide a summary update to the Board.
Subject to the comments above, the Committee APPROVED the report for submission to the relevant commissioning groups. / RA/TA
RA
4.
a
b
c
d
e / Serious Incidents Requiring Investigation (SIRIs) in Q3 2013/14
The DoN presented Paper IGC 03/2014 which provided an update on SIRIs, trends and assurance against Care Quality Commission (CQC) Outcomes 18, 19 and 20. The DoN noted that the Safer Care work was progressing against the top 6 categories of incidents: falls, violence, pressure ulcers, self-harm, medication and going Absent Without Leave (AWOL). However, more focus was required on pressure ulcers, AWOL incidents and medication incidents. The Safe Care programme on medication incidents had been slowed due to staff absence and resourcing delays. A separate update on the falls prevention work taking place in Older Adult Mental Health Services would be provided to the meeting at agenda item 6.
PMcG noted that pressures on the District Nursing service had made it difficult to release staff to take on pressure damage prevention work. However, more senior clinical staff were now available to support this work. The DoN added that the reported increase in the more serious pressure ulcers graded at 3 and 4 coincided with the capacity issues experienced by the District Nursing service. AG asked whether the increase in pressure ulcer incidents related to patients who had developed pressure ulcers whilst in Trust care or patients who had entered Trust care already exhibiting pressure ulcers. PMcG replied that although the general prevalence of pressure ulcers was increasing, there had also been an increase in cases of patients who developed pressure ulcers whilst in Trust care. The Chair asked how the Trust was progressing with discussing the pressures on the District Nursing service with local commissioners. PMcG reported that progress was being made and that local commissioners were considering more sustainable support.
AG asked what action was being taken to improve attendance at Learning Events. The DoN replied that the Head of Learning from Incidents, following discussion with senior management teams, was working on combining learning from incidents, clinical audit and complaints events to encourage more Trust-wide learning and provide for more identification of themes and trends across these areas.
The CEO noted that one ward in the Mental Health Division was reporting an unusually high level of AWOL incidents and asked what was being done to reduce this. EMcL replied that there were environmental issues due to the listed building status of the ward which were being considered by Estates. In particular, Estates were looking into listed building consent for a higher and more secure perimeter fence. TA noted that this ward could also appear to be an outlier because it was including unsuccessful AWOL attempts in its reporting whereas other wards may only be reporting on actual AWOL incidents. Part of the ongoing Safer Care work included improving consistency in reporting.
The Committee noted the report.
5.
a
b
c
d / Incidents involving the physical restraint and seclusion of patients, Q3 2013/14
The DoN presented Paper IGC 04/2014 on reported incidents that involved the physical restraint or seclusion of patients and which provided assurance against CQC Outcomes 4, 7 and 21. The DoN provided an update on the Trust’s review of training and practice around physical restraint. The Trust was reviewing alternative practices and methods of delivering Prevention and Management of Aggression (PMVA) in other organisations, in particular practices which focused on patient engagement and personalised care. The experiences of Trust service users and staff of restraint and seclusion were also being reviewed. The DoN noted that some service users had engaged particularly well with the review in providing feedback.
The CEO asked what the staff reaction had been to the Trust reviewing its current PMVA practices. EMcL and SL noted that staff were not resistant to change but were concerned that any new PMVA practices should be safe and fit for purpose. The MD added that safety was an issue for staff working with challenging patients in environments where staff and patients risked injury if PMVA practices were not appropriate.
AG asked why a high proportion of prone restraints were reported for the new Highfield Unit. WW replied that restraint in the Highfield Unit would be covered at agenda item 7 on patient experience.
The Committee noted the report.
6.
a
b
c
d / Understanding causes and prevention of falls in Older Adult Mental Health Services
DH provided an oral presentation, to accompany Paper IGC 05/2014, on the initiatives that had been put in place to increase the quality of falls prevention and management. DH noted that previously most research into falls had been carried out in Acute or Community settings, rather than in Mental Health services. It had, therefore, been important for the Trust to review its own falls incidents, especially as on average only 26 per cent of falls in the Trust were witnessed. The majority of falls took place unwitnessed and patients were subsequently found. The Trust review had identified that:
- a number of patients placed themselves on the floor, in part due to mental health issues, rather than fell;
- 47 per cent of falls related to patients with functional disorders (rather than a specific illness or diagnosis). This was an unexpectedly high percentage as it had previously been anticipated that most falls would relate to patients with dementia and/or poor mobility; and
- most falls took place within the first 2 weeks of admission or around the 50th day of an inpatient stay. Falls assessments on admission would not, therefore, be as effective for a patient who fell 50 days later. This indicated that the frequency of baseline falls assessments would need to be re-considered.
- the Trust had developed a course with Oxford Brookes University on physical health care for mental health nurses which 75 per cent of the Trust’s registered mental health nurses had now attended;
- environmental improvement work was taking place on wards to improve lighting and provide handrails;
- the Trust was looking into reducing polypharmacy as some patients were on several types of medication and the majority of mental health medication had side effects such as drowsiness which could increase falls risk. PMcG added that this was being taken forward in discussion with local commissioners as there was a drive in primary care towards significant use of secondary preventative medication which may not provide benefit for years and which may not, therefore, be of sufficient benefit to elderly patients;
- two Safer Care projects were focused on falls prevention: (i) developing “always events” around falls assessment and management; and (ii) engagement with patients and their families. The DoN noted that the results of Safer Care work would be reported back to the Committee as part of regular incidents and patient experience reporting; and
- future areas to focus on included: incontinence management (as night-time falls tended to be linked to incontinence); and development of meaningful occupation and activity, in particular through monitoring of the use of the new facilities at the Whiteleaf Centre (as boredom could lead to increased agitation and greater falls risk).
The Committee noted the report.
DH left the meeting.
7.
a
b
c
d / Patient Experience update and report on the Highfield Unit
The DoN and WW presented Paper IGC 06/2014 which provided: at IGC 06(i)/2014, a summary of patient experience activities, results and changes as a result of feedback; and at IGC 06(ii)/2014, a summary of patient experience information collated in January 2014 from the Highfield Unit, actions proposed/undertaken and data and trends on incidents of restraint at the old and new Highfield Units over 2012-13.
AG referred to Table 4 on page 11 of IGC 06(i)/2014 and noted that this was very useful as it summarised patient feedback from various patient council meetings across the Trust. The DoN noted that this could continue to be included in reporting.
WW noted that the relatively high level of restraint at the Highfield Unit had been considered, along with the impact of the new environment, and patients had provided feedback on their experiences in the new Highfield Unit. Overall patients had been positive about the new environment and the quality of care; no comments had been volunteered about restraint or issues with restraint. The report provided graphs to compare levels of restraint at the old and new Highfield Units; overall median levels of restraint were lower on the new Highfield Unit compared to the old unit. There were still occasions when instances of restraint peaked in the new unit but peaks related to the impact of specific challenging patients and issues experienced with the High Dependency Unit. A change in specialist commissioning had also had an impact since April 2013 as the new Highfield Unit had become part of a larger catchment area, which could reach to Wessex, the Isle of Wight and Exeter. New patients were, therefore, being admitted to the Highfield Unit who had had no previous contact or history with the Trust and their previous risk assessments may not have been optimal before admission. The patient-mix on the Highfield Unit could, therefore, be challenging and complex.
The Committee noted the report.
8.
a
b
c
d / Complaints and Patient Advice and Liaison Service (PALS) Report Q3 2013/14
The DoN presented Paper IGC 07/2014 which provided an update on complaints, PALS contacts, compliments received and assurance against CQC Outcome 17. There had been a sustained decrease in the number of complaints received over a 12 month period. The highest number of complaints had been received by the Mental Health Division whilst the highest number of compliments had been received by the Community Services Division.
Although noting the overall decrease in the number of complaints received, the Committee discussed areas which had received a higher proportion of complaints: