Minutes of the Quality Committee, 10Th May 2017

BOD 88/2017 (Agenda item: 18(i)) Quality Committee

[DRAFT] Minutes of the meeting held on 10th May 2017 at 09:00 in the Ascot Room, Corporate Services, Littlemore Mental Health Centre, Oxford OX4 4XN

Present: Martin Howell Trust Chair (Chair of meeting) (MH) Mark Hancock Medical Director (MHa) Ros Alstead Director of Nursing and Clinical Standards (RA) Dominic Hardisty Chief Operating Officer (DH) part meeting Mike McEnaney Director of Finance (MME) Anne Grocock Non-Executive Director (AG) Mike Bellamy Non-Executive Director (MB) Jonathan Asbridge Non-Executive Director (JA)

In attendance: Pete McGrane Clinical Director, Older Peoples Directorate (PMG) John Campbell Head of Nursing, Older People’s Directorate (JC) Wendy Woodhouse Clinical Director, Children and Young People’s Directorate (WW) Rob Bale Clinical Director, Adult Directorate (RB) Kerry Rogers Director of Corporate Affairs & Company Secretary (KR) Hannah Smith Assistant Trust Secretary (HS) Laura Smith Corporate Governance Officer (LS) (Minutes) Sula Wiltshire Director of Quality & Innovation and Lead Nurse - Oxfordshire CCG (SW) Peter Reading PricewaterhouseCoopers - Observing PUBLIC Minutes of the Quality Committee, 10th May 2017

1. Welcome, Apologies for absence and Quoracy Action a The Chair introduced Peter Reading observing for PwC. b Apologies for absence were received from: Stuart Bell; Chief Executive; Susan Haynes, Deputy Director of Nursing; Liz Williams, Programme Director Learning Disability Transition.

2. Minutes of the meeting held on 08 February 2017 a The Minutes were received as a true and accurate record of the meeting.

Matters Arising b Item 4(e) – Sula Wiltshire agreed to pick this issue up with Ian Bottomly and keep the Chief Operating Officer in the loop. c Item 4(f) – The Trust Chair clarified his concerns were regarding ensuring potential blame is not placed on individuals for clinical judgements. d Item 8(e) – The Director of Finance provided an update and explained that a review of the whistleblowing policy was underway to include; review of when to go through whistleblowing process, review of the investigation process, and a review of options available before going to formal whistleblowing e.g. the Freedom to Speak up Guardian. e Item 8(h) – The Chief Operating Officer explained that there had been a number of summits with reviews underway in 33 systems who are struggling. He said at the DTOC summit on 09 May it was highlighted that external bodies do not think the system leadership is good. He said that the DTOC Summit would be writing to the three CEOs to try and come up with a plan together based on best practice from other areas. He said there had been some discussion within the Older Peoples Directorate about whether to take unilateral action to redeploy resources to get people home which would mean increasing recruitment of reablement staff rather than using OUH resources. Pete McGrane said that a third of patients in community hospitals at that time were delays and a more creative solution is needed to reduce these delays. He said that focusing on providing domiciliary care for the 22 patients requiring 4 visits a day from 2 carers would significantly improve the situation.

2 PUBLIC Minutes of the Quality Committee, 10th May 2017 f Mike Bellamy said the Trust should not be taking unilateral action when the system needs to work together. The Trust Chair requested that the Chief Operating Officer identifies a solution but does not implement until agreement from the wider system.

Actions g The Committee confirmed that the following actions from the 8th February 2017 Summary of Actions had been completed, actioned or were on the agenda for the meeting: 5(c), 10(d), 4(b), 5(p), 7(d), 7(f), 10(b) and 15(d) h The actions against items 5(j), 5(o) and 8(d) had been progressed and reporting against them would be held over to the next meeting.

3. Care Quality Commission (CQC) Post Inspection Improvement Plan Update a The Director of Nursing provided an oral update on the CQC inspection of the Out of Hours Service (OOH) and explained that the report had been received on Friday following factual accuracy check with final agreed action plan. She explained that there has been a gap as Priti Naik, Lead for CQC Standards & Quality, is on maternity leave and someone has been appointed into this post on secondment from the CQC. b The Director of Nursing reported that areas for improvement picked up by the CQC included response times, staffing, rota and employment/DBS checks. Pete McGrane said that additional staff have now been recruited. He added that changes to IR35 tax regulations may result in GPs being less willing to work in OOH and this would become clear in the next 6-8 weeks.

C Mike Bellamy asked whether the demand for OOH was still increasing. Pete McGrane confirmed that it was and explained that people are used to a very responsive service from OOH and use it in place of the GP. Sula Wiltshire noted that people are using the NHS very differently now and want to be seen where they want when they want. She said there is a local OOH Delivery Board with representatives across the system. d The Director of Nursing said that increasing numbers of young people are presenting to A&E with new mental health issues rather than going to GPs.

3 PUBLIC Minutes of the Quality Committee, 10th May 2017

This is a real challenge for A&E to deal with and regular meetings have been set up with Oxford University Hospitals NHS FT to address this. Rob Bale added that similar work is underway at Bucks to integrate mental health with urgent care services. e John Allison said it was a positive step that more young people are seeking support for mental health issues and said that an appropriate clinical pathway needs to be put in place. f Sula Wiltshire said there had been a Delayed Transfers of Care (DTOC) summit on 09 May to look at this and explained there was lots of work underway. g Mike Bellamy requested an urgent care update report goes to a future Board of Directors meeting. h The Trust Chair said he would raise this at the next Oxfordshire CEO/Chair meeting. i The Director of Nursing agreed to circulate the final OOH CQC report. j The Committee noted the oral update.

4. Quality Account Report a The Director of Nursing presented paper CQ 11/2017 and requested final comments from the Committee before the report is presented to Audit Committee on 22 May and Board on 24 May. b Mike Bellamy asked whether next years report could follow the priorities clearly so that the report flows better. The Director of Nursing explained there was a national format that needs to be followed, however a more readable version is also put into the public. Anne Grocock said there had been real improvement this year from previous reports. c Mike Bellamy asked whether work undertaken since the CQC inspection in areas requiring improvement could be included in the report so that people can see what work has been done. The Director of Nursing agreed to see if this could be added as well as information on the mock inspections for community hospitals.

4 PUBLIC Minutes of the Quality Committee, 10th May 2017 d The Committee noted the report.

5. Nursing Strategy Further Update a The Director of Nursing presented paper QC 12/2017 which provided an update of progress against the Nursing Strategy and highlighted that nursing revalidation had been a success. She outlined developments of nursing roles which included the introduction of 25 Associate Nurses and creating a generic job description for more advanced nursing roles. She explained that there was still a long way to go and that the Trust would be doing a gap analysis against Magnet standards, particularly focusing on recruitment and retention. b The Director of Nursing reported that the School of Nursing and Midwifery is expected to appoint a Director within the next couple of weeks and noted there was a good field of applicants. She added that Brookes University had funded for her to go to the USA to visit the top 3 Schools of Nursing and learn about their structure. c The Trust Chair asked whether the Trust would be applying for Magnet Accreditation or whether this was an internal check. The Director of Nursing explained that the standards are tailored more to acute hospitals than mental health and community so they will do more development work first, particularly around degrees for band 7s, and eventually apply for accreditation. d Anne Grocock asked what resources are needed to help progress the work and whether reduction in agency costs could help. The Director of Nursing said that the Trust is good at developing strategies but it is difficult to find the resources to progress the work. She said she was working with Tim Boylin on reducing agency spend. e The Trust Chair asked whether the influx of cash could be used to invest in the nursing strategy work. The Director of Finance agreed to look into this. f The Committee noted the report.

6. Nursing Revalidation Policy a Discussed in matters arising.

7. Safety Sub-Committee Escalation Report a The Director of Nursing presented paper QC 14/2017 and highlighted that 6-8 wards had staffing issues with gaps despite use of bank and agency staff however most wards were meeting safe levels of staffing using bank and agency. She explained that work was underway as part of the Carter Review to look at how effectively nursing resources are being utilised at ward level. She said that a module will be added to e-rostering which will enable rostering to become more sophisticated and build in patient acuity. She added that staffing pressures had impacted on training due to difficulties releasing staff. Learning and Development and IM&T are focusing on opportunities to do more teleconference and online training. b The Director of Nursing highlighted good news around pressure ulcers and said there had been no lapses in pressure damage across the Trust for 17 days whilst noting that individual wards had been even longer. c The Director of Nursing said that self harm rates are concerning, particularly Bucks AMHT and the 2 unexpected deaths on Ruby Ward. She explained that the situation on Ruby Ward had stabilised and that work continued with the CCG and regulators. d The Director of Nursing highlighted a rise in secret smoking related incidents and said Kate Riddle was leading on re-engaging smoke free work. She noted tensions between doctors and nurses due to leave being granted for smoking. e The Director of Nursing said there were 765 staff who do not have an up- to-date DBS check in place which is not acceptable. The Trust Chair said this was a major concern and the Director of Finance agreed to follow this up and report back to the next meeting. f Anne Grocock asked whether a reason had been identified for the self- harm incidents in Bucks AMHTs. The Director of Nursing said the incidents mainly involved patients with personality disorder and noted that pathways for Bucks and Oxon are different resulting in patients in Bucks being

admitted quicker. Rob Bale added that work is underway to review the personality disorder pathway. The Director of Nursing agreed to bring a RA/RB report regarding Bucks and Ruby Ward incidents following review. g Anne Grocock queried the high number of RIDDOR incidents and the Director of Nursing explained the majority of these were related to the rise in incidents of violence and aggression. She explained that work is underway with HR to look at managing violence and aggression and support staff.

Incident and Patient Safety Quality Report h John Allison noted the well written report and queried whether there was a problem with disposal of sharps in Podiatry. Pete McGrane said there had been a few incidents where blades were not detached before putting in the sharps bin. He said there were no injuries however there was a risk that the individual sterilising could be injured. i John Allison asked what was happening regarding the young person on Highfield who is requiring exceptional care. Wendy Woodhouse explained this patient had complex presentations managed on open ward with plans for discharge however their presentation worsened and they were sectioned. She said they were trying to find a secure PICU placement with NHS I but this has not happened so patient is being managed in seclusion. She said St Andrews and Huntercombe have both assessed the patient but there has been no outcome. The Chief Operating Officer said there had been lots of escalation to NHS England and the Chief Executive had planned to write directly to NHS England to escalate further. He said the solution was to get tier 4 CAMHS commissioning which would allow the Trust to look at building capacity. j The Director of Nursing said there were similar problems with the individual in long term seclusion on Thames House and explained that the patient was still third on the waiting list for Rampton. She said the case had been escalated to the CQC and is reviewed by the Executive team every week. k The Trust Chair said that as both cases had been escalated to NHS England with no change this now needed to be escalated politically. l Mike Bellamy noted an improvement in violence and aggression and skin

integrity incidents. He said it would useful to know the progress for the skin integrity roll out rather than just the initiative. John Campbell said the skin integrity target is 0 acquired grade 3 or 4 pressure damage by April 2018. He explained that clinical psychologists have worked with clinical teams around patients with long term conditions to help support them better. He added that the Directorate were looking for support from Public Health England on a public awareness campaign for skin integrity. m The Committee noted the report.

8. Safety Sub-Committee Annual Report a The Director of Nursing presented paper QC 16/2017 which provided a summary of areas of good compliance and risk over the last year. The Trust Chair noted that safety thermometers are not used in practice but and the Director of Nursing explained that it is being used much more in physical health than in mental health. It was agreed that safety thermometer would be included in the Directorate Quality Reports. b The Committee noted the report.

9. Effectiveness Sub-Committee Escalation Report a The Medical Director presented paper QC 17/2017 and highlighted that the information governance training target of 95% was achieved thanks to a lot of input from Martyn Ward. He said the next step was to look at how to maintain this as well as looking at basic life support and infection control training. b The Medical Director reported that Mental Health Act (MHA) compliance remains an area of unsatisfactory compliance, particularly around section 17 leave forms. He said there was lots of work ongoing to re-design the form and educate clinical teams. c He explained that the previous concern regarding the legitimacy of paramedics to possess and supply controlled drugs other than diazepam and morphine had not been resolved. The Trust Solicitors were aware of the issues and are drafting a letter to the Home Office asking for exemption and changes to future legislation.

8 PUBLIC Minutes of the Quality Committee, 10th May 2017 d Anne Grocock noted the plans to bring Public Health and Physical Health groups together. She asked whether this would include the Diabetes Steering Group and where this would report to. John Campbell explained that the Diabetes Steering Group would remain separate and would continue to report up to Physical Health Group which then reports to the Effectiveness Sub Committee.

Clinical Audit Report e The Medical Director presented paper QC 18/2017 and explained that despite changes in staffing in the corporate audit team the position was not further behind than normal. He noted that most of the reports had been rated good. f The Committee noted the Effectiveness Sub-Committee Escalation Report and Clinical Audit Report.

10. Well Led Sub-Committee Escalation Report a The Director of Finance provided an oral update and said the meeting received updates on recruitment and retention, whistleblowing, information governance training, Iwantgreatcare, equality and diversity, the staff survey and the ongoing performance review. He said that they checked the impact of the Cost Improvement Programme (CIP) and made sure there was appropriate clinical sign off. b He said that the gender identity policy for staff had been circulated for sign off by the Well Led Sub Committee and would then come to Quality Committee for final sign off. c The Committee noted the oral update.

11. Caring and Responsive Sub-Committee Annual Report a Dominic Hardisty, Chief Operating Officer joined the meeting. b The Chief Operating Officer presented paper QC 20/2017 and said there were lots of areas of good practice and any areas of concern had been discussed at mitigations/reviews put in place. He explained that a review was underway to ensure the meeting is meeting CQC standards.

Complaints and PALS Annual Report c The Chief Operating Officer presented paper QC 21/2017. Mike Bellamy commented on how effective PALS is and how quickly they provide a response. d The Committee noted the Caring and Responsive Sub-Committee Annual Report and Complaints and PALS Annual Report.

12. Strategy For Friends, Families and Carers a The Chief Operating Officer presented paper QC 22/2017 and explained that there was a plan to re-launch the Strategy For Friends, Families and Carers in June as part of National Carers Week. b He added that the Trust had been awarded two star triangle of care status and they are keen to move to three stars. c Anne Grocock asked whether the governors had been involved in this. The Chief Operating Officer explained that governors had not yet been involved but a focused session with interested governors would be planned to get their input. d The Committee noted the strategy.

13. Board Assurance Framework (BAF) and Trust Risk Register (TRR) a The Director of Corporate Affairs presented paper QC 23/2017 and highlighted links had been made between the BAF and TRR. b The Director of Nursing asked whether the potential impact from the OUH financial position should be showing as red on the risk register. It was agreed that this would be discussed further at Board Seminar. c Mike Bellamy asked when the Board would see complete CIP ideas and the Director of Finance said it would be going to Board at the end of May. d The Trust Chair reported that the Lead Governor had raised concerns about an operational matter and said it needed to be made clearer to governors

what their responsibilities are. Anne Grocock said there was a similar issue regarding what goes to public and private Board meetings. The Director of Corporate Affairs said she was reviewing this and said that the Lead and Deputy Lead Governor now receive the private agenda so they can challenge any items they do not think should be private. Sula Wiltshire said as a governor she is aware that there has been some disquiet from other governors that they may be straying into areas which are not there responsibility. e The Committee noted the Board Assurance Framework and Trust Risk Register.

14. Quality and Safety Reports

Older Peoples Directorate a Pete McGrane provided an oral update and agreed to circulate the report with the minutes. He highlighted overdue serious incident (SI) actions had increased from 9 to 22 in month 11 to 12. He added that there had been 2 cases of c-diff in the year to date. b Pete McGrane reported that Personal and Patient Safety Training (PPST) is currently at 87%, resuscitation training 83% and safeguarding 88%. He said that the Directorate were planning a safety week to improve training rates. c Pete McGrane said that the staff survey results showed that a higher number of staff in the Directorate were having PDRs however they found them less useful. He said there would be a focused piece of work to improve PDRs. d Pete McGrane reported that 78% of the performance indicators had been achieved and noted that there were some areas of significant over performance. Work is underway to understand the reasons for the over performance.

Children and Young Peoples Directorate e Wendy Woodhouse presented paper QC 25/2017 and highlighted the CQC action plan was on target. She said the Directorate were working on documentation on carenotes and were waiting for further advice from

Lynda Dix regarding the segregation policy. She reported that Iwantgreatcare patient feedback system was working well and feedback was positive, complaints and MP requests were on target and audit performance was good. f Wendy Woodhouse said that following a recent serious incident involving a young person who died by hanging, the Directorate are reviewing good practice and procedures where young people have care from both NHS and private sector. She will be circulating a risk note to inpatient and community teams. g Wendy Woodhouse provided an update on the CYP performance review and highlighted CYP report against 1000+ indicators and were below on 11. She said that 8-12 week waits were being achieved for most of CAMHS however 4 weeks waits were not being hit consistently. h Wendy Woodhouse provided an update on tenders and said that the Public Health Promotion and Bucks CAMHS bids had been successful. She added the most capable provider process for SWBaNES would finish in June 2017 and the Bucks Speech and Language Therapy contract ended in April 2017. She added that the Directorate was looking at bidding for community forensic CAMHS for Oxon, Bucks and Berks as well as new models of care for CAMHS tier 4 and adult eating disorders. i Mike Bellamy said he and John Allison did a visit to Cotswold House Oxford and noted the majority of patients were Oxford University students. He said that they needed better links with the university health service to provide better care for these patients. The Trust Chair said Sue Dopson was trying to look into this previously. Wendy Woodhouse said this had been highlighted to the CCG when looking at Community Eating Disorder Services as well as concerns that universities often allow people to carry on when not fit for study. The Chief Operating Officer agreed to raise this issue DH with Oxfed, who provide nurses to Brookes University and colleges, and Oxford University. j The Committee noted the reports.

15. Well Led Review Update a The Director of Corporate Affairs provided on oral update regarding the

Well Led Review. She said that a self-assessment of the Board and Extended Executive had been completed and an overall rating and development plan had been approved. She explained that this would be considered as part of the ongoing review by PwC with the full report expected to be finalised in June or July. b The Committee noted the oral update.

16. Transition of Learning Disability Services from Southern Health NHS FT to Oxford Health NHS FT

Joanna Glasscock joined the meeting. a Joanna Glasscock presented paper QC 26/17 regarding the transition of learning disability services from South Health NHS FT (SHFT) and explained the key issue is managing quality particularly around the management of policies and procedures. b The Trust Chair asked whether the plan to complete full integration of policies and procedures within 6 months was quick enough. The Director of Nursing said this would be looked at in more detail at Board Seminar, however she felt it was better to do a thorough review and get it right than to rush and make a mistake. c The Chief Operating Officer noted that further discussion was needed around Evenlode. d John Allison asked whether the Trust was prepared for any follow through in light of the prosecution against SHFT. The Director of Finance said there is a separation however this will not be the case if individuals involved in the incident transfer to the Trust. The Director of Nursing added that the Trust had not seen the level of detail required to know whether staff involved in the incident are still employed or are under disciplinary or NMC review. She asked that this be reviewed weekly at the Executive meeting. e The Director of Finance said the Trust should not be taking any liability unless risks had been identified before the transition and no action taken.

Joanna Glasscock left the meeting.

13 PUBLIC Minutes of the Quality Committee, 10th May 2017 f The Committee noted the report.

17. Oxfordshire Joint Management Group (JMG) a The Chief Operating Officer presented paper QC 27/2017 and said that the situation is moving in the right direction but remains a concern. b The Committee noted the minutes.

18. Buckinghamshire Joint Management Group (JMG) a The Chief Operating Officer presented paper QC 28/2017 and said there were no major issues to escalate. b The Committee noted the minutes.

19. Any Other Business a No other business to discuss.

The meeting was closed at: 12:25 Date of next meeting: Wednesday 12 July 2017 09:00-12:00 Unipart Conference Centre (Effectiveness Sub-Committee in attendance)