Report to Trust Board · Trust Board 26 November 2013 Incorporating community services in Exeter, East and Mid Devon Trust Secretariat Page 1 of 25 . Report to. Trust Board . Date

Quality Assurance Committee Minutes 10 September 2013 Northern Devon Healthcare NHS Trust Trust Board 26 November 2013 Incorporating community services in Exeter, East and Mid Devon

Trust Secretariat Page 1 of 25

Report to Trust Board

Date Tuesday 26 November 2013

Agenda Number 2.2 Agenda Item Quality Assurance Committee Minutes 10 September 2013

Sponsor Andy Ibbs, Commercial Director

Prepared by Geraldine Garnett-Frizelle, Minute Secretary

Presented by Chris Snow, Non-Executive Director and Chair

EXECUTIVE SUMMARY 1 Purpose and Key Issues

The purpose of this paper is to present the minutes of the Quality Assurance Committee meeting held on Tuesday 10 September 2013, numbers 110/13 to 143/13. Significant Issues of Interest: • Item 127/13 – The target response rate for the Friends and Family Test for North Devon District

Hospital and A&E is 25%. The response rate for A&E was 0.9% and the overall Trust response rate is 6.0%. Options for increasing the response rate in A&E are being explored.

• Item 135/13 – The Trust’s Quality Account 2012-13 received limited assurance from the external auditors. A Significant Event Audit was undertaken to review the process.

• Item 138/13 – There has been a Devon-wide agreement to proceed with the Liverpool Care Pathway Version 12 as this helps staff and supports the training programme to provide palliative care.

Key Risks Discussed: • Item 113/13 – The Committee was advised that there was feedback that patients were not

receiving analgesia on time. The Committee requested assurance on what action was being taken to address this.

• Item 123/13 – There is a risk of a significant financial penalty for the Trust if the target for Clostridium difficile for the year is breached. The Trust is currently discussing any cases outside of the Trust’s control with the Northern, Eastern and Western Devon Clinical Commissioning Group.

Key Decisions Taken: • Item 114/13 – Following a presentation and discussion, the Committee approved the

introduction of the treatment – Coblation Tonsillectomy. 2 Supporting Information

The minutes are attached.



3 Controls and Assurances

The minutes of the meeting are considered by the Quality Assurance Committee for accuracy. Following discussion, amendments may be recorded as appropriate. The minutes are then formally approved by the Committee. An accurate record of the proceedings of the meeting is required in order to ensure that the Board meets its duties in accordance with the Trust's Scheme of Delegation, Standing Orders and Standing Financial Instructions. Copies of the Quality Assurance Committee minutes are presented to the Audit and Assurance Committee and to the Trust Board to note. The Trust's clinical governance management arrangements have been developed to meet the requirements of the NHS Litigation Authority's Risk Management Standards for Acute Trusts and of the Healthcare Commission's Standards for Better Health.

4 Legal Implications

The legal implications have been considered and none have been identified.

5 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report.

6 Patient, Public and Staff Involvement

The Trust's business planning process incorporates patient and public involvement. Robust and effective financial control and risk management systems ensure that the Trust's services can be developed and delivered to meet the needs of patients in the medium term.

7 Cost Implications

There are no cost implications. 8 Potential Risk to the Organization

If the minutes are not approved by the Quality Assurance Committee the Trust will be at medium risk of not acting in accordance with the organisation’s Standing Orders, Standing Financial Instructions and Scheme of Delegation.

9 Committee Prompts

• Has the Board had an opportunity to raise questions or concerns with the Chair of the Committee?

• Is the Board confident that there are effective systems for identifying potential issues early and for keeping the Committee informed?



10 Recommendations

The Board is asked to RECEIVE the minutes of the Quality Assurance Committee meeting held on Tuesday 10 September 2013.

11 References

Not applicable.

12 Strategic Objectives

The Trust’s Strategic Objectives were reviewed by the Board in February 2012.

Highest quality Flexible and multiskilled workforce

X Sustainable services X Efficient and effective Integrated health and social care Local provider of choice

13 Principal Risks

The Principal Risks have been identified through the Trust’s risk management processes. They are updated as and when required.

Financial planning & management Clinical records management Strategic & business planning Leadership & management Workforce numbers Unsafe behaviour Workforce skills External demands

X Procedural management Partnership arrangements Equipment & facilities arrangements Communication



Minutes of a meeting of the Quality Assurance Committee held in the Boardroom,

North Devon District Hospital, on Tuesday, 10 September 2013 PRESENT: John Coop Associate Medical Director

Katie Cross Consultant Surgeon Alison Diamond Medical Director

Tim Douglas-Riley Non-Executive Director Carolyn Mills Director of Nursing

Chris Snow Non-Executive Director and Committee Chair

IN ATTENDANCE:

Mike Ambridge Medical Equipment Manager Fiona Baker Lead Nurse Infection Prevention and Control (North) Laurie Baxter Associate Specialist (for Item 114/13) Juliet Cross Head of Corporate Governance Geraldine Garnett-Frizelle Minute Secretary Becky Haynes Interim Risk Manager Sarah James Head of Quality and Safety Mandy Kilby Investigations Lead Stuart Kyle Associate Medical Director and Chair of the Drugs and

Therapeutics Committee (for Items 112/13 and 113/13) Maureen Manser Clinical Audit Manager Ian Robinson Head of Podiatry (Joint Member) Nick Rudling Safeguarding Adults Lead Sallie Scott Lead Midwife (Deputy for Toby Cooper) Lindsay Stanbury Deputy Directorate General Manager (Deputy for Sharon

Bates)

ACTION 110/13 CHAIR'S REMARKS

The Chair advised the Committee that due to the number of papers due for presentation and time constraints for some of the presenters, he proposed that a number of the papers on the Open Agenda be brought forward. In addition, the Committee was asked to agree to bring forward a number of papers from the Confidential section of the Agenda to ensure there was sufficient time for discussion, before returning to complete the Open Agenda. The Committee AGREED to both proposals. The Chair welcomed Dr Stuart Kyle to the Committee who was attending to give a presentation on the Governance of Medicines Management.

111/13 APOLOGIES

Apologies were received from:

Darryn Allcorn Head of Workforce Development Sharon Bates Directorate General Manager for Clinical Support

Services Toby Cooper Head of Midwifery (Children’s Service) Niall Ferguson Director of Pharmacy



Tina Naldrett Assistant Director of Nursing Julie Poyner Compliance Manager John Taylor Clinical Director Jan West Lead Nurse Infection Prevention and Control (East)

112/13 GOVERNANCE OF MEDICINE MANAGEMENT

Dr Stuart Kyle, Chair of the Drugs and Therapeutics Committee and Associate Medical Director, gave a presentation on the Revised Medicine Governance Structure. The Committee was advised that: • Following a review, the Drugs and Therapeutics Group now meet bi-monthly and it is

felt there is now appropriate representation. • Following Transforming Community Services, a bi-monthly Acute Trust Working

Group has been established. • As part of the review, the work of the Safer Treatment Action Group had been looked

at and their Terms of Reference revised to ensure they were fit for purpose and that membership was appropriate. The Group now meets bi-monthly and one of its functions is to review trends in medicine incidents across the Trust and put systems in place to help prevent recurrence.

• The Medicines Management Policy has been amended to clarify who is the lead for the Pan Devon Patient Group Direction Group.

• A review will be undertaken of the Prescribing Interface Group to establish how frequently meetings are required.

• The Formulary now has linked clinical pathways for GPs.

The Committee discussed Medicines Management and was advised that: • On joining the Trust, Junior Doctors have to complete an online learning package. • There is Eastern representation on the Drugs and Therapeutics Committee through a

nursing representative and a Pharmacy representative, although there is no Eastern clinician on the Committee.

The Committee NOTED the update on the Governance of Medicines Management.

113/13 DRUGS AND THERAPEUTICS COMMITTEE

Dr Stuart Kyle, Chair of the Drugs and Therapeutics Committee, presented the minutes of the meeting held on 18 July 2013. The Committee was advised that the key issues were: • The Acute Coronary Syndrome pathway was approved following a pilot within the

Medical Directorate. • New NICE Guidance was approved and recommended drugs added to the

Formulary. • A Standard Operating Procedure for the preparation and administration of injectable

drugs was approved, enabling existing policies to be harmonised across the Trust.



• The Non-Medical Prescribing Policy was approved. It was noted that prescribers needed to maintain their competence by using these skills on a regular basis and attending forums.

A query was raised regarding Formulary Management (Item 5). The minutes stated that Tina Naldrett, Assistant Director of Nursing, had attended the Learning from Patient Experience Group and reported that there was feedback that patients were not receiving analgesia on time. It was noted that there was no action attached to this and the Committee asked for assurance on what was being done to address this issue. Stuart Kyle agreed to raise this with Tina Naldrett and provide an update for the next meeting. SK In addition, a further query was raised regarding the NICE Clinical Guidelines presented to the Drugs and Therapeutics Committee. Katie Cross asked how the Guidelines are disseminated and was informed that they are received by the Medical Director in the first instance and then forwarded to the relevant clinician. The Committee requested that a check is carried out to ensure this is happening and an update provided to the November meeting. AD The Committee RECEIVED the minutes of the Drugs and Therapeutics Committee meeting held on 18 July 2013.

114/13 CLINICAL HOTSPOT

The Chair welcomed Laurie Baxter, Associate Specialist, who was presenting a Clinical Hotspot on Coblation Tonsillectomy. Alison Diamond, Medical Director, introduced the presentation with a brief background to the Clinical Hotspot. The Committee was advised that: • Coblation tonsillectomy represents a new treatment for the Trust. • It is a procedure already used extensively in the United Kingdom. • A few procedures have already been undertaken at the Trust approved by the

Medical Director on a case by case basis. • It is now proposed to offer the procedure more widely and it therefore needs formal

approval by the Quality Assurance Committee. Dr Baxter advised the Committee that: • Current methods in use for carrying out tonsillectomies were:

o “Cold steel” incision with bleeding initially controlled by pressure on a swab and residual bleeding controlled with ligatures.

o Electrosurgery – monopolar or bipolar diathermy. • Coblation is a variation of electrosurgery that uses lower temperatures than

diathermy and uses a probe to generate a radio frequency current through a solution of sodium chloride. It was introduced in the UK in the late 1990s and is used in Trusts across the country, including in the South West Peninsula.

• The benefits to the patient of coblation include a minimal risk of primary and secondary haemorrhage, reduction in pain following the procedure therefore requiring less analgesia, reduction in nausea and vomiting, reduction in operating time as the technique is more efficient and effective, reduction in length of stay for patients who



can often return home on the day of surgery, earlier resumption of a normal diet and fluid intake for patients which facilitates the recovery process.

• The benefits to the Trust of adopting this new procedure include an opportunity to review the current service requirements and techniques, updating practice where practicable to meet the needs of the patients, more efficient theatre utilisation, disposable equipment which reduces the requirement for sterilisation and traceability of equipment, no additional financial cost to the organisation to implement the procedure as the equipment is already on site.

• Dr Baxter was trained in this procedure in her previous employment and has already undertaken 300 audited cases. Use of this procedure now forms part of training for ENT surgeons.

A number of queries were raised and the Committee was informed that: • It would be reasonable to expect a minimum of 6 procedures a year to be undertaken

to maintain competence. Dr Baxter envisaged no difficulty in achieving this. • If approved, patients will be told about the procedure and offered the choice of opting

for it instead of traditional procedures. • An audit tool is being prepared for Dr Baxter by Clinical Audit to assess use of

coblation and outcomes for patients. • Nursing staff are already fully trained to deal with patients undergoing tonsillectomy.

If ward managers identify any additional training needs, this will be provided. • In her previous post, Dr Baxter had used the procedure with patients from rural

Cornwall. These patients were treated as a day case rather than as a 24 hours inpatient. There have been no problems in relation to the need to travel in a rural area if there were post-operative problems.

Following discussion, the Committee APPROVED the introduction of the Coblation Tonsillectomy

[As agreed at the beginning of the meeting, the Committee at this point went into Confidential session for a number of items, minuted separately under the Confidential Minutes, before returning to the Open Agenda]

115/13 PATIENT STORY

Carolyn Mills, Director of Nursing, presented the Patient Story. The Committee was advised that: • The patient story was collected as part of the evaluation process for the Torrington

Community Cares Project jointly led by the Trust and the Northern, Eastern and Western Devon Clinical Commissioning Group which is looking at ways to make best use of Torrington Community Hospital in the long-term, at the same time as assessing a new model of care focussing on supporting people to live safely and independently in their own homes.

• The patient story relates to a patient who, following a fall and a stay in hospital, developed a severe infection and required an intensive 14-week course of daily intravenous antibiotics. However, she was able to be discharged and admitted into the “virtual” ward to receive her care at home in the Torrington area, rather than have a lengthy stay in hospital.



• The story highlights two key issues: o People do not always realise the level of care that can be delivered within a

community setting in their own homes; and o Patients preferring to be cared for at home when they get the support required

for them to feel safe. • The Patient Story will also be presented to the Trust Board. The Committee RECEIVED the patient story.

116/13 MINUTES OF THE MEETING HELD ON 9 JULY 2013

The minutes of the meeting held on Tuesday, 9 July 2013, minute numbers 083/13 to 109/13, were considered and two amendments were requested. Item 089/13 Joint Safeguarding Children Board, last paragraph: Replace “regarding MASH procedures” with “Child Protection procedures.” Item 100/13 Safer Care Delivery Committee a comma should be inserted in the sentence: “The Committee also discussed the wider issue of the Trust’s responsibilities under the new national guidance on Duty of Candour, and how to manage sharing the learning on Bob whilst protecting both patient and staff confidentiality”. GGF Subject to these amendments, the minutes of the meeting held on 9 July 2013 were APPROVED. The Committee’s attention was drawn to the new format for the Executive Summary sheets introducing the minutes and was advised that it was hoped that this would provide a point of reference for items of significance contained within the minutes.

117/13 MATTERS ARISING

The Committee reviewed the Action Grid attached to the minutes and noted: Action 1 – 048/13 – Emerging Issues The Medical Director advised the Committee that an audit of mortality statistics for post-operative deaths had been undertaken. In approximately 40% of the notes audited, no cause of death had been recorded and this information will have to be obtained from the Coroner. Action ongoing.

Action 2 – 061/13 – Research and Development Group The Committee was informed that the Head of Quality and Safety, the Medical Director and Mark Cartmell, Director of Research and Development, had met and agreed the performance indicators that need to be presented to the Trust Board. Reporting will commence from November 2013. Action complete.



Action 3 – 078/13 – Any Other Business The Committee was advised that the Chair and key Committee members had met to discuss the programme of work for the Committee and the review had now been completed. Action complete. Action 4 – 089/13 – Joint Safeguarding Children Board The Committee was advised that presentation of the Terms of Reference of the Joint Safeguarding Children Board had been deferred to the November meeting. Action ongoing. The Committee was further advised that the Director of Nursing was aware of the concerns relating to the recent Ofsted inspection of Devon County Council Safeguarding Children services and any implications for the Trust will be monitored through the Joint Safeguarding Children Board. There are currently no implications for the Trust. Action complete. Action 5 – 093/13 – Quality Account 2012-13 The Committee was advised that a report had been presented to the Audit and Assurance Committee meeting in August and the Chair of the Quality Assurance Committee had been in attendance. Action complete. Action 6 – 094/13 – Hospital Transfusion Committee The Chair advised that he and the Medical Director had discussed ways of addressing poor attendance at Hospital Transfusion Committee meetings and the Medical Director will discuss this with the Chair of that Committee who is a Consultant at the Royal Devon and Exeter NHS Foundation Trust. There are governance issues which may need to be addressed. It was agreed that the action should be amended to reflect this. Action ongoing. Action 7 – 094/13 – Hospital Transfusion Committee The Head of Corporate Governance advised that she had met with the Risk Manager to look at the statement that a number of risks had been closed on the Corporate Risk Register without consultation with the Transfusion Team. Following a check, it was established that three risks, (Risk ID 1214, 1230 and 1231) had been closed by the Risk Lead as the last actions had been superseded by the EHR specification. One risk (Risk ID 2050) had been closed by the Risk Lead as actions had been completed. Action complete. Action 8 – 095/13 – Learning from Patient Experience Group The Committee was advised addressing smoking on Trust premises is an ongoing issue being addressed through various routes including the sending out of a standard letter.



Action complete. Action 9 – 097/13 – Infection Prevention and Control Committee The Committee was advised that the overarching risk relating to breaches of targets for MRSA and C. Difficile had been reviewed and this has already been recorded on the Corporate Risk Register as a Trustwide risk regarding compliance with national standards. Action complete. Action 10 – 097/13 – Infection Prevention and Control Committee The Committee was advised that individual Never Events from the National Framework are not recorded as individual risks on the Corporate Risk Register. Action complete. Action 11 – 102/13 – Clinical Audit and Effectiveness The Committee was advised that the Trust is partially non-compliant with NICE guidance relating Chronic Heart Failure due to insufficient resources in the cardiac team to be able to extend the rehabilitation exercise classes. The non-compliance has been recorded on the Corporate Risk Register and the risk has been accepted. Action complete. The Committee NOTED the actions that had now been updated and AGREED the completed actions.

118/13 RESEARCH AND DEVELOPMENT GROUP

Minutes of the Meeting held on 11 July 2013 Sarah James, Head of Quality and Safety, presented the minutes of the Research and Development Group meeting held on 11 July 2013. The Committee was advised that the key issues were: • The Group had been informed that regulations and process for research IRMER

(Ionising Radiation (Medical Exposure) Regulations) compliance were not being followed within the Research and Development Department. Once this had been identified, a risk had been added to the Corporate Risk Register. A process has now been put in place to gain retrospective approval and for study centres to be informed. A working practice document has also been developed for obtaining future IRMER approvals.

• Three serious adverse events had been referred back to the Principal Investigator for further review.

• The Terms of Reference for the Group had been reviewed and agreed. Terms of Reference The Terms of Reference were also presented on the agenda for information. The Committee RECEIVED the minutes of the Research and Development Group meeting held on 11 July 2013 and the Group’s Terms of Reference.



119/13 JOINT SAFEGUARDING CHILDREN BOARD

The Committee NOTED that the Terms of Reference for the Joint Safeguarding Children Board had been deferred and would be presented to the November meeting.

120/13 SAFEGUARDING ADULTS BOARD

Nick Rudling, Safeguarding Adults Lead, presented the minutes of the Safeguarding Adults Board meeting held on 16 July 2013 and the Board’s Terms of Reference. Minutes of 16 July 2013 The Committee was advised that the key issues were: • Training provision has been revised and a full day specifically for Trust staff is being

developed. A potential provider for this year has been identified. • Since the launch of the electronic incident reporting system, performance reporting

around safeguarding adults has become more robust, although some incidents are still being reported on the paper system which is making analysis difficult. A dip in reporting was noted for April which may have been the result of the changeover of reporting systems; this is being closely monitored.

• A meeting had taken place regarding the risk relating to use of restraint and actions agreed to take the risk mitigation forward.

• The Mental Capacity Act Facilitator secondment has now been in place for nearly six months and is proving successful. A repeat audit is due to commence in the autumn.

The Committee RECEIVED the Safeguarding Adults Board minutes of the meeting held on 16 July 2013. Terms of Reference The Committee was informed that the Terms of Reference had been reviewed as part of the annual review process. Key changes included: • A review of membership had been undertaken. • Learning Disability workstreams had been included in the programme of work. • There had been changes to frequency of meetings which will be on a quarterly basis

and new dates for the coming year. The Committee RECEIVED the Safeguarding Adults Board Terms of Reference.

121/13 TRUST COMPLIANCE REPORT – AUGUST 2013

Juliet Cross, Head of Corporate Governance, presented the Trust Compliance Report for August 2013. The Committee was advised that the key issues were:



• The Care Quality Commission undertook an unannounced inspection of Tiverton and District Hospital on 2 and 3 May 2013. The final report has been received and an action plan has been returned to the Care Quality Commission detailing how the Trust would meet the compliance actions. The actions are almost complete. Carolyn Mills REQUESTED that the report be presented to the Committee and it was AGREED that this would be circulated by email to members of the Quality Assurance Committee. JFC

• Preparations for the formal Level 2 Assessment for CNST, scheduled for 15 and 16 October 2013, are progressing. A self-assessment was due to take place during the first week of September and the CNST Core Group will review the outcome to identify shortfalls and make necessary adjustments before the formal assessment.

• Preparations for the formal Level 2 Assessment for the NHS Litigation Authority, scheduled for 4 and 5 March 2014, are underway.

• The Quality Governance Framework is being updated to enable the Trust to evidence examples of good practice against the new criteria included in Monitor’s recently published Compliance Framework 2013-14.

The Committee RECEIVED the Trust Compliance Report for August 2013.

122/13 SENIOR DOCTORS APPRAISAL ANNUAL REPORT

The Committee NOTED that the Senior Doctors Appraisal Annual Report had been deferred and would be presented to the November meeting.

123/13 INFECTION PREVENTION AND CONTROL COMMITTEE

Fiona Baker, Lead Nurse Infection Prevention and Control (North), presented the minutes of the Infection Prevention and Control Committee meetings held on 2 July and 6 August 2013. The Committee was advised that the key issues discussed at the meetings were: • There were no cases of MRSA Bacteraemia reported in May or June 2013. • There were three cases of Clostridium difficile in the acute trust, one over the profile

limit. A further three cases were reported in June bringing the total to six. It was recognised that there was a high financial risk for the Trust of going over the limit for 2013-14 which has been set at 10. As previously noted, there has been an upward trend Trustwide over the last six months, a trend also reflected in national data.

• The Committee had received the findings of a Significant Event Audit into the cases of Clostridium difficile which had confirmed that there were no episodes of prescribing outside Trust formulary.

• The Committee had received at its August meeting a report detailing changes to national guidance for Clostridium difficile and minor changes to the Policy were approved. One of the changes relating to stopping the prescription of proton pump inhibitors for patients predisposed to Clostridium difficile is being reviewed with Pharmacy.

• There were five outbreaks of gastro-intestinal illness in May 2013, two in community hospitals and three on medical wards at North Devon District Hospital. Norovirus had been identified as the cause in two of the outbreaks. There were two outbreaks of gastro-intestinal illness in June 2013, one in a community hospital and one in a



medical ward at North Devon District Hospital. No causative organism was identified for either outbreak.

The Committee queried whether there would be a financial penalty for the Trust if the target for Clostridium difficile for the year is breached and the Director of Nursing confirmed that there would be a fine of £600k. However, the Trust would discuss with the Northern, Eastern and Western Devon Clinical Commissioning Group any cases identified that were outside the Trust’s control. The Committee RECEIVED the minutes of the Infection Prevention and Control Committee meetings held on 2 July and 6 August 2013.

124/13 MATERNITY SERVICES PATIENT SAFETY FORUM

Sallie Scott, Lead Midwife, presented the minutes of the Maternity Services Patient Safety Forum meetings held on 12 June and 14 August 2013. The Committee was advised that the key issues were: • The action plan for a Serious Incident Requiring Investigation report relating to baby

identification tags had been completed. • The Forum noted that the Caesarean Section rate for the Trust is at 26.7% which is

the third highest in the region. The Committee RECEIVED the minutes of the Maternity Services Patient Safety Forum meetings held on 12 June and 14 August 2013. The Committee NOTED that the Maternity Services Patient Safety Forum Committee Compliance Report had been deferred and would be presented to the November meeting.

125/13 MEDICAL DEVICES COMMITTEE

Mike Ambridge, Medical Equipment Manager, presented the minutes of the Medical Devices Committee meeting held on 1 August 2013. The Committee was advised that the key issues were: • The Medical Devices Management Key Performance Indicators had been presented

for Quarter 1 2013-14. • The issue of technical obsolescence and financial obsolescence was discussed.

The Committee will monitor depreciation trends but is not in a position to evaluate the financial implications. This will be raised with the Deputy Director of Finance.

• Training – Log books have been rolled out to all clinical areas and six monthly random audits will continue to be completed by Workforce Development to monitor compliance.

The Committee RECEIVED the minutes of the Medical Devices Committee meeting held on 1 August 2013.

126/13 SAFER CARE DELIVERY COMMITTEE



Minutes of the Meeting held on 6 August 2013 The Committee NOTED that the minutes of the Safer Care Delivery Committee meeting held on 6 August 2013 had been deferred and would be presented to the November meeting.

Safer Care Delivery Committee Compliance Report The Head of Quality and Safety presented the Compliance Report for 2012-13 and the Committee was advised that the key issues were: • The Committee had met six times from April 2012 to March 2013 and no meetings

had been cancelled. • All meetings were quorate. • Attendance has not met 75% in all cases. • The Group discharged its responsibilities in accordance with its Terms of Reference

and received routine reports and approved key Trust documents. • Areas of development included a continued review of and development of actions to

address patient safety risk to the Trust and a review of the provision and use of patient safety data in the Trust.

The Committee RECEIVED the Safer Care Delivery Committee Compliance Report for 2012-13. Terms of Reference The Head of Quality and Safety presented the Terms of Reference for the Safer Care Delivery Committee and advised that they had been reviewed as part of the annual review process. Minor amendments to membership had been made. The Committee RECEIVED the Safer Care Delivery Committee Terms of Reference.

127/13 LEARNING FROM PATIENT EXPERIENCE GROUP

Carolyn Mills, Director of Nursing, presented the minutes of the Learning from Patient Experience Group meeting held on 18 July 2013. The Committee was advised that the key issues discussed were: • Friends and Family Test

o There is a target of 25% response rate for North Devon District Hospital and A&E. Currently the A&E response rate is 0.9% and the overall Trust response rate is 6%. Options for increasing the response rate in A&E are being explored with the Team.

o Glossop Ward have scored 50%+ for the national Friends and Family test against a target of 60%+. This is being closely monitored and a piece of work focusing on balanced score card data for this ward is being completed by the medicine division.

o The Test is an important part of the patient experience triangulation for the quality agenda for the Trust.

• The Mystery Shopper Scheme in association with the Patients’ Association has restarted.



• The top four Complaint themes remain Clinical Care and Treatment, Communication, Attitude of Staff and Access to Clinical Services.

• The top four PALS themes also remain the same – Information Provision, Access to Clinical Services, Communication and Attitude of Staff (combined) and Clinical Care and Treatment.

The Committee RECEIVED the minutes of the Learning from Patient Experience Group meeting held on 18 July 2013. Compliance Report 2012-13 The Committee was advised that the key issues were: • The Committee had met six times in 2012-13 and all meetings were quorate. • Attendance at Committee meetings has met the requirements of the Terms of

Reference. • The Committee had reviewed its effectiveness and concluded that key decisions had

been made and workstreams monitored. • The Committee had discharged its responsibilities in accordance with its Terms of

Reference and received routine reports and approved key Trust documents. • Areas of development had included the development of the patient stories presented

to the Quality Assurance Committee and the Trust Board, the outcome of which has been listening to user feedback and acting upon it. A further development has been the use of volunteers on the wards which has led to the collection of much more responsive real-time feedback.

The Committee RECEIVED the Learning from Patient Experience Group Compliance Report for 2012-13. Terms of Reference The Committee was advised that the Terms of Reference had been deferred and would be presented to the November meeting.

128/13 CLINICAL AUDIT AND EFFECTIVENESS PROGRAMME

Maureen Manser, Clinical Audit and Effectiveness Manager, presented the Clinical Audit and Effectiveness Programme Exception Report and update. The Committee was advised that the key issues were: • There are currently 166 topics registered on the Trust’s Annual Clinical Audit and

Effectiveness Programme which were identified through the process now in place for developing, delivering and monitoring the Programme.

• The programme is rolling and topics are added to the programme as and when they are identified throughout the year.

• From September 2013 progress and exception reporting for Clinical Audit and Effectiveness projects will form part of the Divisional Performance meetings.

• All projects are progressing to plan apart from 30 which appear on the Exception Report. Of these: o Six did not commence on the planned start date but are National Clinical Audits

and therefore out of the Trust’s control; o Thirteen are awaiting action plans;



o Four relate to record keeping audits which have not yet commenced; and o Seven have specific reasons for not progressing.

Following discussion, the Medical Director advised that compliance with GP Standards was not being monitored yet. The GP Standards are currently being consulted on. Any audits of compliance will be delayed until later in the year following agreement, to give time for them to be embedded. The Committee REQUESTED an update at the November meeting on ID450 NPSA/MDA Alert MDA 2012/20 Oral swabs with foam heads as this had been discussed by the Safety Alerts Group. JFC The Committee RECEIVED the Clinical Audit and Effectiveness Programme Exception Report and update.

129/13 NICE STANDARDS

Maureen Manser, Clinical Audit and Effectiveness Manager, presented the NICE Quality Standards update. The Committee was advised that: • The report provides a progress update on the implementation of NICE Guidance

across the organisation. • Forty three have been published, of which thirty two are relevant to the Trust, nine

are awaiting confirmation and two are not relevant. • Thirteen are still to be allocated a Clinical Audit and Effectiveness Facilitator. • Four require no further action as they show compliance with all the component

statements that are relevant to the Trust. • Eighteen have an action plan to address the statements relevant to the Trust. • One Quality Standard, QS27 – Epilepsies in children and young people, has three

statements not able to progress to plan as there is no Epilepsy Nurse Specialist in the Trust. The Committee requested that it be established whether this was a commissioning problem and that in future that information be included on the Executive Summary. MM

• Individual reports will be presented to the Divisional Performance meetings. The Committee RECEIVED the NICE Quality Standards update.

130/13 NICE GUIDANCE EXCEPTION REPORT

Maureen Manser, Clinical Audit and Effectiveness Manager, presented the NICE Guidance Exception Report for August 2013. The Committee was advised that: • 861 items of NICE Guidance have been published since 1 June 2001 which have all

been individually assessed for relevance to the Trust by the Medical Director and respective Clinical Leads and a total of 326 were deemed relevant.

• The majority of relevance to the Trust relate to Clinical Guidelines and Technical Appraisals.



• There are 24 items of Guidance that have not yet fully completed the process and therefore appear on the Exception Report. Of these: o Four have not yet undergone a baseline assessment by their Division; o Seven have undergone a baseline assessment but have not yet identified

whether an action plan is required; o Ten have an action plan in place and are in the process of identifying the gaps;

and o Three have completed the process and are partially or non-compliant and have

been placed on the Corporate Risk Register by the relevant Divisions. • It is planned that in future the data will be available via Covalent which will improve

the presentation of the report. The Committee RECEIVED the NICE Guidance Exception Report for August 2013.

131/13 CLINICAL AUDIT – POLICIES

The Committee was advised that the Clinical Audit and Effectiveness Policy, the National Confidential Enquiries Best Practice Policy and the NICE Guidance Implementation Policy had been deferred for presentation to the November meeting.

132/13 INCIDENT MANAGEMENT AND INVESTIGATION POLICY

Mandy Kilby, Investigations Lead, gave a verbal update to changes to the Incident Management and Investigation Policy. The Committee was advised that: • The Policy had been reviewed and a number of minor revisions had been made to

ensure that the policy met the following requirements: o Contractual Duty of Candour; o Updated RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences

Regulations) regulations 2013; and o Information Governance Toolkit requirements for reporting, managing and

investigation Information Governance Serious Incidents Requiring Investigation.

The Committee NOTED the revisions to the Incident Management and Investigation Policy.

133/13 ORGAN DONATION COMMITTEE

Lindsay Stanbury, Deputy Directorate General Manager for Clinical Support Services, presented the Organ Donation Committee Compliance Report for 2012-13 and revised Terms of Reference. Committee Compliance Report 2012-13 The Committee was advised that: • The Organ Donation Committee had met twice in 2012-13 and two meetings had

been cancelled due to the number of apologies received. Both meetings held were quorate.



• Attendance at meetings had not been 75% in all cases and as a result the membership of the Committee has been reviewed.

• The Committee discharged its responsibilities in accordance with its Terms of Reference and received routine reports and approved key Trust documents.

• Areas of development included an annual workplan and review and update of the Trust’s Organ Donation Policy and Tissue Donation Policy in line with local and national developments.

The Committee RECEIVED the Organ Donation Committee Compliance Report for

2012-13 Terms of Reference The Committee was informed that the Terms of Reference had been reviewed as part of the annual review process. There had been only one change; membership had been reviewed and revised to address issues related to attendance at meetings. The Committee RECEIVED the Organ Donation Committee Terms of Reference.

134/13 IMPROVING THE SAFETY OF PATIENTS IN ENGLAND

Carolyn Mills, Director of Nursing, presented the Improving the Safety of Patients in England report. The Committee was advised that: • The report was published by the National Advisory Group in August 2013. The

Group was led by Don Berwick, President Emeritus and Senior Fellow of the Institute of Healthcare Improvement.

• The report is a review of what changes are needed to support the lessons learned from the Mid-Staffordshire NHS Foundation Trust Public Enquiry and others.

• Ten recommendations were made to support a system in the NHS devoted to continual learning and improvement in patient care, top to bottom and end to end.

• The recommendations will be reviewed by the Executive Team and cross-referenced with the Trust’s responses to the Mid-Staffordshire NHS Foundation Trust Public Enquiry and the Keogh Mortality Review.

• Where gaps are identified, an Action Plan will be developed and monitored via the Trust’s risk management arrangements.

• Progress reports will be presented to the Quality Assurance Committee and the Trust Board.

The Committee RECEIVED the Improving the Safety of Patients in England report.

135/13 QUALITY ACCOUNT 2012-13 SIGNIFICANT EVENT AUDIT REPORT

Sarah James, Head of Quality and Safety, presented the Significant Event Audit – Quality Account 2013-14 report. The Committee was advised that:



• Following publication of the Trust’s Quality Account 2012-13, a limited assurance report was presented to the Trust by the External Auditors (Grant Thornton LLP) which related to one mandatory performance indicator within the Quality Account, Readmission within 28 days.

• Grant Thornton’s report stated that “The Trust used the Dr Foster benchmarking tool to calculate the percentage of patients readmitted within 28 days indicator. We were able to confirm the accuracy of the data submitted to Dr Foster by the Trust but have been unable to agree the output from Dr Foster to the Trust’s information systems. We are therefore unable to confirm the accuracy, validity, relevance or completeness of this indicator”.

• A Significant Event Audit including a round table review was undertaken and a number of recommendations were agreed, including: o A letter to be sent to the Audit Commission outlining the concerns raised through

the investigation process; o A letter to be sent to the Department of Health outlining the concerns raised

through the investigation process; and o The Significant Event Audit report and proposed letters to go to the Audit and

Assurance Committee for approval prior to sending. The Committee RECEIVED the Quality Account 2012-13 Significant Event Audit report.

136/13 LOCAL SUPERVISING AUTHORITY ANNUAL REPORT 2012-13

Carolyn Mills, Director of Nursing, presented the Local Supervising Authority Annual Report 2012 – 13 to the Nursing and Midwifery Council. The Committee was advised that: • The report was published in July 2013 and was prepared by the South West, South

Central and South East Coast Local Supervising Authorities. • It provides an overview on how the three Local Supervising Authorities provide

information to the Nursing and Midwifery Council on how the standards for the statutory supervision of midwives are being met through a quarterly monitoring process.

• The report also provides quantitative and qualitative information and evidence in order to meet statutory requirements.

• Five priorities have been identified for the NHS England Local Supervising Authorities (South) for 2013-14: o Local Supervising Authority Function o Monitoring safety and sharing good practice o Monitoring standards of supervision o Investigating poor practice o Communication and engagement.

• The Local Supervising Authority Report and Action Plan for the Trust will be presented to the next meeting.

The Committee RECEIVED the Local Supervising Authority Annual Report for 2012-13 for South West, South Central and South East Coast Local Supervising Authorities.

137/13 TRUST RESPONSE TO FRANCIS REPORT



Carolyn Mills, Director of Nursing, gave a verbal update on the Trust Response to the Francis Report. The Committee was advised that: • A draft report and action plan which set out the Trust’s progress against the

recommendations of the Francis Report where action is required for the Trust to meet those recommendations was presented to the Board at a Board Briefing session on 9 September 2013 for discussion.

• The Board agreed that the report needed to be cross-referenced with the Keogh Mortality Review and the Berwick Report before being formally presented to the Trust Board for approval at their meeting on 24 September 2013.

• Once approved by the Trust Board, the report and action plan will be presented retrospectively to the Quality Assurance Committee meeting in November 2013.

The Committee NOTED the verbal update on the Trust Response to the Francis Report.

138/13 EMERGING ISSUES

Liverpool Care Pathway Alison Diamond, Medical Director, updated the Committee on developments relating to the Liverpool Care Pathway. The Committee was advised that: • Following the Clinical Hotspot presentation relating to the implementation of Version

12 of the Liverpool Care Pathway which had been presented at the March Quality Assurance Committee meeting and approved, there had been a significant amount of national activity relating to the use of the Pathway.

• An independent review of the Liverpool Care Pathway was undertaken by the Department of Health and the findings were published in July with a number of recommendations that have a bearing on the NHS.

• The review and recommendations were discussed at a Devon-wide meeting and it was agreed to proceed to Version 12 as this helps staff and supports the training programme.

• Karen Ricketts, Consultant in Palliative Medicine, is undertaking an audit looking at the quality of the use of the Pathway to provide Board assurance that the Pathway is being used appropriately. An update of the audit results will be provided to the Quality Assurance Committee. AD

Maureen Manser, Clinical Effectiveness Lead, advised that the Trust is also registered for the national End of Life Audit. The Committee NOTED the verbal update on the Liverpool Care Pathway.

139/13 ANY OTHER BUSINESS There was no other business raised for discussion.

140/13 DATE OF NEXT MEETING



The next meeting of the Quality Assurance Committee will be held on Tuesday, 11 November 2013 between 10.00 – 1300 in the Boardroom, Exeter International Airport Offices.

141/13 CONFIDENTIAL SECTION

Items for discussion in the confidential session could include confidential clinical governance or individual patient issues.

142/13 EXCLUSION

The meeting RESOLVED that, due to the confidential nature of the final business to be transacted, the meeting moved to a confidential session. This was proposed by Tim Douglas-Riley and seconded by Alison Diamond.

143/13 CLOSE OF MEETING

There being no further business, the meeting closed at 12:00.



Quality Assurance Committee Action Grid – Open Section Updated 25 October 2013

12 March 2013 048/13 – Emerging Issues

1 A report to be presented to the Quality Assurance Committee on reported high mortality statistics for post-operative deaths.

AD 09.07.13 May 13 – Report to be presented to July meeting. This item relates specifically to fractured neck of femur. Jun 13 – Work is still ongoing. Sep 13 – An audit of mortality statistics for post-operative deaths had been undertaken and in approximately 40% of the notes audited no cause of death had been recorded. This information will have to be obtained from the Coroner. Nov 13 – AD has chased up with the Coroner.

Ongoing

9 July 2013 094/13 – Hospital Transfusion Committee

2 Chair and Medical Director to discuss how to address poor attendance at the Hospital Transfusion Committee meetings and address governance issues.

CS/AD 10.09.13 Sep 13 – Governance issues added to action.

Ongoing

10 September 2013 113/13 – Drugs and Therapeutics Committee

3 Drugs and Therapeutics Committee Minutes 18.07.13. 1. Assurance to be

sought from Tina Naldrett on what action is being taken regarding the feedback to the Learning from Patient Experience Group that patients are not receiving analgesia on time.

SK

12.11.13

Sep 13 – Tina Naldrett provided the following update: “Following the listening to user experience feedback about the timeliness of analgesia administration, there are several ways we are trying to address and improve this. Late administration is viewed as a medicines error. They are all

Closed



2. Assurance to be sought that the process for the dissemination of NICE Clinical Guidelines is being followed and

AD

12.11.13

reported through Datix, including late or missed doses and we review each incident to decide if a fuller SEA is required. We also look for the emergence of themes around this on patient safety and matron’s walkabouts so we can identify places in which this is the norm. Self medication is encouraged for those who have the capacity, as it enables people to administer their medicines including their own analgesia in a timely way. In addition, Matrons in community hospitals and senior nurses in our acute setting lead teams who are asking patients if they are comfortable on an hourly basis through the RU OK campaign and this has reduced the number of people reporting discomfort through late analgesia administration. Vulnerable patients are assessed and cared for through a more intensive approach called Comfort Rounding, with the same outcome for those who may not easily identify their need.”



Guidelines are being disseminated as appropriate.

116/13 – Minutes of the meeting held on 9 July 2013

4 Item 089/13 Joint Safeguarding Children Board, last paragraph: Replace “regarding MASH procedures” with “Child Protection procedures”. Item 100/13 Safer Care Delivery Committee minutes – comma to be inserted in the sentence: “The Committee also discussed the wider issue of the Trust’s responsibilities under the new national guidance on Duty of Candour , and how to manage sharing the learning on BOB whilst protecting both patient and staff confidentiality.

GGF

GGF

10.09.13 10.09.13

Oct 13 – Amendments made

Closed

121/13 – Trust Compliance Report – August 2013

5 The Care Quality Commission report on the unannounced inspection of Tiverton and District Hospital on 2 and 3 May to be circulated to the Committee.

JFC 10.09.13 Sep 13 – Report circulated.

Closed

128/13 – Clinical Audit and Effectiveness Programme

6 Update on ID450 NPSA/MDA Alert MDA 2012/20 – Oral swabs with foam heads to be provided.

JFC 12.11.13

129/13 – NICE Standards

7 Information to be provided on the Executive Summary sheet, where relevant, to indicate if there are commissioning issues.

MM 12.11.13

138/13 – Emerging Issues

8 Liverpool Care Pathway Audit being undertaken by Karen Ricketts looking at the quality of use of the Pathway to provide Board assurance that the Pathway is being used

AD 12.11.13

Nov 13 – Liverpool Care Pathway update on the Agenda.



appropriately. Update of audit results to be provided to the Committee.

Documents

Report to Trust Board · Trust Board 26 November 2013 Incorporating community services in Exeter, East and Mid Devon Trust Secretariat Page 1 of 25 . Report to. Trust Board . Date