Minutes of the Governance Committee held on Tuesday 27 January 2009 at 2.00pm in Meeting Room 1, Beckside Court Batley Present: Helena Corder Valerie Aguirregoicoa Dr Ajit Mehrotra Dr James Lee Chris Boyne Sue Smith
In attendance: Sheila Dilks Neill McDonald Jane Oâ€™Donnell Robert Flack Liz Butterfield Karen Chetham Barry Lane Alison Fearnley
Director of Corporate Services (Acting Chair) Non-executive Director General Medical Practitioner Medical Advisor Internal Audit Manager Assistant Director of Clinical Governance, Professional Development and Standards
Executive Director of Patient Care and Professions Assistant Director of Medicines Management and Prescribing Assistant Director Infection Control and Prevention Director of Provider Services Head of Knowledge and Learning Agenda Item AC/09/09 and AC/09/10 Telehealth Project Manager (Agenda Item GC/09/08) Assistant Director of Human Resources Corporate Governance Administrator
It was noted that Helena Corder would Chair the meeting in the absence of Mike Potts. GC/09/01
Apologies for absence Apologies for absence were received from Mike Potts, Chief Executive, Sue Ellis, Director of Human Resources and Organisational Development, Sarah Brackwell, Professional Executive Committee Representative, Dr Adrian Kenny, Medical Director, Terry Services, Assistant Director of Corporate Services and Risk Management, Peter Flynn, Director of Performance and Information and Bryan Machin, Executive Director of Finance.
Accuracy of minutes of meeting held on the 19 November 2008 The minutes of the Governance Committee held on 19 November 2008 were AGREED as a true and accurate record of the meeting once the following amendments were made: GC/08/ 59
Findings from the Health Service Journal â€“ QOF Local Issues
It was AGREED to add the following sentence to the end of the paragraph. Training events have occurred and are ongoing.
GP Appraisal Aggregated Report – Role of the Responsible Officer
It was AGREED that Sheila Dilks would redraft the second paragraph to read as follows: Sheila also advised that work had been undertaken to look at improving the GP Appraisal aggregated report following the issues raised at the last meeting. She also reported that Dr Anderson had set up two integrated clinical groups with CHFT and MYHT to explore cross cutting clinical issues. Finally Sheila Dilks advised that she thought her name should be recorded in the ‘Present’ column rather than being recorded as being ‘In attendance’, as she believed that she was a core member of the Governance Committee. It was recognised this was not consistent with the Terms of Reference (ToR). It was therefore AGREED that Helena Corder would revise the ToR). GC/09/03
Matters arising GC/08/88
Policies and Procedure (ratification process)
It was recognised that Helena Corder and Sue Smith were reviewing the policy ratification process to ensure that a robust system was in place. A flow diagram was being developed which would be explicit on what polices and procedures etc should go to which Committee’s etc. GC/08/142
Information Governance Update
Helena Corder advised the meeting that a discussion was timetabled at the next Information Governance Committee meeting to discuss information sharing protocols as previously agreed. It was noted that information sharing protocols were now on the PCT website. In addition it was recognised that actions were in place to support sharing information via email with the Local Authority. GC/08/145
Accreditation Panel Terms of Reference and Processes
It was noted that the revised Accreditation Panel Terms of Reference and Processes report would be tabled at the March Governance Committee meeting. Helena Corder also advised that the Governance Committee was not able to delegate authority to the panel to act. It was recognised that this would be the Board’s decision. GC/08/146
Protocol for Handling Health and Social Care Complaints
It was noted that an update on Handling Health and Social Care Complaints would be provided at the next meeting. Page 2 of 12
PALS Quarter 2 Report
Helena asked given the improved response to the questionnaire whether or not she was still to instruct the PALS team to stop undertaking the PALS “Tell us what you think” Questionnaire. GC/09/04
Infection Control in Dentistry Jane O’Donnell provided a verbal update. It was noted that the Business Case to support decontamination standards in General Dental Practices had been successful. Work was ongoing with developing infection prevention and decontamination quality indictors for the dental contract.
Information Governance update Helena Corder provided a brief verbal update on the key issues being considered and managed by the Information Governance Group: • •
Information Sharing Protocols – these were being revised Use of NHS Numbers – work was ongoing
Helena would provide a more detailed update at the next meeting. GC/09/06
Research and Research Governance Committee Revised Terms of Reference Sue Smith introduced the report and explained that following approval of the proposed local infrastructure the Terms of Reference had been revised following discussions at the last meeting. Following discussion it was suggested that the membership should be revised to include additional clinical involvement eg a GP representative on the group. The revised Terms of Reference were AGREED subject to the revised membership as outlined above.
Learning – Building Capability and Capacity for the future Sue Smith presented the Learning – Building Capability and Capacity for the Future report to the Governance Committee. Sue gave background to the paper and explained the purpose of the report was to update the Governance Committee on progress to strengthen the PCT’s training and education function. Within this were proposals to continue to build the learning capacity and capability of staff in order to deliver safe, high quality and cost effective services. Sue highlighted the four worksteams which the Learning Building Capability and Capacity Group had focused on to take work forward: • Mandatory training • Compulsory training (renamed Competency based Training) • E-Learning • Long Term Workforce Page 3 of 12
Progress against the above workstreams was noted by the Governance Committee. Sue explained the proposals for developing collaborative learning with the establishment of a Collaborative Learning Centre which would incorporate partners across the whole of Kirklees and Calderdale Health and Social Care Community. It was noted this would include Kirklees Community Healthcare Services. Sue added that in order to consider the viability of such a programme a feasibility study would need to be conducted. A discussion ensued and the Collaborative Learning Centre was elaborated on. Following discussion the Governance Committee AGREED to support the following in terms of the next stage of development: • •
Engage partner agencies in discussion at an appropriate level to engage interest to support this vision Conduct a feasibility study. This study would not only consider how such a partnership could be taken forward but also to identify any potential venue possibility – recognising this needs to be around organisational development Identify key leads within the interested sectors to take forward such a vision and build an educational brand for Kirklees and Calderdale Health and Social Care. Determine current investment and future financial opportunities.
Considering the above it was therefore AGREED to establish a Project Team to take this work forward as quickly as possible. Sue also AGREED to provide a progress report to the March Governance Committee. GC/09/08
Telehealth Project – Operational Documents Karen Chetham was welcomed to the meeting to present the Telehealth Project Operational Documents. Karen provided an overview of the Telehealth service and explained the documents in support of the implementation of the new Telehealth Service. She explained that Telehealth technology allowed clinicians to remotely monitor patients’ vital signs and is part of the self care agenda supporting patients to become more knowledgeable about their condition. It was recognised that NHS Kirklees was currently in the process of purchasing 100 units of Telehealth equipment. The units are aimed at patients who have long term conditions, and a recent history of admissions to hospitals or are frequent users of services, such as GPs, Ambulances etc. It was recognised that Community Matrons would be the main means of dispersing the equipment in the early implementation stages. The project was aiming to start installing Telehealth units into patient’s homes mid to end of March 2009. Page 4 of 12
It was noted that the scheme had been piloted in a number of other areas and that feedback had been positive. There was a discussion regarding the different types of units available their efficiency and whether the devices were suitable for vulnerable patients to use. Reference was made to two different units recognising different systems were recommended for certain patients/conditions. The Governance Committee requested greater assurance regarding the clinical benefits. Sheila Dilks advised that both systems were well evaluated in terms of their efficiency and that there was evidence to support reduced admissions to hospital. She reassured the Governance Committee that the aims of the project would be achieved and that an evaluation process would be undertaken to identify any issues. It was noted that the Long Term Conditions Board supported and approved the Telehealth Units and that the HIT teams and GPs had been involved in demonstrations etc. It was recognised that the Long Term Conditions Board would monitor the outcomes and it was AGREED these would be shared with the Governance Committee. The Governance Committee reviewed the supporting operational documents and a number of amendments were suggested. In particular, the following points were noted: • • • •
It was felt that the documents required a certain level of literacy to understand them – it was therefore recommended that these are reviewed by the Readers Panel and Communications Team Consent form – it was felt it was in the patients best interest that patients should consent to their GP/hospital doctor being informed about them using the Telehealth service Flow Chart – Telehealth process: normal hours – reference should be made to Single Point of Access It needs to be made clear that the patient will be expected to take part in the evaluation process
The Governance Committee APPROVED the operational documents subject to the above amendments/suggestions and AGREED the project could begin installing Telehealth units in patient’s homes. GC/09/09
Mandatory Training Programme for 2009/2010 and Indicative Budgets Liz Butterfield joined the meeting to present the 2009/2010 Mandatory Training Programme and Indicative Budgets report to the Governance Committee. She explained that it had become evident that Mandatory Training needed to be more robust and that discussions had taken place concerning how this could be achieved and making it more fit for purpose in the future.
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It was therefore proposed that Mandatory training sessions for 2009/2010 be delivered in whole one day sessions wherever possible split by clinical and non-clinical days. It was recognised that this would reduce travelling time for staff and allow services to rota staff more appropriately to cover services and provide better patient care. Two days was proposed for Clinical staff training and one day for nonclinical staff. Liz went on to explain the proposed programme in detail and highlighted the costings. The total budget for 2009/10 amounted to ÂŁ83,605. It was noted the costs do not include costings associated with trust employed trainers, administration cost and any on-costs. It was recognised that refresher courses needed to be explored for some areas. Concerning this the potential for e-learning was recognised. In addition it was recognised that attendance at whole day sessions needs to be sensibly managed to ensure services and patient care is not disrupted. There was a discussion regarding whether there are any incentives for staff to undertake their mandatory training. It was recognised that the SHA were developing a standard consistent approach across Yorkshire and the Humber eg a Training and Education passport and Mandatory training requirements are linked to the PDR and KSF process in which staff are required to have completed all mandatory training in order to qualify for their annual increment. Liz provided the Governance Committee with assurance that the programme would be proactively managed by the Training and Education Department. The Governance Committee RECEIVED and NOTED the report and APPROVED the proposed Mandatory Training Programme. It was AGREED the Governance Committee would receive a further update in May 2009. GC/09/10
Mandatory Training Figures for Quarter 3 2008/09 The Governance Committee reviewed the Quarter 3 Mandatory Training Figures. It was noted that it was projected that 81% of staff will have completed Fire Training by the end of the year. It was recognised that e-learning is being explored for future Fire Training refreshers. It was noted that the issues regarding the venue for Moving and Handling Training had been resolved and that a 0.5 WTE Moving and Handling trainer had been appointed.
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There was a discussion regarding uptake of Mental Capacity Act training. Uptake of 22% appeared to be low. It was recognised that this is a one-off training requirement for all clinical and front-line staff. A PCT employed identified trainer is now delivering this training. It was emphasised that managers need to be more proactive at identifying which staff have not completed their mandatory training. It was recognised that Training for Board members needed to be organised for this year. Appropriate training requirements for this year need to be identified. It was recognised that the programme needs to vary from last year. The Governance Committee RECEIVED and NOTED the 2008/09 Quarter 3 Mandatory Training Figures. GC/09/11
PALS Quarter 3 Report The Governance Committee RECEIVED and NOTED the PALS Quarter 3 report. It was noted that 2,407 PALS enquiries had been received between October and December 2008. Of which there were 566 that were nondental queries. It was recognised that the PALS questionnaire was not particularly useful to the Governance Committee and that exception reporting would be more informative. The Governance Committee RECEIVED and NOTED the PALS Quarter 3 report.
Practice Protected Time â€“ New Model Sue Smith presented the Practice Protected Time â€“ New Model report to the Governance Committee. Sue explained that significant progress had been made to establish a reformed programme of PPT events. The Governance Committee received the proposed programme for 2009/10 which features six centralised events that have quality as its focus using external speakers as appropriate. It was noted that wherever possible, sessions would be a mix of presentations and interactive workshops. Topics will be of relevance and importance for clinicians and the PCT. A pool of credible external and consultant speakers is being sourced. It was recognised that E-learning would also be encouraged wherever possible. It was noted that the PPT Steering Group had been established and its inaugural meeting would be held in February. Terms of Reference for the PPT Steering Group were shared with Governance Committee. Sue AGREED to rephrase the paragraph regarding Funding and Infrastructure support as this was thought to be misleading. Page 7 of 12
It was AGREED that the Governance Committee would receive an evaluation of the new model and how if was working in practice in August/September 2009. The Governance Committee RECEIVED the report and NOTED the progress achieved. GC/09/13
Preparations for 2008/09 Standards for Better Health Assessment – Progress Report. The Governance Committee received an update on progress with the PCT’s Standards for Better Health (SfBH) 2008/09 assessment and preparations for NHS Kirklees’ declaration of compliance to the Care Quality Commission (CQC) in April 2009. Sue Smith explained that the SfBH Steering Group with standard leads was continuing to collate evidence and assess compliance. Sue provided assurance that support to leads was being provided. It was recognised that as previously the HCC is inviting comments from the following parties: • • • •
Patient & Public Involvement Forums Overview and Scrutiny Committee Strategic Health Authorities Local Safeguarding Children Boards
In addition, this year, third party commentary will also be sought from Local Involvement Networks (LINks) and Learning Disability Partnership Boards to give their views and experiences of people in the community. The Governance Committee suggested that third party commentary should also be invited via personal contact not only by letter. It was recognised compliance with decontamination standards was a possible area of concern. Assessment of compliance to date suggested that all other areas remain compliant with the standards at this stage. It was acknowledged that any gaps in evidence need to be identified quickly along with a mechanism for dealing with these, to enable Governance Committee to provide assurance to the Board of compliance against the standards. It was noted that dates had been agreed for members of the Quality and Clinical Governance Team to provide detailed assurances to Board members prior to Board sign off in March 2009. The Governance Committee RECEIVED and NOTED progress with the PCT’s SfBH assessment and preparations for the declaration of compliance to the Care Quality Commission.
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Clinical Governance in Dentistry and Optometry Sue Smith introduced the Clinical Governance in Dentistry and Optometry report to the Governance Committee. She explained that the report highlighted the work currently being undertaken to support clinical governance in Dentistry and Optometry. It was noted it is proposed to develop a Quality and Outcomes style Framework (QoF) for Dentistry to support a range of clinical governance activity. In addition, it is planned to fund and support a baseline self assessment as a first step to identify what current clinical governance systems exist in Optometry. Both initiatives are intended to make a significant difference to the quality of the patient experience and improve patient safety. Sue commended this excellent work to the Governance Committee. It was AGREED that the Governance Committee would receive a full report in March 2009. The Governance Committee NOTED the report and APPROVED the ongoing work in support of these initiatives.
NHS Kirklees Employment Check Processes Barry Lane introduced the NHS Kirklees Employment Check Processes report to the Governance Committee. Barry explained that the report presented information regarding Employment check processes and action taken to minimise risks within NHS Kirklees. The report also highlighted a summary update of likely changes to Employment check processes and provided assurance on collective action to implement the local procedure to meet the changes. The Governance Committee NOTED the contents of the report and the actions taken to ensure adequate checks on existing employees working with Children, It was noted that Governance Committee would receive a further update regarding the introduction of the Safeguarding Authority Processes and local implementation steps in June or July 2009 when further guidance had emerged and local planning had been well advanced.
Policies and Procedures for Ratification Sue Smith introduced the Policies and Procedures that required ratification by the Governance Committee. Sue highlighted the key changes for each policy. The Governance Committee APPROVED the following Policies and Procedures: â€˘
Child Protection Policy Page 9 of 12
• • • • • •
Professional Practice Process Policy for Health Visiting and School Nursing Teams Dress Code Policy for Clinical Staff Kirklees Smoke Free Policy Guidelines for insertion, care and removal of peripheral intravenous cannulae Intravenous Therapy Guidelines Medicines Management Policy – It was noted that Controlled Drugs would be covered by a separate policy which would be submitted to the next Governance Committee for approval. It was recognised that until the Controlled Drugs Policy was approved the existing Controlled Drugs policies would continue to be used. Patient Access Policy – NOT APPROVED – The Committee wanted greater assurance that the Equality Impact Assessment Tool had been undertaken correctly.
Minutes of the Information Governance Committee The Governance Committee RECEIVED and NOTED the minutes of the Information Governance Committee held on 7 October 2008.
Minutes of the Pharmacy Panel Meeting The Governance Committee RECEIVED and NOTED the minutes of the Pharmacy Panel Meeting held on 30 October 2008.
Minutes of the Medicines Management Committee The Governance Committee RECEIVED and NOTED the minutes of the Medicines Management Committee held on 2 September, and 28 October 2008.
Minutes of the South West Yorkshire Area Prescribing Committee The Governance Committee RECEIVED and NOTED the minutes of the South West Yorkshire Area Prescribing Committee held on 26 September 2008.
Minutes of the Clinical Audit and Effectiveness Forum The Governance Committee RECEIVED and NOTED the minutes of the Clinical Audit and Effectiveness Forum held on 30 October 2008.
Minutes of the Infection Control Committee The Governance Committee RECEIVED and NOTED the minutes of the Infection Control Committee held on 30 September 2008.
Minutes of the Training and Education Group The Governance Committee RECEIVED and NOTED the minutes of the Training and Education Group held on 8 September 2008. Page 10 of 12
Any other business GC/09/24.1 Workforce Scorecard Barry Lane tabled a Workforce Scorecard update report to the Governance Committee and gave background to the development of the Workforce Scorecard concept. It was noted there were over 25 measures currently measured by the Workforce Scorecard and that the Governance Committee would receive an update on a subset of these measures every four months, dependent upon each measure’s reporting frequency as defined by the Scorecard. Barry highlighted the key points to note in terms of the Workforce Scorecard and Dashboard. There was a discussion regarding timely attendance at Corporate Induction Training. It was recognised that there was little value to be gained in new staff attending Corporate Induction training 12 weeks after joining the organisation. It was emphasised that all managers should ensure that new starters have attended Corporate Induction training within 4 to 6 weeks maximum. The Governance Committee RECEIVED and NOTED the Workforce information contained in the January 2009 Workforce Scorecard based on figures at 31 October 2008. GC/09/24.2 Potential Pharmacy Closure Neill McDonald advised the Governance Committee that the Co-op Pharmacy located in Denby Dale had given notice that it intends to close if it does not find a buyer for the business. It was AGREED if this goes ahead Neill would liaise with the Communications Team regarding the publicity of this.
Issues to highlight to the Board • • •
Standards for Better Health Declaration HCC Medicines Management Post Discharge Study Health Visiting Shortage/Safeguarding issues
Date and time of next meeting It was AGREED that the next meeting of the Governance Committee would take place between 9.30am and 12.00 Noon on Wednesday 18 March 2009 in the Committee Room at St Luke’s House, Huddersfield.
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