Minutes of the Governance Committee Meeting held on Wednesday 16 June 2009 at 9.30am in the Board Room, Broad Lea House Present: Mike Potts Helena Corder Valerie Aguirregoicoa Sue Smith Dr Ajit Mehrotra Peter Flynn Terry Service Helen Jones In attendance: Neill McDonald Jane Oâ€™Donnell
Assistant Director of Medicines Management and Prescribing Assistant Director of Infection Control and Prevention (left the meeting at 9.45am) Internal Audit Manager Apprentice, Quality and Clinical Governance Team Corporate Governance Administrator Assistant Director of Workforce, Commissioning and Policy Assistant Director of Safeguarding Children and Vulnerable Adults
Michelle Marsden Natalie Penn Alison Fearnley Laura Campbell Karen Hemsworth
Chief Executive and Chair Director of Corporate Services Non-executive Director Assistant Director of Quality and Clinical Governance GP Director of Performance and Information (left the meeting at 11.00am) Assistant Director of Corporate Services and Risk Management (from 10.00am) Internal Audit Manager
Apologies for Absence Apologies for absence were received from Dr Jim Lee, Medical Director, Bryan Machin, Executive Director of Finance, Sheila Dilks, Executive Director of Patient Care and Professions and Sue Ellis, Director of Human Resources and Organisational Change.
Minutes of the last meeting held on 5 May 2010 The Minutes of the Governance Committee meeting held on 5 May 2010 were AGREED as a true and accurate record.
Matters arising from the Minutes of the last meeting GC/10/58 â€˘
Governance Committee Risk Register
Update on Urgent Care Mike provided a further verbal update regarding the Urgent Care Contract. He reported that all the recommendations following the Carson Report had now been implemented. It was noted that Page 1 of 10
agreement had been reached regarding a suitable laptop for GPs and software testing was underway. It was noted that the contract was continuing to be robustly monitored however performance had dropped during the last few weeks. It was recognised that Tony Cooke was re-assessing the level of risk on the Risk Register. GC/10/59
Review of Governance Committee Effectiveness
It was noted that the Governance Committee had received a report in May 2010 regarding the six principles of Governance Standards for Public Bodies published in 2004. The purpose of this was to put into context the review of the way the Governance Committee was working and its effectiveness. The Governance Committee reviewed the self assessment document which incorporates the six principles of good governance. The following points were highlighted: 2.0 Membership, Induction and Training With reference to 2.1 a discussion ensued regarding the issue of only one Non-executive Director (NED) being in attendance at the Governance Committee. It was felt that if Valerie was unable to attend it was difficult for an alternative NED to step in and be effective. It was recognised that a review of meetings would need to be undertaken due to the reduction in management costs which the PCT has to achieve. It was AGREED that NED representation at this meeting would be raised with Rob Napier. 3.0 Meetings and Administration It was recognised that timely circulation of agendas and papers in advance of the meeting could be improved on to allow members to prepare adequately. It was agreed that agenda papers should not be tabled at the meeting and that the author of the paper should take ownership for distributing late papers. In addition permission to defer a paper should be sought from the Chair. It was highlighted that cover sheets should be completed in detail to include an executive summary of the issues that are relevant to the organisation. 4.0 Decision Making With reference to 4.4, regarding minutes of sub-committees being reported to the Board. It was felt that the Board did not spend sufficient time going through the minutes of sub committees reported to the Board. It was AGREED that each sub committee is to include a standing agenda item regarding â€˜issues to highlight to the boardâ€™, so that the Board can easily identify and significant issues that it needs to be aware of. Page 2 of 10
Following discussion of the proforma areas the Governance Committee AGREED that the Committee was functioning effectively. GC/10/61
Care Quality Commission update
Sue Smith advised that she was taking a report to the Local Medical Committee (LMC) on 8 June to update on CQC registration of GPs. Sue had agreed to provide regular updates to the LMC regarding this as and when there was something significant to update on. In addition Sue was also providing an update on CQC registration of Dentists at the Local Dental Committee (LDC) in July. GC/10/85
Information Governance update Helena Corder provided an update on the key issues being progressed by the Information Governance Committee. The following key points were highlighted: IG Toolkit Internal Audit had undertaken a further audit of compliance with the IG Toolkit. The current IG Toolkit score is 74% which is about average for PCT’s locally. It was recognised that a Version 8 of the IG toolkit is expected to be launch in June 2010 with a return date of 31 October 2010 and 31 March 2011. The Governance Committee noted that meeting the requirements of IGT 8 will be challenging, particularly working with reduced management costs. Mike AGREED to raise the Committee’s concerns regarding this with the Strategic Health Authority (SHA). Records Management Policy The PCT Records Management Policy had been reviewed and approved by the Governance Committee. Appendix D which shows where all PCT records are held is almost complete and will go to the Information Governance Committee for discussion and approval. Purchase of portable storage devices It was noted that the Information Governance Committee had approved the purchase of four portable storage device solutions to enable the PCT to store the Predictive Risk minimum data-set in a secure environment, until such time that the PCT has more permanent solutions for the storage and sharing of this data. The Governance noted that this is a ‘high risk’ area but is supported by the Director of Performance and Information. Revised Email Policy It was noted that following ongoing discussions about the revised Email Policy a review of the COIN (Communities of Interest Network) had taken place and a suggested approach to sending secure personal information had been set out. This was reviewed by the Governance Committee in Appendix B of the report. It was noted that it is now secure to send personal information between fellow NHS organisations but this did not include the Local Authority. Page 3 of 10
Report on Internet Use The Governance Committee reviewed a report which had been carried out on the use of the internet following concerns being raised about inappropriate use of the internet and face book in particular. It was recognised that the PCT was exploring blocking this site however this may prove difficult given that NHS Calderdale have a legitimate face book page. Following discussion the Governance Committee AGREED that face book and other inappropriate sites should be blocked with the exception of providing access to individual staff that require to use this for work purposes. It was highlighted that staff should be made aware that internet use is being monitored within the PCT. The Governance Committee RECEIVED and NOTED the Information Governance update report. GC/010/86
Governance Committee Risk Register Report Helena Corder presented the Governance Committee Risk Register Report to the Governance Committee. She explained that the risk register report had been modified to only show mitigated risks of medium and higher level. These included the following: • • • • • • •
Loss of person identifiable data Child Protection/Safeguarding Care quality commissions assessment – Sue Smith to undertake a full review prior to next Governance committee meeting Risk Management – this was noted to be improving and it was suggested that this could possibly reduced from medium to low Data quality and security – Peter Flynn provided assurance that this had been updated Infection Control Emergency planning – it was noted that the Board had recently received a report on emergency planning/preparedness. It was recognised that NHS Kirklees is the lead PCT for emergency planning across the West Yorkshire region and that a report would be presented to each of the five Governance Committees. It was recognised that an annual report on emergency planning/preparedness would be programmed into the Governance Committee Work Programme.
In addition to the above it was noted that a new risk had been added regarding the potential impact of the lack of formalised disaster recovery plans and assurance provided to the PCT from The Health Informatics Service (THIS). The Governance Committee NOTED the report and ACCEPTED the levels of risk identified.
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Patient Safety Strategy to Support Effective Commissioning 2010-2012 Sue Smith introduced the report and explained that comments previously received had been incorporated into the final draft. The Governance Committee reviewed the revised Patient Safety Strategy and accompanying action plan. It was recognised that the action plan incorporated 14 objectives which were AGREED by the Governance Committee. It was AGREED that progress against the action plan would be presented to the Governance Committee three times a year. It was recognised that this would scheduled into the Governance Committee Work Programme. The Governance Committee AGREED the patient Safety Strategy to Support Effective Commissioning and accompanying action plan.
Environmental Update The Governance Committee received an update on the implementation plan for the environmental strategy. It was recognised that work was underway with regard to reducing the figures across the Trust with regard to domestic and clinical waste due to high carbon production. The Governance Committee noted a letter from Roger French, Director of NHS Economic Programmes, NHS Yorkshire and Humber and a report to NHS Y&H Board setting out the expected actions across the region to manage climate change. The Governance Committee noted the PCT’s position in regard to this report. It was recognised that work was being undertaken to sign up environmental champions within the PCT. Valerie Aguirregoicoa enquired what work was being undertaken with primary care colleagues to reduce waste. Terry Service provided assurance that there was a programme of work to underpin this. Dr Mehrotra suggested that this could be focused via the LMC. The Governance Committee RECEIVED and NOTED the Environmental update.
Safeguarding Update The Governance Committee received a further update in relation to the safeguarding children and vulnerable adults agenda. Karen Hemsworth joined the meeting and provided a summary of the key issues. In particular the following areas were highlighted • • • •
Performance against the Vulnerable adults work programme Performance against the Safeguarding Children work programme Chief Executive’s Checklist – noted that majority of areas are compliant Review of Safeguarding Policies Page 5 of 10
• • • •
Work was underway with LMC representatives to develop and agree safeguarding standards for General Practice Appointment of named doctor for child protection - Dr Jane Ford One Serious Case Review was currently underway The third edition of the Safeguarding Newsletter was received and noted by the Governance Committee
Karen AGREED to liaise with Helena to update the Risk Register in terms of Child Protection /safeguarding. Finally Karen provided an update on the Serious Case Review into the Shannon Matthews Case. It was noted that the Executive Summary into the SCR was due to be published later that day. Karen highlighted the findings of the SCR and the recommendations. It was recognised that the SCR was very thorough and does not highlight any systematic failings. The Governance Committee commended Karen and the Safeguarding Team for all their hard work surrounding this case. The Governance Committee RECEIVED and NOTED the Safeguarding update report. GC/10/90
Serious Untoward Incidents (SUIs) Terry Service provided an overview of the SUIs currently open and reported on the STEIS (Strategic Executive Information System) website. It was noted that there are currently 30 SUIs open on STEIS relevant to the PCT. It was noted that the PCT is working with both commissioned services and NHS Yorkshire and Humber to close a number of cases that appear to be legacy cases. The Risk Management Overview Group is actively reviewing cases to determine where it is appropriate to close them. The Committee RECEIVED and NOTED the Serious Untoward Incidents report.
Workforce Scorecard Report The Governance Committee received a summary of 2009/10 Workforce Scorecard data. It was noted that overall sickness rates for 2009/10 were below the PCT’s target but have been increasing over the year. Overall turnover rates have been dropping consistently and are below the PCT’s Target rate. It was recognised that the proportion of sickness absence due to Musculoskeletal injuries was high and whether this was due to home or work related issues ie were staff sitting correctly. It was noted that a self assessment was undertaken when the PCT moved into the new premises.
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A discussion took place regarding whether the PCT has the right profile of staff. Valerie was interested in the profile of PCT Commissioning staff compared with other PCTs Commissioning Directorates. It was recognised that the PCT could only do comparisons against whole PCTs ie Provider plus Commissioner. Also, comparing the PCT against other PCTs would not determine a â€œrightâ€? profile, it would only show what the PCT looked like compared with other PCTs. It was recognised that this type of benchmarking information (at whole PCT level) was recently published regionally therefore there would be little benefit in doing it again. The Governance Committee RECEIVED and NOTED the Workforce Scorecard Report. GC/10/92
2010/2011 Workforce Scorecard Targets Laura Campbell presented the 2010/11 Workforce Scorecard Targets to the Governance Committee. She explained that the Workforce Scorecard had been refreshed for 2010/11 and where appropriate, targets/benchmarks had been reviewed and amended. Laura went on to highlight the changes. It was recognised that expected turnover for 2010/11 was likely to be much lower than 2009/10. The Governance Committee requested that the percentage of long-term sickness is reported on in more detail. Laura AGREED to confirm the number of current long-term sickness cases in future reports, as well as the percentage. There was a discussion around the quality of sickness reporting. Concerning this it was recognised that the sickness categories were limited and that the ESR can only report on its prescribed categories of sickness. It was AGREED that future reports would focus on the commissioning function only. KCHS data would be reported through the relevant reporting mechanism (committee) within KCHS. The Governance Committee RECEIVED and NOTED the report and ACCEPTED the changes that have been made to the Workforce Scorecard for 2010/2011.
Quality and Outcomes Framework (QOF) Exception Visits Sue Smith presented the QOF Exception Visit report to the Governance Committee. She explained that the PCT had carried out further analysis regarding QOF exception reporting using data extracted form QMAS (Quality Management System) to compare exception reporting levels during the period 2008/09. It was noted that significant variation and a higher than expected level of exception reporting was identified in 9 practices across 39 of the QOF domains. Sue highlighted the findings of the exception reporting at each of the nine practices.
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Terry raised a question around how QOF reports are reviewed and quality assured before payments are made. The question related to other data steams that indicated consistent patterns of low performance over periods of time such as patient opinion surveys but which still ended up with the practice being paid and no enforcement action being taken. The process and governance arrangements were unclear and as the funding involved across the PCT was significant it was noted as an area where improvement could be made. The Committee noted that QOF related to a practice rather than an individual contractor therefore it would not be managed under the Performance Advisory Group agenda. It was AGREED that Mark Jenkins would be asked to produce a report to the next committee meeting to advise on the systems used, the reporting process leading to the Board and what actions are being taken when a practice is performing poorly. The Governance Committee RECEIVED and NOTED the QOF Exception Visit report. GC/10/94
Policies, Procedures and Guidelines for approval The Governance Committee APPROVED the Safeguarding Vulnerable Adults Policy and Operational Procedure.
Minutes of the Pharmacy Panel meeting The Minutes of the Pharmacy Panel meeting held on 18 March 2010 were RECEIVED and NOTED by the Governance Committee.
Minutes of the Information Governance Committee The Minutes of the Information Governance Committee held on 18 March 2010 were RECEIVED and NOTED by the Governance Committee.
Minutes of the Medicines Management Committee The Minutes of the Medicines Management Committee held on 19 March 2010 were RECEIVED and NOTED the Governance Committee. It was highlighted that the costs for ScriptSwitch had been covered in the first year. A decision would be taken whether to continue to use ScriptSwitch within the next few months. Dr Mehrotra asked what GPs should prescribe/do if a patient attended post 72 hours for emergency hormonal contraception. It was AGREED that Neill would ask the CaSH team and advise Dr Mehrotra.
Minutes of the Clinical Governance Leads Meeting The Minutes of the Clinical Governance Leads Meeting held on 19 January 2010 were RECEIVED and NOTED by the Governance Committee.
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Minutes of the Kirklees Infection Control Committee The Minutes of the Kirklees Infection Control Committee held on 17 February 2010 were RECEIVED and NOTED by the Governance Committee.
Minutes of the Emergency Planning Strategic Meeting The Minutes of the Emergency Planning Strategic Meeting held on 22 January 2009 were RECEIVED and NOTED by the Governance Committee.
Minutes of the Effectiveness Group meeting The Minutes of the Effectiveness Group meeting held on 26 February 2010 were RECEIVED and NOTED by the Governance Committee.
Minutes of the Performance Advisory Group Minutes of the Performance Advisory Group held on 2 February 2010 were RECEIVED and NOTED by the Governance Committee.
Issues to highlight to the Board • • • •
CQC visit to Holme Valley Memorial Hospital SCR – Shannon Matthews Case Progress on Environmental agenda Review of Governance Committee function & Effectiveness
Any other business Inpatient Results It was noted that inpatient results have been published for providers. Results for Mid Yorkshire NHS Hospitals Trust are to be shared with Mike Potts. Jane O’Donnell rejoined the meeting. MRSA Jane reported that the Health Protection Agency was publishing weekly reporting of hospital apportioned cases of MRSA bacteraemia and CDif infection. This is reported by individual hospital and data is not validated. It was recognised that the DOH want it reporting weekly as part of patient choice.
Date and time of next meeting It was AGREED that the next meeting of the Governance Committee would take place on Wednesday 11 August 2010 at 9.30am in the Ibbotson Room at Broad Lea House, Bradley Business Park. Page 9 of 10
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