Committee Annual Report - NHS Wales QS... · 2011. 10. 6. · Committee Annual Report 1 Title of Committee: Quality and Safety (Q&S) Committee 2 Name and role of person submitting

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Committee Annual Report

1 Title of Committee: Quality and Safety (Q&S) Committee 2 Name and role of person submitting this report: Mrs Hilary Stevens - Chair, Quality and Safety Committee and Independent member Mrs Grace Lewis-Parry – Director of Governance and Communications 3 Dates covered by this report: April 2010- March 2011 4 Number of times Committee met during the year: 6 5 Assurance/s this committee is designed to provide:

Evidence based and timely advice to the Board to assist it in discharging its functions and meeting its’ responsibilities with regard to the quality and safety of healthcare;

Assurance to the Board in relation to the LHB’s arrangements for

safeguarding and improving the quality and safety of patient/service user centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales;

Scrutiny of the Healthcare Standards in relation to improvement in clinical

practice and the patient/service user experience. 6 Overall *RAG status against committee’s annual objectives / plan: Green 7 Main tasks completed / evidence considered by the Committee during this

reporting period: The Committee scrutinised:

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• Patient Safety Issues : Pulse Oximetry, Mistaken Identity in Radiology, Record Keeping and Documentation, using SBAR as a communication tool, Pressure Ulcers and development of Agenda ‘Item Zero’ and RAMI dashboard.

• Reports and updates : BCUHB Complaints Oct 2009 – Jan 2010, Serious

Incidents, Director of Public Health, Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust Jan 05 – March 09, Integrated Governance, 1000 Lives plus, Service Change – Identified Clinical Risks, Healthcare Standards for Wales (HCS) Assurance, Revised Healthcare Standards 2010, National External Audit Audiology Services, CHC visits, Fundamentals of Care, Ombudsman’s Annual Summary of Performance 2009/10, National Reporting and Learning System (NRLS) organisational feedback, BCU Quality and Safety review with WAG minutes, National audit of continence care, Out of Hours unscheduled care update, BCUHB Progress against the Francis report, Putting things right, NCEPOD report : An Age Old Problem, Leadership walkrounds.

• Aims and actions report on draft National Health Service (Concerns,

Complaints and Redress Arrangements) (Wales) Regulations 2010. • Responses to consultations: Putting things right – a better way of dealing with

concerns about the health service. • Action plans: Healthcare Standards Improvement plan and updates, Action on

Patient Safety Annual plan, HIW Review of Histopathology services provided by former North East Wales Trust: updated report and plan.

• Work Programme: Healthcare Inspectorate Wales 2010-13. • Strategies: Infection Prevention and Control Strategy 2009-2012, Transforming

Care. • Frameworks: Nursing and Midwifery Assurance Framework, Patient Safety – a

model framework for Governance and Scrutiny. • Approval of Policies, procedures and guidance :

Consent to Examination or treatment policy Risk Management Policy and Strategy Guidance on the reporting and handling of serious incidents and other

patient related concerns / no surprises.

• Presentations: Q&S Performance Dashboard, 1000 Lives Plus: What the Q&S Committee needs to know and Board member involvement, Equality and Human Rights Scheme: Impact Assessment and the Committee’s responsibilities, RAMI and HSMR – What they mean: perils and pitfalls.

• Committee governance developments

Annual Cycle of Business

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Sub-Committee Annual reporting arrangements and Terms of Reference overview

Q&S Committee self assessment checklist Clinical Programme Group (CPG) Q&S monitoring report schedule

received to date: Women and Maternal Care CPG Pharmacy and Medicines Management CPG Primary, Community and Specialist Medicine CPG

• Minutes and issues of significance from each Quality & Safety sub-committee:

Risk Management (Chair – Dr Lyndon Miles) Clinical Effectiveness (Chair – Dr Lyndon Miles) Improving Service User Experience (Chair – Hilary Stevens) Improving Prevention and Control of Infection (Chair – Michael Williams) Safeguarding Children and Vulnerable Adults (Chair – Rev Hywel M

Davies) including Safeguarding / Child Protection reports (In-Committee) and Welsh Health Specialised Services Committee (WHSSC)-

Quality & Patient Safety sub-committee.

• Establishment of Q&S Sub-Committees Lead Officers Group. • Staffside and BCCHC representation (invited to attend meetings). • Establishment of CPG Q&S monitoring system and initiation of CPG

presentations of same for scrutiny, monitoring and accountability purposes. • Approval of Management of Patient Group Directions.

8 Main action plan themes / tasks due for completion in forthcoming year:

• Development of Putting It Right following appointment of Facilitator for this initiative

• Continued development of the Committee Cycle of Business • Initiation of Sub-Committee review to ascertain ongoing fitness for purpose,

plus consideration of the need for a rolling programme of sub-committee presentations to the parent Committee.

• Continuing development of Patient Safety Dashboard • Development of Committee self-assessment

9 New risks and issues identified by this Committee in-year:

I. Inadequate assurance provided for scrutiny / monitoring purposes provided on Q&S systems/processes/structures by one CPG

II. Attendance – quorum issues and time/workload commitment concerns III. Magnitude of agenda and ability to accommodate all business into available

meetings – need to develop more ‘intelligent’ information, focus the agenda and delegate to Sub-Committees to inform their cycles of business

10 If appropriate, have these new risks been escalated as an issue of

significance, or to the relevant Chief of Staff for consideration?

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Yes

I. Above was escalated to the Chief of Staff concerned. CPG re-submitted satisfactory information, CoS personally attended a Q&S meeting, and adequate assurance on Q&S systems and procedures were then provided

Remaining issues are being actively managed by the Committee / Board (BCUHB Committees Review being planned as at 31.3.11). 11 Further comments:

Appendix 1 contains the Committee’s Register of Attendance Appendix 2 contains the Committee’s Terms of Reference Appendix 3 contains the Q&S Sub-Committees’ Annual Reports

*Key: Red = not on target to achieve all actions, and may not achieve these actions by the next quarter Amber = not on target to achieve all actions, but has plans in place to see these actions achieved by

the next quarter Green = on target to achieve all actions LJ/cttee annual report.doc v0.02 Jan 11

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Appendix 1

1.4.10 3.6.10 5.8.10 7.10.10 7.12.10 4.2.11

M Williams Chairman Ad hoc

observer . Apols . . . . Dr L Miles Vice Chair Member Y Y Y Y Apols Apols

H Owen-Jones Independent Member Vice Chair Y Y . Y Apols Y

HM Davies Independent Member Member Y Y Y Apols Apols Apols

H Stevens Independent Member Chair Y Y Apols Y Y Y

M Burrows Chief Executive In

Attendance Part Y Apols . Apols Y

M Scriven Medical Director In

Attendance Part Y Apols Apols Apols .

J Galvani

Director of Nursing Midwifery & Patient Services

In Attendance Apols Apols Apols Y Y Y

G Lang

Director of Primary Care, Community and Mental Health Services

In Attendance Y Apols Y Y Apols Y

Dr KD Griffiths

Director of Therapies and Health Sciences

In Attendance Apols Apols Y Part Apols Y

G Lewis-Parry

Director of Governance & Communications

In Attendance Y Y Y Y Part Y

M Common

Director of Improvement and Business Support

In Attendance . Y . Part . Y

A Jones Director of Public Health

In Attendance Y Y Y Y Apols Apols

N Pryce-Howard

Asst Director Quality and Safety

In Attendance

Y Y Y Y Y Apols

Dr B Tehan

Asst Medical Director Patient Safety

In Attendance

. . . Part Part part

S Hockings Staffside (wef Aug)

In Attendance Y Part Apols Y

M Singleton Staffside (wef Aug)

In Attendance Y Apols Part Y

Secretariat Liz James LJ DD LJ LJ LJ LJ Date minutes submitted to Health Board 27.5.10 24.6.10 23.9.10 25.11.10 27.1.11

CHC Reps Y . Y Y - part . Apols

J Jones

Head of Research, Clinical Audit & Effectiveness -Interim Y Y

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J Newman

Asst Director – Improvement & Business Support Y Y

H Piggott Asst Director - Nursing Y Y Y

C Jenn Asst Director of Finance Y

D Fletcher Assoc Chief of Staff (Ops) Y

C Howe

Head of Quality Improvement –Interim Y

T Heywood NLIAH Y

M Denwood Asst Director – Safeguarding Y Y

S Hughes-Jones

Head of Equality, Diversity & Human Rights Y

M Sykes

Asst Director – Organisational Development Y

M Townsend WAO Y

A Bithell Chief of Staff – PMM Part

J Dean Independent member Observer

F Giraud Assoc Chief of Staff (Nursing) Part

S Jones Public Health Part

AM Rowlands Asst Director Nursing Part

M Lloyd Jones Senior Nurse Part Dr R Atenstaedt

Public Health Wales Part

Dr O Williams Chief of Staff – PC&SM Part

K Jones PC&SM Part

T Hinstridge Pharmacist Senior Manager Part

M Davidge

NHS Institute for Innovation & Improvement Part

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Appendix 2

Betsi Cadwaladr University Health Board Terms of Reference and Operating Arrangements

QUALITY AND SAFETY COMMITTEE

INTRODUCTION The LHB’s standing orders provide that “The Board may and, where directed by the Assembly Government must, appoint Committees of the LHB either to undertake specific functions on the Board’s behalf or to provide advice and assurance to the Board in the exercise of its functions. The Board’s commitment to openness and transparency in the conduct of all its business extends equally to the work carried out on its behalf by committees”. In line with standing orders (and the LHB’s scheme of delegation), the Board shall nominate annually a committee to be known as the Quality and Safety Committee. This committee’s focus is on all aspects aimed at ensuring the quality and safety of healthcare, including activities traditionally referred to as ‘clinical governance’. PURPOSE The purpose of the Quality & Safety Committee, hereafter referred to as “the Committee”, is to provide:

evidence based and timely advice to the Board to assist it in discharging its functions and meeting its’ responsibilities with regard to the quality and safety of healthcare;

assurance to the Board in relation to the LHB’s arrangements for

safeguarding and improving the quality and safety of patient/service user centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales;

scrutiny of the Healthcare Standards in relation to improvement in clinical

practice and the patient/service user experience. DELEGATED POWERS AND AUTHORITY The Committee will, in respect of its provision of advice to the Board:

oversee the initial development of the LHB’s strategies and plans for the development and delivery of quality and patient safety, consistent with the Board’s overall strategic direction and any requirements and standards set for NHS bodies in Wales;

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consider the implications for quality and patient safety arising from the development of the LHB’s corporate strategies and plans or those of its stakeholders and partners;

consider the implications for the LHB’s quality and patient/service user

safety arrangements following review reports and actions arising from the work of external reviewers.

The Committee will, in respect of its assurance role, seek assurances that governance (including risk management) arrangements are appropriately designed and operating effectively to ensure the provision of high quality, safe healthcare across the whole of the LHB’s activities. To achieve this, the Committee’s programme of work will be designed to ensure that, in relation to all aspects of quality and patient/service user safety:

• there is clear, consistent strategic direction, strong leadership and transparent lines of accountability;

• the organisation, at all levels (Clinical Programme Groups and Corporate

teams) has a citizen centred approach, putting patients/service users, patient/service user safety and safeguarding above all other considerations;

• the provision of care across the organisation (Clinical Programme Groups and

Corporate teams) is consistently applied, based on sound evidence, clinically effective and meeting agreed standards;

• the organisation, at all levels (Clinical Programme Groups and Corporate

teams) has the right systems and processes in place to deliver, from a patient/service user perspective - efficient, effective, timely and safe services delivered by caring and competent staff ;

• the workforce is appropriately selected, trained and responsive to the needs of

the service, ensuring that professional standards, registration/revalidation/indemnity requirements and safeguarding arrangements are maintained;

• there is an ethos of continual quality improvement and regular methods of

updating the workforce in the skills and competencies needed to demonstrate quality improvement throughout the organisation;

• there is good team working, collaboration and partnership working to provide

the best possible outcomes for its citizens;

• risks are actively identified and robustly managed and mitigated at all levels of the organisation;

• decisions are based upon valid, accurate, complete and timely data and

information;

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• there is demonstrable continuous improvement in the standard of quality and patient/service user safety across the whole organisation – continuously monitored through the development and scrutiny of performance against Healthcare Standards for Wales;

• all reasonable steps are taken to prevent, detect and rectify irregularities or

deficiencies in the quality and safety of care provided, and in particular that:

Sources of internal assurance are reliable, eg. internal audit and clinical audit teams have the capacity and capability to deliver;

Recommendations made by internal and external reviewers are considered and acted upon on a timely basis; and

Lessons are learned from patient/service user safety incidents, complaints and claims.

The Committee will advise the Board on the adoption of a set of key indicators of quality of care against which the LHB performance will be regularly assessed and reported on through Annual Reports. Authority The Committee is authorised by the Board to investigate or have investigated any activity within its terms of reference. In doing so, the Committee shall have the right to inspect any books, records or documents of the LHB. It may seek any relevant information from any employee and all employees are directed to cooperate with any reasonable request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers it necessary, in accordance with the Board’s procurement, budgetary and other requirements. Sub Committees The Committee may, subject to the approval of the Board, establish sub committees or task and finish groups to carry out on its behalf specific aspects of Committee business. The agreed sub-committees are attached as Appendix 1. Each of the five Sub-Committees will be Chaired by an Independent Member of the Committee. MEMBERSHIP Chair Independent Member Vice Chair Another Independent Member of the committee Members A minimum of five Independent members, to include the Chair of

the LHB Audit Committee and the Vice Chair of the LHB Board Secretary As determined by the Board Secretary

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In attendance All Executive Directors holding portfolios containing aspects of quality and safety of clinical care and information governance:

Chief Executive Medical Director Director of Nursing, Midwifery and Patient Services Director of Primary, Community and Mental Health Services Director of Therapies and Health Science Director of Public Health Director of Governance and Communications Director of Improvement & Business Support Assistant Director of Quality and Safety Associate Medical Director – Patient Safety The Health Board Chairman will attend to observe proceedings on an ad-hoc basis

By invitation The Committee Chair may extend invitations to attend committee

meetings to the following, as required:

Director of Planning Director of Workforce and Organisational Development Director of Finance Chiefs of Staff Representatives of Partnership organisations Public and Patient Involvement Representatives Trade Union Representatives Community Health Council Representatives as well as others from within or outside the organisation whom the committee considers should attend, taking account of the matters under consideration.

Member Appointments The membership of the Committee shall be determined by the Board, based on the recommendation of the LHB Chair, and subject to any specific requirements or directions made by the Assembly Government. Appointed Independent Members shall hold office on the Committee for a period of up to 4 years. Tenure of appointments will be staggered to ensure business continuity. A member may resign or be removed by the Board. Independent Members may be reappointed up to a maximum period of 8 years. Committee members’ terms and conditions of appointment, (including any remuneration and reimbursement) are determined by the Board, based upon the recommendation of the LHB Chair {and on the basis of advice from the LHB’s Remuneration and Terms of Service Committee}. Support to Committee Members

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The Board Secretary, on behalf of the Committee Chair, shall:

Arrange the provision of advice and support to committee members on any aspect related to the conduct of their role; and

Co-ordinate the provision of a programme of organisational development

for committee members.

COMMITTEE MEETINGS Quorum At least four individuals must be present to ensure the quorum of the Committee, comprising two Independent Members and two Directors. Frequency of Meetings Meetings shall be held no less than bi-monthly, and otherwise as the Chair of the Committee deems necessary – consistent with the LHB’s annual plan of Board Business. REPORTING AND ASSURANCE ARRANGEMENTS The Committee Chair shall:

report formally, regularly and on a timely basis to the Board on the Committee’s activities. This includes verbal updates on activity, the submission of committee minutes and written reports, as well as the presentation of an annual report;

bring to the Board’s specific attention any significant matters under

consideration by the Committee;

ensure appropriate escalation arrangements are in place to alert the LHB Chair, Chief Executive or Chairs of other relevant committees of any urgent/critical matters that may affect the operation and/or reputation of the LHB.

The Board Secretary, on behalf of the Board, shall oversee a process of regular and rigorous self assessment and evaluation of the Committee’s performance and operation including that of any sub committees established. RELATIONSHIP WITH THE BOARD AND ITS COMMITTEES/GROUPS Although the Board has delegated authority to the Committee for the exercise of certain functions as set out within these terms of reference, it retains overall responsibility and accountability for ensuring the quality and safety of healthcare for its citizens.

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The Committee, through the Committee Chair and members, shall maximise cohesion and integration across all aspects of governance and assurance through the:

joint planning and co-ordination of Board and Committee business; and sharing of information

The Committee shall embed the LHB’s corporate standards, priorities and requirements, e.g. equality, diversity and human rights through the conduct of its’ business. APPLICABILITY OF STANDING ORDERS TO COMMITTEE BUSINESS

The requirements for the conduct of business as set out in the LHB’s Standing Orders are equally applicable to the operation of the Committee, except in the following areas:

Quorum REVIEW These terms of reference and operating arrangements shall be reviewed annually by the Committee with reference to the Board. CHAIR’S ACTION ON URGENT MATTERS ▪ There may, occasionally, be circumstances where decisions which would normally

be made by the Committee need to be taken between scheduled meetings. In these circumstances, the Committee Chair, supported by the Committee Secretariat as appropriate, may deal with the matter on behalf of the Board – after first consulting with two other Independent Members of the Committee. The Secretariat must ensure that any such action is formally recorded and reported to the next meeting of the Committee for consideration and ratification.

▪ Chair’s action may not be taken where the Chair has a personal or business

interest in the urgent matter requiring decision. Date Terms of Reference Approved:……………………………………………… Signed:…………………………………………………………(Chair) Date:………………………………………….. V2.0

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APPENDIX 1

Sub-Committees of the Quality & Safety Committee

1) Risk Management 2) Infection Prevention and Control 3) Safeguarding 4) Improving Service User Experience 5) Clinical Effectiveness The Risk Management Sub-Committee has dual reporting lines both to the Audit and Quality & Safety Committees in order to ensure that all risks are acknowledged and actioned. Quality & Safety Sub-Committee Structure

Quality & Safety Committee

Risk Management Sub-Committee Responsibilities will include: - Clinical, Operational and Corporate Risk - Assurance Framework - Risk Register - Health and Safety - Medical Devices - Safer Patient Group - *Radiation Protection - *Blood Transfusion - Consent, Capacity & Ethics

Infection Prevention and Control Sub-Committee Responsibilities will include: - Surveillance - Training - Decontamination - Immunisation - Links with Public - Health

Safeguarding Sub-Committee Responsibilities will include: - Children - POVA - Domestic Abuse - Vulnerable groups - MAPPA - MCA - DOLS - Tissue Viability - Continence - Nutrition

Improving Service User Experience Sub-Committee Responsibilities will include: - PPI - Voluntary Sector - Bereavement - Public Members - Multi Faith Services - Complaints & Litigation - Organ donation

Clinical Effectiveness Sub-Committee Responsibilities will include: - NICE and all guidance - Confidential Enquiries - SPI and 1000 lives - Research and Development - Audit and - Effectiveness - Drugs and Therapeutics - Safer Medication Practice Resuscitation

CPG 2

CPG 3

CPG 4

CPG 5

CPG 6

CPG 7

CPG 8

CPG 9

CPG 1 *Blood Transfusion

CPG 10

CPG 11 *Radiation Protection

Integrated Risk Sub-Group Reviews complaints, claims, incidents and risks

DC/sh June 2011 Page 1 of 5

Improving Prevention and Control of Infection

Sub-Committee Annual Report

1 Title of Sub-Committee: Improving Prevention and Control of Infection Sub Committee 2 Name and role of person submitting this report: Heather Piggott, Assistant Director of Nursing.

3 Dates covered by this report: April 2010-March 2011 4 Number of times Sub-Committee met during the year: The Sub-Committee met 5 times during 2010-2011. 5 Assurance/s this Sub-Committee is designed to provide: Assurance that BCUHB is committed to preventing wherever possible, avoidable healthcare related infections and ensuring that appropriate measures are in place to minimise and control unavoidable infections within the healthcare setting.

Key parameters for the Sub Committee: 1. To ensure that strategies for the prevention and control of infection to

be relevant and implementable in all parts of the BCUHB. 2. To incorporate the requirements and recommendations from the Welsh

Assembly Government’s key strategy documents into the health board. 3. To reflect and bring together the progress and good practice of the

within the organisation. 4. To enhance the ongoing progress against the Local Delivery Plan. 5. To monitor infection rates and control measures and ensure that

corrective actions are taken when required

6 Overall *RAG status against Sub-Committee’s annual objectives / plan: Green


1 Main tasks completed and evidence considered by the Sub

Committee during this reporting period:

Objective 1: Develop a range of infection prevention and control strategies designed to prevent the occurrence of infections and manage and minimise the effect of those infections that do occur. RAG status - Green

Action 1: By June 2010, the Infection Prevention and Control team will have developed, in conjunction with the CPGs a comprehensive infection prevention and control strategy that reflects both the National requirements, under the AOF and the local needs of the service users and providers to ensure there is “zero tolerance” of preventable healthcare associated infections and when infections do occur they are managed in an appropriate manner to minimise their impact.

This action is about developing a comprehensive infection prevention and control strategy that both monitors and manages the impact of infections within BCUHB.

The development and dissemination of the Improving Infection

Prevention and Control Strategy.

The development and dissemination of a CPG role definition for Improving Infection Prevention and Control within their areas.

The requirement of CPGs to report on their plans and outcomes for

Improving Prevention and Control, and to nominate leads and key contacts.

The requirements of CPGs to develop actions plans to take forward

improving prevention and control within their areas.

Objective 2: Ensure that decontamination and the management of invasive devices is managed and monitored across the Health Board.

RAG status - Green

Action 2: By January 2010, develop a comprehensive decontamination strategy designed to ensure that all equipment and facilities conform to the relevant Health and Technical memorandums or “Good practice” for the management of invasive devices and their facilities

Implement a strategic decontamination group that scrutinises

decontamination and reports to the Improving Prevention and Control of Infection Sub Committee.


Develop and implement a strategic plan for decontamination in line with National and local guidelines.

In conjunction with the CPGs collate identified risks in relation to

decontamination and ensure there are plans in place to remove or minimise those risks identified.

Ensure there are local operational groups in place within the health board that scrutinizes and oversees the management and facilities associated with medical devices

Decontamination strategy completed and awaiting ratification.

Risks related to decontamination collated and action plans

requested from CPGS in relation to the identified risks.

Strategic and operational groups in place and reports received by the Improving Prevention and Control of Infection Sub Committee

Objective 3: Ensure that there is an adequately resourced Infection Prevention and Control team in place to facilitate the control of infections. RAG status – Amber Resources required to support Primary Care Action 1: By May 2010, carry out a service review in relation to infection control personnel.

Action 2: By July 2010, develop a proposed infection control structure for BCUHB that takes into account the needs of both primary and secondary healthcare.

Service and staffing structure reviews has been undertaken and will be considered under the Pathology CPG structure review now underway.

Objective 4: Patients will be treated in physical environments that minimise the risk of infection.

RAG status - Green Action 1: Monitor progress against infection control audits and progress against planned infection control programme on a quarterly basis.

Action 2: Monitor the required 90% compliance with hand hygiene and hospital cleanliness within the LDP

Objective 5: BCULHB will develop and implement comprehensive surveillance and audit programmes, based on national programmes and local need and making use of recognised audit tools, to monitor and direct their infection prevention and control programmes.


Action 1: Monitor and report on a monthly basis the incidence of key preventable infections associated with Clostridium difficile, Staphylococcus Aureus Blood stream infections, Ventilator Associated Pneumonias, Central Venous Catheter infections, Surgical Site infections and Outbreaks of infections

Achieved a 28% reduction in clostridium difficile against a AOF

target of 20% reduction.

MRSA bloodstream infections have increased by 1.9% = 1 extra case. MSSA blood stream infections have reduced.

VAPS and CVC related infections have fallen significantly with :

VAPs = 1 infections rate 0.4% CVCs = 6 infections rate of 1.1%

Surgical Site Infection data sets remain problematical with issues

related to compliance with data sets that require addressing.

Outbreaks infections across BCUHB were 96 - the majority of these outbreaks were related to viral gastro enteritis and were of short duration.

Objective 6: By November 2010 develop BCUHB protocols and procedures relevant to infection prevention and control, based on National policies, local needs and expert practice RAG status - Green

Currently there are 12 protocols that have been either submitted or ratified by the Sub Committee or are currently at consultation phase.

There are another 6 that are in their developmental stages and will

be submitted to the Sub Committee before the consultation process begins.

Objective 7: All staff will understand the impact of infection and infection prevention and control practices and be empowered to discharge their personal responsibilities to patients, other staff, visitors and themselves RAG status - Green Not all staff have received updates in infection control

Action 1: All staff on induction to be informed of their responsibilities and receive information in respect of infection prevention and control

Action 2: Effective prevention and control training and education will be included within induction, mandatory training and professional


development programmes and made available as appropriate to all staff.

7 Further comments:

The majority of the targets set within the Improving Infection Prevention and Control Committee for 2010-2011 have been met. With the Key AOF target of achieving a greater than 20% reduction in clostridium achieved. The mandatory infection surveillance programmes indicate that there has been significant gains in reducing key infections related to central venous catheters, ventilator associate pneumonias and orthopaedic surgical site infection rates. Areas of concern are related to compliance with hand hygiene in a number of CPGs, Caesarean section SSI and mrsa bactermias. These areas of concern will be key components for improvement in 2011. *Key: Red = not on target to achieve all actions, and may not achieve these actions by the next

quarter Amber = not on target to achieve all actions, but has plans in place to see these actions

achieved by the next quarter Green = on target to achieve all actions LJ/subcttee annual report.doc v0.03

Committee Annual Report

Note: the overall *RAG status below relates to the performance of the Sub Committee over the year against the current Terms of Reference and not the status of the risk management arrangements within BCUHB.

1 Title of Committee: Risk Management Sub Committee 2 Name and role of person submitting this report: Mary Popplewell, Assistant Director ~ Risk and Assurance 3 Dates covered by this report: 1.4.10 – 30.3.11 4 Number of times Committee met during the year: 4 5 Assurance/s this committee is designed to provide: To support the Quality & Safety Committee in discharging it’s responsibilities for risk management, by informing it’s agenda, determining it’s risk management priorities and carrying out tasks and duties in accordance with the agreed cycle of business ( Appendix 1 – Attendance record) ( Appendix 2 – Terms of Reference v4.0) 6 Overall *RAG status against committee’s annual objectives / plan: Terms of Reference Objectives Evidence Status To provide leadership, commitment and operational support to the risk management process

Risk Framework approved including standardised Risk Register template.

Amber

To co-ordinate the development of the BCUHB Risk Management Policy and Strategy

Risk Management Policy & Strategy approved.

Green

Item QS11.023.1.2

1

Terms of Reference Objectives Evidence Status Ensure systems are put in place to

of

s

urgent

the reporting

PG review and monitor the ongoing development and implementationthe Risk Management Strategy within Clinical Programme Groupincluding developing and implementing a system forescalation and resolution of risk management issues

Process forof risk management arrangements from Cand Corporate Functions developed and agreed.

Amber

Co-ordinate and maintain the

ard

e

Board Assurance d to

d. It

review of the Board AssuranceFramework and submit to the Bofor consideration and approval at least twice a year ensuring alignment with key CorporatObjectives

Framework, aligneStrategic Direction, developed and agreehas not been considered or approved by the Board.

Red

On behalf of the Board develop and

ich will

Corporate Risk Register to

maintain a comprehensive Corporate Risk Register whbe reviewed at each meeting and presented to the Board on a half yearly basis

be developed following high level risks identifiedby CPG and Corporate Function.

Red

To facilitate LHB Board compliance

on

Welsh Risk Management with external standards; good practice guidance; and legislati

Pool Assessment Reports and MIAA Risk Review considered by the Sub Committee.

Green

To ensure that appropriate lace to

d

Internal the monitoring systems are in p

ensure compliance against the relevant LHB Board’s internal controls systems, processes anPolicies

Statement on Control considered by Sub Committee.

Green

Manage an on-going process of self

d

Self assessment st

dard

Sub

assessment and improvement against the Healthcare Standar27.4 to enable the annual self-assessment submission

submission againStandards for HealthService in Wales Stan22 – Managing Risk and Health & Safety considered by theCommittee

Green

Oversee the on-going development,

are

tandards

by the review and implementation of relevant sections of the HealthcStandards Improvement Plan

Healthcare SImprovement Plan 2009/10 consideredSub Committee.

Green

2

Terms of Reference Objectives Evidence Status Co-ordinate external risk management review (incluWRP), investigation and inspectvisits to the LHB, ensuring that action plans are developed and implemented to address any riskmanagement issues of concern that are identified

ding ion

Management

rts and

Welsh RiskPool Assessment undertaken. Repoaction plans considered bythe Sub Committee.

Green

Receive reports from internal risk

MIAA Risk Matrix review

d reviews, ensuring that action plansare developed and implemented to address any issues of concern that are identified

and Welsh Risk Pool Action Plans considereby the Sub Committee.

Amber

To ensure the effectiveness of all

ction

Issues of Significance and

&

ssion

working groups with accountabilityto the Risk Management Sub-Committee, including the produof relevant minutes, plans, reports and other documentation

Minutes of working groups received by the Sub Committee. Annual Reports from HealthSafety Forum and Violence and AggreManagement Group.

Amber

To ensure there is a training

of

staff

d

licy and

ework.

strategy developed for raisingawareness and understanding the responsibilities for risk management of managers,and the Board

Training issues includewithin the Risk Management PoStrategy and Risk Management FramRisk Assessment Training being undertaken.

Green

To act as the approval body for

ures

policies and written control documents pertaining to its responsibilities and functions

Policies and Procedapproved as appropriate. (See “Approval of ” sectionlater)

Green

To provide an Annual Report to the

l Report considered Audit Committee and the Quality & Safety Committee providing positiveassurance that the Sub-Committee has met its terms of reference and key duties

Annuaand amended following discussion at Sub Committee.

Green

7 Main tasks completed / evidence considered by the Committee during

B – Tasks undertaken at meeting of 31.3.11 to be reported in 2011/12

onitoring of: d Risk Management Project (Datix)

mmittee

this reporting period:

(NAnnual report) M

• Integrate• Sub Groups of the Risk Management Sub Co

3

o Health & Safety Forum o Clinical Ethics, Capacity & Human Rights Sub-Group

Progression of : Framework

nts Fire Safety

eview of : of Reference

signatures for receipt of NHS Pension Scheme

eceipt of: Maturity Review (MIAA 607BCU_1011_001)

ents report

Approval of: anagement Policy and Strategy

gement Policy and Procedure –

re for Management of Incidents between ntly

ce Protecting Employees from Violence and

Main action plan themes / tasks due for completion in forthcoming

• Agree an Annual Cycle of Business for the Risk Management Sub

the systems are put in place to review and monitor the

agement Policy and Strategy

ntegrated Risk Management

ate the reporting arrangements of the Sub Groups of the Risk Management Sub Committee

o Medical Devices Oversight Group

• Assurance• CPG reporting arrangeme• Policy for the Management of

R

• Terms• Risk of not obtaining

Choice Packs R

• Risk • Healthcare Standards Improvement Plan 2009/10 • Statement on Internal Control • Welsh Risk Pool Final Assessm• Welsh Risk Pool Report – 2009/10

• Risk M• Risk Management Framework • North Wales Trust Waste Mana

extension of review date • Joint Operational Procedu

Countess of Chester NHS Foundation Trust and BCUHB (subsequesuperseded with SLA)

• Procedure and GuidanAggression (V&A)

8

year:

Committee • Consolidate

ongoing development and implementation of the Risk Management Strategy within Clinical Programme Groups including developing and implementing a system for urgent escalation and resolution of risk management issues

• Review the Risk Man• Review the Risk Management Framework • Monitor the phased implementation of the I

Project • Consolid

4

9 New risks and issues identified by this Committee in-year:

roject within agreed timescales

s

risks been escalated as an issue of significance, or to the relevant Chief of Staff for consideration?

Y

one

= not on target to achieve all actions, and may not achieve these actions by the next quarter

• Failure to implement the Integrated Risk Management P

• Failure to consolidate the reporting arrangements of CPGs and Corporate Function

10 If appropriate, have these new

es □ No [please explain]…………………………………..

11 Further comments: N *Key:

ed RAmber = not on target to achieve all actions, but has plans in place to see these actions achieved by

the next quarter Green = on target to achieve all actions LJ/cttee an

nual report.doc v0.02 Jan 11

5

Appendix 1 Risk Management SubCommittee Attendance 2010/2011 8.7.10 3.9.10 9.12.10 20.1.11 Dr Lyndon Miles Vice Chair Chair Y Y Y Y Mr P Barry Risk Manager (I) In Attendance Y Y Y Y

Mr M Common Director Improvement & Business Support Past Member Apols

Mr K Dawes Risk Manager (I) In Attendance Apols Apols Y Y

Mrs J Galvani

Director Nursing, Midwifery and Patient Services Member Apols Y Apols Apols

/ Mrs H Piggott Asst Director - Nursing Deputy Y Apols Y Y

Dr KD Griffiths Director Therapies & Health Sciences Member Apols Y Apols Y

Mrs S Hockings Staffside In Attendance Y Y Apols

Mr D Harries Head of Internal Audit & Assurance (I) In Attendance Y Y Apols Apols

Mrs L Joannou Asst Director - Primary Care Support In Attendance Y Y Apols

Mrs A Kemp Asst Chief of Staff Ops- Radiology CPG In Attendance Apols Apols Y Y

Ms D Lamb Principal Public Health In Attendance Y

Mrs G Lewis-Parry Director Governance & Communications Member Apols Y Apols Y

Mrs C Lynes Asst Chief of Staff (N) P,C&S Medicine CPG In Attendance Apols Y Y Y

Ms H MacArthur Asst Director Finance (I) In Attendance Apols Y Y Ms V Nelson Staffside In Attendance Y Y Y

Ms M Popplewell Asst Director - Risk & Assurance In Attendance Y Y Y Y

Ms N Pryce-Howard

Asst Director - Quality and Safety In Attendance Y Y Y Y

Mr M Scriven Medical Director Member Y Apols Apols Apols / Dr M Duerden Asst Medical Director Deputy Apols Y Mrs H Simpson Director of Finance Past Member Apols Mr M Singleton Staffside In Attendance Apols Y Y

Mr K Woodward NW Regional Counter Fraud Manager (I) In Attendance Y Y . Y

Mrs S Williams

Asst Chief of Staff - Anaesthetics, Critical Care & Pain Mgt CPG In Attendance Y Apols Apols Apols

Mr A Jones Director - Public Health Past Member Apols Other Officers in Attendance

Diane Rose Programme Administrator (I) Secretariat DR DR DR SR

John Jones For C Lynes Y Rob Peel For H MacArthur Y Huw Jones For D Harries Y Y Dr Kath Clarke For S Williams Y

Rod Taylor Head of Operational Estates Apols

Stan Nuttall For Rod Taylor Y (I) Interim

Appendix 2

Betsi Cadwaladr University Health Board Terms of Reference and Operating Arrangements

RISK MANAGEMENT SUB COMMITTEE

1. ACCOUNTABILITY The Risk Management Sub - Committee is accountable to the Quality & Safety Committee. 2. REMIT To support the Quality & Safety Committee in discharging it’s responsibilities for risk management, by informing it’s agenda, determining it’s risk management priorities and carrying out tasks and duties in accordance with the agreed cycle of business. 3. CHAIR Independent Member of the Board 4. LEAD DIRECTOR Director of Governance & Communications (Vice Chair)

5. MEMBERSHIP Members The Director of Governance & Communications

The Medical Director & Director of Clinical Services or deputy The Director of Nursing, Midwifery and Patient Services or deputy The Director of Therapies and Health Science

Assistant Director of Assurance & Risk Assistant Director of Quality & Safety Assistant Director Primary Care Support Assistant Director of Finance Public Health representative 3 CPG representatives with responsibility for risk (to represent all CGPs)

3 Staffside representatives In attendance Senior officers from Risk Management

Senior officers from Internal Audit Senior officers from Health and Safety Management

1

Senior officers from Local Counter Fraud Specialist

By invitation LHB Officers with lead responsibility for: - Medical Devices - Radiation Protection - Blood Transfusion - Incident Reporting - Complaints and claims management

6. AUTHORITY 6.1 As per Schedule 3 of the BCUHB Standing Orders the Risk

Management Sub - Committee is authorised by the Board via the Quality and Safety Committee to investigate any activity within its terms of reference.

6.2 It is authorised to seek any additional information it requires from any

employee of the LHB and all employees are directed to co-operate with any request made by the Sub-Committee.

6.3 The Sub-Committee also reserves the right to request additional detail

in relation to a CPG performance, where a trend or a concern has been identified.

7. CONDUCT OF MEETINGS 7.1 Meetings will be formally minuted, with names attached to allocated

actions and collated into a summary action plan. Minutes will be approved at the next meeting.

7.2 Attendance at each meeting will be monitored, so that the Chair can

initiate action in the event that a member fails to attend more than three consecutive meetings without good reason and without providing an appropriate deputy.

7.3 Secretariat will be provided by the office of the Director of Governance

& Communications 7.4 Quorum 7.4.1 The Sub-Committee shall be deemed quorate provided four members

are present, including an Independent Member* and one of the LHB Board of Directors or Assistant Directors.

*In the event that an Independent Member cannot be present the meeting will be deemed quorate providing the Lead Director is in attendance.

2

7.4.2 In exceptional circumstances the Sub-Committee may be Chaired by the Director with lead responsibility for the Sub-Committee.

7.5 Frequency of Meetings 5 times per year. 8. RESPONSIBILITIES & FUNCTIONS WILL INCLUDE 8.1 To provide leadership, commitment and operational support to the risk

management process; 8.2 To co-ordinate the development of the BCUHB Risk Management

Policy and Strategy; 8.3 Ensure systems are put in place to review and monitor the ongoing

development and implementation of the Risk Management Strategy within Clinical Programme Groups including developing and implementing a system for urgent escalation and resolution of risk

management issues; 8.4 Co-ordinate and maintain the review of the Board Assurance

Framework and submit to the Board for consideration and approval at least twice a year ensuring alignment with key Corporate Objectives;

8.5 On behalf of the Board develop and maintain a comprehensive

Corporate Risk Register which will be reviewed at each meeting and presented to the Board on a half yearly basis;

8.6 To facilitate LHB Board compliance with external standards; good

practice guidance; and legislation; 8.7 To ensure that appropriate monitoring systems are in place to ensure

compliance against the relevant LHB Board’s internal controls systems, processes and Policies;

8.8 Manage an on-going process of self assessment and improvement

against the Healthcare Standard 27.4 to enable the annual self-assessment submission;

8.9 Oversee the on-going development, review and implementation of relevant sections of the Healthcare Standards Improvement Plan; 8.10 Co-ordinate external risk management review (including WRP),

investigation and inspection visits to the LHB, ensuring that action plans are developed and implemented to address any risk management issues of concern that are identified;

8.11 Receive reports from internal risk reviews, ensuring that action plans

3

are developed and implemented to address any issues of concern that are identified;

8.12 To ensure the effectiveness of all working groups with accountability to

the Risk Management Sub-Committee, including the production of relevant minutes, plans, reports and other documentation;

8.13 To ensure there is a training strategy developed for raising awareness

and understanding of the responsibilities for risk management of managers, staff and the Board;

8.14 To act as the approval body for policies and written control documents

pertaining to its responsibilities and functions. 8.15 To provide an Annual Report to the Audit Committee and the Quality &

Safety Committee providing positive assurance that the Sub-Committee has met its terms of reference and key duties.

9. REPORTING 9.1 The minutes of the meeting shall be formally reported to the Quality &

Safety Committee and the Audit Committee of the LHB Board. 9.2 Issues of significance from the Risk Management Sub-Committee will

be reported to the Quality & Safety Committee and each of its Sub-Committees.

10. CHAIR’S ACTION ON URGENT MATTERS 10.1 There may, occasionally, be circumstances where decisions which

would normally be made by the Committee need to be taken between scheduled meetings. In these circumstances, the Committee Chair, supported by the Committee Secretariat as appropriate, may deal with the matter on behalf of the Board – after first consulting with two other Independent Members of the Committee. The Secretariat must ensure that any such action is formally recorded and reported to the next meeting of the Committee for consideration and ratification.

10.2 Chair’s action may not be taken where the Chair has a personal or

business interest in the urgent matter requiring decision.

4

DATE OF ACCEPTING THE TERMSOF REFERENCE AND APPROVAL Date: Chair of Risk Management Sub Committee signature Vice Chair of Risk Management Sub Committee signature V5.0 APPROVED

5

Clinical Effectiveness Sub-Committee Annual Report: Draft for update & completion by May 2011. To be agreed by

Chairman

1 Title of Sub-Committee: Clinical Effectiveness Sub Committee 2 Name and role of person submitting this report: Dr Lyndon Miles – Chairman 3 Dates covered by this report: 01 April 2010 – 31 March 2011 4 Number of times Sub-Committee met during the year: The committee met 4 times over the year with 2 meetings cancelled. 5 Assurance/s this Sub-Committee is designed to provide: • To support the Quality & Safety Committee in discharging its

responsibilities for clinical effectiveness, by providing assurances of continuous quality improvement and patient safety.

• To provide leadership and direction with regards to the clinical effectiveness agenda across the organisation through the delivery of a clinical effectiveness strategy.

6 Overall *RAG status against Sub-Committee’s annual objectives / plan: AMBER: Objectives and annual report plan to be developed for 2011/12.

During 2010/11 the sub-committee has agreed membership and terms of reference although attendance has been sporadic. A plan will be developed for 2011/12 to deliver the Clinical Effectiveness Strategy. Sub groups have provided terms of reference, issues of significance and progress reports.

7 Main tasks completed / evidence considered by the Sub-Committee

during this reporting period: • Agreed terms of reference and membership. • Sub Groups established.

1

• Completion of evidence (corporate) for Standards for Health Services in Wales: Standard 7 – Safe and Clinically Effective Care.

• Review of National Audit reports/recommendations • Evidence of participation in National Confidential Enquiries. • Issues of Significance from sub groups. 8 Main action plan themes / tasks due for completion in forthcoming

year: • Development of Clinical Effectiveness Strategy. • Development of Clinical Effectiveness Assurance Frameworks within all

Clinical Programme Groups (CPGs). • Agreed Cycle of Business for Clinical Effectiveness Sub-committee and

Sub Groups. • Development of annual work plan for Clinical Effectiveness Sub-committee

to deliver Clinical Effectiveness Strategy across BCUHB. 9 New risks and issues identified by this Sub-Committee in-year: • Reorganisation and finalising of CPG structures has had an impact on

identifying key personnel/leads for Clinical Effectiveness Sub-committee and its sub groups. This has been a particular issue (ongoing) for Clinical Audit Group.

• No obvious robust assurance frameworks within CPGs for the development of reporting of and ongoing review of clinical effectiveness issues.

10 If appropriate, have these new risks been escalated to the relevant

Chief of Staff for consideration?

Yes x No □ [please explain]………………………………….. Letter sent to Chiefs of Staff March 29, 2011 requesting they identify Clinical Effectiveness Leads, CPG clinical effectiveness assurance frameworks and work plans to facilitate further discussion on May 19, 2011 at next Clinical Effectiveness Sub Committee Meeting. 11 Further comments:

• A presentation will be given to the Board of Directors outlining the strategy and emphasising the need for full CPG involvement.

*Key: Red = not on target to achieve all actions, and may not achieve these actions by the next quarter Amber = not on target to achieve all actions, but has plans in place to see these actions achieved by

the next quarter Green = on target to achieve all actions

2

Sub-Committee Annual Report

1 Title of Sub-Committee: Improving Service User Experience 2 Name and role of person submitting this report: Heather Piggott, Assistant Director of Nursing. 3 Dates covered by this report: April 2010- March 2011 4 Number of times Sub-Committee met during the year: The sub-committee met 6 times during 2010-2011 5 Assurance/s this Sub-Committee is designed to provide: BCUHB will listen to the experience of its patients and service users and carers and describes we will use this information to improve our services. By ensuring that service user opinions are taken into account, BCUHB can make sure that service users are involved, listened and responded to so that they receive an experience that holistically meets their physical, spiritual and emotional needs and expectations in a manner that promotes human rights. 6 Overall *RAG status against Sub-Committee’s annual objectives / plan: Green 7 Main tasks completed / evidence considered by the Sub-Committee

during this reporting period: Objective 1: Develop a range of strategies related to Service User Experience which will meet the needs of all service users, relatives and carers and will lead to improved service user experience.

Action 1: By June 2010, the Corporate Team to work with Clinical Programme Groups (CPGs) to agree how corporate and CPG roles interface, this will include the development of CPG Improving

1

Service User action plans and outcome measures to assess the impact of the Improving Service User Experience Strategy in each CPG. This work will be aligned to the Single Equality Scheme. This action is about developing systems and channels of communication between CPGs and corporate functions to ensure that a culture which promotes the importance of service user engagement, equality and human rights prevails within BCUHB. This commitment has been underpinned by: • The development and dissemination of the Improving Service User

Experience Strategy • The development and dissemination of a CPG role definition for

Improving Service User Experience within CPGs • Close links between Improving Service User Experience and Equality &

Human Rights • The requirement of CPGs to report on their plans and outcomes for

Improving Service User Experience, and to nominate leads and key contacts.

• The requirements of CPGs to develop actions plans to take forward Improving Service User Experience within their areas.

• The development of Health Board wide improving service user experience targets that must be included in CPG plans, hence promoting a consistent approach within BCUHB, whilst taking into account the individuality of CPGs.

Action 2: By December 2010, develop and implement a volunteering strategy for BCUHB, evaluate the strategy by December 2011. Action 3: By December 2010 expand volunteering services in secondary and primary care. A draft BCUHB volunteering policy and Volunteer Toolkit for in-house volunteers managed by the Health Board has been developed. They are based on recognised good practice developed by Central area. During 2011, an action plan will be developed to standardise volunteering opportunities within BCUHB and to increase the number of ward-based ‘Robin Volunteers’. In December 2010, Ward Volunteers based at Glan Clwyd Hospital won the ‘UK Befriending Project Recognition Award 2010’. Action 4: By December 2010 develop and implement an advocacy service for service users, evaluate the service by December 2011. Work has commenced on the development of a model for a Patient Advice and Support Service for BCUHB. The concept requires further development and liaison with relevant stakeholders prior to piloting the model in one area of the Health Board.

2

Action 5: Develop and implement a BCUHB Bereavement Strategy, evaluate the strategy by March 2011. A baseline in relation to the co-ordination of bereavement services pre-BCUHB has taken place. Best practice from other NHS Trusts and key documents have been reviewed in preparation for the drafting of BCUHB’s Bereavement Strategy. During 2011, it is proposed that a BCUHB Bereavement Group will be formed to ensure a consistent approach, develop strategy and supporting action plans. Objective 2: Service Users and carers will always be treated with dignity and respect and their privacy protected. Action 1: By July 2010, undertake a benchmarking exercise with other areas across the UK and utilise good practice.

A baseline and evidence of good practice was collated in response to the Older People’s Commissioner for Wales review and call for: Evidence on Dignity and Respect in Hospitals. The aims of the review are to:

• Consider older people’s experiences, both good and bad, when they are hospital in-patients

• Make practical recommendations where people are not treated with dignity and respect.

• Identify and spread good practice. BCUHB’s response was finalised in August 2010. The Older People’s Commissioner will share and spread identified good practice throughout Wales. Action 2: Develop a BCUHB wide action plan for Dignity and Respect aligned to the Single Equality and Human Rights scheme, ensuring that examples of good practice are maintained and shared. A BCUHB wide action plan has been developed; thirty-seven actions were identified for the time period 2010/2011; of these twenty-two have been achieved and fifteen are progressing. Some of the key achievements for 2010 include: • Developing a regional approach to Dignity and Respect by working in

partnership with Local Authorities and other agencies to create a network of Dignity Champions throughout North Wales.

• Review of hospital nightclothes; and modified split back nightdresses identified that allow ease of patient management whilst maintaining patient dignity.

3

• MUST, nutritional screening tool and training rolled out throughout BCUHB.

• A long-term project requiring ward sisters to undertake degree level leadership modules introduced.

• Care of the Dying Pathway available throughout BCUHB. • ‘Taking Inspiration from Patients’, study day using patients’ stories as a

way of engaging staff in the dignity agenda, to be delivered in early 2011. Objective 3: Service users will be welcomed to BCUHB in a friendly, professional manner by staff who are courteous, polite and listen to service users’ feelings and preferences. Action 1: By July 2010, undertake a benchmarking exercise with other areas across the UK and utilise good practice. Action 2: By December 2010, develop a programme of Customer Care training for all staff. Action 3: By December 2010, develop a professional and etiquette guide. All staff who undertake BCUHB’s Induction Training now have Customer Care training. To build on this introduction to Customer Care training, a more detailed training module is in development and will be circulated to relevant stakeholders for comment by April 2011. Objective 4: BCUHB will develop a plan to enable everyone who receives or uses it services to do so through the medium of Welsh or English, according to personal choice and to encourage other users and providers to use and promote the Welsh Language in the health sector. Action 1: By December 2010, mainstream the Welsh Language in the organisation’s key policies and initiatives by working with each Clinical Programme Group All CPGs have been asked to complete a detailed monitoring return which measures the consideration given to the language when planning and delivering services, recruiting and communicating with patients and the wider public. A process is ongoing to identify Welsh langue champions within each CPG who will take responsibility for ensuring compliance with the Welsh Language Scheme. The main focus during the first year of the scheme has been on the Welsh Assembly Government’s (WAG’s) identified priority areas of Mental Health, Children and Young People and Older People.

4

Action 2: By December 2010, communicate the requirements of the BCUHB Welsh Language Scheme clearly so that the language will be an intrinsic part of the delivery of services by others The Welsh Language Team continues to promote the requirements of BCUHB’s Welsh Language Scheme to all staff and has developed guidelines for external contractors or voluntary organisations who may be delivering services on behalf of the Health Board.

Action 3: By December 2010, ensure an adequate number of staff who can provide a Welsh medium service by assessing each new vacant post and advertising language requirements as part of the recruitment process. An innovative competency levels scheme has been developed to assess the linguistic needs of each post. The new system is almost ready for implementation and will require managers to stipulate a Welsh language competency level for each vacant post. Corresponding training arrangements are also being developed

Actions 4 & 5: Increase the number of staff who are able and who actually work through the medium of Welsh; provide appropriate training, including vocational training, and language improvement training and taster courses. By December 2010, ensure that sufficient numbers of Welsh speaking staff are available across the services and monitor the level of language ability according to the standard levels. By April 2011, a training plan will be in place that specifically addresses the needs of staff that provide direct patient services, or have contact with the public. The level of training will be matched with the requirements of the post.

Action 6: By December 2010, ensure that each new member of staff receives language awareness training. Also to ensure that language awareness training resources are made available to current staff. All staff receive a Welsh language awareness session at induction. The Welsh Language Team also offer awareness sessions to specific teams as the need arises.

Action 7: Promote specific activities provided through the medium of Welsh so that Welsh speakers may choose to use them. The Welsh Language Team is working to promote all services available through the medium of Welsh through the website and local awareness campaigns.

5

Objective 5: Care is delivered in a place where individuals feel confident of the services provided, that they are safe, well looked after, respected and satisfied with their experiences. This could be in their home, clinic, community setting or hospital. Action 1: By May 2010, the Transforming Care roll-out project will commence across all BCUHB wards. Roll-out will be completed by 2012. The Transforming Care roll-out is underway over thirty ward areas are now engaged in the programme. Action 2: All wards are required to undertake Fundamental of Care audits annually. The audit tool has two levels of data collection: operational and user, across twelve standards. Operational level data is based on the findings of documents, records, observations and staff knowledge. The User level or patient level is based on the experience of care of five randomly selected patients who may or may not need assistance from friends/relatives/carers to complete. The results of the Fundamentals of Care audits for 2010 indicate that there is an improvement in the scores for 11 of the 12 elements. In 2009, Standard 10 (Oral Health and Hygiene) was one of the lowest scoring operational scores, and is the only standard to have fallen in the 2010 audit. The main reason for this is the variable use of an oral assessment tool. This is also supported by a recent audit of oral hygiene practices that revealed that, in the majority of clinical areas there was no standardised oral assessment tool and the majority of staff were using clinical judgment. Numerous assessment tools have now been identified and one will be introduced as a PDSA with a view to further roll out across the organisation. Objective 6: Develop processes for systematic service user feedback and for gathering service user stories which can be monitored, evaluated and will lead to improved service user experience, ensuring that the whole organisation learns from patient feedback. Action 1: By September 2010, develop a framework for the safe management of patient stories; ensuring that this work is aligned to the Single Equality Scheme and that patient stories reflect equality and human rights issues.

6

In September 2010, the ISUE-sub group ratified BCUHB’s framework ‘Undertaking Patient Experience Stories’. The framework was launched at a narrative conference hosted by Glyndwr University. A number of patient stories have been recorded and a secure database created to record available stories and note improvement actions taken as a result. Patient stories have been presented to a number of committees and groups and have formed part of educational programmes. During 2011, people who have sensory impairments will be asked to share their experience of accessing BCUHB services. Members of the Improving Service User Experience Team will be presenting the framework at CPG Board Meetings. Staff training in relation to taking and recording patient stories will be delivered in partnership with Glyndwr University. Action 2: By March 2011, develop a process for the collection, evaluation and monitoring of systematic patient feedback through patient satisfaction surveys in all clinical areas across BCUHB. Ensure this information is disaggregated in respect of protected characteristics. A number of approaches have been adopted to systematically gain feedback through patient satisfaction surveys, these include: • By December 2010, the Picker Inpatient Survey will be conducted within

BCUHB’s three acute hospitals. The results of the survey will be available early 2011, and will allow for comparison of patient experience across sites, CPGs, and wards.

• The Comment Card scheme has been revised and an electronic comment card system introduced for BCUHB. Depending on funding paper copies of the comment cards will be available from 2011.

• Routine telephone surveys have been conducted throughout 2010, focusing on areas that patients have raised as concerns. The main concerns are around admission and discharge information. Small tests of change, such as Ward Welcome information, discharge leaflets and communication pathways have been implemented and it is proposed that these will be introduced throughout BCUHB during 2011.

• A database of surveys being conducted within CPGs has been developed.

• The Public Members and Connection Groups continue to provide a public perspective on matters relating to service user experience.

• Equality monitoring forms part of survey work.

7

Objective 7: Develop processes for systematic process across BCUHB to learn from complaints and compliments and improve service user experience ensuring that the whole organisation learns from patient feedback. Action 1: Develop a BCUHB-wide Complaint’s policy which supports and reflects the proposed new WAG guidelines. A BCUHB wide policy is being developed, and will reflect the requirements of the NHS redress scheme: ‘Putting Things Right’. Action 2: Develop action plans to support the implementation of the Healthcare Standard for complaints and reporting arrangements to ISUE. This action was completed in January 2010. Action 3: Develop a BCUHB-wide report for Board submission and assurance which provides the level of detail required for monitoring, overview and scrutiny. Complaints, compliments and concerns are reported quarterly to the Quality and Safety Committee and form part of Integrated Governance reporting. Action 4: Implement the CPG Patient Experience and Equality Role definition, support CPGs in the effective management of complaints and agree CPG specific complaints performance and monitoring targets. A CPG Quality and Safety Reporting template has been agreed and CPGs report to the Quality and Safety Committee on an annual rolling-programme. Action 5: Undertake a training needs analysis for complaints training and develop a strategy to support this. A training needs analysis has been undertaken in readiness for the implementation of WAG’s NHS redress scheme, ‘Putting Things Right’. Relevant staff will receive investigation training by the National Patient Safety Agency Faculty. Action 6: Develop a BCU-wide Complaints Leads Group. A Corporate Complaints Managers’ group is in operation and meets quarterly. A BCUHB Complaints Scrutiny group was established in October 2010, it reports to the Patient Safety Steering Group and any themes or issues of significance are highlighted at the ISUE-sub-group Action 7: Develop guidance and good practice for operational and devolved complaints management within CPGs.

8

BCUHB is awaiting the draft of WAG’s ‘Putting Things Right’ redress scheme; it is anticipated that this will be presented to the Quality and Safety committee in March 2011. BCUHB’s policies, procedures and guidance will be based on the final version of the redress scheme. Action 8: Develop systems to ensure that information relating to patient experience is correlated to provide an overview of Service User Experience in BCUHB. Ensure mechanisms are in place to disaggregate this information in respect of protected characteristics. This action will be progressed during 2011. Action 9: Ensure within CPGs and across the Board, that lessons are identified and learned to ensure improvements to services. The Complaints Scrutiny Group, Claims Scrutiny Group and the Patient Safety Steering Group are responsible for indentifying service improvements. Lessons learnt from incidents, complaints and claims are formally reported on a quarterly basis to the Quality & Safety Committee as well as being communicated to the corporate teams and CPG staff. Objective 8: Further develop links with local faith leaders ensuring adequate spiritual support is available, as appropriate and to develop a wider strategy for the pastoral care of service user, staff and relatives.

Action 1: By September 2010, develop a strategy for Spiritual and Religious care. Action 2: By March 2011, Modernise Chaplaincy services enabling extension of spiritual, religious pastoral care of patients and staff to extend beyond the traditional boundaries of acute and community hospitals. The above actions will be commenced during 2011; the full assessment conducted as part of the Spiritual Care Standards for Wales will inform strategy development. Action 3: By December 2011, improve multi-faith facilities and resources in acute and community hospitals and increase awareness of equality issues relating to practice of religion, spirituality amongst staff. The multi-faith facilities have been reviewed and improved. All three acute hospitals have multi-faith chapels with screened space for Muslim prayers; the Maelor Hospital has a separate prayer room. A few hospitals have Christian chapels. Chapels have resources not specific to any particular religious faith, i.e. pebble pools, spiritual sayings and relaxation leaflets, as well as standard religious resources i.e. prayer cards and religious books. The new Mental Health Unit at Wrexham Maelor Hospital has been furbished with a Reflection Room. Each acute hospital has a list of local multi-faith contacts for referrals,

9

copies of local and national church directories, list of hospital chaplains nationally; a new interfaith website will provide additional resources. A multi-faith contact directory is held by on-call chaplains. Spiritual care information and contact cards are available. Chaplains are members of the Interfaith Council for Wales and local interfaith networks. Action 4: By December 2011, carry out a full assessment of pastoral, spiritual care services against the new Spiritual Care Standards On 25th May 2010, WAG published Standards for Spiritual Care in Wales; consequently a review of BCUHB’s Spiritual Care Services was undertaken and the outcome reported to the ISUE sub-committee in September 2010. BCUHB meets the majority of the standards in full, however a number of issues of significance were identified these will form the basis of future action plans and include: • Encouraging staff to record patients’ religion/beliefs on admission forms. • Develop a written framework for referral to the Spiritual Care Team • Increase the involvement of the Spiritual Care Team in the induction of

new members of staff. • The Spiritual Care Team should have access to patient data in order to

respond to referrals and to track patients receiving spiritual care as they move through the system.

• The level of staffing in the Spiritual Care Team should be considered a priority.

Objective 9: Develop services that can support service users and carers in a setting of their choice especially for end-of-life decisions.

Action 1: By September develop a standardised model for Bereavement Care across BCUHB. Action 2: By September 2011, develop policy, procedures and protocols for Bereavement Care that meets the DOH Guidelines: When a Patient Dies: advice on developing bereavement services in the NHS, 2005. While ensuring that Bereavement has appropriate senior management support. A full Bereavement and Mortuary service review is to commence early 2011, with engagement from all stakeholders and general public. Following the review and confirmation of the service model a bereavement group will be formally instigated to agree on BCUHB policy and protocols. Action 3: By December 2010, provide good quality written information A BCUHB Bereavement information booklet for acute and community deaths has been developed and will be available January/February 2011. Action 4: By September 2011, review and standardise bereavement facilities for bereaved families following a death.

10

An initial scoping exercise has been completed within the three acute hospital sites. Scoping of community services will commence in early 2011.

Action 5: By September 2011, improve staff training at all levels in the care of the dying, deceased and bereavement, the option of organ donation. Staff training is taking place throughout BCUHB; however more regular teaching is required with the flexibility to deliver the sessions at ward level. Greater emphasis needs to be placed on developing a standardised approach to education for all BCUHB staff in bereavement issues. Organ donation training and consent training for a new all-Wales post mortem consent procedure has been a priority during the latter part of 2010, in accordance with the Human Tissue Authority licence regulations. The Palliative Care Team are taking the lead on BCUHB’s Breaking Bad News policy and subsequent training programme, with assistance from Bereavement Services.

Action 6: By September 2010, roll-out the Bereavement Contact Card introduced in East to all wards across BCUHB. A secondment for a bereavement support post has been agreed to commence 2011, projects such as the Bereavement Card and Bereavement box system will be delegated as part of this secondment.

Objective 10: Staff will receive training in Improving Service User Experience to match core competency in the Knowledge & Skills Framework. Action 1: Conduct a Training Needs Analysis: to ensure that managers/staff with a lead role for improving service user experience are equipped with the necessary knowledge and skills to do so. This Training Needs Analysis will be undertaken as and when members of the ISUE Team have been appointed. Action 2: Develop (a) implement (b) and evaluate (c) a training programme linked to the core competency requirements in the Knowledge & Skills Framework for all staff covering all aspects of improving patient experience. This objective has not been met and will be taken forward in 2011

11

Objective 11: BCUHB will develop an Arts in Health and Wellbeing programme

Action 1: By September 2010, introduce an Arts in Health and Wellbeing (AIHWB) steering group reporting to ISUE. An AIHWB steering group has been formed, with key relations to the Therapies & Clinical Support CPG and the ISUE sub-committee. Its function is to support the AIHWB managers in steering the programme forward. In addition there are Task and Finish Project Groups. The group is a BCUHB wide group with key relations to T&CS CPG and ISUE Sub-Committee. It is an - representation and volunteers. Partnerships are represented through the North Wales AIHWB Stakeholder Group. Action 2: By December 2010, introduce an Arts, Health and Well being Co-ordinator. The establishment of an Art, Health & Well being Co-ordinator post is subject to adequate funding of the strategy. Action 3: By March 2011, develop a 5-year strategy. An Arts in Health & Wellbeing Programme Strategy 2011-2016, has been developed for BCUHB outlining the direction in which the programme will develop over the next five years. The aim of the strategy is to both celebrate a long standing legacy of arts in health across North Wales over the past ten years, sustain longevity of current activity and capture a strategic pathway which will help support the professional development of all aspects of arts in health across the Clinical Programme Groups, bringing a value added dimension to reinforce and help deliver our health boards organisational key themes of `making it safe, better, sound, work and making it happen`. Action 4: By March 2011, achieve Charitable status of the programme to

secure funding. This subject is ongoing in discussion with Fund Raising Manager

8 Main action plan themes / tasks due for completion in forthcoming

year: • to further develop links with the CPGs to ensure a consistency of

approach to Improving Service User Experience within BCUHB • Roll out of Robins across BCUHB • Introduction of the new customer care training programme across

BCUHB • Introduction of patient advice and support project across BCUHB • Review of Chaplaincy service • Review of Bereavement Service • Introduction of electronic patient feedback data collection system • Embedding patient stories into organisational culture • Patient information to be standardised across BCUHB • Fundraising for the Robins charitable fund

12

9 New risks and issues identified by this Sub-Committee in-year:

• Ongoing delays with restructuring in the Service User Experience team and CPGs causing operational difficulties.



Yes □ No □ [please explain]………………………………….. 11 Further comments: The majority of the targets set within the Improving Service User Experience Strategy for 2010-2011 have been met. A number of the targets were connected to amalgamating systems and processes throughout BCUHB to make sure that the patients’ and citizens’ voices are heard and acted upon. Therefore, 2010 was a period of change whilst best practice was, shared roles defined and plans agreed for the Health Board. The accomplishment of this work means that the Team is well placed to progress with targets and developmental work identified for 2011. 2010 has also been a year where the Team can demonstrate excellence in their work through compliance with national guidance and standards such as the Spiritual Care Standards for Wales and external recognition such as the award presented to the Ward Volunteers at Glan Clwyd. *Key: Red = not on target to achieve all actions, and may not achieve these actions by the next quarter Amber = not on target to achieve all actions, but has plans in place to see these actions achieved by

the next quarter Green = on target to achieve all actions LJ/subcttee annual report.doc v0.03

13

Improving Service User Experience Sub- Committee update for Quality and Safety

Committee

Improving Service User Experience sub-committee

• Chair – Hilary Stevens• Executive Leads – Jill

Galvani and Grace Lewis Parry

• Lead Officer – Heather Piggott

• Representatives from across BCUHB, Community Health Council and Third sector

• Service user Stories• Service user Feedback• Comments, Complaints,

Compliments and Litigation• Volunteer Services• Spiritual and Pastoral Care

(Chaplaincy)• Equality and diversity and

human rights• Welsh Language• Dignity and Respect• Bereavement Services• Free to Lead Free to Care• Transforming Care• Arts Health and Wellbeing• Carers

Achievements in 2010-2011

• Service User Experience Strategy• CPG engagement• National award for the Robins at YGC• Patient Stories Framework• Dignity and Respect action plan• Development of Customer Care training programme• Development of Patient Advice and Support Service• Development of Pets as Therapy written control

document

Achievements in 2010-2011

• Welsh language lessons for all new staff• Development of Welsh language training plan• 30 wards involved in Transforming Care• Bi-annual Fundamentals of Care audits• Development of service user feedback

systems• Full review of spiritual care services

undertaken• BCUHB Bereavement leaflet• Arts, Health and Wellbeing strategy

Plan for 2011-2012

• Develop CPG links further• Rollout of Robins across BCUHB• Rollout of Customer Care training programme• Rollout of Patient Advice and Support Service• Fundraising for Robins Charitable fund• Spread Arts, Health and Wellbeing

programme across BCUHB• Rollout of the Welsh language training plan.

Plan for 2011-2012

• Review of Chaplaincy Service• Review of Bereavement Service• Introduction of electronic patient feedback system• Embedding patient stories into organisational culture• Standardise patient information across BCUHB• Develop BCUHB Complaints policy based on NHS

Redress• Establish a Care and Compassion task and finish

group

Safeguarding Annual Report March 2011 FINAL 1

Sub-Committee Annual Report 1 Title of Sub-Committee: Safeguarding Children & Vulnerable Adults Sub-Committee 2 Name and role of person submitting this report: Michelle Denwood, Assistant Director of Safeguarding 3 Dates covered by this report: 2010 - 2011 4 Number of times Sub-Committee met during the year: 5 meetings per annum 23.04.10 07.06.10 10.09.10 26.01.11 25.03.11

5 Assurance/s this Sub-Committee is designed to provide: Introduction

The Health Board has placed Safeguarding on a strong footing ensuring that robust systems and processes are in place to Safeguard Children & Vulnerable Adults who are at risk of harm, exploitation and where abuse has occurred to support the victim.

This report serves to inform the Health Board of the ongoing safeguarding activities undertaken within a ten month period in relation to Safeguarding Children, Young People and Safeguarding Vulnerable Adults for the period of 2010-2011, and the priorities identified for 2011-2012 as agreed by the Safeguarding Children & Vulnerable Adult Sub-Committee.

Assurance

The Terms of Reference were formally agreed by the Quality & Safety Committee and assures the Board of their responsibilities which are:-

To ensure the organisation complies with section 28, 27(2) (a) (b) and section 25 And section 31 of the Children Act 2004; To ensure the organisation complies with the Protection of Vulnerable Adult Policy/and Strategic Guidance; To ensure the organisation complies with safe recruitment and monitoring arrangements following CRB & ISA guidance; To provide leadership, commitment and operational support to the Safeguarding Process;


Ensure systems are put in place to review and monitor the ongoing development

and implementation of the Safeguarding Strategy within Clinical Programme Groups including developing and Implementing a system for urgent escalation and resolution of issues;

To facilitate LHB Board compliance with external standards; good practice guidance; and legislation; Manage an on-going process of self assessment and improvement against the Healthcare Standard 17 to enable the annual self-assessment submission; To ensure that recommendations made by internal and external reviews are

considered and acted upon; Oversee the on-going development, review and implementation of relevant sections of the Healthcare Standards Improvement Plan;

To ensure the effectiveness of all working groups with accountability to the Safeguarding Sub committee including the production of relevant minutes, plans, report and other documentation;

To provide an Annual Report to the Quality & Safety Committee providing positive assurance that the Sub-Committee has met its terms of reference and Safeguarding duties. 6 Overall *RAG status against Sub-Committee’s annual objectives / plan:

Annual Objectives 2009/2010 Status Review/Redesign: A new Safeguarding Children, Vulnerable Adult & Domestic Abuse Betsi Cadwaladr University Health Board structure.

GREEN

Ratify the Safeguarding Reporting Framework as agreed by the Quality & Safety Committee

GREEN

Develop the Safeguarding Children & Vulnerable Adult Quality Assurance Framework

GREEN

Implement Betsi Cadwaladr University Health Board Safeguarding Vulnerable Adult Policy

GREEN

Review and implement the organisational Physical Restrictive Practice Policy in compliance with Deprivation of Liberty Safeguards

AMBER

Review all Policies & Procedures from former organisations under the guidance and direction of the Policy & Procedures Task-group

AMBER

Agree and review funding for Local Safeguarding Children Boards in accordance with the increased funding requests due to increased statutory activities and Welsh Assembly Government and CSSIW requiring full independent Chairs and Independent Authors of Serious Case Reviews.

GREEN

Full participation with the consultation undertaken by Professor Mansel Aylward's review of Safeguarding and Protecting Children in the NHS in Wales titled: A Report

GREEN

Implementation of Serious Case Review recommendation Action Plans from Reviews identified during 2008-2009, 2009-2010.

GREEN

Contribute to the National Review of Adult Protection. Care of Social Services Inspectorate Wales (CSSIW) undertook an inspection of


Adult Protection processes across 22 Welsh Local Authorities, and HIW undertook an inspection of arrangements across the NHS underpinning Health Care Standards 17.3 & 17.4.

GREEN

AMBER • Develop a Mini-strategy arising from the Inspectorate report and review of ‘In Safe Hands’.

• Implement and evaluate 19 recommendations GREEN

Revise the Vulnerable Adult Training Programme which underpins the National Guidance and Regional Policy & Procedures.

GREEN

Commence implementation of the E-Learning package for Level 2 Child Protection Training

GREEN

7 Main tasks completed / evidence considered by the Sub-Committee during

this reporting period:

The corporate direction of the Safeguarding Agenda is clearly strengthened by combining the Safeguarding Children, Vulnerable Adult and Domestic Abuse Agenda. Safeguarding is highly emotive, political and the agenda is significantly increasing. The complexity of abuse cases, and high level of risk is making the organisational agenda challenging with increased expectation of further multi-agency activity.

Safeguarding Children & Vulnerable Adults

7.1 Safeguarding Team Structure

The combined Team Structure, developed by the Assistant Director of Safeguarding and ultimately the Director of Nursing, Midwifery and Patient Services was formally agreed by the Board after undergoing consultation as guided by the Organisational Change Policy. This structured approach reduces duplication, strengthens expertise and knowledge and has led the way for NHS organisations across Wales. The incorporation of the designated post for Domestic Abuse has proved innovative and vital due to the increasing agenda.

7.2 Quality Assurance Framework

The Quality Assurance Framework was developed to ensure the Health Board was compliant with all statutory legislation and best practice guidance. It is currently used as the mini strategy of which all Clinical Programme Groups measure their compliance.

7.3 Safeguarding Reporting Structure Agreement was made to develop a Safeguarding Reporting Structure. Two

Operational Forums, Children and Young People and Vulnerable Adult report to the Safeguarding Children and Vulnerable Adult Sub-Committee and ultimately to the Quality & Safety Committee and key tasks for example Training, Policy & Procedures, Self-Harm are achieved through Task Groups of which all have Terms of Reference. Clinical Programme Groups have identified membership ensuring the agenda is incorporated within their core activities.

7.4 Safeguarding Vulnerable Adults


The annual agenda reflects the outcome of two National Inspections carried out by Care of Social Services Inspectorate Wales and Health Inspectorate Wales and the reviews of ‘In Safe Hands’ published during March 2010. This has had significant impact upon Adult Protection throughout the year.

• The review of ‘In Safe Hands’ commissioned by WAG during May 2009. The

Glamorgan University published its report in March 2010 and it made 16 recommendations for the Welsh Assembly Government to consider. Following the publication, the Project Board undertook a wider informal consultation of the Revised National Guidance which ended on 30th June 2010. The timetable is unclear and the Assembly is not expected to respond until late Autumn this year.

• Care of Social Services Inspectorate Wales (CSSIW), National Inspection to test

the robustness of Adult Protection systems was undertaken during November 2009. The final report was published in March 2010. It highlighted areas of good practice and recommended action where improvements were necessary for Local Authorities.

• Health Inspectorate Wales Adult Protection Report 2009 – specific to the NHS,

Wales. An inspection of Adult Protection arrangements across the NHS in Wales underpinning Health Care Standards 17.3 & 17.4 was undertaken. The final report in March 2010 made 19 recommendations for the NHS. The key themes were, training, primary care engagement, patient safety issues e.g. pressure sores and CRB checks.

• The ‘All Wales Interim Policy and Procedures for Adult Protection’ published Nov

2010 which replaces the four regional documents and will be introduced on April 1st 2011.

Betsi Cadwaladr University Health Board Action:

Following the publication of the above documents and action plan the Health Board response was positive. A mini strategy was developed arising from the Inspection Report Review of ‘In Safe Hands’ in order to comply with the recommendations. A plan to roll out the National Policy by the agreed implementation date of April 1st 2011 was agreed.

7.5 Training

POVA training is mandatory for Health Board staff working with or coming face to face with a Vulnerable Adult as outlined in the National Guidance. The Clinical Programme Groups are required to develop a local training development plan for staff at the appropriate level to commensurate with their work in accordance with the Health Care Standards 17.3 & 17.4. The Training Task Group is exploring POVA E-Learning at Level 2, which will provide greater flexibility, promote knowledge and reduce cost and ultimately risk. Levels of Training

During the last 10 months over 100 training sessions were delivered at Level 2 and Level 3 across the Health Community. This is an underestimate as not all Clinical Programme Group Leads have reported their training sessions accurately and data in areas was not recorded with localities showing percentages.


In Wrexham and Flintshire there was a high level of cancellations due to poor uptake of the training sessions. Fifty sessions planned and twenty one had to be cancelled. POVA Training Compliance based on CPG returns over a 10 month calculation period CPG CPG Average Primary Community Specialist. 52.5% Emergency Specialist Surgery / Dental 48.3% Anaesthesia Critical Care Pain

33%

Mental Health & Learning Disability (level 3) 63.3%

Corporate Support Services (facilities) 30.8% Therapies & Clinical Support. 73.3% Radiology 39.3% Pathology 59.3% Cancer / Palliative Medical & Clinical Haematology

75%

Primary Care Cannot determine % (120 staff)

Women & Maternal Care. 27.6% BCUHB compliance estimate 50.24%

Independent Sector POVA training is provided by the Local Authority in Wrexham, Flintshire and Denbighshire. Gwynedd and Anglesey and Conwy Locality Health Boards are expected to provide training for Nursing Home staff where care has been commissioned by the NHS for continuing Health Care. Last year 250 staff received Level 2 POVA training from BCUHB. POVA training at Level 2 was provided on request for all the North Wales CHC Locality based Advocates. Audit In November 2010, a POVA training effectiveness audit was undertaken to test the robustness and appropriateness of training at Level 2 & Level 3 and was co-ordinated by the CPG Leads. Three hundred questionnaires were sent out equally across the three localities to staff who had undertaken POVA training during the last 6-12 months. A response of 33% was received; however, the overall feedback was positive, nevertheless, the audit highlighted some areas for improvement in order to close the loop.

7.6 POVA Activities Following the restructure of the Betsi Cadwaladr University Health Board, POVA

referrals have been centralised across the Health Community. Social Services will continue to take a lead in Adult Protection working in partnership with key stakeholders including the NHS.


From April 1st 2010 until January 2011, 300 POVA referrals raised by BCUHB staff were received an increase of 2% compared to the same period last year, the overall number of referrals may well exceed that of the preceding year.

The figures vary across the three localities the breakdown being:- East – 74 Central – 134 West – 92

Additional activities are generated following formal multi-agency procedures of which NHS senior and operational representation is required.

7.7 Significant Events

Last year 13 significant events were reported to the Safeguarding Sub-Committee

arising from POVA referrals. This is an increase of 1 compared to last year’s figure of 12.

The number of BCUHB staff alleged to have been implicated in the abuse of a

Vulnerable Adult was 8, all were investigated following both internal and Pova procedures, which for some involved criminal investigations, however, not all were upheld. Following the death of 3 service users, the cases were referred as a ‘Serious Case Review’, 3 Internal Management Reviews were undertaken in order to improve practice, highlight areas of good practice and as necessary develop an improvement plan.

7.8 Safeguarding Children, Young People and Domestic Abuse

7.8.1 Policy, Procedures, Protocols

The Safeguarding Children Policy & Procedures Task Group has developed an

Action Plan to identify and review all policies/procedures/protocols from previous NHS organisations.

7.8.2 Training

• The Training Task Group was requested to develop a combined Safeguarding

Children & Vulnerable Adult and Domestic Abuse Training Strategy. • The annual training programme was reviewed but consistent support from the

corporate training department and the provision of venues continues to cause an inconsistent approach.

• The E-Learning training package commenced implementation after undertaking pilots within key areas. This package has been secured by monies from Charitable Funds for a period of three years.

Gwynedd & Anglesey

Wrexham & Flintshire

Conwy & Denbighshire

Total

Level 1 Induction Programme Level 2 278 458 634 1370 Level 3 364 212 114 690 Level 4 60 in Total 60


• Training specific to meet the requirements of Midwifes is delivered by the

‘Named Midwifes’; this includes Level 2 training and update events relating to specific operational incidents.

• Additional training is delivered for Emergency Doctors, Medical Staff and

Nursing Staff in Ysbyty Glan Clwyd:- Medical Staff: 17 Nursing Staff: 13

• Level 4 training was co-ordinated by the Named Doctor and provided both inter-agency and multi-agency participation, no Level 4 training was provided by Public Health Wales; however, one event was cancelled due to low attendance caused by clash of training events.

• Domestic Abuse – and specific CAADA DASH Training: Total: 343. This programme and the implementation of CAADA DASH has significantly increased awareness and compliance across the organisation. All three District General Hospital, including some Minor Injury Units, have accessed this training and fully endorse and comply with the identification and reporting of Domestic Abuse.

• Training is currently provided for Primary Care and GPs by Public Health

Wales/Child Protection Service, and increased attendance is noted of General Practitioners attendance at training provided by Betsi Cadwaladr University Health Board. The figures obtained from Public Health Wales which includes Dentists, Optometrists, Pharmacists and GP’s are:

2010: Level 2 – 541 2011: Level 2 – 404 Level 3 – 53 Level 3 – 90

7.8.3 Supervision/formal process of professional support Statutory Guidance and the All Wales Child Protection Procedures 2008 requires

Health Visitors, School Nurses and Midwifes to have clinical case supervision. The structure and provision of supervision provided by the Safeguarding Nursing Team varies significantly across the organisation, to standardise this activity a Supervision Procedure is under development. Although this procedure refers predominantly to nursing staff who hold a case load, it also refers to adhoc supervision, and advice for all employees (medical and nursing) contractors and volunteers. The Named Doctors also provide supervision, advice and case management support as required.

The statistical data to monitor compliance is difficult to measure for the Case

Management Supervision of Health Visitors and School Nurses; however, in accordance with existing local activities the overall compliant rate in accordance to their data collection is an average of 70% with Flying Start achieving 100% in some areas. Additional group supervision provides peer support and encourages inter-agency participation to discuss new guidance or is case specific.


7.8.4 Local Safeguarding Children Boards (LSCBs) There are currently four LSCBs each operating Executive Boards, Development

Groups, Sub Groups and Task & Finish Groups. Betsi Cadwaladr University Health Board participation is a statutory requirement under Sec 31 (1) Children Act 2004.

Under Section 28 of the Children Act 2004, each of the statutory partners in a

Safeguarding Board have a statutory duty to make arrangements for ensuring that:-

• Their functions are discharged having regard to the need to safeguard and promote the welfare of children.

• Any service provided by another person pursuant to arrangements made by

the person or body in the discharge of their functions are provided having regard to that need.

LSCB ANNUAL COSTINGS 2009-2010 Invoice Total

Gwynedd & Anglesey

26,560.00

Conwy & Denbighshire 17,838.00

Flintshire 4,166.00

Wrexham 5,000.00

TOTAL 53,564.00

7.8.5 Multi-Agency Public Protection Arrangements The MAPPA Guidance has statutory authority (duty to co-operate) sec 67 & 68 of

the Criminal Justice and Court Services Act (2000) imposed duties upon the Police and Probation Services to establish arrangements to work together with support and engagement with statutory agencies to manage the risks posed by dangerous offenders in the community.

MAPPA 2: High risk of harm – monthly meetings in each Local Authority area Total: 95 cases involving children

MAPPA 3: Very high risk of harm – on a basis of need in each Local Authority area: Total: 28 meetings Strategic MAPPA: 4 times per year, inclusive of 3 sub-groups

7.8.6 Multi-Agency Risk Assessment Conference (MARAC)


MAPPA Guidance requires monthly meetings in each Local authority area to manage and co-ordinate multi-agency protective measures for victims of Domestic Abuse. The statistical attendance data as recorded by the Strategic MAPPA was challenged due to data management. It was clearly recognised that there is a significant increase in activity relating to this agenda, requiring increased attendance at meetings, implementation of training and both inter-agency and multi-agency governance arrangements. Total number of cases heard within the identified period involving children – in 6 Local Authority areas: Total: 1167. Local Authorities also hold weekly Domestic Abuse Panels to discuss low/medium cases in one area. Joint Risk Assessment Panels – which includes Health, Education, Police and Local Authority, are held to discuss incidents involving families which involve the Police.

7.8.7 Audit The Safeguarding Children Team identified annual audit activities relating to the action plans from Serious Case Reviews, Internal Management Reviews and Government Guidance – NHS, HCS 17.1 & 17.2. The Local Safeguarding Children Boards (LSCB’s) completed Self Assessment Tools and developed annual Section 28 Children Act 2004 assessments for each participating agency. The significant increase in Safeguarding and Child Protection activities, increased complexity of cases and the increase in Multi-agency activities, as required by the LSCB, has shown to reduce attendance figures at some key Forums by team members.

7.8.8 Significant Events The LSCB’s agreed that three cases met the criteria to undertake a Serious Case Review. Three Serious Case Reviews were ratified by the LSCB’s; the Executive Summary of one case was published on the Website. Three cases were agreed to be Multi-agency cases of interest and three Single-agency Desktop Reviews were undertaken. There were nine professionals who were involved in allegations of abuse or causes of concern about a person who works with children. All were investigated following internal procedures, and All Wales Child Protection Procedures, not all cases were upheld. There were 42 cases indentified as very high risk.

8 Main action plan themes / tasks due for completion in forthcoming year:

Outstanding Action Plan 2009 – 2010

ACTION PLAN TIMESCALE 1 Develop and implement an Action Plan for recommendations

identified from existing Health Care Standard 17, National Review of ‘In Safe Hands’, HIW Inspectorate Report and CSSIW Inspection of Local Authorities which includes the reporting of Pressure Ulcers Grade 3 & 4.

May 2011

2 Assist the ratification and implementation of the corporate June 2011


Restrictive Physical Intervention Procedure. 3 Review all policies and procedures from former organisations

under the guidance and direction of the Policy & Procedures Task Group.

Sept 2011

Action Plan 2011 – 2012

ACTION PLAN TIMESCALE 1 Implementation of the agreed Safeguarding Children &

Vulnerable Adults Structure. July 2011

2 Implement a Clinical Programme Group and Corporate action plan relating to ‘Doing Well, Doing Better: Standards for Health Services in Wales 2010 - 2012.

May 2011

3 Review and audit existing Serious Case Reviews action plans relating to recommendations.

2 x annually Aug 2011 & Nov 2011

4 Implement and disseminate the identified recommendations; identified lessons and good practice from Serious Case Reviews and Internal Reviews.

Review of progress and activity 6 x annually

5 All CPG’s and corporate departments to record and review training data/statistics and complete annual training needs analysis.

May 2011

6 Implement the E-Learning Child Protection package across the organisation.

Aug 2011

7 Secure funding to develop and implement the Protection of Vulnerable Adults E-Learning package.

Aug 2011

8 Betsi Cadwaladr University Health Board to develop and implement the Training Strategy with greater engagement with Primary Care, GPs and Care Homes funded to provide NHS care.

April 2011

9 Implement an identified action plan relating to the implementation of statutory guidance and procedures relating to Domestic Abuse.

Oct 2011

10 Strengthen and develop internal procedures relating to Escalating Concerns with and closure of Care Homes (providing services WAG May 2009).

June 2010

11 Ratify the final Safeguarding Children & Vulnerable Adult and Domestic Abuse Strategy.

June 2011

12 Ratify the Safeguarding Children & Vulnerable Adult and Domestic Abuse Procedures.

June 2011

13 Formally consider the appointment of a Named Doctor for the Protection of Vulnerable Adults.

May 2011

The implementation will be monitored by the Assistant Director of Safeguarding with appropriate delegation to the Operational Forum and Task Groups

9 New risks and issues identified by this Sub-Committee in-year:

New Risks


Named Doctor for Betsi Cadwaladr University Health Board

Although the organisation is compliant with the statutory legislation, Children Act 2004 (sec 28 -2.108), and has identified Named Doctors from the two previous NHS Trust organisations the third post holder retired, no agreement has been made regarding the revised structure for Betsi Cadwaladr University Health Board.

The Named Doctor should take the strategic and professional medical lead on all aspects of the health service contribution to safeguard children across the organisation and other agencies.

It is also recognised that named professional roles should always be explicitly defined in job descriptions and sufficient time and funding should be available to fulfil their strategic responsibilities. The organisation requires consistent strategic direction with identified accountability and responsibility to support the Assistant Director of Safeguarding whose duties also include the responsibility and accountability for the Named Nurse function.



New Risks

This issue has been shared as an issue of significance to the Quality & Safety Committee and shared with the Director of Primary, Community and Mental Health and Chief of Staff; Children & Young People Clinical Programme Group. The Local Safeguarding Children Boards have expressed their concern and interest regarding the delay of decision making and plans for resolution.

Yes √ □ No □ [please explain] 11 Further comments:

The safeguarding activities for the organisation both operational and strategic due to the significant reviews relating to the Protection of Vulnerable Adults and complexity and number of cases relating to children, has proved to be challenging within a new organisation. The safeguarding structure when fully appointed to, will make a fundamental difference to the Protection of Children & Young People, Vulnerable Adults and the protection of those subject to Domestic Abuse, as full enhanced engagement with multi-agency activities, Clinical Programme Groups and operational staff will increase knowledge and ultimately reduce the risks to service users, employees and the organisation.

Safeguarding Children & Vulnerable Adults Sub-Committee

Terms of Reference

1. Accountability The Safeguarding Sub - Committee is accountable to the

Quality & Safety Committee.

2. Remit To support the Quality & Safety Committee in discharging it’s responsibilities for Safeguarding, by informing it’s agenda, determining its priorities and carrying out tasks and duties in accordance with the agreed cycle of business.

3. Chair Independent Member of the Board

4. Lead Director Director of Nursing, Midwifery and Patient Services

5. Membership 5.1 Members: Chair - Non Officer Member The Director of Nursing, Midwifery and Patient Services Assistant Director of Nursing Safeguarding/Named Nurse Child Protection Named Doctor BCUHB Medical Director CPG Safeguarding Leads Public Health Wales Designated professional PPI GP Assistant Director of Workforce & Organisational Development (Employment, Strategies & Practices) 5.2 In attendance- at times, other specific professionals maybe co-opted onto the group to provide a source of specialist advice and expertise. Specialist child protection legal advice will be sought as required from the BCUHB solicitors and Welsh Health legal Services.

5.3 By invitation LHB Officers with lead responsibility for Safeguarding

Frequency Bi monthly

6. Authority 6.1 As per Schedule 3 of the BCUHB Standing Orders the Safeguarding Sub – Committee s authorised by the Board via the Quality and Safety Committee to investigate any activity within its terms of reference.

TOR - Safeguarding Sub-Committee Page 1 23.04.10 revised Aug 2010

6.2 It is authorised to seek any additional information it requires from any employee of the LHB and all employees are directed to co-operate with any request made by the Sub-Committee. 6.3 The Sub-Committee is authorised to obtain outside legal or other independent professional advice and to secure the attendance of non-LHB employees with relevant experience and expertise if it considers this necessary. 6.4 The Sub-Committee also reserves the right to request additional detail in relation to a CPG / Directorate / Divisional performance, where a trend or a concern has been identified.

7. Conduct of meetings

7.1 Meetings will be formally minuted, with names attached to allocated actions and collated into a summary action plan. Minutes will be approved at the next meeting. 7.2 Attendance at each meeting will be monitored, so that the Chair can initiate action in the event that a member fails to attend more than three consecutive meetings without good reason and without providing an appropriate deputy 7.3 Secretariat will be provided by the office of the Director of Nursing, Midwifery and Patient Services.

8. Quorum 8.1 The Sub-Committee shall be deemed quorate provided four members are present, including an Independent Member and at least two of the LHB Board of Directors. In exceptional circumstances the Sub-Committee may be Chaired by an Independent Member Chair of one of the other four Quality & Safety Sub-Committees.

9. Responsibilities & Functions will include

9.1 To ensure the organisation complies with section 28,27(2)(a)(b) and section 25 and section 31 of the Children Act 2004 9.2 To ensure the organisation complies with the Protection of Vulnerable Adult Policy/and strategic Guidance. 9.3 To ensure the organisation complies with safe recruitment and monitoring arrangements following CRB & ISA guidance


9.4 To provide leadership, commitment and operational support to the Safeguarding process 9.5 To co-ordinate the development of the BCUHB Safeguarding Strategy; 9.6 Ensure systems are put in place to review and monitor the ongoing development and

implementation of the Safeguarding Strategy within Clinical Programme Groups including developing and Implementing a system for urgent escalation and resolution of issues;

9.7 To facilitate LHB Board compliance with external standards; good practice guidance; and legislation; 9.8 Manage an on-going process of self assessment and improvement against the Healthcare Standard 17 to enable the annual self-assessment submission; 9.9 To ensure that recommendations made by internal

and external reviews are considered and acted upon 9.10 Oversee the on-going development, review and implementation of relevant sections of the Healthcare Standards Improvement Plan; 9.11 To ensure the effectiveness of all working groups with accountability to the Safeguarding Sub committee including the production of relevant minutes, plans, reports report and other documentation 9.12 To provide an Annual Report to the Quality & Safety Committee providing positive assurance that the Sub-Committee has met its terms of reference and Safeguarding duties.

10. Reporting 10.1 The minutes of the meeting shall be formally reported to the Quality & Safety Committee. 10.2 Issues of significance from the Safeguarding Sub- Committee will be reported to the Quality & Safety Committee and each of its Sub-Committees.


Documents

Committee Annual Report - NHS Wales QS... · 2011. 10. 6. · Committee Annual Report 1 Title of Committee: Quality and Safety (Q&S) Committee 2 Name and role of person submitting