ARGYLL & BUTE CHP COMMITTEE MEETING Wednesday 29 … · 29/08/2012 · Argyll & Bute CHP Committee...

Wednesday 29 August 2012 An Roth- Community Enterprise Centre

Craignure, Isle of Mull

12.30pm – Lunch

1.00pm – Committee Meeting (to which members of the public are welcome to atte nd)

AGENDA

1. Chairman’s Welcome Robin Creelman

2. Apologies Robin Creelman 3. Conflicts of Interests Robin Creelman 4. Minutes from Previous Meeting 4.1 Minute – 25 June 2012 (attached) Robin Creelman 5. Matters Arising 6. NHS Highland Organisational Issues Robin Creelman

6.1 Meeting of Highland NHS Board - 14 August 2012 (verbal) 6.2 Minute of the Meeting of Highland NHS Board – 5 June 2012 (attached)

7. Clinical Governance 7.1 Clinical Governance & Risk Management Report (attached) Pat Tyrrell 7.2 Infection Control Report (attached) Pat Tyrrell 7.3 Health Improvement Report (attached) Elaine Garman 8. Financial Governance 8.1 Finance Report (attached) George Morrison

ARGYLL & BUTE CHP COMMITTEE MEETING

11am–12.15pm – Visit to Mull Progressive Care Centr e

9. Staff Governance 9.1 Argyll & Bute CHP Partnership Forum 12 July 2012 (attached) Derek Leslie/

David Logue 9.2 Argyll & Bute CHP Partnership Forum Away Day Feedback (verbal) David Logue

9.3 PDP/R and eKSF Implementation (attached) David Logue 10. Performance Management

10.1 Delayed Discharge (attached) Derek Leslie 10.2 Admissions, Discharge & Transfer (ADT) Policy Audit (attached) Pat Tyrrell

11. Mental Health Services Modernisation Project

11.1 Update Report (attached) John Dreghorn

12. AOCB*

13. Date, Time & Venue for Next Meeting Wednesday 31 October 2012 at 10.30am, Meeting Room s J03-J07, Mid Argyll Community Hospital & Integrated Care Ce ntre, Lochgilphead

* to be notified to Chairman in advance of meeting

The Committee Meeting will be followed by a Public Meeting

Argyll & Bute CHP Committee Date of Meeting : 29 August 2012

Agenda item : 4.1

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MINUTE OF MEETING OF THE ARGYLL & BUTE CHP COMMITTEE

Argyll & Bute Community Health Partnership Aros Lochgilphead Argyll PA31 8LB www.nhshighland.scot.nhs.uk/

Mid Argyll Community Hospital and

Integrated Care Centre

27 June 2012

Present Mr Robin Creelman, Chairman, Argyll & Bute CHP

Mr Derek Leslie, Director of Operations, Argyll & Bute CHP Dr Michael Hall, Clinical Director, Argyll & Bute CHP Ms Pat Tyrrell, Lead Nurse, Argyll & Bute CHP Ms Elaine Garman, Public Health Representative, Argyll & Bute CHP Ms Mary Wilson, AHP Representative, Argyll & Bute CHP Ms Elizabeth Reilly, Area Dental Committee Representative Ms Tricia Morrison, CVO Representative, Argyll & Bute CHP Mr Duncan Martin, Chairman, Public Partnership Forum Councillor Elaine Robertson, Argyll & Bute Council Representative Councillor George Freeman, Argyll & Bute Council Representative

In Attendance Apologies

Mr George Morrison, Head of Finance, Argyll & Bute CHP Mr David Ritchie, Communications Manager, Argyll & Bute CHP Caroline Henderson, Clinical Services Manager, Oban, Lorn & Isles Hospital Mr Stephen Whiston, Head of Planning Contracting & Performance, Argyll & Bute CHP – by vc – agenda items 6 and 7 Dr Jenny Hall, Research Fellow, Centre for Health Science, UHI, Inverness -by vc – agenda item 13.3 Mrs Sheena Clark, PA to Director of Operations - Minute Secretary Mr Garry Coutts, NHS Highland Mr David Logue, Head of HR, Argyll & Bute CHP Mr John Dreghorn, Project Director, Mental Health Modernisation Ms Glenn Heritage, CVO Representative Ms Dawn Gillies, Staffside Representative Mr Donald Barr, Area Optical Committee Representative Mr Neil Robinson, Area Pharmaceutical Committee Representative Mr Cleland Sneddon, Argyll & Bute Council Representative Mr Jim Robb, Argyll & Bute Council Representative

1 CHAIRMAN’S WELCOME The Chairman opened the meeting by welcoming everyone to the Mid Argyll Hospital and Integrated Care Centre. Mr Creelman paid tribute to Mrs Katy Murray who sadly passed away last month, and recognised her many commitments and her contribution to the work of the CHP Committee and Public Partnership Forum.

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Mr Creelman acknowledged the significant work of Mr Bill Brackenridge on behalf of the CHP during his 6 year term of office as Chairman. 2 APOLOGIES Apologies for absence were noted as above. 3. CONFLICTS OF INTEREST No conflicts of interest were declared. 4. MINUTE FROM PREVIOUS MEETING 4.1a Minute of Meeting held on 25 April 2012 The Minute of the meeting on 25 April 2012 was accepted as a complete and accurate record of the meeting. The Committee: • Approved the content of the Minute of the meeting on 25 April 2012. 4.1b Minute of Public Session – 25 April 2012 Mr Creelman stated that he had welcomed the public’s comments advising their concerns on specific NHS and community care matters within the Bute locality, which enabled the CHP to consider and respond to the questions raised. With regard to question two of the Minute, the incident detailed had been fully investigated and an action plan, agenda item 4.1c, has been drawn up to address the issues raised. 4.1c Bute Locality – Public Session Action Plan The CHP Committee commended the circulated plan which detailed the actions by the CHP in response to the points raised during the public session. Mr Leslie advised that the public session and discussions had been valuable to the CHP in addressing the issues raised and to ensure an effective system of communication between agencies. It was noted that the Marie Curie Manager has met with the patient concerned to discuss the issues raised. Mr Creelman stated that the CHP’s response had been positive, well investigated and actioned. Ms Robertson emphasised the need to work to the care plan and ensure availability of documentation to record and highlight any issues. Ms Tyrrell advised that this was part of the quality assurance process. The Committee: • Noted the contents of the Minute of the Public Session, 25 April 2012 and the actions of

the CHP to address the concerns and issues raised.


Agenda item : 4.1

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5. MATTERS ARISING FROM PREVIOUS MEETING HELD ON 25 APRIL 2012 Health Improvement – Breast Feeding – Ms Tyrrell reported that the CHP had received a gold award for stage 3 of the UNICEF accreditation and was a tribute to all staff involved. Harm Reduction Services – Ms Robertson enquired if needle exchanges were operational in all areas of the CHP. Ms Garman advised that in areas of the CHP where this was not the case, David Greenwell and Pharmacy representative were having discussions to progress and resolve any issues. 6 COWAL 24/7 REVIEW BRIEFING REPORT The circulated paper provided the CHP Committee with a progress report on the review undertaken with regard to the future provision of the GP out-of-hours arrangements in Cowal and the review of the medical input into the hospital and in respect of day time and out-of-hours in Cowal Community Hospital. Mr Whiston reminded the Committee that the review resulted from the GP who previously provided the Strachur out-of-hours cover deciding in 2007 to opt out of providing this service. The subsequent arrangement with the Tighnabruaich practice to cover the out-of-hours ceased in 2010 when the GP also decided to opt out. The review, which runs until September/October 2012, is being carried out by the Cowal 24/7 Review Group which was set up in October 2011 and is jointly chaired by a member of the public and a Helensburgh & Lomond GP/Locality Clinical Director. The group includes representatives from communities, Public Partnership Forum, Argyll & Bute Council, town and rural GP practices, hospital casualty and out of hours service GPs, nursing and staff from Cowal Community Hospital and the Cowal community, Scottish Ambulance Services, Cowal Community Management, Argyll & Bute CHP Management and the Union. The Scottish Health Council local representative has also attended meetings to provide support and direction and to help craft and design the process to involve and engage with the public. Mr Whiston highlighted that the review is taking into account a number of national policies, including :

• Framework For The Sustainability of Services and the Medical Workforce in Remote Acute Care Community Hospitals

• Health Improvement Scotland - Draft Quality Indicators ~ June 2011 Primary Care Out-of-Hours Services- publication June 2012

and the review group are comfortable with the process being followed and the consideration of the options. Tables 1 and 2 of the report detailed what medical staff work in which areas over a 24 hour period, by shifts, departments and location. Table 3 detailed the nurse practitioner workforce resource in the casualty department. Mr Whiston asked members to be aware of the small number, 432, of GP out of hours home visits in the Dunoon town catchment area during January to December 2011, as reported in the activity profile report. Tables 4 and 5 detailed the 2011/12 budget for the existing service. The option appraisal process carried out during February/March 2012 was developed through engagement, discussion, refinement and reflection from all members of the review

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group and relevant stakeholders. The outcome identified 17 options which reflected the complexity of the service and the expectations of the public and stakeholders and the determination of the group to ensure a comprehensive process was undertaken. During March/April 2012 the17 options were taken out for public consultation to :

• review and to obtain feedback on patients’ experience • present the variety of information about the service and to ask questions about the

current service. • consider the health and wellbeing profile information of Cowal’s population • look at the initial service alternative “options”

The Cowal 24/7 group held a workshop on 19 April 2012 to undertake and review an assessment process to identify a shortlist of the options, assessing their compliance to the review objectives and parameters. Thereafter a report was produced identifying a viable shortlist of 7 options to put forward for formal appraisal, which was presented to the Cowal Project Group for its consideration and which was approved at its meeting on 26 April 2012. Mr Whiston confirmed that the options in the report were not ranked but were listed by option number, not option preference. The first stage of the option appraisal, non-financial benefits and risk, was completed on 21 June 2012, with the remaining stages due to be completed by October 2012, when the CHP Management Team and CHP Committee will receive a recommendation for consideration and decision to implement. Mr Creelman declared his particular interest as a resident of Cowal and stressed that the review and outcome required to be patient centred. In response to Mr Freeman’s enquiry about local Councillor representation on the Cowal 24/7 Group, Mr Whiston advised Councillor Bruce Marshall was a member. Mr Freeman expressed surprise that out of hours cover for Lochgoilhead was provided from the Vale of Leven Hospital and queried if the travel time to the Vale was less than to Cowal Community Hospital. Mr Whiston replied that travelling time was similar, i.e. 45 minutes to 1 hour, with the time obviously increasing due to any road closures. The consultation has reflected the conclusion by the community to include the option for Lochgoilhead to continue to receive out of hours provision from Vale of Leven Hospital. A detailed analysis was undertaken of home visits activity levels when it was reported that 50% of NHS24 call outs should have been categorised as ambulance hospital admissions. Dr Hall commented that to ensure clinical safety and surroundings for the patient, there is a need to move away from home visits, with only palliative care and mental health patients perhaps requiring a home visit. Mr Creelman emphasised the need for the home visit element of the out of hours provision to be fed into the review process. Mr Whiston responded that this issue has been raised and recorded with Clinicians on the Project Group during the appraisal process. Dr Hall advised the members on a recent visit to the Stirling Ambulance Service where the paramedic practitioner model was demonstrated. This out of hours cover has proved very successful in other rural communities, with no GP out of hours in small villages. It was noted that to develop this model requires a 2 year training programme to upskill paramedics. This specialist training requires Scottish Government initiative, but should not be seen as a GP replacement. Mr Leslie reiterated that whilst the process being carried out by the Cowal 24/7 Group was to address the challenges in sustaining out of hours services in Cowal, the challenges have a wider application and need to be addressed from a national and strategic perspective.


Agenda item : 4.1

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The CHP Committee was required to determine that a reasonable engagement and information process has been followed, with an outcome which is not predetermined and has been fully monitored, with input from the Scottish Health Council, and has been conducted under and adhered to clear governance procedures. The need for partnership support in the process was noted and Mr Leslie advised that there is a natural requirement for Locality Managers to discuss the review at Local Area Community Planning Group (LACPG) meetings. Mr Freeman commented that this group is not a decision making body and Council endorsement should be sought through the Area Committee. Mr Whiston confirmed that information on the review had been submitted to all stakeholders to provide an opportunity to comment and participate.

7. RENAL REPLACEMENT THERAPY SERVICES – ARGYLL & BU TE CHP Mr Whiston explained the background to the paper and the current service provision for Argyll & Bute haemodialysis and peritoneal dialysis patients. Haemodialysis is not provided within Argyll & Bute CHP. At the time of reporting there are 15 haemodialysis patients receiving treatment within NHS Greater Glasgow & Clyde and 3 North Argyll patients at the Belford Hospital in Fort William. Although the normal pathway for patients would be to the Vale of Leven Hospital, due to capacity issues, the 3 patients receiving their treatment at the Belford Hospital are as a result of either clinician referral or patient choice. Mr Leslie acknowledged Councillor Robertson’s involvement and engagement with the North Argyll residents in seeking the CHP’s participation in considering requests for a local satellite renal unit, which has attracted local and national interest. A representative group recently met with Mr Mike Russell, MSP and the Cabinet Secretary to discuss their proposals and the CHP provided a briefing to the Scottish Government, based on the content of the circulated report. The Cabinet Secretary had commented that dialysis needs will progress around the CHP and estimated numbers will rise due to the impact of demography and an increase in long term conditions and these factors need to be considered when looking at service provision. The Cabinet Secretary recognises the challenges facing the CHP and has received an assurance that patients will receive a rigorous standard of haemodialysis in a hospital setting.

The Committee : • Noted the status of the review • Considered the issues with regard to the current service delivery arrangements:

o day time Medical Input o out of Hours arrangements Dunoon o out of hours Arrangements Rural Cowal (Tighnabruaich & Strachur) o out of hours Arrangements Lochgoilhead

• Noted the progression of the review process which has identified a short list of 7 options from the original 17 long list of options

• Noted the next stage and timetable for completion of the review

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It is important that the public and patients recognise the CHP’s acknowledgement of the travelling time and distance incurred by them, but also the requirement for the CHP to ensure an effective, sustainable and safe service. The normal pathway for patients would be to the Vale of Leven Hospital, which is currently running at full capacity. As the Belford Hospital, Fort William has capacity, at present 3 patients per week travel together by taxi for a return journey from the North Argyll to Fort William, at an annual cost of approximately £30k. The CHP are continuing their discussions with the Scottish Ambulance Service regarding the transport of the patients attending the Belford Hospital. Mr Creelman requested clarification that the 3 patients had chosen to travel to Fort William for treatment and was advised that for all it was a personal choice. In relation to an Argyll & Bute CHP Renal Development, Councillor Freeman asked for clarification on the disparity in the detailed capital and revenue costs within the report for Inverclyde Hospital unit and the Belford Hospital unit. Mr Whiston advised the costs should not be seen as ‘like for like’ as the scale of the dialysis unit within Inverclyde Hospital was significantly greater than the unit within the Belford Hospital, resulting in costs being significantly less in Fort William. There is no clear correlation between the number of units and the cost. Mr Leslie stated that the most appropriate cost comparator for Argyll & Bute CHP was the Belford Hospital, which is currently running under capacity. With the recent changes in guidance to the Highland & Islands Travel Scheme there is more of an incentive for the organisation to look at repatriating business back to NHS Highland. Mr Whiston concluded that the overview of the current and projected future demand for renal replacement therapy does not identify an appropriate geographic point within Argyll and Bute to establish a local service enhancing access to all residents. The capital and running costs of a stand alone unit are significant and the level of likely activity would not result in an affordable or cost effective use of the service and staff even based on a normal dialysis cycle for patients of 2-3 days. The location of existing units in Glasgow (Vale, RAH and IRH) and the proximity of the Belford Hospital to North Argyll clearly offers greater access in terms of proximity for the adjacent Argyll and Bute localities. The CHP should therefore look to work with NHS Greater Glasgow & Clyde & NHS Highland to plan for its future provision. Councillor Robertson thanked the CHP for addressing the concerns raised by North Argyll renal patients and was comforted by the content of the report and the assurances given by Mr Leslie that a full and detailed review is being undertaken, which should be completed by September 2012.

The Committee :

• Considered the current profile of service delivery • Considered the future projections / need for Renal Replacement Therapy • Noted the current financial costs of hospital dialysis


Agenda item : 4.1

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8. NHS Highland Organisational Issues 8.1a Draft Minute of Highland NHS Board Meeting –5 June 2012 The draft Minute was not circulated or tabled as it was noted as unapproved by the Chair of the NHS Board. Mr Creelman advised the Committee on a number of the points and actions resulting from the meeting. The approved draft Minute of 5 June 2012 will be included in the papers for the CHP Committee meeting in August 2012. The Committee: • Noted the CHP Chairman’s summary of the draft minute of Highland NHS Board –5 June

2012 8.2 CHP Annual Report 2011/12 This document was circulated as an aid memoire of the activity of the CHP Committee during the reporting period 2011/12, and to inform on the role and remit, updated membership and future planning of the group. The Committee: • Noted the contents of the CHP Annual Report 2011/12 9. CLINICAL GOVERNANCE 9.1 Clinical Governance & Risk Management Repo rt Ms Tyrrell spoke to the previously circulated papers and highlighted a number of areas from the report. RISK MANAGEMENT Ms Tyrrell advised that the report focussed on the three categories of the highest reported incidents, medications, pressure ulcers and falls. Incidents Medications – in the final quarter of 2011/12 there were 24 medication incidents reported, which is a decrease in the previous reporting period. Of the 24 incidents, 21 had been finally approved and graded, 15 – insignificant, 5 minor and 1 moderate. The moderate incident was due to a power failure at a health centre resulting in vaccines not being stored at the appropriate temperature and subsequent loss of vaccines. Pressure ulcers – reporting is in the early stages, with NHS Highland’s zero tolerance of avoidable pressure ulcers leading to an improved focus across all care settings on effective risk assessment and care plans. Clinical Quality Indicators (CQI) are nationally agreed measures of quality which allows the assessment of performance against a range of key indicators. All inpatients wards in Argyll & Bute CHP monitor their compliance with the standards for pressure ulcer prevention and management on a monthly basis. With the improved compliance with CQIs, aiming for 95% or greater, there should also be a decrease in the number of pressure ulcers within the ward areas. Councillor Robertson highlighted the seemingly high figure of 7 incidences of pressure ulcers reported within Dunaros in January 2012. Ms Tyrrell explained that the rates reported were per 1000 occupied bed days.

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Falls – all areas are now focussing on risk assessment and prevention of falls within all clinical settings, together with a wider community focus on falls prevention which is a key element of the Reshaping Care for Older People programme. The CHP Falls Co-ordinator works closely with clinical staff to provide support in implementing actions which reduce both the environmental and individual risks which can lead to people falling. Significant Event Reviews (SERs) Ms Tyrrell provided details of the recent report commissioned by the Cabinet Secretary for Health to review the clinical governance systems and processes of NHS Ayrshire and Arran, and in particular those relating to their management of critical incidents, adverse events, action planning and local learning. Ms Tyrrell advised that although the CHP currently has a robust system for identifying, conducting, reviewing and monitoring SERs, a review of our existing services will be carried out to ensure that we address any of the relevant findings from the report and the CHP Committee will be advised of the conclusions. Complaints Ms Tyrrell reported that to ensure adherence to the management of standard complaints, a number of complaints may require a comprehensive review, i.e. SERs. Due to the complexity of the review and the necessity to obtain information from other organisations, the process for achieving the 20 day response target can be delayed. Progress of investigating a complaint is tracked through the Datix system and complainants are kept informed of the timescale for receiving a final response by the NHS Complaints Team issuing a ‘holding’ letter. Councillor Freeman expressed some concern regarding the monitoring of primary care complaints and the notification of outcomes. Dr Hall advised that the complaint process for Primary Care is determined by the Scottish Government for independent practices to resolve any complaints locally. He also stressed that any issues identified directly to the CHP are thoroughly investigated and if required the Practice will be visited by the CHP Clinical Director and Primary Care Manager. Ms Tyrrell stated that new standards for management of complaints include Primary Care, a copy of which will be sent to Councillor Freeman for information. It was advised that in preparation of an annual appraisal, a GP should submit details of any complaints for discussion with the external appraiser. Ms Tyrrell referred to the NHS Highland patient opinion website where patients can submit comments/complaints and which is administered by the Complaints Team. The 2011/12 Patient Experience Survey of GP and local services provides details of people’s experiences, and individual practice reports are available. It was suggested that the Complaints process be an agenda item for a future Committee Development Session. Health & Safety The details in the circulated report relating to the following were noted :

• HSE Improvement Notice • Risk Assessment • Workplace Inspection


Agenda item : 4.1

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• Fire Safety Quality External Reviews The details in the circulated report relating to the following were noted :

• Healthcare Environment Inspectorate • Care Inspectorate Child Protection Follow Through Inspection

Scottish Patient Safety The details in the circulated report were noted. Better Together Survey The details in the circulated report were noted. Further analysis of the results is underway and will be presented to the CHP Committee in August 2012. The Committee: • Noted the contents of the Clinical Governance and Risk Management Report 9.2 Cleanliness, Hygiene and Infection Control Repo rt Ms Tyrrell spoke to the previously circulated paper and highlighted a number of areas from the report. Staphylococcus Aureus Bacteraemia (SAB) including M RSA: Ms Tyrrell reported that NHS Highland is well within the target of 0.26 cases per 1000 acute occupied bed days rate, with a reported figure of 0.18 April 2011-March 2012. Since the last report there have been two SAB cases in Argyll & Bute CHP, both of which were true community acquired cases and the patients were admitted to the Lorn & Islands Hospital. The roll out of a new screening process for MRSA has been completed across the CHP, with some outstanding medical records issues being addressed in Islay which is due for completion at end June 2012. Clostridium Difficile Infection (CDI): Ms Tyrrell advised that Argyll & Bute CHP reported incidences of CDI continues to be low, with one reported case in Lorn & Islands Hospital since the last report. Initiatives are continuing to reduce CDI cases and enhanced surveillance is carried out on every CDI case, with immediate feedback to staff. Hand Hygiene Argyll & Bute continues to meet compliance standards, with no complacency reported or evident within any area of the CHP. A mandatory module for all staff is available via E-learning on Learnpro NHS, with a revalidation/refresher period of 3 years.

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A key way to prevent the spread of infections includes enhanced public engagement in the hand hygiene process, together with the availability of information at http://www.washyourhandsofthem.com. Cleaning and the Healthcare Environment Compliance rates for Argyll & Bute hospitals were as detailed in the circulated report. Ms Tyrrell advised a delay this month in reporting figures for Dunaros and Islay hospitals due to problems with access to a new system, which are being resolved. With regard to Argyll & Bute Council staff working within the newly built Mull Progressive Care Centre, Ms Tyrrell clarified that they will operate and be supervised within NHS Highland compliance guidelines, with audits regularly carried to ensure compliance. Outbreaks/Incidents A Significant Event Review on the Clostridium difficile outbreak in Raigmore Hospital in January 2012 has been completed. The findings from this report have been reviewed by the CHP Infection Control Group to ensure that any gaps in Argyll and Bute are addressed. During the last reporting period, Norovirus has been prevalent within the community setting and patients admitted with restrictions with symptoms to several hospitals within NHS Highland, including Glenaray Ward of Mid Argyll hospital. Mr Creelman commented on the need to review cleaning frequency and estates conditions, with items of risk being removed and areas repaired as required. Ms Tyrrell confirmed there is an awareness of these issues which are being closely monitored.

Healthcare Environment Inspectorate (HEI) Ms Tyrrell advised that the final written report of the announced HEI inspection of Oban, Lorn & Islands hospital in April 2012 has been received. As well as excellent verbal feedback from the inspection team, the written report was very positive and noted that staff were complying well with national standards and requirements. Mr Creelman congratulated all staff for the continued high standard of compliance and their contribution to the very positive report. These comments were endorsed by Councillor Robertson. The Committee: • Noted the contents of the Cleanliness, Hygiene and Infection Control Report 9.3 Health Improvement Ms Garman spoke to the previously circulated paper which reported on the following areas : Childhood Immunisation There has been an uptake in Argyll & Bute of 96.3% of MMR1 by 5 years of age, against an NHS Highland average of 95.4% and a Scottish average of 96.4%. Efforts continue to tackle health inequalities and the need for immunisation uptake in every Practice is highlighted during Practice visits by the Primary Care Manager. It is necessary to continue to deliver a positive message to the public on the benefits of immunisation.


Agenda item : 4.1

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Bowel Screening Argyll & Bute CHP recorded an uptake of 59.1% at end October 2010, against a national uptake of 53.7%, with a higher percentage of women than men locally and nationally recorded. Capacity issues within NHS Greater Glasgow & Clyde has resulted in a delay in Argyll & Bute patients receiving their pre-colonoscopy assessment appointments within 14 days of notification by the Scottish Bowel Screening Centre. The appointment of additional staff in NHS Greater Glasgow & Clyde has now provided more capacity within the system to achieve timeous appointments. Breast Screening Ms Garman advised that there is currently a national consultation underway to rationalise the use of mobile units in Scotland and the number of assessment centres, with consideration being given to combine assessment centres for screening and symptomatic patients. She and Mr Whiston recently attended a workshop to look at the use of the proposed merged service within small communities and the potential impact on the CHP and to consider access times. Cervical Screening Ms Garman reported that national uptake rates by women eligible for screening are falling. The CHP recorded an uptake of 79.5% at end of 2011, against a national target of 80%. In Argyll & Bute, as at end 2011, 16.2% of women defaulted on appointments. After three defaults the details of women eligible for screening appointments are removed from Practice lists. The importance of screening uptake is discussed and highlighted during Practice visits by the Primary Care Manager. Abdominal Aortic Aneurysm Screening The national programme will be phased in across the NHS Highland Board area this year, with the existing programme in North Highland migrating to the new national system. Argyll & Bute will implement the programme in October 2012 which will be delivered in eight centres throughout the CHP by existing radiographers together with healthcare support workers. If a positive screening is reported, patients will either be referred to vascular services in Glasgow or followed up by the local screening service and appropriate health promotion advice provided. Mr Leslie advised that the importance of screening should be on the agenda of Local Area Community Planning Group meetings and communities encouraged to participate in available screening programmes. The Committee: • Noted the contents of the Health Improvement Report 3.30pm - Dr Jenny Hall, Research Fellow, Centre for Health, University of Highlands & Islands joined the meeting by vc and it was therefo re agreed to move to item 13.3 and thereafter revert to the order of the agenda.

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13.3 Isle of Lismore Evaluation Report Dr Jenny Hall highlighted the key points from the circulated final report - executive summary :

• Background to the report • Aims and objectives of the evaluation • Study design methods • Findings and views of the community • Recommendations

The detail of the report on the aims, objectives and recommendations of the proposed new model has previously been shared with the Lismore community. Mr Creelman commented that although some of the issues raised are unique to Lismore, the majority are common to rural areas, i.e. concerns of an island setting being ‘cut off’ from medical and social care services due to weather conditions. Councillor Robertson advised that the outcome of the evaluation process has shifted the balance of care on Lismore and has provided some confidence to the island residents, with the majority of the recommendations probably already achieved. She congratulated all the participants in the review. Ms Henderson reiterated the usefulness of the report and confirmed that a number of the recommendations have been actioned. Engagement with the community will continue and a community sub-group will be set up to deal with any emerging issues. Ms Tyrrell advised that GPs are pivotal in ensuring community confidence on how risk is managed. An emergency planning exercise will be carried out with Argyll & Bute Council. Ms Garman advised that as part of emergency planning, it is important that Electricity Boards have accurate postcode information to ensure that vulnerable patients who may require assistance are easily identified. Mr Creelman stated that there is a specific policy available which Electricity Boards should adhere to when dealing with vulnerable cases. Mr Martin enquired if a telehealth pod was available on the island. Ms Henderson confirmed the availability of a unit and advised that earlier issues around a telephone signal have been resolved. Mr Leslie commented that initially the presentation did not reflect the level of CHP engagement with the public. It is important to continue to build community confidence and to refresh public engagement. Mr Leslie asked that a report detailing the strands of improvement in service delivery is brought to a future CHP Committee meeting. Mr Leslie credited the Lorn and Islands team in their involvement in achieving a positive outcome for the Lismore community. The Committee: • Noted the contents of the Isle of Lismore Evaluation Report


Agenda item : 4.1

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10. FINANCIAL GOVERNANCE 10.1 Finance Report Financial Position Mr Morrison spoke to the circulated report and advised that for the two months ended 31 May 2012 the CHP recorded an overspend of £86,000, with the main pressure being unachieved savings targets. Table 1 of the paper provided a summary of budgetary performance across Argyll & Bute CHP for the two months ended 31 May 2012. Cost pressures have been identified in three localities, commissioned services and management and corporate budgets. Mr Creelman enquired if there was provision within the budget for new drugs. Mr Morrison confirmed this was the case for patented drugs but that the value fluctuates depending on the drug. The CHP prescribing team work with GPs to ensure best use of the prescribing budget. Dr Hall advised that a number of drugs previously issued to the community by NHS Greater Glasgow & Clyde are now being charged to the CHP. Mr. Freeman asked for clarification on the inclusion of forecast slippage of £950k against budget reserves. Mr. Morrison explained that this was effectively a balancing figure required to support a year-end forecast break-even position for the CHP. In effect it included two elements; genuine forecast slippage on budget reserves and also a requirement to address forecast overspends across the CHP. Mr. Morrison acknowledged that the presentation was not entirely clear and agreed to separate these two elements in future reports to improve clarity. Mr Leslie advised that use of reserves is a legitimate management response and decision, without which there would be a risk of not preserving existing services. Mr Creelman confirmed that he was satisfied with Mr Morrison’s reporting of this point. Cost Improvement Programme 2012/13 A cost improvement plan of £5m was approved for 2012/13 by the CHP. Several of the cost improvements will arise naturally (e.g. prescribing drugs coming off patent, restricted uplift to SLA values), however a balance of £2.24m requires to be delivered through management action. To support managers in their efforts to achieve cost improvements a number of quality and efficiency reviews will be undertaken across Argyll & Bute, with any improvements generated contributing to the targets held by individual budget managers :

- Commissioned services - Prescribing costs - Out of hours services - Radiology services - Laboratory services - Administration services - Service Quality (Infection control/Fall prevention/Tissue viability) - Energy costs - Transport services - Catering services - Domestic services - Procurement - Allied health profession - Maternity services

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Mr Leslie acknowledged that 2012/13 will be a financially challenging year, particularly for operational units but provided an assurance that the CHP can achieve efficiencies without affecting front line services and can make a beneficial impact on service quality. Mr Leslie provided additional details of the quality and efficiency reviews :

- Out of hours services – a wider, strategic scrutiny will be undertaken to look at the disposition of assets and services.

- Commissioned services – the methodology applied by NHS Greater Glasgow & Clyde will be questioned to ensure that any efficiency savings achieved by them are subsequently reflected in charges to the CHP.

Mr Martin highlighted the service review currently being undertaken by NHS Greater Glasgow & Clyde and the requirement for the CHP to be fully sighted on developments. Mr Leslie advised that Mr Whiston has made representation to NHS Greater Glasgow and Clyde around the engagement process. Highlands & Islands Travel Scheme (HITS) Mr Morrison advised on a national decision to transfer funding from HITS to health boards baseline allocations, with the CHP receiving a budget of £1.6m per annum, which is protected for cost increase for 2 years. This transfer creates both financial risks and opportunities for the Board/CHP. The Core Team recently discussed and agreed an initiative to review the use of HITS funding to ensure efficiency in allocation of patient travel payments throughout the CHP. Financial System The new national financial system is now operational with the CHP data now on the new reporting system. Mr Morrison reported that delays in the implementation in the system resulted in overdue payments to suppliers for several weeks at the start of April 2012 and delayed budget input and the development of budget reports at the start of the financial year. Forecast Outturn for 2012/13 Mr Morrison advised that there is scope to implement measures to control expenditure and operate within budget to deliver a year-end break-even position, which is contingent on three main actions : - managers take early action to identify and implement measures to achieve savings. - managers exercise control over emerging cost pressures. - settlement of the patients services contract with NHS GG&C is agreed at an acceptable and affordable value. The Committee: • Noted the contents of the Finance Report 11. STAFF GOVERNANCE 11.1 Argyll & Bute CHP Partnership Forum Draft Minute - 19 April 2012 The Argyll & Bute Partnership Forum minute of 19 April 2012 had been previously distributed and the contents were noted.


Agenda item : 4.1

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The Committee: • Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of

19 April 2012 11.2 Argyll & Bute CHP Partnership Away Day – 31 M ay 2012 The CHP Committee agreed to defer this item to the next meeting to enable discussion and feedback from Staffside representatives. 11.3 PDP/R and eKSF Implementation The distributed paper reported that work is continuing to deal with the shortfall in the target of 80% completion. A number of actions have been proposed and interim targets set to address the issues identified in relation to Bank staff to ensure that they are engaged with and participate in the review process. Mr Leslie advised that the focus for the 1st quarter of 2012/13 will be the completion and signing off of Bank staff reviews. 10 PARTNERSHIP WORKING 12. PARTNERSHIP WORKING 12.1 Argyll & Bute Public Partnership Forum Draft N otes – 29 May 2012 Mr Martin advised that only a few members attended and therefore the meeting was not quorate. It has been agreed to appoint an interim Vice Chair until July 2013 when elections for both the Chair and Vice Chair would take place. Mr Martin, Mr Creelman and Ms Champion will meet to discuss the integration agenda. Councillor Robertson highlighted the non-attendance of a Social Work representative on the group. Ms Tyrrell will follow up this with Anne Austin, Service Manager, Community Care Resources, Argyll & Bute Council. The Committee: • Noted the contents of the Argyll & Bute CHP Partnership Forum Draft Minute of

19 April 2012

The Committee: • Noted that this fell short of the target of 80% and demonstrated that considerable work

remains outstanding in relation to including staff who are on employee “bank”, in the PDP/KSF process.

• Noted the interim targets for April - June 2012 • Approved the proposed actions to address this shortfall and engage with bank staff in

relation to KSF. • Noted progress against trajectory for 2012/13.

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13. PERFORMANCE MANAGEMENT 13.1 Delayed Discharge/Joint Performance Report Mr Leslie provided an update on the previously circulated report which detailed the CHP’s performance against the Scottish Government Target. There was one reported breach of >6 weeks, due in part to issues around the case being examined through partnership and the process of submitting the census. Actions have been undertaken to resolve the issues identified. The Committee: • Noted the contents of the Delayed Discharge Report. 13.2 Admissions, Discharge & Transfer (ADT) Policy and Audit Mr Leslie requested that this agenda item be deferred to ensure appropriate scrutiny of circulated report and attached policy document. The Committee: • Agreed the deferment of this agenda item to the next meeting. 14. MENTAL HEALTH SERVICES MODERNISATION PROJECT 14.1 Update Report Mr Leslie advised that this update is reported in various fora throughout the CHP. A number of points were highlighted from the report. Inpatient Services - since the last reporting period the bed compliment has been reduced by 1 to 40 beds. Resettlement Group – is continuing work on plans to discharge/transfer the small number of patients with highly complex needs requiring specialist long term care. Mock HAI Inspection – Heidi May, Director of Nursing recently undertook a mock HAI inspection of ICU, Succoth and Tigh na Linne. An action plan will be drawn up to resolve the issues raised. An update on the work to be carried out will be included in the next report to the CHP Committee. Mr Creelman commented that it is important to recognise and manage any HAI risks. Ms Tyrrell advised that this is a national issue within Mental Health facilities and national guidance is provided by Mental Welfare Commission and HEI. Communications and Engagement – a series of public and staff engagement events were held during May/June 2012 to provide a project progress update. The Committee: • Noted the current key issues and progress against the action plan


Agenda item : 4.1

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15 PAPERS FOR NOTING 15.1 eHealth Steering Group Minute, 2 May 2012 The Committee: • Noted the eHealth Steering Group Minute of 2 May 2012 16 AOCB There was no other competent business highlighted. 17 DATE, TIME & VENUE FOR NEXT MEETING : Wednesday 29 August 2012 at 10.30am An Roth Community Enterprise Centre, Craignure, Isl e of Mull

Highland NHS Board14 August 2012

Item 2(a)

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HIGHLAND NHS BOARD

Assynt House

Beechwood Park

Inverness IV2 3BW

Tel: 01463 717123

Fax: 01463 235189

Textphone users can contact us via

Typetalk: Tel 0800 959598

www.nhshighland.scot.nhs.uk/

DRAFT MINUTE of MEETING of theBOARD

Board Room, Assynt House,Beechwood Park, Inverness

5 June 2012 – 8 30 am

Present Mr Garry Coutts, ChairMr Robin CreelmanMrs Myra DuncanMr Mike EvansDr Michael FoxleyMr Ian GibsonDr Iain KennedyMr Alasdair LawtonMrs Gillian McCreathMr Okain McLennanMr Colin PunlerMr Ray StewartMs Sarah WedgwoodMs Elaine Mead, Chief ExecutiveDr Ian Bashford, Board Medical DirectorMrs Anne Gent, Director of Human ResourcesMr Nick Kenton, Director of FinanceMs Heidi May, Board Nurse Director

Also present Dr David Alston, Non Executive Board member designateMrs Jan Baird, Transitions Director (Items 53 & 54)Mr Eric Green, Head of Estates (Item 67)Dr Rod Harvey, Clinical Director, Raigmore Hospital (Item 36)Mrs Linda Kirkland, Head of Business TransformationMr Chris Lyons, Director of Operations, Raigmore Hospital (Item 57)Una Lyon, Lead Nurse, Raigmore Hospital (Item 57)Cllr John McAlpine, Non Executive Board member designateMrs Gill McVicar, Director of Operations, North & West (Item 63)Dr Ken Oates, Consultant in Public Health Medicine (Item 64)Mr Kenny Oliver, Board Performance ManagerMr Mike Perera, Mental Health Projects Manager (Item 63)Mrs Lorraine Power, Board Services AssistantMr Brian Robertson, Head of Adult Social CareMr Nigel Small, Director of Operations, South & Mid (Item 63)Dr Lesley Anne Smith, Head of Quality (Item 58)Mrs Cathy Steer, Head of Health Improvement (Item 61)Mr Simon Steer, Head of Community Care (Item 62)Ms Maimie Thompson, Head of Public Relations & EngagementDr Emma Watson, Infection Control Doctor (Item 36)

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Apologies – Apologies were received from Mr Bill Brackenridge and Dr Margaret Somerville,Director of Public Health and Health Policy.Welcome – The Chair welcomed Mr Alasdair Lawton and Dr Michael Foxley to the Board meeting.Mr Lawton and Dr Foxley had recently been appointed as Non Executive Board members for NHSHighland from 1 June 2012 for a period of 4 years. The Chair also welcomed Dr David Alston andMr John McAlpine who had been nominated by Highland Council and Argyll & Bute Councilrespectively and had still to be formally appointed to the Board.

35 Declarations of Interest

Board members declared the following interests: Garry Coutts – Scottish Social Services Council (SSSC), ex officio of SSSC on the Care

Inspectorate, University of the Highlands and Islands. Myra Duncan – Member of Scottish Government Joint Improvement Team Action Group on

Reshaping Care. Colin Punler – Member of Pentland Housing Association Board and in relation to item 5.3

on the agenda, an employee of Dounreay. Ray Stewart – Member of Unite and Staffside Chair Sarah Wedgwood – Non-Executive on Penumbra.

The Board

a Noted the Declarations of Interest.

The Chair advised that item 4.7 on the agenda, the Control of Infection Report, would beconsidered prior to other business on the agenda.

36 Infection Control ReportReport by Liz McClurg, Interim Infection Control Manager and Emma Watson,Infection Control Doctor on behalf of Heidi May, Board Nurse Director & ExecutiveLead for Infection Control

Heidi May, Board Nurse Director introduced Dr Emma Watson, Infection Control Doctor and DrRod Harvey, Clinical Director, Raigmore Hospital to present the report to the Board. In addition tothe usual Infection Control Report there were additional updates on Staphylococcus aureusbacteraemia (SAB) in NHS Highland and the Significant Event Report in relation to the Clostridiumdifficile outbreak at Raigmore Hospital in January 2012.

The Executive Summary of the main Infection Control Report, which summarised the keyinformation in the report, is detailed below:

Staphylococcus aureusbacteraemia (SAB)

Target of 0.26 cases per 1000 acute occupied bed daysmet and exceeded.

NHS Highland rate April –March 2012 is 0.18.

Clostridium difficile Target of 0.39 per 1000 total occupied bed days in patientsaged 65 and over met and exceeded.

NHS Highland rate April –March 2012 is 0.26.

Significant Event Review on the Clostridium difficileoutbreak in Raigmore Hospital in January 2012 completed.

Hand Hygiene Compliance with hand hygiene 97% in March and April2012.

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Work on how to achieve consistent compliance with allstaff groups ongoing.

Cleaning and the HealthcareEnvironment

Cleaning Compliance 93% in March and 95% in April2012.

Estates Monitoring Compliance 95% in March and 96% inApril 2012.

Maintaining the fabric of patient areas in older buildings toenable effective cleaning is a challenge. The effectivenessand application of existing monitoring tool is beingreviewed

Significant HAI incidents /outbreaks, emerging threats

Clostridium difficile infection outbreak in Ward 2CRaigmore Hospital April 2012. An incident debrief hasbeen held.

A Significant Event Review is not planned, as therecommendations from the one undertaken following theoutbreak in January will apply

Nationally norovirus outbreaks are continuing to arisedespite the time of year. Wards in Caithness General andRaigmore hospitals have been closed to admissions.

Antimicrobial Prescribing Continuing compliance above 95% with antibiotic choice inmedicine and choice and duration of prophylaxis incolorectal elective surgery. Working with general surgeryto improve compliance above median of 91%.

Surgical site infections Orthopaedic and caesarean section surgical site infectionsrates remain low, and within anticipated levels.Work is ongoing with the colorectal surgeons to reduce theSSI rate in elective patients.

Decontamination Risks identified and detailed in the main report regardingwasher disinfectors, local decontamination units in Argyll &Bute, decontamination of instrument compliance inIndependent Dental Practitioner practices.

During discussion on the main Control of Infection Report, Dr Watson confirmed that NHSHighland maintained its performance as one of the highest performing Board in Scotland andemphasised that all operational units were monitored in relation to cleaning and hygiene andmonitoring antibiotic prescribing. In relation to work in the community it was confirmed that MrBrian Robertson, Head of Adult Social Care would work with infection control teams regarding carehomes and the social care sector.

Significant Event Review – Raigmore Hospital

Heidi May, Board Nurse Director then referred to the Significant Event Report following theClostridium difficile outbreak at Raigmore Hospital in January 2012. The Raigmore SeniorManagement Team, led by Dr Rod Harvey, Clinical Director undertook a Significant Event Review(SER) to understand what had happened and with the intention of reducing risk of furtheroutbreaks occurring in the future. Dr Harvey then gave a presentation to the Board regarding theSER. A significant event was defined as:

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An event that did or had the potential to cause serious harm to an individual or group ofindividuals (patients or staff);

An unusual or extraordinary clinical event with or without an adverse outcome; An event that may cause reputational damage to the organisation.

The presentation outlined the process for a Significant Event Review, the process for the Reviewmeeting, summarised the reasons behind the outbreak and the recommendations of the review.The reasons given for the outbreak were:

Sub optimal standards of cleanliness in some ward areas Capacity issues with domestic & nursing staff

Poor infrastructure Availability of single rooms Degraded washing & toilet facilities difficult to clean

A vulnerable patient population Use of proton pump inhibitor drugs No evidence of inappropriate antibiotic use

After the presentation there followed a lengthy and detailed discussion by the Board on theSignificant Event Review. Some of the issues raised included:

Whether families were usually involved in the formal process of a review and if they hadsight of the final report. It was noted that families were not usually involved in the reviewalthough the report was shared with the patient / family once complete.

It was confirmed that the process for SERs was the same across NHS Highland. Sharing of lessons learned was done via the Clinical Governance Forum and the Infection

Control Improvement Group. While it was acknowledged that the learning was shared thiswas not written formally and the Board Nurse Director confirmed that she would follow upthis issue, possibly with a formal flow chart.

The Chair requested that further consideration be given to engaging with patients andfamilies at an appropriate stage in the process.

The Board Nurse Director and the Board Medical Director gave assurance to the Board thatthe recommendation and actions in the report would be progressed and the action plansigned off.

Reference was made to the issues around staff and staffing and the emphasis on reflectivelearning. Some of the workforce issues related to issues for the Staff GovernanceCommittee and the Highland Partnership Forum.

The Chair asked that Una Lyon, Lead Nurse at Raigmore Hospital address the specificactions relating to staff and also highlighted the importance of staff completing Datixreporting of issues, particularly in relation to patient care.

The Director of Human Resources confirmed that some of the issues relating to staff wouldbe followed up through the Staff Governance Committee.

It was noted that there were no Terms of Reference in the report and Dr Harvey confirmedthat these were contained within Standard Operating Procedures and could be circulated tothe Board for information.

A question was raised regarding the degree of independent of the Significant Event Reviewand it was acknowledged that as many of the people involved in the event were alsoinvolved in the review that there was not a great deal of independence, however the aimwas for people to reflect and learn from the event. The Chair was broadly independentalthough they too worked in the hospital.

Mention was made of proton pump inhibitor drugs and Okain McLennan, Chair of theFormulary Committee confirmed that a formulary note had been issued linking the use ofthese drugs with Clostridium difficile and that this would be followed up with further advice.

Following discussion the Chair confirmed that the Board had received assurance that lessons werebeing learned, issues around staffing were being addressed and the various actions being taken

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forward. The various issues would be progressed via the Clinical Governance Committee and theStaff Governance Committee.Pseudomonas at Raigmore Hospital

The Chief Executive then updated the Board on a situation relation to the Intensive Care Unit atRaigmore Hospital. As a result of routine testing the bacterium Pseudomonas was identified inthree patients who were being treated in the hospital. The clinical condition of the patients was notaffected and they had all since been discharged from hospital. As a precaution the InfectionControl and Prevention Team advised that the unit needed to be temporarily closed to allow athorough and rapid cleaning process. Cleaning and retesting had been done over the weekendand all patients and staff had returned to the unit on 4 June. Ms Mead confirmed that testing hadalso been undertaken in other high-risk areas such as renal, the Special Care Baby Unit (SCBU)and the Medical and Surgical High Dependency Units and these had all come back negative inrelation to Meropenem resistant Pseudomonas. On a question raised by one of the Boardmembers, Ms Mead explained that Pseudomonas is a very resistant bacterium that is often foundin soil and water. It is more likely to infect people who are hospitalised and have underlying healthproblems, particularly the very young and the elderly and is unlikely to cause serious infection inhealthy people.

The Chair thanked those attending for the updates to the Board and highlighted the importance ofsuch learning exercises and the need for open and transparent reporting of these issues. Therewas a need for NHS Highland to focus on the learning and to ensure that any harm to patients isminimised and to ensure quality and safe care for all patients.

The Board

a Noted the contents of the Infection Control Report.

b Noted that more detailed report on the recent Clostridium difficile outbreak at RaigmoreHospital.

c Remitted to the Board Nurse Director to follow up the issue in relation to sharinglearning.

d Agreed that further consideration be given to engaging with patients and families at anappropriate stage in the process.

e Remitted to the Lead Nurse at Raigmore to address the specific actions relating to staffand noted that some of the issues raised would be followed up through the StaffGovernance Committee.

f Remitted to the Clinical Director at Raigmore to circulate the Terms of Reference to allBoard members for information.

g Noted the update on Pseudomonas at Raigmore Hospital.

The Board adjourned at 9.30 am and resumed at 9.45 am.

37 Minutes of Meetings

The following minutes of meetings were approved:

21 March 2012 3 April 2012 3 April 2012 – Board in Committee

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The Board

a Approved the Minutes of Meetings held on 21 March and 3 April 2012.

b Noted the Board Rolling Action Plan.

38 Matters Arising

Mr Gibson referred to the action plan and the risk register relating to Adult Social Care which hehad anticipated being on the agenda for this Board meeting. Dr Smith confirmed that a reportwould be submitted to the next meeting of the Board in August. Dr Foxley referred to the GaelicLanguage Plan, which had been discussed at the last meeting and asked if he could have a copyof the plan. Reference was made to the NHS Highland newspaper and it was confirmed thatanother edition was planned for around the end of August 2012.

The Board

a Noted that a report on the Adult Social Care Risk Register would be submitted to theAugust Board meeting.

b Agreed that a copy of the Gaelic Language Plan be sent to Dr Foxley, as requested.

REPORTS BY GOVERNANCE COMMITTEES

39 Argyll & Bute CHP Committee – Draft Minute of Meeting held on 25 April 2012

In the absence of Mr Brackenridge, Mr Robin Creelman updated on items discussed at themeeting, including eKSF, delayed discharges which continued to be at a low level and the financialoutturn for the CHP. It was noted that the eKSF figures were not as good as anticipated and thatthe trajectory would need to be amended for 2012/13. Mr Creelman congratulated staff in relationto the financial position within the CHP. Dr Iain Kennedy noted that there had been no medicalleadership in attendance at the meeting and asked if he could offer any help in encouragingclinicians to attend. Mr Creelman advised that Dr Mike Hall, Clinical Director was a regularattendee at the meeting. He did confirm that it was sometimes difficult to engage with GPs andwould welcome Dr Kennedy’s assistance in this matter.

40 Mid Highland CHP Committee – Draft Minute of Meeting held on20 April 2012

Mr McLennan, Chair of Mid Highland CHP updated on items discussed at the meeting, includingWest Ardnamurchan Unscheduled Care and the significant progress made in relation to theEmergency Response Team. The Chief Executive confirmed that progress had been made,however there were still some anxieties among nursing staff and Ms Mead sought the Board’ssupport in assisting this group of staff and in providing the care necessary in this community. TheBoard endorsed the need to support this group of staff.

41 North Highland CHP Committee – Draft Minute of Meeting held on 17 April 2012

Colin Punler, Chair of North Highland CHP, updated on issues discussed by North Highland CHPCommittee including the High Risk Medicines Project and the North Highland CHP FinancialPosition. It was noted that the end of year position for the CHP was an overspend of £780k. MsWedgwood asked if the High Risk Medicines Project was one that would be rolled-out across NHSHighland and the Chief Executive confirmed that this project had been rolled out and the NorthCHP was the final area in this process.

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42 Raigmore Hospital Committee – Draft Minute of Meeting held on 16 April 2012

Mike Evans, Chair of Raigmore Hospital Committee updated on the last meeting of the RaigmoreCommittee including issues around discharge care plans, the Quality and Performance report,tissue viability, Kyle Court accommodation and JAG Accreditation. It was confirmed thatappropriate arrangements were in place regarding discharge planning. With regard to Kyle Court,the Raigmore Hospital Patient Lodge, the Chief Executive advised that a further report would besubmitted to the Senior Management Team regarding the usage of this facility and how theaccommodation might be managed in the future.

Dr Kennedy commended Raigmore in relation to cancer access targets and advised that ChrisLyons, Director of Operations had attended the last meeting of the Area Clinical Forum to updateon waiting times for return patients.

Mrs Gent, Director of Human Resources noted that there had been no real discussion on issuesrelating to staff governance, partnership working or health and safety and asked that these issuesbe considered at the next meeting.

43 South East Highland CHP Committee – Draft Minute of Meeting held on 29 March2012

Gillian McCreath, Chair of the South East Highland CHP Committee updated on the last meeting ofthe Committee and confirmed that it had been agreed to hold a final meeting of the Committee inJune. The Chief Executive confirmed that the operational units in Highland Council area had beenasked to hold another meeting of their committees as the new HH&SC Committee was nowunlikely to meet until August or September 2012. Dr Foxley asked about the various tiers ofmanagement in the new structure and if there was a structure diagram. The Director of HumanResources advised that there was a list and a version of the structure could be produced andissued to Board members.

Mr Gibson referred to item 10.1 of the minute and the discussion on improving services relating topharmacy and prescribing and the reference to the Change Fund monies and whether there was3rd sector involvement. The Chief Executive confirmed that NHS Highland was working closelywith the 3rd sector and with the national team at Scottish Government and that work on theproposals should be finished by the end of June and a report would be submitted to the nextmeeting of the Board.

The Board

a Noted the Minutes.

b Noted that Dr Kennedy had offered his support in relation to ensuring clinical engagementat the Argyll & Bute CHP and other committees as appropriate.

c Endorsed the need to support nursing staff in the West Ardnamurchan area.

d Noted that a report on Kyle Court Accommodation would be submitted to the SeniorManagement Team.

e Remitted to the Chair and Director of Operations of Raigmore Hospital to ensure thatissues relating to staff governance, partnership working and health and safety wereincluded on the agenda for the next meeting of the Committee.

f Agreed that the CHP / Raigmore Governance Committees in Highland Council areashould hold one further meeting as the new HH&SC Committee was now unlikely to meet

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until August / September 2012.

g Agreed that a structure diagram should be issued to Board members once available.

h Noted that an update on the Change Fund Proposals would be submitted to the nextmeeting of the Board.

44 Audit Committee – Draft Minute of Meeting held on 15 May 2012

Mr Ian Gibson, Chair of the Audit Committee updated on issues discussed by the Committee,including the Internal Audit report on Consultant Contracts and asked who was responsible for thiswork and for taking an overview. Anne Gent, Director of Human Resources advised that a numberof members of staff in the medical staffing team had taken ownership of this area of work ensuringthat Consultant Contracts were developed, reviewed and signed off, however the managementresponsibility was with the Operational Clinical Directors. It was noted that a further report wouldbe submitted to the Audit Committee in due course. There had been a detailed discussion at theAudit Committee on Integrating Care in the Highlands in relation to governance and assurance. Inrelation to the Laboratory Managed Service Contract Review it was noted that a report on progresswith the Action Plan would be submitted to the next meeting of the Committee. Regarding theminute of meeting of 15 May, Bill Brackenridge had been noted as being present and as anapology which required to be amended.

45 Clinical Governance Committee – Assurance Report of 8 May 2012

Sarah Wedgwood, Chair of the Clinical Governance Committee updated on issues discussed bythe Committee and confirmed that Senior AHPs now attended the meeting. There had been adetailed discussion on the eHealth Strategy and it was noted that the Information GovernanceCommittee and the Area Medical Records Committee would report back to the ClinicalGovernance Committee on progress.

46 Improvement Committee Assurance Report of 30 April 2012 and Balanced Scorecard

The Board noted the Improvement Committee Assurance Report of 30 April 2012 and BalancedScorecard. The Chair highlighted items that had been discussed, including Children & AdolescentMental Health Services (CAMHs) and Waiting List Management – use of Unavailability.

47 Area Clinical Forum – Draft Minute of Meeting held on 29 March 2012

Dr Iain Kennedy, Chair of the Area Clinical Forum, confirmed that he had updated on the meetingof 29 March 2012 at the April Board meeting and therefore gave a verbal update on the mostrecent meeting held on 31 May 2012. He highlighted the National Area Clinical Fora Chairs Groupwhich meets quarterly with the Cabinet Secretary. The four aims of the Group were to:

1. Champion Quality2. Act as a direct interface between clinicians and the Government3. Report on Service Provision4. To positively challenge to ensure the best clinical outcomes for every person.

48 Pharmacy Practices Committee – Minute of Meeting held on 10 April 2012

The Board noted the minute of meeting held on 10 April 2012 in relation to pharmaceuticalservices at Units 2 & 3 Cradlehall Shopping Centre, Cradlehall Court, Inverness, IV2 5WD.

49 Governance Committee Annual ReportsReport by Kenny Oliver, Board Secretary on behalf of Elaine Mead, Chief Executive

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As part of the Annual Accounts process a number of Annual Reports relating to NHS HighlandCommittees are produced and considered by the Audit Committee. The reports circulated were:

Appendix 1 – Audit Committee Appendix 2 – Staff Governance Committee Appendix 3 – Remuneration Sub-Committee Appendix 4 – Clinical Governance Committee Appendix 5 – Improvement Committee Appendix 6 – Risk Management Steering Group Appendix 7 – Endowment Funds Committee Appendix 8 – Argyll & Bute CHP Committee Appendix 9 – Mid Highland CHP Committee Appendix 10 – North Highland CHP Committee Appendix 11 – South East Highland CHP Committee Appendix 12 – Raigmore Committee Appendix 13 – Spiritual Care Committee Appendix 14 – Control of Infection Committee Appendix 15 – Health & Safety Committee Appendix 16 – Pharmacy Practices Committee

The Chair welcomed the Annual Reports and referred to the time spend by the Board onscrutinising minutes of Governance Committees. In relation to the revised management structureit was also proposed to review the reporting to the Board by Governance Committees andconsideration was being given to the relevant committees submitting an assurance report to theBoard. Ms Wedgwood highlighted the need also for exception reporting to the Board. The Chairconfirmed that work was in progress to review the mechanisms in place and that the Chair, ChiefExecutive and the new Chief Operating Officer would do this, with input from the Board Secretary.

The Board

a Noted the Minutes.

b Noted that Bill Brackenridge had attended the Audit Committee meeting on 15 May 2012and should therefore not be noted in “apologies”.

c Noted: the Clinical Governance Committee met on 8 May 2012. the Assurance Report and agreed actions resulting from the consideration of the

specific items detailed. the next meeting of the Clinical Governance Committee will be held on 7 August 2012.

d Noted: the Improvement Committee met on 30 April 2012. the Assurance Report and agreed actions resulting from the review of the specific

topics detailed and the Balanced Scorecard. the next meeting of the Improvement Committee will be held on 2 July 2012.

e Noted the views of the Audit Committee on the attached Annual Reports of theGovernance Committees.

f Noted that work was in progress to review the mechanisms for governance committees toreport to the Board and that this would be taken forward by the Chair, Chief Executive,Chief Operating Officer and Board Secretary.

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Council/Highland NHS Board Joint Committees

50 Highland Council Partnership – Joint Committee on Children and Young People –Minute of Meeting of 16 March 2012

Mr Ian Gibson updated on the last meeting of the Joint Committee on Children and Young Peopleincluding Performance Reporting and Children’s Disability Services – Additional ResidentialRespite Provision.

The Board

a Noted the minutes.

CORPORATE GOVERNANCE / ASSURANCE

51 Membership of CommitteesReport by Garry Coutts, Chair, NHS Highland

As a result of the recent decision to establish the Highland Health and Social Care Partnership andthe end of term for 2 experienced Board Members it was felt that this was an opportune time toreview and revise the membership of NHS Highland Board Governance Committees. Due to therecent Local Government Elections we are not able to identify the Local Authority Representativesuntil the administrations have been agreed.

There had been circulated report detailing current membership of committees and proposedmembership. The Board agreed that Sarah Wedgwood should be appointed as Vice-Chair until30/06/14. The Board also agreed the Non-Executive membership on the following committees:

Community Health Partnerships

Highland Health and Social Care Partnership Ian Gibson – Chair(until Feb 2013)Gillian McCreathMyra Duncan

Argyll & Bute Community Health Partnership Robin Creelman – ChairBill BrackenridgeLocal Authority Member – TBA

Governance Committees

Audit Committee Mike Evans – ChairMichael FoxleyGillian McCreathOkain McLennan

Clinical Governance Committee Sarah Wedgwood – ChairIain KennedyAlasdair LawtonBill BrackenridgeMichael Foxley

Staff Governance Committee Colin Punler – ChairRobin CreelmanIan GibsonRay StewartMyra Duncan

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Endowment Funds Committee Ray Stewart – ChairIan GibsonBill BrackenridgeColin PunlerMike Evans

Remuneration Sub-Committee Garry Coutts – ChairSarah Wedgwood – Vice-ChairIan GibsonRobin CreelmanColin PunlerRay Stewart

Highland Council Committees

Adult and Children’s Committee Ian GibsonGillian McCreathMargaret Somerville

Joint NHS Highland and Argyll & Bute Council Committee

Argyll & Bute Health and Care StrategicPartnership

Robin Creelman – ChairLocal Authority Member – TBA

Non-Executive Representation on other NHS Highland Committees

Area Control of Infection Committee Okain McLennan – ChairGillian McCreath

Health & Safety Committee Alasdair Lawton

Pharmacy Practices Committee Bill BrackenridgeOkain McLennan

Risk Management Steering Group Sarah Wedgwood

Spiritual Care Committee Sarah Wedgwood

Non-Executive Representation on other Committees/Groups

National Appeal Panel for Entry toPharmaceutical Lists

Okain McLennan

Dr Foxley asked if Non-Executives who were not members of committees would still receiveagendas and papers. The Chair confirmed that all Board members would receive papers for eachof the governance committees and encouraged members to attend a variety of meetings eachyear.

The Board

a Agreed that Sarah Wedgwood be appointed as Vice-Chair until 30/06/14.

b Agreed to the proposed membership for Highland Health and Social Care CommunityHealth Partnerships and that the Chair should be appointed until 30/06/14.

c Agreed to the proposed membership for Argyll and Bute Community Health Partnershipand that the Chair should be appointed until 30/06/14.

d Agreed to the proposed appointment of Chairs for the main Governance Committees to30/06/14.

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52 Establishment of Highland Health & Social Care PartnershipReport by Garry Coutts, Chair

At the Board meeting in December 2011, the Board agreed to establish a single operational unitcovering the whole of Northern Highland, co-terminus with Highland Council. This report updatedon progress with the establishment of the Highland Health & Social Care Partnership. MyraDuncan asked about third sector representation on the Committee and it was confirmed that one ofthe patient / public representatives would be from the third sector. Mr Stewart referred to page 259and highlighted that the wording regarding “Staffside membership” should be amended to read“Staffside membership x 2”. Mr Stewart also referred to section 6.6 on paged 261 relating to StaffPartnership and confirmed that it had been agreed that there would be 3 separate partnership fora,for Raigmore, North & West and South & Mid, rather than one overarching Partnership Forum.The Chair advised that the Highland Council would also have an Adult and Children’s Committee,which would include representation from NHS Highland.

There followed some discussion on the name of the committee and the service. It was generallyagreed as there was no longer a “partnership” with Highland Council in view of the Lead AgencyModel that the word “partnership” should not be included in the name. Accordingly the Boardagreed that the Committee should be called the “Highland Health & Social Care Committee” whichrelated to the Highland Health & Social Care Service.

The Board

a Note the ongoing work to establish Highland Health and Social Care Partnership and inparticular the setting up of Highland Health and Social Care Partnership GovernanceCommittee.

b Following discussion Agreed that the Committee should be called the “Highland Health& Social Care Committee” which related to the Highland Health & Social Care Service.

53 Integrating Care in the Highlands – Forward PlanReport by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive

As Planning for Integration reached conclusion and integrating services in the Highlands becomesa priority, a number of actions were carried forward to ensure the development of longer-termsustainable processes and procedures. This report updated on the Forward Plan for IntegratingCare in the Highlands. Section 2 of the report summarised the major areas of work and theproposals to take these forward, including property, finance, human resources and informationmanagement and technology (IM&T). The last meeting of the Planning for Integration ProgrammeBoard would be held on 11 June. The terms of reference for the group had been revised to reflectthat Highland Council and NHS Highland were now “Integrating Care in the Highlands” and thework would continue with a programme management approach. A revised risk register would alsobe submitted to the Programme Board. Dr Foxley asked about completion of the revisedInformation Sharing Protocol. Mrs Baird advised that while the date for completion had slipped thatall agencies were committed to this, including the local authorities, the police and the fire andrescue services. A question was raised regarding the monitoring and performance management inrelation to data sharing, the baseline information used and the performance measures. The Chairadvised that this would be an area of work for the Improvement Committee. Mention was made ofthe new Highland Strategic Commissioning Group and it was confirmed that the Programme Boardwould consider the role and remit on 11 June.

The Board

a Noted the forward plan moving on from Planning for Integration.

31

b Noted the proposed approach to ensure long term and sustainable arrangements are putin place to support the Integrated front-line services.

c Noted the development of Programme scope for Central/Corporate services and theappointment of a Programme Manager.

54 Integration of Adult Health and Social Care in Scotland – Consultation on ProposalsReport by Jan Baird, Transitions Director on behalf of Elaine Mead, Chief Executive

The Scottish Government had launched its consultation on Integration, which would run until 31July. The Highland Partnership had of course implemented integration of adult and children’s’services under existing legislation namely the Community Care and Health (Scotland) Act 2002.The consultation document outlined the impact on current legislation and configuration ofCommunity Health Partnerships, detailing two options for partnerships to consider across Scotland.A Lead Agency model was one of the options. Jan Baird, Transitions Director updated on theconsultation, confirming that the consultation period had been extended to 11 September 2012.There was also tabled additional comments in relation to questions 7 and 17 of the consultationregarding committee arrangements and clinical involvement respectively. The Chair highlightedthe need for appropriate engagement with clinicians when they could have the most impact. TheChief Executive supported the Chair’s comments and also suggested that the word “fail” in thesecond paragraph of the tabled paper should be amended to read “have struggled”. In view of therevised timescale for submission of comments it was agreed that the final submission would besubmitted to the August meeting of the Board prior to submission to the Scottish Government. TheChair suggested that the draft response be circulated to Board members for any additionalcomments and it was noted that the draft would be further circulated to gather views acrossleadership and management forums in NHS Highland.

The Board

a Noted the consultation proposals.

b Noted the consultation response drafted on behalf of NHS Highland.

c Agreed further circulation of the draft to gather views across leadership and managementforums in NHS Highland.

d Noted that the draft response would be circulated to Board members to allow furthercomments prior to submission to the August Board meeting.

55 Interim Financial Position as at 31 March 2012Report by Nick Kenton, Director of Finance

Mr Kenton updated on the interim financial position to 31 March 2012. The report was based uponthe most up to date information for the end of the financial year and should be viewed asprovisional as it was still subject to audit scrutiny. The current out-turn for 2012/13 highlighted thatthe Board had met its financial targets with a small underspend of £85,000 against the RevenueResource Limit (RRL) and a £8,000 underspend against the Capital Resource Limit (CRL), subjectto audit. Tables 1 and 2, provided a summary breakdown of the initial year-end out-turn andshowed a range of relatively small movements which net to an overall improvement of £85,000 onthe previous estimate of break-even. There were a number of reasons contributing to thismovement which were detailed in section 3 of the report and included:

Improvements in prescribing positions Underspend in resource transfer Increases in tertiary costs – primarily cardiology

32

Table 3 detailed the levels of savings achieved and incorporated an additional column to highlightthe full year effect of 2011/12 savings and confirmed a recurring shortfall as previously estimated,to be carried into 2012/13 of just under £9m. Capital expenditure was summarised within table 4highlighting a minor underspend of £8,000.

The Chair extended the thanks of the Board to all managers who had worked to achieve thefinancial out-turn of a £85,000 underspend for NHS Highland for 2011/12. He highlighted the AuditCommittee and the Board in Committee meetings to be held on 18 June to consider the NHSHighland Annual Accounts.

The Board

a Noted the financial out-turn of a £85,000 underspend.

b Noted that this was subject to audit review.

c Noted the non-recurrent savings carried into 2012/13.

56 Approach to Benefits RealisationReport by Nick Kenton, Director of Finance

The overall strategic direction for NHS Highland was based around a Quality & EfficiencyFramework. As part of this ethos, there had been a change in emphasis regarding the delivering ofefficiency improvements. This had seen an increasing focus on realising the financial benefits ofquality improvements as opposed to more traditional methods of reducing costs. There wasconsiderable international evidence of the value of this approach. However, it was recognised thatthe change in emphasis to a benefits realisation approach would take time to embed within anorganisation. The purpose of the report was to present a brief resume of the savings delivered in2011/12 in the context of this approach and to present a summary of the progress to date in2012/13. The Director of Finance spoke to the report highlighted the benefits realised in 2011/12which were detailed in 12 categories. The savings equated to £18.9m of which £10.9m was non-recurring.

For 2012/13, it was mutually agreed to allocate the targets afresh and in effect to write off anytargets not met from previous years. The result is a set of financial targets that should beachievable for each unit, as well as a system-wide target that will require co-operation betweenunits. The targets could be broadly summarised as follows:

Argyll & Bute CHP – 2.2%North & West Highland – 2% plus share of adult social care savingsSouth & Mid Highland - 2% plus share of adult social care savingsRaigmore – 3%Corporate services – 5%Pharmacy, facilities - 3%

In addition to the above, for Northern Highland there is a target of £9m for system-wide benefitsrealisation arising from quality initiatives. It was anticipated that these would take time to deliverfinancial benefits and it was assumed that around £4.5m would delivered in the current financialyear, with the balance delivered in next financial year. Good progress was being made inidentifying efficiencies through tackling waste, harm and variation and this would be reportedthroughout the year. It was also vital that a system-wide approach is adopted in respect of benefitsthat require co-operation across management units and a group has been established thatincludes all Directors of Operations, chaired by the Director of Finance, to take this forward.

33

The Chair welcomed the report and the work in progress. Elaine Mead, Chief Executive referred tothe additional £9m target relating to system wide benefits and highlighted the need for qualitymeasures to be whole system and to ensure that savings were not double-counted.

The Board

a Noted the approach to benefits realisation.

57 Raigmore Hospital Quality Approach to Improvement in 2012/2013, 2013/14 and2014/15Report by Chris Lyons, Director of Operations, Raigmore Hospital on behalf of ElaineMead, Chief Executive

This report to the Board set out to summarise the approach to quality improvement adopted by theRaigmore Management Team. The approach adopted was in line with the Highland QualityApproach and the Highland Quality and Efficiency Plan. Mr Chris Lyons, Director of Operations atRaigmore Hospital presented the report to the Board. As well as outlining the approach adopted,the report covered quality improvement proposals in relation to reducing harm, variation and waste.In relation to some of the workforce issues, the Director of Human Resources confirmed that thesewould be addressed in the NHS Highland Workforce Plan, which would be submitted to the Augustmeeting of the Board. The Chief Executive advised that Raigmore would find it challenging todeliver the plans in isolation and this could only work with a whole systems approach. AccordinglyMr Lyons was working closely with the Director of Operations for South and Mid as well as theDirectors of Operations for other operational units. It was noted that the new Health & Social CareCommittee would monitor performance, with any issues being reported to the ImprovementCommittee. The report was welcomed and a question was raised as to whether this approachwould be replicated elsewhere in the system. The Chief Executive confirmed that this approachwas being adopted across the whole organisation including Argyll & Bute CHP and that similarreports would be submitted to the Board by the Directors of Operations in the other operationalunits. It was noted that while NHS Highland might see the benefits of some of the initiatives thisyear that others may not come to fruition until future years.

The Board

a Noted the approach to quality improvement in 2012/2013 by Raigmore HospitalManagement Team.

b Noted the details of the quality improvement initiatives and the expected benefits of theimprovements planned and underway.

c Noted the initial work to identify quality improvement in 2013/14 and 2014/15.

d Noted that the NHS Highland Workforce Plan would be submitted to the August meetingof the Board.

e Noted that similar Improvement Plans for other Operational Units would be submitted tothe next meeting of the Board.

58 Hospital ScorecardReport by Lesley Anne Smith, Head of Quality on behalf of Elaine Mead, ChiefExecutive

NHS Board Chief Executives agreed in November 2011 that it was important to establish a coreset of measures, which could be used to track a number of key areas of healthcare quality acrossScotland.

34

As a result, colleagues across Scotland have explored a range of potential measures, andconsidered the role of this national ‘scorecard’ alongside the local systems, which individual NHSBoards have developed or are developing. The result of this work was the ‘Hospital Scorecard’.Dr Lesley Anne Smith, Head of Quality spoke to the report. The Scottish Government Health andSocial Care Management Board (HSCMB) examines the scorecard on a quarterly basis to gainassurance and identify areas of potential concern about the quality of healthcare services in acutehospitals across NHSScotland based on their assessment of the full range of indicators.

The Scorecard used RAG coding where red indicated an outlier, amber indicated above averageand green below average. It was noted that re-admission rates at the Belford Hospital was anoutlier and, while it was thought that this was due to a coding discrepancy, ISD had been asked toinvestigate this. Dr Foxley emphasised the need to know the reasoning behind this and for furtherdiscussion and analysis. Dr Smith confirmed that the data would be scrutinised by the ClinicalGovernance Committee who would hold operational units to account regarding the detail andunderstanding the reasons behind the data.

The Board

a Noted the publication of the Hospital Scorecards for June 2011 and September 2011together with the management and assurance actions being taken in response to thedata.

59 Chief Executive’s and Directors’ Report – Emerging Issues and UpdatesReport by Elaine Mead, Chief Executive

This month’s report incorporated updates on: DALLAS – Delivering Assisted Living Lifestyles At Scale Diabetes Care across the northern NHS Highland area Fire Safety - County Hospital, Invergordon Highland Eating Disorder Out Patient Service and the Eden Unit Specialist In-Patient Facilities Investigation into the Management Culture in NHS Lothian Magnetic Resonance Imaging (MRI) Scanner Replacement – Raigmore Hospital Reform of Police and Fire Services Regional Planning – North of Scotland Planning Group and West of Scotland Planning

Group Rise in cases of Whooping Cough (Pertussis)

The Chief Executive advised that a short life working group on the Investigation into theManagement Culture in NHS Lothian would meeting following today’s Board meeting. Mrs Gent,Director of Human Resources highlighted the need for NHS Highland to understand theimplications and the cultural issues so that the Board could be re-assured and have a betterunderstanding of where NHS Highland stood in relation to these issues.

Some concern was expressed regarding the reform of the Police and Fire service in the move to amore centralised service which might impact locally on community planning. The Chief Executiveconfirmed that this had been raised at the last Community Planning meeting when reassurancehad been given that the new structures would not be detrimental to local planning.

The Board

a Noted the emerging issues and updates report.

35

STRATEGY AND POLICY

NHS Highland Strategic Framework

60 Developing a Quality Approach to Engagement and Communications: Setting up forSuccess – Next Steps 2012/13Report by Maimie Thompson, Head of Public Relations and Engagement on behalf ofElaine Mead, Chief Executive

A report was presented to Board in February 2012, which set out the scope of work required todevelop strategic communication and engagement. This report summarised the communicationsand engagement strategic framework, and the high-level action, which would support prioritisationand tracking of management actions during 2012/13. Maimie Thompson, Head of PR &Engagement spoke to the report highlighting the 5 key workstreams. Developing each of the workstreams would be a significant undertaking and further focussed work and expertise was requiredon:

Work Stream 1: widening involvement and engagement including currentinfrastructure and approaches for developing groups and people on groups.

Work Stream 2: building capacity and capability to support effective communications(internal, external, media and political) at both strategic and tactical levels. This mustinclude developing our key messages

Work Stream 3: training and support to promote and deliver the outcomes fromCEL(2010)04, including options appraisal

Work Stream 4: develop and implement Social Media and Social Marketing Strategy Work Stream 5: re-design of internet (Public facing website) and intranet (internal

website for NHS staff)

The Chief Executive confirmed that work was in progress in each of the operational units and theDirectors of Operations were all involved in projects locally and in building relationships withpartners and communities. Sarah Wedgwood suggested that the new District Partnerships shouldbe open and a place where members of the public could raise relevant issues. The Chairconfirmed that these would not be part of the formal governance structure and as such could adopta different style. There were a number of routes that could be used by members of the public toraise issues, including escalating directly to Chief Executives, via public / patient representatives orvia a member of a district partnership who also sits on a governance committee.

Mr Punler commended the approach to engagement and communication and agreed that NHSHighland’s vision, culture and reputation were key. It was also important that staff lived the valuesand believed the vision. Elaine Mead, Chief Executive confirmed that there was work in progressrelating to organisational values which would be submitted to a future meeting of the Board.

Mr McLennan asked about the role of Non-executives on the District Partnerships and the Chairconfirmed that there would be a Board member on each Partnership. Maimie Thompson advisedthat if any Non-Executives were interested in being involved in any short life working groups tocontact her direct.

The Board

a Noted the ongoing work to develop more robust strategic communications andengagement to support delivery of NHS Highland’s aims and objectives.

b Discussed and Agreed the framework including considering the identified assumptionsand risks.

c Discussed and Agreed the outline forward plan.

36

The Board adjourned at 12.10 pm for lunch and resumed at 12.40 pm.

61 Highland Quality Approach to Staff Health and Well BeingReport by Cathy Steer, Head of Health Improvement, Pamela Cremin, WorkforcePlanning & Development Manager, Linda Rawlinson, Occupational Health Strategyand Development Manager and Bob Summers, Head of Health and Safety; on behalfof Anne Gent, Director of Human Resources and Dr Margaret Somerville, Director ofPublic Health

Anne Gent, Director of Human Resources and Cathy Steer, Head of Health Improvement spoke tothe report which aimed to alert the Board to the approach being developed to promote staff healthand wellbeing that responds to national policy and supports the Boards strategic vision to provideBetter Health, Better Care and Better Value through placing quality and innovation at the heart ofwhat we do to support staff health and well-being. Mrs Steer updated on some of the ongoingworkstreams including Healthy Working Lives, Occupational Health Services, Health & Safety andusing an assets based approach to health and wellbeing. The Board welcomed the report andendorsed the approach being taken.

The Board

a Noted the position in developing a quality approach to staff health and wellbeing.

b Endorsed the approach and support the ‘next steps’ section of the report.

62 Highland Quality Approach to Strategic CommissioningReport by Linda Kirkland, Business Transformation Manager and Simon Steer, Headof Community Care on behalf of Elaine Mead, Chief Executive

Mr Simon Steer, Head of Community Care spoke to the report which highlighted the differencesbetween commissioning, procurement and purchasing and showed the commissioning processdiagrammatically. The report detailed the components of the Commissioning agenda that we needto pursue:

1. A Shared Understanding of what we mean by “Commissioning” is required.2. Capacity and Capability needs to be developed to enable all organisations to contribute.3. A Spectrum of Proportionate Engagement needs to be understood.4. Planning Investment over the next 3 to 5 years is required to build stability and breadth in

the provider base.5. Provider Base; User Engagement and Community Development – All of the above need to

take place with the full and equal engagement of all sectors to ensure that the providerbase and community capacity is developed to full potential.

Mrs Kirkland advised that this work linked very closely with the work on benefits realisation, as didthe Procurement Strategy.

The Board

a Agreed the definition of a Highland Quality Approach to Strategic Commissioning asdescribed

b Agreed that work be undertaken to develop awareness, understanding, capability andcapacity to progress the Highland Quality Approach to Strategic Commissioning acrossall sectors.

37

63 Highland Quality Approach to Older Adult Mental Health Services: Update onImplementation of National Standards across Highland Health & Social CarePartnership AreaReport by Nigel Small & Gill McVicar, Directors of Operations on behalf of Dr KenProctor, Associate Medical Director and Heidi May, Board Nurse Director (attached)

The Scottish Government published the National Dementia Care Strategy and Dementia CareStandards in 2011. NHS Highland has to meet these national standards, and accommodate theexpected increase in dementia sufferers, within a set budget and at the same time deliver servicesin the most cost effective way. The Northern Highland Older Adult Mental Health ServicesRedesign Steering Group has been assessing NHS Highland’s compliance with the delivery of thestandards. As the Argyll and Bute CHP review has been reported previously, this report focusedon services in the Highland Council area. Nigel Small, Director of Operations spoke to the report,highlighting different workstreams as well as links with work on Anticipatory Care Plans andPolypharmacy.

The Chair welcomed the report which highlighted some of the excellent work in relation to olderadult mental health services and also referred to a recent award received in Argyll & Bute CHPrelating to their work with Alzheimers’ Scotland. He confirmed that the Board would look forward toreceiving future reports on key milestones being implemented and making a difference for patients.

The Board

a Noted the range of initiatives to improve care in Older Adult Mental Health CommunityServices.

b Noted the proposals to re-design in-patient care for dementia patients in the HighlandHealth and Social Care Partnership area.

c Noted that Directors of Operations are developing action plans to implement therecommendations around appropriate requirements for hospital beds.

d Noted the requirements for re-investment into community and specialist acute services.

e Noted the introduction of the patient care system “The Butterfly Scheme” for patientswith dementia in acute hospitals in NHS Highland.

f Noted the work already carried out and future proposal to support communications andengagement.

64 Joint Health Protection Plan 2012 – 2014Report by Ken Oates, Consultant in Public Health on behalf of Margaret Somerville,Director of Public Health

The report updated on the Joint Health Protection Plan for 2012-14. This had been produced byNHS Highland with Highland Council and Argyll & Bute Council. Dr Ken Oates, Consultant inPublic Health Medicine spoke to the report which highlighted national and local priorities for 2012-14. The Plan had been approved by both local authorities. Dr Oates highlighted issues aroundprivate water supplies and e-coli 157and advised that many private water supplies which hadpreviously been untreated were now treated. The Board agreed the Joint Health Protection Planfor 2012-14.

The Board

a Agreed the content of the Joint Health Protection Plan for 2012-14.

38

b Noted that the relevant committees of Highland Council and Argyll & Bute Council hadalready approved the Joint Health Protection Plan.

c Once all agencies have signed it off, Agreed to it being placed on the NHS Highlandwebsite.

65 Procurement StrategyReport by Malcolm Iredale, Head of Procurement on behalf of Nick Kenton, Director ofFinance

The Draft Procurement Strategy for NHS Highland had been circulated and this identified theProcurement Principles, and a process for meeting them. Nick Kenton, Director of Financeupdated on the report and confirmed that it aligned with the overall Quality Framework on relationto reducing harm, variation and waste. Mr Kenton also referred to CEL(2012)05 which outlinedKey Procurement Principles. The Chair referred to guidance relating to national contracts andlocal contracts. Mr Kenton advised that while there were national contracts in place that therecould be exceptions in remote and rural areas and it might be possible to get local suppliers onnational contracts. Mr Punler asked if our procedures had been updated in light of the Bribery Actand Mr Kenton advised that he would check this and report back.

The Board

a Noted the role of Procurement within overall Board activities.

b Agreed the procurement principles detailed in section 3 of the Procurement Strategy.

c Approved the Procurement Strategy.

d Noted that the Senior Management Team would agree a Procurement Workplan.

66 Asset Management Group – Terms of ReferenceReport by Nick Kenton, Director of Finance

Nick Kenton, Director of Finance spoke to the report. The Asset Management Group (AMG) wasestablished to provide a robust process for managing the Board’s capital investment programme.In the light of the significant constraints on capital expenditure in recent times, it had becomeincreasingly clear that the Terms of Reference of the AMG required revisiting and that thereneeded to be a focus on managing the entire asset base (including assets that are below thecapital threshold) rather than just new capital developments. There had also been issues aroundthe difficulty in securing clinical engagement and this meant that the membership of the AMGrequired revisiting at the same time. In addition, a recent internal audit report noted the fact thatthe AMG did not formally report into a ‘parent’ committee and recommended that the AMG shouldreport to one of the standing committees of the Board. Following discussion it had been suggestedthat the AMG should report directly into the Board itself. This would require an amendment to theBoard’s Standing Orders. In the light of this, revised draft Terms of Reference were now submittedto the Board for consideration. Gillian McCreath noted that Infection Control experts would not befull members of the Group. Mr Kenton offered assurance that for any proposals relating toinfection control that the relevant people would be involved in the process.

The Board

a Approved the Terms of Reference for the NHS Highland Asset Management Group.

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67 Property and Asset Management StrategyReport by Eric Green, Head of Estates on behalf of Nick Kenton, Director of Finance

CEL(2010)35 required all Boards to provide a Property Asset Management Strategy to ScottishGovernment and provided guidance as to how this was to be achieved. Eric Green, Head ofEstates spoke to the report highlighting some of the issues in relation to backlog maintenance andspace utilisation and improving services and the environment for patients. On a question raisedrelating to infection control, Mr Green confirmed that infection control doctors were now involved indiscussions relating to prioritisation of estates work.

The Board

a Approved the Property Asset Management Strategy.

b Noted the progress on improving performance.

c Noted the issues around backlog maintenance and the plans to tackle this problem.

68 Any Other Competent Business

Industrial Action by the BMA – 21 June 2012 – The Board noted the proposed industrial actionto take place on 21 June 2012 by the BMA.

69 Date of Next Meeting

The next meeting of the Board will be held on Tuesday 14 August 2012 at 8.30 am in the BoardRoom, Assynt House, Beechwood Park, Inverness.

The meeting concluded at 1.45 pm.

Argyll & Bute CHP Committee Date of Meeting: 29 August 2012 Item No: 7.1

1

Argyll and Bute CHP Clinical Governance and Risk Ma nagement Report Report by Pat Tyrrell, Lead Nurse Fiona Campbell, Clinical Governance Manager

The CHP Committee is asked to:

• Note the contents of the Clinical Governance and Risk Management Report.

1. CONTRIBUTION TO THE BOARD’S CORPORATE OBJECTIVES NHS Highland’s mission is to provide patient-centred services tailored to people’s needs in a systematic and consistent way – to provide quality care to every person every day. The Board approach embraces the Healthcare Quality Strategy for Scotland and also takes account of the priorities within the NHSScotland Efficiency and Productivity Framework for SR10. NHS Highland vision is to :

• Provide quality care at all times; • Support people and communities to maximise their own health; • Develop precisions driven services so that when people need our care they

experience timely, focussed, effective services that minimise the duration and frequency of contact;

• Ensure that every health pound spent delivers maximum health gain.

2. RISK MANAGEMENT 2.1 Incidents The following information relates to incidents reported in the last financial quarter – 1 April to 30 June 2012. The information reflects the position on 24/07/2012.

2

FIGURE 1 Argyll and Bute Incidents Last 13 months

A total of 527 incidents were reported in Argyll and Bute during Quarter 1 of 2012/13 This represents an 8.8% reduction from Quarter 4 of 2011/12. (578 incidents). By Locality these are as follows:

- Cowal & Bute 123 (23.3%) - Helensburgh 9 (1.7%) - Mid Argyll, Kintyre & Islay 275 (52.2%) - Oban Lorn & Isles 101 (19.2%) - Outwith NHS Highland (pts from GGC) 19 (3.6%)

FIGURE 2 Category by Locality

The top category of incident for A&B during the first quarter was slips trips and falls.


3

By locality the top categories were as follows:

- Cowal & Bute – Slips, trips & falls (48); - Helensburgh – Medication errors (3); - Mid Argyll, Kintyre & Islay – V&A (73); - Oban Lorn & Isles – Slips, trips & Falls (27)

FIGURE 3 Grade of Incidents by Locality

During Quarter 1 of 2012/13 Incidents were graded as: Low – 318 (60.3%) Medium – 191 (36.2%) The remaining 18 incidents were still to be graded. FIGURE 4 Incidents with a Major or Extreme Consequ ence

4

During Quarter 1, 4 incidents were graded with a consequence of major or extreme. By Locality:

- Mid Argyll & Kintyre – 2; - Cowal & Bute – 1; - Outwith NHS Highland – 1

Broken down into Category: - Grade 4 Pressure Ulcer developed in patient’s own home - Error in completion of referral letter - Medication Dispensing Error - Discharge Planning Each of these incidents has been reviewed and actions identified to address gaps. FIGURE 5: INCIDENTS BY LOCALITY WITH OUTCOME

2.1.2 Pressure Ulcer Prevention Implementation of NHS Highland Zero Tolerance approach to preventable pressure ulcers continues with a range of measures being taken to improve the identification and management of those patients at risk of developing pressure ulcers in all settings. The following tables indicate a downward trend in June 2012 in the numbers of pressure ulcers reported through Datix; monthly performance is being monitored across the CHP.


5

FIGURE 6 Number of Patients with Hospital Acquired Pressure Ulcers per Operational Unit in NHS Highland since June 2011

FIGURE 7 Number of Patients with Community Acquired Pressure Ulcers per Operational Unit in NHS Highland since June 2011

6

FIGURE 8 Monthly Rate of Pressure Ulcers acquired i n Hospital per 1000 OBDs in Argyll and Bute since April 2011

TABLE 1 Rate of Pressure Ulcers per 1000 Occupied B ed Days and Pressure Ulcer CQI Compliance Scores for each in patient ward fr om January 2012.

MONTH JAN FEB MARCH APRIL MAY JUNE JULY Rate

per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI Rate

COWAL AND BUTE Victoria Hospital 6 90 0 85 0 - 6 92 0 95 0 100 95 CCH Ward 1 0 - 0 - 0 - 0 100 0 100 0 CCH Ward 2 3 - 0 - 4 - 0 100 6 100 0

100

97.5

MID ARGYLL, KINTYRE AND ISLAY Glenaray 0 57 0 97 25 100 5 97 4 95 0 100 95 Glassary 0 95 0 95 0 100 0 100 0 100 0 Cara 0 95 0 95 0 100 0 100 0 100 0 Knapdale 0 95 0 95 0 100 0 100 0 100 0

100

100

Campbeltown 4 42 0 95 0 0 100 5 97.5 2 95 100 Islay 0 - 5 - 10 100 0 95 0 100 0 90 85 OBAN, LORN AND ISLES Ward A 0 73 0 90 0 100 0 95 0 100 0 90 100 Ward B 0 93 0 95 0 100 0 95 3 95 0 95 97 Ward I 2 52 2 100 6 100 0 100 0 100 2 100 100 Dunaros 0 86 7 47.5 0 75 7 - 0 93 0 100 nr

2.1.3 Falls Prevention As with Pressure Ulcer prevention, all departments are working hard to reduce the risks and the numbers of falls in healthcare settings. The graph below illustrates an overall downward trend across NHS Highland.


7

FIGURE 9 Monthly Rate of Falls with Harm per 1000 O BDs in NHS Highland since January 2011

FIGURE 10 Number of Patient Falls with Harm per Ope rational Unit for First

Quarter 2012-2013

Although the above figures illustrate the rate of falls with harm (this is thought to be a more reliable indicator) it is noted that the overall number of falls in Rothesay Victoria Hospital overall is higher than in other units; this, in spite of actions that have been taken to minimise risk to individual patients. The layout and environment within this old hospital may be a

Overall consequence of all patient falls with harm for NHS Highland: Insignificant – 49 (28.32%) Minor – 75 (43.35%) Moderate – 11 (6.34%) Major – 1 (0.57%) Extreme -0 The rest remain ungraded. There were 7 patients reported as sustaining a fracture: Argyll & Bute – 2 hip fractures North & West – 3 hip fractures, 1 shoulder fracture South & Mid – 1 hip fracture, 1 wrist fracture

8

contributory factor; further assessment will be carried out to identify potential solutions to further reduce the risk to patients.

TABLE 2 Rate of Falls with Harm per 1000 Occupied B ed Days and Falls

Prevention CQI Compliance Scores for each in patien t ward from January 2012.

MONTH JAN FEB MARCH APRIL MAY JUNE JULY Rate

per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI %

Rate per 1000 OBDs

CQI Rate

COWAL AND BUTE Victoria Hospital 7 84 4 93 13 - 12 90 0 93 2.97 100 98 CCH Ward 1 8 0 0 14 98 0 95 0 CCH Ward 2 3 7 0 0 98 0 95 3.22

100

100

MID ARGYLL, KINTYRE AND ISLAY Glenaray 8 97 0 100 0 100 8 100 0 97 4.10 100 100 Glassary 14 6 6 100 14 100 6 100 6.67 Cara 0 4 0 100 0 100 0 100 0 Knapdale 0 3 0 100 0 100 8 100 0

100

100

Campbeltown 2 98 6 0 97 4 96 3 97 2.80 nr 96 Islay 0 100 0 100 0 95 4 95 0 95 0 95 83 OBAN, LORN AND ISLES Ward A 0 95 0 100 14 100 0 100 0 100 6.67 96 100 Ward B 0 80 5 100 0 96 0 96 0 100 0 97 100 Ward I 7 95 6 100 8 100 3 100 4 100 2.43 100 100 Dunaros 0 95 7 100 0 100 0 - 14 100 0 96 96

FIGURE 11 RIDDOR Reportable Incidents

There was 1 RIDDOR reportable incident reported in Quarter 1 of 2012/13 which was related to staff injury when moving and handling a patient


9

2.2 Significant Event Reviews 2.2.1 Healthcare Improvement Scotland: The Management of Significant Adverse

Events in NHS Ayrshire and Arran June 2012 Argyll and Bute CHP has a robust system in place for identifying, conducting, reviewing and monitoring Significant Event Reviews. An exercise is underway to compare performance in Argyll and Bute CHP / NHS Highland with the recommendations contained in the report commissioned by the Cabinet Secretary for Health so that lessons can be learned and improvements made. 2.2.2 Health care Improvement Scotland: Suicide Reporting System Skills Development

Short Life Working Group Fiona Campbell, Clinical Governance Manager is part of a national short life working group. There are 3 objectives:

1. Agree the knowledge areas most in need of support and development (e.g. how recommendations and actions are implemented/governance framework/involving families and carers/the purpose and expectations of a review, etc). 2. Agree the skills which would most benefit from support and development (e.g. investigation skills/interviewing colleagues/objective analysis/making SMARTER recommendations/MDT communication, etc). 3. Agree an approach to supporting NHS boards develop and implement skills and knowledge required to carry out an effective review (e.g. online toolkit with resources and guidance/training pack with practical examples, facilitated seminars, etc).

The work of the group is due to complete at the end of September 2012. 3 COMPLAINTS TABLE 3 Argyll and Bute Complaint Performance repo rt

Target Amber Red April 12

May 12

June 12

Number of complaints received 4 5 ~ 6

7 and over 5 4 7

Achievement against 20 day 80% 70 - 79%

Under 69% 20% 25% 29%

Number of complaints over 40 working days old * 0 ~ 1 or more 0 2 2 Number of further correspondence over 20 working days old * 0 ~ 1 or more 0 0 1 Number of complaints categorised as high risk 1 2

3 and over 1 0 1

10

4. HEALTH AND SAFETY and FIRE SAFETY 4.1 Expectant Mothers Risk Assessment Following on from the work which has been undertaken on general risk assessments the Health and Safety team identified that there was a need for a specific assessment in relation to new and expectant mothers. To meet this need a specific risk assessment form has been developed, this facilitates the assessment process by identifying those hazards that are a particular risk to this staff group. It is a requirement of the Management of Health and Safety at Work Regulations that the risks to new and expectant mothers are assessed once the employer is notified of the pregnancy. It is expected that the form will be adopted across NHS Highland in due course. 4.2 Mull PCC Health and Safety Manager and Risk Advisor, Fire Safety are continuing to provide advice and support to the building of the new Mull PCC. 4.3 Argyll and Bute Hospital Risk Assessment A review of the risks associated with the continued use of the Argyll and Bute Hospital is underway. The main topic areas included in the review are: Health and Safety, including points of ligature; fire safety; fabric of the building; infection control and the quality of the environment. A paper is being developed and will be presented to the Core Management Team in August 4.4 3i Fire Risk Assessments Fire risk assessments using the 3i system continue to progress. Risk assessments have been completed and issued to duty holders in Garelochhead; Kilcreggan; and Campbeltown. These include a covering document, a full risk assessment, an action plan, a list of significant findings, plans and a photographic reference sheet. Islay assessment is planned and will take place in August 2012. 4.5 Fire Safety Training Some 579 Argyll and Bute CHP employees have completed the Learnpro Fire Safety e-learning package. In addition 135 staff in high risk areas (mainly sleeping areas /ward staff) have received face to face training. 5. QUALITY 5.2 Scottish Patient Safety The latest dashboard report for Lorn and Islands Hospital, Oban is included in Appendix One. Focus on Medicines Management, especially INR, continues to address areas where there has not been improvement in process and outcome.


11

APPENDIX ONE

Argyll & Bute CHP Committee Date of Meeting: 29 August 2012

Item No: 7.2

INFECTION CONTROL REPORT Report by Pat Tyrrell, Lead Nurse The CHP Committee is asked to: • Note the contents of the report.

1 Aim The purpose of this paper is to update CHP Committee members of the current status of Healthcare Associated Infections (HAI) and infection control measures in Argyll and Bute CHP and NHS Highland.

2 Background In line with the NHS Scotland HAI Action Plan 2008, there is a requirement for a HAI report to be presented to the Board on a two monthly basis. 3 Scaling factor used in reporting incidence rates To ensure consistency with wider UK and ECDC reporting, and in light of decreases in the observed rates, Health Protection Scotland have changed the scaling factor used in reporting incidence rates to ‘per 100 000 bed days’ instead of the previously used ‘per 1000 bed days’. It should be noted that NHS Highland figures for Staphylococcus aureus bacteraemia (SAB) and Clostridium difficile are provisional until validated by HPS on a quarterly basis. 4 Summary This report provides an overview for the Board of Infection Prevention and Control with particular reference to the incidence of Healthcare Associated Infections (HAI) against Scottish Government HEAT targets, together with results from cleanliness monitoring, hand hygiene audit results and surgical site infections. Staphylococcus aureus bacteraemia (SAB)

HEAT Target 26 per 100,000 bed days, (0.26 per 1,000 bed days). NHS Highland rate April – June 2012 is 21.7 per 100,000 bed days, (0.217 per 1,000 bed days).

Clostridium difficile

HEAT Target 39 per 100,000 bed days, (0.39 per 1,000 OBDs). NHS Highland rate April – June 2012 is 40 per 100,000 total occupied bed days, (0.40 per 1,000 OBDs) in patients age 65 and over.

Hand Hygiene

National Compliance 95%. Compliance with hand hygiene 97% in May and June 2012.

Cleaning and the Healthcare National Compliance 90% and above.

2

Environment

Cleaning Compliance 95% in May and 92% in June 2012. Estates Monitoring Compliance 96% in May and 95% in June 2012.

HEI Inspections Lorn & Islands - 1 requirement and 4 recommendations. Belford - 1 requirement and 5 recommendations. MacKinnon Memorial - 1 requirement and 3 recommendations. Raigmore Hospital – 9 requirements and 2 recommendations

Significant HAI incidents / outbreaks, emerging threats

In June 2012, a source of meropenem resistant pseudomonas was linked to the Intensive Care Unit, Raigmore Hospital which was temporarily relocated to allow a thorough and rapid cleaning process. There were Norovirus outbreaks in Raigmore and Caithness General Hospitals and two NHS Care Homes in May 2012.

Antimicrobial Prescribing National Indicators

Hospital based empirical prescribing - non compliant. Surgical prophylaxis – compliant. Primary care empirical prescribing – compliant.

Surgical site infections (SSIs)

There has been an increase in post discharge Caesarean Section SSIs January 2012 - March 2012 above the 95% confidence limit with a rate of 6.8% (10 infections from 146 procedures). Inpatient infections were nil during this time period. Orthopaedic surgical site infection rates remain low, and within anticipated levels. Work is ongoing with the colorectal surgeons to reduce the SSI rate in elective patients. There were no elective SSIs in May 2012.

Decontamination The Central Decontamination Unit has been awarded ISO 13485:2003 accreditation for another year. A planned preventative maintenance programme is in place for the washer disinfectors which are beyond their life expectancy. A programme of audit of all General Dental Practitioner contractor decontamination units will be complete by the end of September 2012.

4 Contribution to Board Objectives

3

Our key objective is “to reduce to an absolute minimum the chance of acquiring an infection whilst receiving healthcare and to ensure our hospitals are clean”. This report presents a comprehensive view of HAI data and activities for scrutiny and feedback from the Board. 5 Governance Implications 5.1 Staff Governance

As additional information is distributed more widely it should ensure staff are better informed in respect of current issues relating to Infection Prevention & Control and the management of HAI in our healthcare premises - “Infection Prevention is Everybody’s Business”.

5.2 Patient and Public Involvement

The distribution of regular information to the patient/public sector should increase awareness and facilitate increased participation of patient/public representatives in the Infection Prevention & Control agenda.

5.3 Clinical Governance

By improving infection prevention & control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI.

5.4 Financial Impact

By reducing the incidence of HAI in our healthcare premises, financial savings can be achieved through lower rates of infection.

5.5 Better Health, Better Care, Better Value

By improving infection prevention & control practices, we will endeavour to provide a healthcare environment for patients that minimises the risk of HAI.

6 Risk Assessment By risk assessing infection prevention & control practices, we will endeavour to minimise the risk of HAI. 7 Planning for Fairness As Infection Control policies are updated they are impact-assessed for equality and diversity. 8 Communications and Engagement Work is ongoing around raising awareness with staff to make sure they consistently apply the principles of Standard Infection Control Precautions. Hand hygiene is the single most important procedure for preventing cross infection, as hands are of special significance in the transmission of infections. All Health Boards are required to demonstrate, every two months, a minimum of 95% compliance with the five moments and technique for hand hygiene. A Hand hygiene module is now available online. The module is mandatory for all staff. There are two public representatives on Argyll and Bute CHP Infection Control Group. In addition regular Infection Control reports are presented to the PPF at CHP and locality levels.

4

Argyll and Bute CHP Healthcare Associated Infection Report –

August 2012

Section 1 – NHS Highland Board Wide and Argyll and Bute Issues

Staphylococcus aureus (including MRSA)

Current HEAT status

With effect from April 2011, all Boards are expected to achieve a rate of 26 Staphylococcus aureus bacteraemia (SAB) cases per 100,00 bed days (0.26 per 1000 acute occupied bed days) or lower by year ending March 2013. For NHS Highland that means no more than 73 cases. April – June 2012, there were 14 Staphylococcus aureus bacteraemia cases, a rate of 21.7 per 100,000 acute occupied bed days, (0.217 per 1,000 acute occupied bed days) FIGURE 1: YEAR ON YEAR CUMULATIVE SAB NUMBERS IN NH S HIGHLAND

Staphylococcus aureus is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. The most common form of this is Meticillin Sensitive Staphylococcus Aureus (MSSA), but the more well known is MRSA (Meticillin Resistant Staphylococcus Aureus), which is a specific type of the organism which is resistant to certain antibiotics and is therefore more difficult to treat. More information on these organisms can be found at:

Staphylococcus aureus :

http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346

MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252

NHS Boards carry out surveillance of Staphylococcus aureus blood stream infections, known as bacteraemias. These are a serious form of infection and there is a national target to reduce them. The number of patients with MSSA and MRSA bacteraemias for the Board can be found at the end of Section 1 and for each hospital in Section 2. Information on the national surveillance programme for Staphylococcus aureus bacteraemias can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/publicationsdetail.aspx?id=30248

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National Context National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia rate January – March 2012 was 29.2 per 100,000 acute occupied bed days (AOBDs) (0.292 per 1,000 AOBDs). NHS Highland rate was 23.3 per 100,000 AOBDs (0.233 per 1,000 AOBDs). FIGURE 2: FUNNEL PLOT OF STAPHYLOCOCCUS AUREUS BACTERAEMIA RATES

FOR ALL NHS BOARDS IN SCOTLAND AGAINST ACUTE OCCUPI ED BED DAYS (X100, 000), JANUARY – MARCH 2012.

HG = NHS Highland Initiatives to reduce SAB Infections The Board has seen a recent increase in the number of SAB infections in comparison to last year’s figures. There appears to be no single cause and confidence remains high at this point that the target will be met. Each SAB is reviewed in microbiology and, if it is felt that the SAB could have been avoided or prevented, then a clinical review meeting is held with the relevant clinical team who are responsible for ensuring that learning outcomes are disseminated to staff and that processes are in place to monitor practice. A renewed focus is being planned on aseptic technique and peripheral vascular cannula (PVC) management. MRSA Screening The roll out process across acute hospitals and community hospitals is complete. NHS Boards are required to ensure MRSA screening becomes part of their local integrated approach to improving the quality of person centred, safe and effective patient care. All Boards have now received the final tranche of funding to ensure that NHS Scotland minimum MRSA screening policy is fully embedded as a business as usual function by the end of March 2013.

6

TABLE 1 shows the cumulative totals for SAB within Argyll and Bute CHP for the years since 2009-2010: Hospitals 09/10 10/11 11/12 12/13 Lorn and Islands, Oban 8 3 0 4 Victoria Hospital, Rothesay 1 1 0 0 Mid Argyll Hospital, Lochgilphead 0 1 0 0 Argyll & Bute Hospital, Lochgilphead 0 0 0 0 Campbeltown Hospital 0 0 0 0 Dunaros, Mull 0 0 0 0 Islay Hospital, Bowmore 0 0 0 0 Cowal Community Hospital, Dunoon 0 0 0 0 There has been an increase in the number of SAB cases in Lorn and Islands Hospitals in 2012-2013. All of these cases appear to have been community acquired, two of which may have been healthcare associated. . Each case has been subject to microbiology review; there does not appear to have been anything to have prevented these cases. Clostridium difficile

Clostridium difficile Infection (CDI) With effect from April 2011, all Boards are expected to achieve a rate of 39 cases of Clostridium difficile per 100,000 total occupied bed days (OCBDs), (0.39 cases per 1000 total occupied bed days) or lower among patients aged 65 and over by year ending March 2013. For NHS Highland that means no more than 86 cases. April – June 2012, NHS Highland Clostridium difficile rate was 40 cases per 100,000 total occupied bed days, (0.40 per 1,000 OBDs) (21 cases) in patients age 65 and over. April – June 2012, NHS Highland Clostridium difficile rate was 30 cases per 100,000 total occupied bed days, (0.30 per 1,000 OBDs) (20 cases) in patients aged 15 – 64. There is no national HEAT target for this age group. National Context National data published by Health Protection Scotland identifies that the overall Clostridium difficile infection (CDI) rate for NHS Scotland during the period January – March 2012 in patients aged 65 and over was 27.5 cases per 100,000 total occupied bed days (OBDs) (0.275 per 1,000 OBDs). NHS Highland’s rate for the same period was 44 cases per 100,000 OCBDs, (0.44 per 1,000OBDs).

Clostridium difficile is an organism which is responsible for a large number of healthcare associated infections, although it can also cause infections in people who have not had any recent contact with the healthcare system. More information can be found at:

http://www.nhs.uk/conditions/Clostridium-difficile/Pages/Introduction.aspx

NHS Boards carry out surveillance of Clostridium difficile infections (CDI), and there is a national target to reduce these. The number of patients with CDI for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on the national surveillance programme for Clostridium difficile infections can be found at:

http://www.hps.scot.nhs.uk/haiic/sshaip/ssdetail.aspx?id=277

7

The overall Clostridium difficile infection (CDI) rate for Scotland during the period January – March 2012 in patients aged 15 – 64 was 37.8 cases per 100,000 total occupied beds days (OBDs) (0.378 per 1,000 OBDs). NHS Highland’s rate for the same period was 40.5 cases per 1000 OBDs (0.405 per 1,000 OBDs). FIGURE 3: FUNNEL PLOT OF CDI INCIDENCE RATES IN PA TIENTS AGED 65 AND

OVER FOR ALL NHS BOARDS IN SCOTLAND, JANUARY – MARC H 2012.

FIGURE 4: FUNNEL PLOT OF CDI INCIDENCE RATES IN PA TIENTS AGED 15 – 64

YEARS FOR ALL NHS BOARDS IN SCOTLAND JANUARY – MARC H 2012.

HG = NHS Highland

8

FIGURE 5: CLOSTRIDIUM DIFFICILE TOXIN POSITIVE EPISODES IN NHS HIGHLAND IN PATIENTS AGED 65 AND OVER.

FIGURE 6: NHS HIGHLAND CUMULATIVE CLOSTRIDIUM DIF FICILE TOXIN POSITIVE

EPISODES ALL AGES. NHS Highland is currently reporting a higher Clostridium difficile rate than the HEAT target. The following initiatives are in place to bring down the rates in line with national target. Initiatives to reduce CDI Cases • Continued promotion of good hand hygiene across all staff groups and general public

including the introduction of new mandatory, on line training module for multidisciplinary staff.

• Promoting prudent antimicrobial prescribing message to all prescribers in NHS Highland. • A plan to reduce Proton Pump Inhibitor (PPI) prescribing. • A plan for fabric maintenance. • A plan to increase the availability of single rooms in order to isolate all infected cases. • Attention to environmental cleanliness. • A plan to employ Hydrogen peroxide vapour fogging to eliminate environmental

contamination. To further increase the reduction of Clostridium difficile infections, Raigmore is testing a different approach to the control of infection at ward level. Exemplar wards are being developed where staff will be training in advanced infection control techniques, and where advanced monitoring of standards is undertaken by the Senior Charge Nurse with the support of the Infection Control Team. The fabric of these wards will be updated to ensure

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that where possible it is microbiologically cleanable. In addition to this Hydrogen Peroxide “fogging” will be used as an evidence based additional precaution to further increase the reduction of background environmental contamination from, for example Clostridium difficile spores. Raigmore will begin this new “exemplar ward” approach on one ward to begin with (Ward 4C) to test the effectiveness of this approach. Preparations have begun and it is expected that the whole process will be implemented within 6 weeks, and then evaluated. Enhanced surveillance is carried out on every CDI case with immediate feedback to staff concerned. Surveillance includes 30-day follow up from diagnosis TABLE 2 shows the cumulative CD Toxin Positive Case s in each CHP Hospital for the years since 2009-2012

Hospitals 09/10 10/11 11/12 12/13

Lorn and Islands Hospital, Oban 0 1 2 1

Cowal Community Hospital, Dunoon 3 1 2 1

Victoria Hospital, Rothesay 3 0 1 0

Dunaros, Mull 0 1 0 0

Argyll & Bute Hospital, Lochgilphead 0 0 0 0

Mid Argyll Hospital, Lochgilphead 0 0 1 0

Campbeltown Hospital 0 0 1 1

Islay Hospital, Bowmore 0 0 0 0 TABLE 3 shows the cumulative CD Toxin Positive Case s in community for the years since 2009-2012

09/10 10/11 11/12 12/13

North CHP 10 1 5 1

Mid CHP 16 14 6 5

South East CHP 19 11 12 4

Argyll & Bute CHP 2 4 2 1 Anti Microbial Prescribing Table 4 shows NHS Highland progress against the 3 n ational indicators Antimicrobial Indicator NHS Highland progress

Hospital-based empirical prescribing In acute admission areas, antibiotic prescriptions are compliant with the local antimicrobial policy and the rationale for treatment is recorded in the clinical case note in above 95% of sampled cases.

Non-compliant Two areas are monitored, as required, in Raigmore Hospital. Median compliance with antibiotic prescribing guidelines, based on data from April 2011 to May 2012, has fallen from 96% to 94.5% for the Acute Medical Admissions Unit and remains at 91% for Surgical Admissions Ward (4A).

10

Insufficient documentation of the reasons for varying from guideline recommendations is the main issue behind this fall in results. Recent feed back to clinical teams has focussed on improving this particular issue.

Surgical antibiotic prophylaxis Duration of surgical antibiotic prophylaxis is less than 24 hours and compliant with local antimicrobial prescribing policy in above 95% of sampled elective colorectal surgical cases.

Compliant. Data to the end of March 2012 shows continuing compliance above 95% with antibiotic choice and duration of prophylaxis.

Primary care empirical prescribing Seasonal variation in Quinolone use (summer months vs. winter months) is less than 5%.

Compliant. Data to the end of March 2012 indicates continuing compliance with this measure. For NHS Highland, prescribers used 1.9% less Quinolone during the winter months, compared to the previous summer months.

Antimicrobial Prescribing Guidance (Management of Infection Guidance) The current section on treatment of genital tract infections has been updated and is in line with shared clinical guidelines from Highland Sexual Health department. The new gentamicin policy has been rolled out to all clinical areas. Specific advice on additional antibiotic doses during prolonged surgical procedures has been developed and agreed. Advice on Improving Antibiotic Prescribing In the latest edition of The Pink One, prescribers are being encouraged to avoid using low doses of antibiotics in adults when treating active infections, as highlighted by audits in primary care. The use of low doses can lead to treatment failure and the development of resistant organisms. The first-line antibiotic for treating caesarean section post-operative wounds in the community has changed, following a review of microbiological information on recent infections. This information has been shared with primary care prescribers via The Pink One and the community midwifery service. National Prescribing Indicators for Primary Care 2012 Of the ten recently published indicators, two relate to antibiotic prescribing aimed at reducing total antibiotic use and reducing use of antibiotics which are associated with higher risk of infection with Clostridium difficile. Work on these indicators will be taken forward by the primary care pharmacist advisors in conjunction with GP practices and support from the Antimicrobial Management Team. Use of Proton Pump Inhibitors (PPIs)

The use of PPIs has been clearly identified with increasing the potential of acquiring Clostridium difficile. Advice on avoiding unnecessary proton pump inhibitor use and restricting the use of broad spectrum antibiotics to patients with severe infection has been issued following the recent Clostridium difficile outbreak. This was done in conjunction with good practice points to review antibiotic prescriptions regularly and stop promptly. Through the Formulary sub group, a short life working group has been convened to review the use of PPI in hospital and primary care.

11

Hand Hygiene

NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining an average of 97 % compliance. The National Hand Hygiene Audit Report for the period 21/05/2012 – 01/06/2012 showed that NHS Scotland compliance rate was 96%; NHS Highland’s rate was 99%. The Argyll and Bute Hand Hygiene audit results are included in Appendix One for each hospital. Non compliance with hand hygiene requirements is unacceptable and all staff must comply with the NHS Highland Hand Hygiene Policy. Hand hygiene audits are undertaken each month by all clinical areas and the results are displayed within the clinical areas. The expected pass rate is 95% and above for compliance and technique. Compliance which drops below 90% is deemed unacceptable but does occur. Staff groups are identified, the reason for failure closely examined and the area is subject to frequent audit until improvement is maintained. Hand Hygiene training Hand hygiene training is available via E-learning on LearnPro NHS. The module is mandatory for all staff with a revalidation/refresher period of 3 years. In addition to undertaking the module, staff are required to demonstrate in their work place that they are able to carry out the procedure to a high standard. Cleaning and the Healthcare Environment

Domestic Service teams continue to carry out monthly cleaning and estates audits. The compliance rates for Argyll and Bute Hospitals are included in Appendix One.

Good hand hygiene by staff, patients and visitors is a key way to prevent the spread of infections. More information on the importance of good hand hygiene can be found at:

http://www.washyourhandsofthem.com/

NHS Boards monitor hand hygiene and ensure a zero tolerance approach to non compliance. The hand hygiene compliance score for the Board can be found at the end of section 1 and for each hospital and community hospitals within each CHP in section 2. Information on national hand hygiene monitoring can be found at:

http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx

Keeping the healthcare environment clean is essential to prevent the spread of infections. NHS Boards monitor the cleanliness of hospitals and there is a national target to maintain compliance with standards above 90%. The cleaning compliance score for the Board can be found at the end of Section 1 and for each hospital and community hospitals within each CHP in Section 2. Information on national cleanliness compliance monitoring can be found at:

http://www.hfs.scot.nhs.uk/online-services/publications/hai/

Healthcare environment standards are also independently inspected by the Healthcare Environment Inspectorate. More details can be found at:

http://www.nhshealthquality.org/nhsqis/6710.140.1366.html

12

Table 5 National Cleaning and Estates Compliance Ja nuary – March 2012

Cleaning Compliance Estates Compliance

NHS Scotland 95% NHS Scotland 95.9%

NHS Highland 94.7% NHS Highland 96.1%

Outbreaks/Incidents No outbreaks during this reporting period. Decontamination All of the completed NHS Highland Local Decontamination Units comply with the Glennie Technical requirements; work is ongoing to make all sites within Argyll & Bute compliant. Clarification has been sought from the Chief Dental Officer as to what sanctions should be applied if there is non compliance in General Dental Practices. A programme of audit of all GDP contractor sites, led by the Head of Decontamination Services will be complete by the end of September 2012. This will enable a more robust assessment of risk to be undertaken. The Endoscopy Decontamination Steering Group is working on a proposal of how to provide compliant decontamination facilities for all sites where endoscopy is carried out.

13

Healthcare Associated Infection Reporting Template (HAIRT) Section 2 – Healthcare Associated Infection Report Cards

The following section is a series of ‘Report Cards’ which provide information on the number of cases of Staphylococcus aureus blood stream infections (also broken down into MSSA and MRSA) and Clostridium difficile infections. Hand hygiene and cleaning compliance completes the report card. This includes information for pan Highland, Lorn and Islands Hospital, Oban, Community Hospitals collectively for Argyll and Bute and NHS Highland out of hospital infections. The information in the report cards is provisional local data, and may differ from the national surveillance reports carried out by Health Protection Scotland and Health Facilities Scotland. The national reports are official statistics which undergo rigorous validation, which means final national figures may differ from those reported here. However, these reports aim to provide more detailed and up-to-date information on HAI activities at local level than is possible to provide through the national statistics. Understanding the Report Cards – Infection Case Num bers Clostridium difficile infections (CDI) and Staphylococcus aureus bacteraemia (SAB) cases are presented for each hospital, broken down by month and the community hospitals within each CHP. Staphylococcus aureus bacteraemia (SAB) cases are further broken down into Meticillin Sensitive Staphylococcus aureus (MSSA) and Meticillin Resistant Staphylococcus aureus (MRSA). Data is presented as both a graph and a table giving case numbers. More information on these organisms can be found on the NHS24 website: Clostridium difficile : http://www.nhs24.com/content/default.asp?page=s5_4& articleID=2139&sectionID=1 Staphylococcus aureus : http://www.nhs24.com/content/default.asp?page=s5_4&articleID=346 MRSA: http://www.nhs24.com/content/default.asp?page=s5_4&articleID=252&sectionID=1 For each acute hospital and community hospitals in each CHP, the total cases for each month are those which have been reported as positive from a laboratory report on samples taken more than 48 hours after admission. For the purposes of these reports, positive samples taken from patients within 48 hours of admission will be considered to be confirmation that the infection was contracted prior to hospital admission and will be shown in the “out-of-hospital” report card. Understanding the Report Cards – Hand Hygiene Compl iance Good hand hygiene is crucial for infection prevention and control. More information can be found from the Health Protection Scotland’s national hand hygiene campaign website: http://www.washyourhandsofthem.com/ Hospitals carry out regular audits of how well their staff are complying with hand hygiene. The first page of each hospital/CHP report card presents the percentage of hand hygiene compliance for all staff in both graph and table form.

14

Understanding the Report Cards – Cleaning Complianc e Hospitals strive to keep the care environment as clean as possible. This is monitored through cleaning compliance audits. More information on how hospitals carry out these audits can be found on the Health Facilities Scotland website: http://www.hfs.scot.nhs.uk/online-services/publications/hai/ The Report Cards show the hospitals’ cleaning compliance percentage in both graph and table form.


Item No: 7.2

Lorn & Islands Hospital Total Staphylococcus aureus Bacteraemia Cases (all ages)

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12 Jun-12

0 0 0 0 0 0 0 0 0 0 0 0 Hand Hygiene Monitoring Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

91 95 98 95 96 98 96 100 99 99 99 100 MRSA Bacteraemia Cases (all ages)

Cleaning Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

95 92 94 96 97 96 97 97 96 95 96 93

Estates Monitoring Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

95 96 93 95 93 95 94 95 94 93 95 93

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12 May-12

Jun-12

0 0 0 0 0 0 0 0 0 0 0 0

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Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12 May-12

Jun-12

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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Argyll & Bute CHP Community Hospitals

Total Staphylococcus aureus Bacteraemia Cases (all ages)

Argyll & Bute Community Hospitals include Argyll & Bute Hospital, Lochgilphead, Campbeltown Hospital, Cowal Community Hospital Dunoon, Dunaros Community Hospital, Isle of Mull, Islay Hospital, Mid Argyll Community Hospital & Integrated Care Centre Lochgilphead, Victoria Hospital & Annex Rothesay

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12 May-12

Jun-12

0 0 0 0 0 0 0 0 0 0 0 0 Hand Hygiene Monitoring Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

97 97 98 93 97 97 97 94 95 95 94 96 MRSA Bacteraemia Cases (all ages)

Cleaning Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

94 94 95 95 94 95 94 95 95 95 95 93

Estates Monitoring Compliance (%)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

95 96 94 95 96 97 95 96 94 97 96 96

Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May-12 Jun-

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11 11 11 11 11 11 12 12 12 12 12

0 0 0 0 0 0 0 0 0 0 0 0

Clostridium difficile Cases (ages 15 and over) MSSA Bacteraemia Cases (all ages)

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12 May-12

Jun-12

0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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Out of Hospital Infections Clostridium difficile Infection Cases

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

.

4 4 3 2 3 1 5 3 0 4 5 1

20

MSSA Bacteraemia Cases MRSA Bacteraemia Cases

Jul-11 Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12 Jul-11

Aug-11

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12

Jun-12

0 4 1 2 2 2 2 0 2 4 3 3 0 0 0 0 0 0 3 1 1 0 1 0


Item No: 7.2

Hospitals Dunoon

Hospital

Ward

one/ Tw

o

Rothesay

Victoria

Mid

Argyll

Hospital

Glenaray

knapdale

Cara

Glassary

Cam

pbeltow

n hosp

Islay H

ospital

Argyll

and Bute

Succoth

ICU

Tigh na

linnhe

Lorn and Islands

Ward A

Ward B

Ward I

Theatre

Dunaros

Mull

Compliance with Hand Hygiene Standards June 2012

100

100

95

95

90

90

100

90

100

100

100

100

100

100

100

July 2012

100

90

95

95

90

95

100

100

95

100

100

100

100

100

100

100

Compliance with Cleaning Standards June 2012

98.1

96.3

94.8

95.7

96.6

78.1

93.7

100

July 2012

N/R

91.9

96.8

98.2

91.2

97.4

98.2

100

CDI June 2012

July 2012

1

SAB June 2012

July 2012

1

Appendix One: Argyll and Bute CHP Hand Hygiene, Cleaning Standard s and HAI by Hospital and Ward August 2012

Appendix One: Argyll and Bute CHP Hand Hygiene, Cleaning Standard s and HAI by Hospital and Ward August 2012

22

Abbreviations

AMT Antimicrobial Prescribing Team

AMAU Acute Medical Admissions Unit

CHP Community Health Partnership

CDI Clostridium difficile Infection

CNO Chief Nursing Officer

CVC Central Venous Catheter

ECDC European Centre for Disease Prevention & Control

GDP General Dental Practitioner

HAI Healthcare Associated Infection

HAIRT Healthcare Associated Infection Reporting Template

HEAT Health Improvement, Efficiency, Access, Treatment

Hemi arthroplasty An operation used to treat fractured hip similar to a total hip replacement, but involves only half of the hip.

ICU Intensive Care Unit

JAG Joint Advisory Group

MSSA Meticillin Sensitive Staphylococcus Aureus

MRSA Meticillin Resistant Staphylococcus Aureus

PICC Peripherally Inserted Central Catheter

PPI Proton Pump Inhibitor

PVC Peripheral Venous Catheter

QUAD Quality Assurance Document

RIDDOR Reporting of Injuries, Diseases and Dangerous Occupational Regulations 1995

SAB Staphylococcus aureus Bacteraemia

SHPN Scottish Health Planning note

SHTM 64 Scottish Health Technical Memoranda – Sanitary assemblies.

SPC Statistical Process Chart

SAPG Scottish Antimicrobial Prescribing Group

SICPs Standard Infection Control Precautions

SPSP Scottish Patient Safety Programme

VAP Ventilator Associated Pneumonia

23

Staphylococcus Aureus Bacteraemia (SAB) criteria

Contaminated blood culture

• Staphylococcus aureus isolated from blood, and • SAB diagnosis incompatible with clinical picture, i.e. no or minimal

clinical signs and symptoms indicating SAB.

Hospital acquired infection

• Staphylococcus aureus isolated from blood cultures taken 48 hours after admission or within 48 hours of discharge, and,

• The presence of clinical signs and symptoms indicating SAB

Community onset-healthcare associated infection

• Staphylococcus aureus isolated from blood cultures taken <48 hours after admission, and

• The presence of clinical signs and symptoms indicating SAB, and • At least one of the following within the past 12 months:

o Hospitalisation or invasive device management as an outpatient / community patient, or dialysis as an outpatient / community patient.

True community infection

• Staphylococcus aureus isolated from blood, and • No hospitalisation within the past 12 months • No dialysis within the past 12 months • No community or outpatient healthcare for invasive device

management in the past 12 months

Argyll and Bute CHP Committee 29th August 2012

Item : 7.3 HEALTH IMPROVEMENT Elaine C Garman, Public Health Specialist The CHP Committee is asked to: • Note this paper

1 Background and Summary

This paper focuses on emergency planning arrangements within the CHP. 2 Emergency Planning Emergency planning comprises planning for major incidents, service continuity (estates issues) and business continuity. In addition there is a specific pandemic ‘flu plan. Each of NHS Highland’s operational units is required to have a suite of plans according to their needs. Argyll and Bute CHP has major incident and service continuity plans for the rural general hospital and each of the community hospitals, the Argyll & Bute Hospital (service continuity plan only) and any primary care premises that we own. MACCHIC’s service continuity plan is provided by the contractors for the building. Over the past year NHS Highland has also been developing its business continuity plans. One is in place for each of the four localities. In addition plans have to be drafted for each of the core services that have been given this designation by NHS Highland where the CHP delivers those services. These critical core services are: maternity services, cancer services, renal services, statutory mental health services, emergency medical services, emergency surgical services, urgent primary care medical services, emergency diagnostic services to support those already listed and payroll. GPs are encouraged to have business continuity plans and we are liaising with NHS GGC to ascertain that they too have business continuity plans for the services that we use. Plans however are limited in their effectiveness if they are not exercised. Each of the localities holds a table top exercise each year. Localities are also encouraged to use different geographical areas of their patch over time. We also take part in many of the multi-agency exercises that take place each year. Argyll and Bute Council is required to hold an exercise every three years for Faslane Submarine Base. ‘Short Sermon’, the exercise for this purpose is being held this year which key members of staff will attend. Argyll and Bute comes into the Strathclyde Emergencies Co-ordination Group (SECG) area. There is a specific Argyll and Bute Working Group which meets regularly and also convenes on specific topics when required. The SECG also provides training or liaises with Scottish Government Resilience Directorate to provide training. At the moment we are trying to target senior managers to attend strategic and tactical training events. 3 Current Issues A weakness with the major incident response is a lack of GPs identified as willing to provide a local response to a major incident in the area as Medical Incident Officers (MIOs). In the time of NHS Argyll and Clyde A&E in the RAH was provided with a further Consultant on the basis someone may have to travel to provide medical assessment of a major incident (not individual patient assessment and triage). When the Emergency Medical Retrieval Team was set up they elected to take that role. However with either of those scenarios there would be inevitable delay before such personnel arrived on scene. In 2009 the CHP asked every GP in

2

the area whether they would be willing to provide such a service with a flat fee, payment for call out, training and equipment provided. There was little or no interest at that time. It is thought that GPs might now be interested and a letter is currently being drafted to see whether this is the case. 4 Summary Much has progressed in emergency planning since the creation of the CHP in 2006. Plans are in place and are being exercised. Focus is currently on the business continuity plans. The situation regarding MIOs is again being tested to see if improvement of provision can be improved.

Elaine C Garman Public Health Specialist 20th August 2012

Argyll & Bute CHP Committee Date of meeting: 29 August 2012

Item No : 8.1

1

FINANCE REPORT REPORT BY GEORGE MORRISON The CHP Committee is asked to: • Note the financial position at month 4 1. Argyll & Bute CHP - Financial Position at Mont h 4 For the four months ended 31st July 2012, Argyll & Bute CHP recorded an overspend of £122,000. This represents a slight increase of £14,000 on the overspend of £108,000 recorded at the end of June. The main pressure continues to be unachieved savings. Targets have been applied to budgets across the CHP however declared savings to date have been limited, thereby creating budget overspends in several areas. Action needs to be taken by managers to identify and implement measures to reduce costs in line with agreed savings targets.

Table 1 below provides a summary of budgetary performance across Argyll & Bute CHP for the four months ended 31st July 2012.

Table 1 – Budget analysis for the 4 months ended 31 st July 2012 Year to Date

Budget Annual Budget Budget Actual Variance

Forecast Outturn

£000 £000 £000 £000 £000 Oban, Lorn & Isles Locality 17,575 5,854 6,061 (207) (500) Mid Argyll, Kintyre & Islay Locality 16,281 5,379 5,474 (95) (269) Mental Health In-Patient Services 7,789 2,437 2,391 46 50 Cowal & Bute Locality 12,507 4,150 4,246 (96) (230) Helensburgh & Lomond Locality 4,900 1,614 1,627 (13) 0 Other Clinical Services 4,962 1,260 1,243 17 (28) General Medical Services 15,120 4,943 4,958 (15) 0 Prescribing 18,109 5,903 5,599 304 250 Dental, Ophthalmic & Pharmacy 11,901 4,244 4,244 0 0 Services from NHS GG & C 47,075 15,525 15,525 0 0 Commissioned Services 3,871 1,311 1,332 (21) (158) Resource Transfer 4,538 1,513 1,513 0 0 Depreciation 3,388 1,129 1,092 37 100 Management & Corporate 7,272 2,328 2,418 (90) (193) Budget Reserves 2,481 0 0 0 243 Total Expenditure 177,769 57,590 57,723 (133) (735) Income (1,296) (489) (500) 11 (15) Planned Management Action - - - - 750 Net Budget Position 176,473 57,102 57,223 (122) 0

Specific attention is drawn to the entry of “Planned Management Action”. This entry is necessary to support a forecast year-end break-even position for the CHP. However it indicates that without action to address savings target shortfalls, it is likely that the CHP will overspend by £750k.


Item No : 8.1

2

In addition to unachieved savings, there are a number of cost pressures contributing to budget overspends. The most significant are; Oban, Lorn & Isles Locality Lorn & Islands Hospital – Medical pay costs overspent by £23k due to locum cover for vacancies. Lorn & Islands Hospital - Admin pay costs overspent by £14k due to ongoing bank use. Lorn & Islands Hospital - Drugs costs overspent by £15k due to increased costs for oncology and haematology drugs. Mid Argyll, Kintyre & Islay Locality Mid Argyll Hospital – Development of Lucentis treatment service. Cost for four months, £22k. Islay - Midwifery services continuing to run 1 wte over establishment. Cost for four months, £15k. Cowal & Bute Locality Cowal - Medical services pay costs overspent by £53k due to ongoing need to cover a hospital medical post plus locum cover for annual leave. Bute - Hospital and community nursing pay costs overspent by £63k due to ongoing use of bank staff. Commissioned Services Patient transfer from Rowanbank to New Craigs in Inverness. Chargeable at £276 per day resulting in an unfunded cost of £34k for the first four months. Loss of income from Argyll & Bute Council A&B Council has unilaterally withdrawn funding for a number of posts which have been in place since 2004. These posts were originally funded through the FUSIONS initiative. The loss of this income has an annual impact of £68k (£23k for the first four months). It affects budgets across three localities. To partly offset these cost pressures and unachieved savings, budget underspends have been recorded in a number of areas, notably; prescribing, change fund, mental health services and depreciation. These underspends have had the effect of restricting the CHPs position at month 4 to a net overspend of £122,000.

2. Cost Improvement Programme 2012/13

The CHP approved budget for 2012/13 contained a requirement to achieve savings of £5m. Several of these savings will arise naturally (e.g. prescribing drugs coming off patent, restricted uplift to SLA values etc) however a balance of £2.24m requires to be delivered through management action.


Item No : 8.1

3

Table 2 below identifies recurring targets by budget manager, sums declared achieved to date, forecast achievements based on current information, and likely shortfalls.

Table 2: Argyll & Bute CHP Cost Improvement Program me 2012/13

Recurring Savings Targets Responsible Manager

Target £ ' 000

Achieved £' 000

Outstanding £ '000

Forecast £ ’000

Shortfall £’ 000

Oban, Lorn & Isles V Kennedy 692 125 567 242 450 Mid Argyll, Kintyre & Islay C West 523 75 448 298 225 Cowal & Bute V Smith 435 161 274 350 85 Helensburgh & Lomond V Smith 154 87 67 90 64 Unfunded Displaced Staff D Leslie 138 0 138 80 58 Board Corporate Services D Leslie 77 0 77 0 77 Pharmacy F Thomson 38 38 0 38 0 E-Health J Brass 35 0 35 0 35 Lead Nurse P Tyrell 32 5 27 5 27 Public Health E Garman 30 30 0 30 0 Human Resources D Logue 28 0 28 0 28 Practitioner Services J Robinson 19 0 19 0 19 Finance G Morrison 18 10 8 18 0 Procurement G Morrison 11 0 11 0 11 Planning S Whiston 10 0 10 10 0

Totals 2,240 531 1,709 1,161 1,079 It is clear from Table 2 that, based on current information, there is likely to be a significant shortfall in excess of £1m against savings targets. This is not an affordable situation and managers are being encouraged to urgently review their plans to achieve cost savings. 3. Other Issues of Note i) Change Fund for Older Peoples Service The Change Fund budget for this financial year is £1.954m. After four months, only £290k of this allocation has been spent leaving £1.664m to be spent in the remaining eight months. Plans are in place to utilise most of the available funding and it is expected that further plans will be developed to utilise all of the available funding. It is unlikely that there will be any call on the £1m of funding banked from last year and this will therefore be carried forward into 2013/14. ii) e-Health Non-recurring Allocation from SGHD Argyll & Bute CHP has received a non-recurring allocation of £1.714m from SGHD for e-Health services. A plan has been developed by the CHPs e-Health Manager to fully utilise this funding. iii) Patients Services SLA with NHS Greater Glasgow & Clyde NHS Greater Glasgow & Clyde continue to claim that Argyll & Bute CHP is underpaying for in-patient, day care and out-patient services provided in Greater Glasgow & Clyde hospitals. The most recent iteration of their costing model identified a claimed underpayment of £5.762m. We are continuing to challenge many of the assumptions made by Greater Glasgow & Clyde in arriving at this figure and I have no doubt that negotiations on a settlement value for 2012/13 will continue for several more months. It is relevant to highlight this issue as a significant financial risk for the CHP and Board.


Item No : 8.1

4

4. Forecast Outturn for 2012/13 It is early in the financial year and scope clearly exists to implement measures to control expenditure and operate within budget to deliver a year-end break-even position. This is contingent on three main actions; - managers take early action to identify and implement measures to achieve savings. - managers exercise control over emerging cost pressures. - settlement of the patients services contract with NHS GG&C is agreed at an acceptable and affordable value. Table 1 highlights the need for management action to close a forecast of gap of £750k. Managers need to address this issue as a matter of urgency before too much of the financial year passes and the gap becomes irrecoverable. George Morrison Head of Finance Argyll & Bute CHP 17th August 2012


Item : 9.1

Page 1 of 7

MINUTE OF MEETING OF THE ARGYLL & BUTE CHP PARTNERSHIP FORUM

12 July 2012 Boardroom, Aros

Lochgilphead

Present Derek Leslie, CHP Director of Operations (Co-Chair) Dawn Gillies, Unison (Co-Chair) Liz McMillan, Unison (Co-Chair) Craig McNally, Unison Christina West, Locality Manager, MAKI Veronica Kennedy, Acting Locality Manager, OLI Betty Cowan, RCN Lorna Low, RCM (VC) Sally Munro, Workforce Development Facilitator (VC) Mavis Gilfillan, Clinical Services Manager (VC) Lorraine Patterson, Acting Locality Manager (by VC) Angela Dewsnap, Personnel Officer Fiona Campbell, Clinical Governance Manager (VC) Alastair Craig, Senior Management Accountant Apologies Pat Tyrrell, CHP Lead Nurse (by VC) Bill Staley, Information and Projects Manager John Dreghorn, Modernisation Project Director Moira Newiss, CHP Business Transformation David Logue, Head of HR Fiona Broderick, Admin Services Manager Helen Duthie, Unison Gaye Boyd, Personnel Manager In Attendance Anne Williamson – Unified Bank (VC) Marie MacKinnon – OOH HUB (VC) Jackie Dickson – secretariat Item

1. Chairman’s Welcome Derek Leslie chaired the meeting, welcomed all to the meeting, made introductions,


Item : 9.1

Page 2 of 7

noted apologies and passed on the Forum’s thanks to Rowena for her support during her time as secretariat. Unison reps. added their thanks.

2. Minute of Previous Meeting Previous minutes were approved as accurate.

3. Matters Arising

3.1 Cessation and Implementation of Long Shifts In Pat Tyrell’s absence the item was to be carried forward. Liz McMillan made the point that this item has been carried forward before and would like to see this finalised as apparently the guidance in this matter (thought to be “24 hour Rotational Nursing Policy Statement”) is not being adopted in all areas. Examples were cited; more than four shifts worked together, day to night shift in one week, staff being refused a move to 12hr shifts. Christina West made the point that to deliver appropriate patient care it is not always possible to strictly adhere to this guidance. Derek Leslie agreed that the guidance referred to and endorsed by this Forum when initially presented, should now be recirculated and implemented consistently across the CHP. Actions: Pat Tyrell to recirculate the appropriate guidance document Localities to implement consistently

PT Locality Managers

3.2 Matching Panels Criteria Gaye Boyd not in attendance, item carried forward Action: Gaye to re-convene sub group for discussion on above

GB

4. Finance Update

Alastair Craig spoke to the paper previously circulated. £86k over spend against budget at the end of May 2012 but £108k at end of June, so slowing down but work to be done on identifying and implementing efficiencies if we are to meet our savings target. Currently we are benefiting from reserves for work not/not yet commissioned. The Scottish Government is to transfer funding to Health Boards’ baseline allocations for patient travel costs (Highlands & Islands Travel Scheme – HITS). Currently this is uncapped i.e. it costs what it costs but that is changing and allocations will be capped. This offers both the potential risk of overspend but also opportunities in the form of reviewing arrangements currently in place e.g. when is it reasonable to fly, take a companion etc. This elicited discussion around the table and it was recognised that there are probably efficiencies to be made in this area, the use of telephone or VC consults were given as other examples but noted that this is a complex issue given the balance to be struck with patient wellbeing,


Item : 9.1

Page 3 of 7

Action: George Morrison to review current practice and take a paper to Core Team for further discussion

GM

5. Mental Health Redesign –Everyone’s Business Paper

The paper was handed out at the meeting; it will be circulated via the Forum distribution; please direct questions to John Dreghorn or Derek Leslie. Action: Derek Leslie to circulate paper

DLe

6. Nurse Bank Anne Williamson outlined the concerns raised by A&B localities via Pat Tyrell; Anne has replied to Pat and is happy for this response to be shared. The issues are the same as those experienced by other areas in the early implementation stages and should be resolved with good communication and familiarity gained through time. In the main there seems to be a lack of confidence in the Unified Bank; examples cited were issues like returning shifts late, local geography is not appreciated, bank staff reporting that they are not asked to take shifts etc. Derek Leslie asked for a copy of the A&B map being used as perhaps we can enhance this information with travelling times etc. As regards returning shifts late; A&B will provide a menu of required return times. A&B CHP had expected an online system whereby bank staff could sign up for shifts rather than the ringing round that currently happens first by the Unified Bank and then locally when a shift is returned unfilled by the Unified Bank. It was suggested to cut down on calls locally that Unified Bank provide details of who they have already contacted when returning shifts unfilled. Anne Williamson felt this would not be possible given call volumes; approx. 15,000 calls for 5,000 shifts in June 2012. Additionally no enhancements can be made to the existing system as a new system is to be put out to tender next year. Derek Leslie ascertained that Unified Bank is hosted in the former Mid CHP under Alison Hudson and will make representations regarding the benefits of an online system to be included in any tender. eKSF and the number of pay codes for bank staff was raised by Veronica Kennedy and Anne confirmed that the intention was to have one pay code for each bank staff member within 3 months; Brian Huston has a small group looking at this. Other issues for note from Anne are that not all staff being contacted locally to do shifts have returned their data protection form so are not known to the Unified Bank. These members of staff should be asked to contact the Unified Bank directly to resolve this. Also some staff have indicated on their forms that they are available to work all areas but if they have not worked areas before they must make contact locally to ensure it is OK for them to take a shift there. The matter of time sheets not being returned was discussed; it is recognised that this is the staff member’s responsibility irrespective of any local arrangements to submit these in bulk. Currently there are around 300 bank staff who have not submitted time sheets within the deadline for July payroll. There is a Staff Bank Operational Group and Veronica suggested that a


Item : 9.1

Page 4 of 7

representative from each locality should attend. Actions: Pat Tyrrell to circulate the response from Anne Williamson Locality Managers to agree timeframes for returned shifts Anne Williamson to provide Derek Leslie the A&B map & Veronica Kennedy with dates of scheduled Staff Bank Operational Group meetings Derek Leslie to contact the former Mid CHP regarding an online system Veronica Kennedy to raise the issue of locality reps. with Locality Managers

PT Locality Managers AW DLe VK

7. Highland Partnership Forum Derek Leslie outlined the agenda items; strategic board vision, quality objectives, quality improvement team, implementation plan, dignity at work, new staff governance standards. Action: Derek Leslie to circulate Wordle (slide with words describing NHS values. This emerged from a canvassing of views during a recent Scottish National Health Services conference. Each word has a different prominence) and new Staff Governance Standards

DLe

8. CFS DVD

The DVD was well received. The main message for managers is to contact the Fraud Liaison Officer (FLO) in Inverness first (Barbra Milne) rather than jump in. It was recognised that although an external investigation can run parallel to an internal investigation, Unison advice to staff members is not to participate in the formal interview part of the internal investigation lest this prejudice the external investigation. This, whilst understandable, may compromise our ability to conclude internal investigations in a timely fashion adhering to any set timeframes (as discussed at Partnership Development Day). Dawn Gillies made the point that this DVD should be accessible to all staff as it brings into focus what type of thing actually constitutes fraud because staff may not actually consider certain actions to be fraudulent. The example given was abuse of TOIL; additional hours not being properly accounted for or taken timeously etc.

Actions: Derek Leslie will request managers to provide him with the protocol for authorising, recording and the general management of toil hours within their areas of responsibility.

DLe


Item : 9.1

Page 5 of 7

David Logue to consider how best to disseminate to all staff

DLo

9. Workforce Planning and eKSF-HCSW eKSF Despite the work being undertaken to deal with the challenges around bank staff (multiple pay codes, availability etc.) there has been little or no improvement in our figures. Christina West reported that although in MAKI they had terminated a number of bank staff who had not worked in over 12 months that data still appears on eKSF lists. Sally Munro confirmed there is a delay in this filtering through to eKSF. Veronica Kennedy asked what had happened with the removal from the list of bank staff who only work a few hours. Sally Munro confirmed that these staff will still need one review at least. Craig McNally suggested that as a large chunk of reviews are due in the latter part of the year more could be done to encourage line managers to spread these throughout the year. Dawn Gillies made the point that some staff do not see the point of eKSF because they do not get the training courses they ask for. Christina West pointed out that paid courses are not always the best developmental route, on the job training can be more effective and LearnPro is another option to consider. Derek Leslie agreed and added that staff need feedback on why they have been refused courses and given alternatives. It is hoped that the Unified Bank’s intention to move to a single pay code for bank staff will significantly improve our position as substantive posts are actually on target. HCSW Sally Munro reported that although it is mandatory for all HCSW to adopt the Code of Conduct it has not been implemented rigorously; of 57 new starts only 23 completed the Code of Conduct and of those only 5 were completed within the set timeframe of 3 months. Workforce planning Sally Munro reported that the Terms of Reference for this group were revisited and a proposal will be put to the Core Team. Action: Christina West to add staff development options to the agenda for the Locality Managers meeting

CW

10. Staff Survey Sub Group

Information from the 2010 survey was used at the Partnership Development Day and an action plan will be brought to this Forum. Action: Sally Munro to bring action plan to Partnership Forum

SM

11. NMAHP, HCSW Policy and SVQ Implementation Plan


Item : 9.1

Page 6 of 7

Pat Tyrrell not in attendance, item carried forward

12. Organisational Change Update

12.1 Mental Health & Mid Argyll Minutes circulated and noted.

12.2 Lorn & Islands Hospital Minutes circulated and noted.

12.3 Bute Minutes circulated and noted.

12.4 Cowal Minutes circulated and noted.

12.5 Helensburgh & Lomond Minutes circulated and noted.

13. Partnership Development Day Well received, in particular the role reversal role plays. It was recommended that senior charge nurses and team leaders are provided with a similar opportunity. The Forum endorsed this idea. Derek Leslie will discuss the actions from the day with David Logue.

14 AOCB The Administration Review was discussed at Core Team and Derek Leslie will be disseminating the decision taken shortly. Whilst it is accepted by the Core Team that there needs to be development of flexible working, cross cover, generic job descriptions and equitable banding of posts across the administration roles, this is to be implemented on an iterative basis, by locality and will include both operational & corporate administration staff. A Lead will be appointed in each locality to take this forward. The disparity in banding for medical (band 4) and non-medical secretaries (band 3) was raised and it is hoped that this review will address this. Derek Leslie briefly discussed an animated video “23½ hours” shown at the recent NHS Scotland Event about a ‘miracle cure’. He will arrange for the video to be shown at the next Partnership Forum.

15. Date and Time of Next Meeting 23 August 2012, 12:30 Boardroom, Aros


Item No : 9.3

1

PDP/R AND e-KSF IMPLEMENTATION 2012/13 Report by David Logue, Head of Human Resources 1. BACKGROUND AND SUMMARY The Board of NHS Highland set 2 targets for 2012/13 :

• An interim target based on ‘pulling through’ reviews awaiting completion (as part of target for 2011/12 ) to ensure that 80% of all staff ( including fixed term and bank), to have a KSF Development Review and Personal Development Plan completed and recorded on e-KSF by the 30 June 2012 .

(As previously reported, this was not achieved, but action continues to complete missing data, and reviews are now reported within current year).

• ALL Agenda for Change staff will be reviewed against a KSF post outline, with at least 80% of reviews being carried out and recorded online using e-KSF (a review to be completed for each post held)

Details of the target definitions are shown in Appendix 1 . The inclusion of bank staff continues to pose a considerable challenge, many do not yet have an nhs.net e-mail address or an assigned manager and KSF outline for the post. Also there is a large proportion of bank staff with multiple contracts. Work to address these issues is continuing with the e-KSF team and managers to ensure that bank staff are engaged with and participate in the review process 2. TARGETS 2012/13 It has been agreed by the Staff Governance Committee and endorsed by the Improvement Committee that NHS Highland will continue to monitor progress against a local target for KSF, and this CHP Committee has clearly indicated that they will closely monitor performance. The trajectory for 2012/13 and a comparison with actual performance are shown in Appendix 2. Figures are currently below planned trajectory, which puts further pressure on the need to achieve these in the remaining months, and indicates that there is a serious challenge in achieving the end year target. 3. MONITORING PROGRESS The position across NHS Highland at 31 July 2012 is as follows:

The CHP Committee is asked to:

• Note the targets for 2012/13 • Note the current progress against trajectory • Note the actions being undertaken to monitor and ac hieve progress against

trajectory.


Item No : 9.3

2

(figures in brackets are those last reported to CHP Committee – 31 May 2012). Area All AfC

staff Review

signed off % of AfC staff

(all) % of AfC staff

(excl bank) Argyll and Bute CHP 2063 121(79) 5.87(3.84) 8.07(5.19) Corporate Services 397 59(35) 14.86(8.75) 16.32(9.02) Mid Highland 483 12(7) 2.48(1.43) 3.54(1.99) North Highland 986 34(12) 3.45(1.24) 4.83(1.69) Operational Support Services

305 12(8) 3.93(2.64) 4.01(2.68)

Raigmore Hospital 3145 67(38) 2.12(1.21) 2.67(1.50) South Highland 736 19(11) 2.58(1.54) 3.28(1.97) Note : Extract from e-KSF 31-07-12 The total percentage for NHS Highland is 3.87% ( 4 .91 % excl bank posts), to this extent therefore Argyll and Bute CHP is performing at a hi gher level than all other units in NHS Highland except NHS Highland Corporate Services. 4. ACTIONS FOR 2012/13 In order to improve performance, reviews should be more evenly spread throughout the year, with monthly targets closely monitored and remedial action taken if these are not achieved. There are still significant numbers of staff who do not have one or more of the following: named manager, e-mail address, no KSF outline or no review. Managers are being provided with updated lists highlighting where data is missing and these are being completed.

Specific actions being undertaken are:

• Concerted efforts in each locality/department to refer to lists to ensure that all staff have: e-mail address named manager KSF outline assigned.

This is particularly relevant for bank staff.

• Each locality/department to set out timetable when PDP reviews will be undertaken. Staff to be informed that this may be less than 12 months since the previous review.

• All managers who are reviewers have clear targets and timetable set in their own Review

and PDPs to carry out the reviews of their own direct reports.

• Close monitoring of monthly targets by each locality/department and reports provided to Director of Operations.

• E-KSF Lead meeting regularly with Locality Managers and Department Heads to discuss

and provide support to address issues in their area. 5. DEVELOPMENT BENEFITS OF KSF E-KSF can be used to support redesign and service improvement processes by using the KSF outlines to support staff in changing roles, and identifying differences in knowledge and skills required. The use of the KSF Foundation outline can ensure that staff are clear of what is expected in a new role following service change, redesign or redeployment, and ensure they receive the support they need in the first year in the post.


Item No : 9.3

3

The use of Foundation outlines for staff moving into new roles as part of service change/redesign ensures supported development into these roles leading to a more efficient and effective service. As KSF/e-KSF is used and staff become familiar with the systems, managers are reporting that they appreciate the value and benefits of having this mechanism to promote regular interaction and discussions on performance and development betw een managers and staff. Staff receiving regular development reviews and agreeing personal development plans will support quality, service improvement and clinical g overnance. 6. PDP ACTIVITY A new target is being proposed by the Scottish Gove rnment to monitor the actual activities completed following the PDP review. The level at 31st March 2012 will be taken as the baseline (this is approx 25%) This target is yet to be confirmed by Scottish Government and National KSF Project Team. This target is to ensure that activities planned in the PDP are actually completed. A ‘Short Guide’ will soon be issued to assist in this process. KSF and e-KSF contribute significantly to Board tar gets in particular as part of Staff Governance, Clinical Governance and Financial Impac t as outline below. 7 CONTRIBUTION TO BOARD OBJECTIVES The achievement of the target is in line with the NHS Highland Board objectives. 8 GOVERNANCE IMPLICATIONS Staff Governance KSF and e-KSF are vital components of meeting Staff Governance standards. Patient focus and public involvement The KSF process enables performance management to assist with improved patient focus and public involvement where appropriate for roles. Clinical Governance KSF process provides the opportunity to monitor development activities of staff including clinical skills and ensures that staff develop and apply the appropriate knowledge and skills in order to be effective in their work. Financial Governance This is part of normal management processes. In addition, workforce costs are a large proportion of the allocated budget. KSF PDP/R and e-KSF support the effective use of staff, in particular through service change and redesign. 8. IMPACT ASSESSMENT The KSF and e-KSF processes are impact assessed at National level.


Item No : 9.3

4

Appendix 1 TARGETS FOR 2012/13 Therefore from 1st April 2012 - 31st March 2013 the targets for staff covered by Agenda for Change will be:

1. All staff excluding bank “ALL Agenda for Change staff (excluding bank staff) will be reviewed against a KSF post outline, with at least 80% of reviews being carried out and recorded online using e-KSF (a review to be completed for each post held)” 2. Bank-only staff “All Agenda for Change Bank staff will be reviewed against a KSF post outline, with at least 80% of reviews being carried out and recorded online using e-KSF (a review to be completed for each bank post held). To be carried out on completion of 391 shift hours (identified through the Staff Bank Management System).” 3. Three Month Interim target (April-June 2012) In addition to the 12 month targets detailed above, the KSF team have been requested to “pull” through the outstanding 34.39% of staff who had not completed a review during 2011-12. This will therefore be a 3 month target as follows:

• Ensure reviews that were not completed or signed-off are followed up and subsequently recorded as completed and agreed

• Undertake reviews for the staff that were not reviewed during 2011-12

• Ensure e-KSF contains the necessary staff details to enable a review to

be completed (i.e. - email, outline assigned, manager assigned) Detailed reports for each area have been provided to managers and reflect current data held in e-KSF(and indicate missing data).

Argyll and Bute CHP Appendix 2 Argyll & Bute CHP Committee

Trajectory for e-KSF 2012-13 31/07/2012 Date of meeting: 29 August 2012

Item No : 9.3

2012/13 Profiled trajectory - all staff

Month End

No of reviews required

this month 2012/13

No of reviews required -

cumulative 2012/13

% Trajectory 2012/13

Actual % 2012/13 No of staff 2012-13(all) 2063

April 55 55 3 2.5 Target 80% all 1650May 110 165 8 3.84 Even spread( Aug-March) 206 per monthJune 120 285 14 4.71July 125 410 20 5.87August 130 540 26September 140 680 33October 145 825 40November 150 975 47December 155 1130 55January 160 1290 63February 165 1455 71March 180 1635 80

A&B CHP e-KSF trajectory 2012/13 compared to Actual

0102030405060708090

100

April May Jun July Aug Sep Oct Nov Dec Jan Feb Mar

Month

% R

evie

ws

% Trajectory 2012/13

Actual % 2012/13

Prepared by sally.munro 22/08/2012

NHS HIGHLANDARGYLL & BUTE CHPLocal Verification of Argyll & Bute CHP DataDelayed Discharge Monthly Census as at 9th August 2012

Local verification involves all detailed validation, verification and inter-agency agreement of the data taking place locally,upon which A&B CHP and its partner authorities sign off the data as 'agreed' before onward transmission from the CHP to NHS Highland to ISD. The data will therefore be forwarded on to ISD, fully validated and verified by both NHS andsocial service colleagues.

Complex Needs (code 9) Other Codes All

Hospital Specialtyunder 6

wksover 6 wks Total

under 6 wks

over 6 wks Total under 6

wksover 6 wks Total

Campbeltown GP Acute 1 1 1 1Cowal Community GP Acute 1 1 2 2 2 1 3Lorn & Islands General Medicine 1 1 1 1

General Surgery 1 1 1 1Geriatric Medicine 2 2 1 1 3 3Total LIDGH 2 0 2 3 0 3 5 0 5

Mid Argyll Geriatric Psychiatry 1 1 1 1Victoria Rothesay GP Acute 1 1 1 1Argyll & Bute Council 3 1 4 7 0 7 10 1 11

Argyll & Bute CHP Total 3 1 4 7 0 7 10 1 11

Principal Reason Groupunder 6

wksover 6 wks Total

1 Community Care Assessment 5 0 52 Community Care Arrangements 1 0 13 Healthcare Assessment 0 0 04 Healthcare Arrangements 0 0 05 Legal/Financial 1 0 16 Disagreements 0 0 07 Other 0 0 09 Complex Needs 3 1 4Argyll & Bute Council 10 1 11

Argyll & Bute CHP Total 10 1 11

To be Signed off by Argyll & Bute CHP and Council Representatives

Name Signature Date

James Robb Jim Robb

Christina West Chistina West

13/08/2012

14/08/2012

To be returned to Information Services, Argyll & Bute CHP. 1 of 1 Issued on 22/08/2012


Item No: 10.2 Audit of Compliance with the Admission, Transfer and Discharge Policy Report by Pat Tyrrell, Lead Nurse, Argyll and Bute CHP The CHP Committee is asked to: • Note the audit results in relation to compliance with the Admission, Transfer and

Discharge Policy • Note the recommendations and actions

1 Background and Summary

The Admission, Transfer and Discharge policy, produced in partnership by the 3 partner agencies, Highland Council, Argyll and Bute Council and NHS Highland was launched in Argyll and Bute in December 2010. The partnership agencies recognised the importance of a jointly agreed policy for Admission, Transfer and Discharge (ATD) from both acute and community NHS facilities. The aim is to provide a consistent co-ordinated approach with multi-disciplinary, multi agency input whilst maintaining the individual’s interests as central to the ATD planning process. The policy applies to all staff in NHS Highland, Highland Council and Argyll and Bute Council involved in the ATD of people from all care groups using the principles of the Community Care Pathway and Single Shared Assessment (Personal Plan). Each Partnership organisation acknowledges the importance of a person centred and outcome focussed approach to the management of ATD, involving individuals and where appropriate, their family members, carers and advocates. Audit of compliance with the policy in Argyll and Bute CHP was undertaken in late 2011 and the attached draft report outlines the key findings. The report also contains a series of recommendations which require to be implemented to address the significant gaps identified in overall compliance with the standards.

2 Findings

The Admission, Transfer and Discharge policy is a central plank of Getting Community Care Right in Argyll and Bute. Adherence to its standards across all settings and disciplines is necessary to ensure that systems are working efficiently and dynamically to: a) ensure that discharge from hospital happens in a timely and effective manner b) prevent avoidable readmission to hospital through effective risk management and anticipatory care planning. Implementation of this wide reaching policy has always been recognised as challenging; for the standards to be applied consistently across all Argyll and Bute hospitals requires changes in both culture and practice within hospital and community services and across all disciplines.

2

Systems and processes have been put in place across all hospitals since the advent of the policy. However the overall findings of this audit indicate that significant progress is still required to truly embed the standards into practice. The audit results show that there is inconsistent:

- application of the planned date of discharge - attendance of key professionals at daily board rounds - use of the outcomes pathway after admission and prior to transfer - identification of individual patient’s risk status and use of anticipatory care plans - documentation in patient’s records of actions and plans - information giving to patients and carers prior to discharge - completion of the education programme by all relevant staff

Anecdotal evidence from most areas indicates that there is also variable support from GPs in implementing the policy. All staff recognise that adherence to the policy is much easier when GPs provide strong clinical leadership and work as part of the multidisciplinary team to achieve the agreed outcomes. It is essential that GPs are centrally engaged in the implementation of the policy if we are to continue to make progress. Through the Reshaping Care for Older People and Change Fund there is an opportunity to explore how we can secure more integrated team approaches with primary care. 3 Recommendations and Actions that have been agreed by the CHP Management

Team:

1. Locality Managers/ Clinical Services Managers and Clinical Directors for each hospital must take responsibility for improving compliance with the standards of the policy and practice must be audited on ongoing basis

2. Locality multi agency groups, which include public representatives, established to

implement the new model of care must take responsibility for monitoring compliance with the policy

3. Locality Managers and Clinical Directors to identify how they can engage GPs at local

level to participate more effectively within the Extended Care Teams 4. Senior Charge Nurses must ensure that the checklists are completed at appropriate

times for every patient admitted to hospital in Argyll and Bute 5. Senior Charge Nurse to ensure that every patient has planned date of discharge set

within 12 hours of admission – this is to be done by the multidisciplinary team 6. Individual patient assessments must identify risk factors in relation to health and/or

social factors and anticipatory care plans developed as indicated within the policy. 7. All relevant information must be communicated with patients/carers and families, both

verbally and in written form where appropriate prior to discharge from hospital

3

8. All staff must complete the education programme by the end of August 2012 9. Amend checklists to include suggested changes 10. Follow up audit to be carried out in November 2012


Item No: 10.2a

NHS Highland

Argyll & Bute CHP

Admission, Transfer and Discharge Policy

Audit Report

March 2012

Carol McEachran Practice Education Facilitator Argyll & Bute CHP

2

Contents

1. Background Page 3

2. Aims of the Audit Page 3

3. Standards Page 3

4. Methodology Page 4

5. Results Page 5

6. Conclusion Page 13

7. Recommendations Page 15

8. Appendix 1 Page 16

3

1. Background

The Admission, Transfer and Discharge policy, produced in partnership by the 3

partner agencies, Highland Council, Argyll and Bute Council and NHS Highland was

launched in Argyll and Bute in December 2010.

The partnership agencies recognised the importance of a jointly agreed policy for

Admission, Transfer and Discharge (ATD) from both acute and community NHS

facilities. The aim is to provide a consistent co-ordinated approach with multi-

disciplinary, multi agency input whilst maintaining the individual’s interests as central

to the ATD planning process.

The policy applies to all staff in NHS Highland, Highland Council and Argyll and Bute

Council involved in the ATD of people from all care groups using the principles of the

Community Care Pathway and Single Shared Assessment (Personal Plan).

Each Partnership organisation acknowledges the importance of a person centred and

outcome focussed approach to the management of ATD, involving individuals and

where appropriate, their family members, carers and advocates.

2. Aim of the Audit

The aim of the audit was to identify and report progress of the implementation of the

ATD Policy within hospitals in Argyll and Bute CHP. Following analysis of the audit

data this report presents progress to date across Argyll and Bute in implementing the

policy and makes some key recommendations to further embed the policy in practice

in order to have measurable positive outcomes.

3. Standards

The Audit tool was devised by Alison Guest (Practice Development Nurse Mid Argyll,

Kintyre and Islay) and Maggie Clark (Long Term Conditions Manager Argyll & Bute

CHP), using measurable standards set within the ATD Policy.

4

4. Methodology

A set of general questions were set to a senior nurse from every ward in every

hospital within the CHP (excluding maternity services). (Appendix 1)

Ten sets of case notes were audited against the audit tool from the following seven

hospitals within Argyll & Bute CHP:

• Lorn and Islands Hospital, Oban (LIH)

• Mid Argyll Hospital, Lochgilphead (MAH)

• Argyll and Bute Hospital, Lochgilphead (A&B)

• Islay Hospital, Bowmore (IH)

• Cowal Community Hospital, Dunoon (CCH)

• Victoria Hospital, Rothesay (VH)

• Campbeltown Hospital, Campbeltown (CTNH)

The notes were chosen by the CHP’s Medical Records Supervisor from the

information on patient external transfers and discharges within the first two weeks in

November 2011. However these dates were expanded either side for hospitals

whose transfers or discharges were less than ten patients within the two week

window.

Data was collected from the patient notes and transferred onto an excel spreadsheet

for analysis.

5

5. Results

General Questions

Every ward has organised multi-disciplinary meetings - the majority of these take

place weekly but in some smaller areas it is as required.

Every ward has daily multi disciplinary board rounds.

There is attendance at meetings from nurses, medical staff, allied health

professionals and in some areas pharmacists, community nurses, social workers and

specialist nurses.

There were variances in the knowledge and uptake of training on the ATD policy. In

some areas all staff had completed the workbook, some were working towards it, and

in one area training had been offered for Senior Charge Nurses only. In some areas

no staff had completed any training.

6

Outcome Pathway

Figure 1 shows the percentage of Outcome Pathway Checklists which were

completed, partially completed or not completed. There are also some results which

were not applicable and this will be explained in the following section.

Figure 1

0102030405060708090

100

A&B MAH IH CTNH LIH VH CCH

completepartiallynotn/a

The results show some large variations across the CHP but it must be noted that 0%

of the checklists were fully completed.

7

Within 12 Hours of Admission

Planned date of Discharge

Figure 2 shows the percentage of patents whose planned date of discharge was set

within 12 hours of admission as per the policy guidelines.

Figure 2

0102030405060708090

100

A&B MAH IH CTNH LIH VH CCH

YesNon/a

Again there are variations across the CHP but in the majority of cases a discharge

date was not set for the patient within 12 hours of admission.

8

At risk patients

In order to identify if a patient is at risk the following criteria was used:

• Over 75 years • On 6 or more prescribed medications • More than one Long Term Condition(SPARRA data) • Markers of frailty – history of falls or unplanned admissions.

(Reference: Argyll & Bute Council & Argyll & Bute Community Health Partnership (2011) ‘Getting Community Care Right in Argyll and Bute - Implementation Guide’). However there were variances in results as not every patient the auditor would

categorise as being ‘at risk’ was identified on admission or during hospital stay as

being ‘at risk’. It was therefore decided to present both sets of results as it is the

nursing and medical staff’s judgement that should be used as to whether a patient is

deemed ‘at risk’ or not. Figure 3 illustrates the number of patients using both sets of

data.

Figure 3

0

10

20

30

40

50

60

70

data fromnotes

using riskcategories

At riskNo riskn/a

9

There is a difference between both sets of results, however it should be noted the

auditor did not meet or assess the patients the data using the ‘at risk’ categories

information came solely from the audited notes.

From the case notes one patient was identified as being at risk and had an

Anticipatory Care Plan.

Adults with Incapacity

The data for this area of audit was also taken solely from the case notes and not from

the judgement of the auditor. Of the 4 patients who were identified as Adults with

Incapacity, 3 had a Power of Attorney. Steps had been taken to appoint a Power of

Attorney for the remaining 1 patient.

Complex Care Needs

No patients from the sample were identified as having a complex care need, this data

came solely form the audited case notes.

Within 24 Hours of Admission

Patient information leaflet

No patients form the sample received a ‘Care on Leaving Hospital’ or ‘Patient Choice’

leaflet.

Referral to others

In some cases referrals were made to others within 24 hours of admission, however

not all referrals were made within this time scale but his was often due to the

identification of problems once the patient had been assessed by nursing, medical,

allied health professionals or other agencies.

10

At Least 24 Hours Prior to Discharge

Informing the patient’s carer, care or sheltered home

Figure 4 illustrates the number of carers, care or sheltered home had been informed,

it should also be noted some patients’ next of kin were not formally noted as carers

but on discharge would perhaps be taking on this role temporarily until the patient’s

condition improved.

Figure 4

0

5

10

15

20

25

30

35

40

45

Yes No n/a

number ofpatients

Where the data from the case notes showed the information had not been passed on

it was more than likely it had been but had not been documented.

11

Informing the patient/carer of the patient’s condition and treatment plan

Figure 5 illustrates the number of patients and, where appropriate carers, who were

informed of the patient’s condition and treatment plan.

Figure 5

05

1015202530354045

Yes No n/a

number ofpatients

In the cases where the data showed the patient’s condition and treatment plan were

not discussed with the patient and/or carer, it could be most likely nursing and or

medical staff had discussed this information but it had not been documented.

Ordering Transport

Transport arrangements are not needed for all patients as they will organise with

family or friends to be collected form hospital on discharge. However where transport

was required it was documented in 8 cases that it had been organised - it is assumed

it must have been or the patient would not have been discharged from hospital as

they would have been physically unable to leave unaccompanied.

12

Medications

Of the 59 patients who required medication on discharge, 29 had received their

medication and it had been explained to them, of the remaining 30 patients it was

unclear or not documented if their medication had arrived from pharmacy and had

been explained and given to them prior to discharge. The following are examples of

what was written in some patients’ notes:

• ‘Medications √’

• ‘Medication dispensed’

These examples do not clearly state whether medication had been explained or

indeed given to the patients.

Transfer Letters

Nurse to nurse transfer letters were have been required for 19 patients, 7 letters were

written, there was no information documented as to whether the remaining 12 were

written or not.

Out Patient Appointments

19 patients required an out patient appointment following discharge from hospital. 14

appointments were made, 5 appointments were either not made prior to discharge or

not documented as being arranged.

Contact Telephone Number

15 patients and or carers were given a post-discharge contact telephone number 52

were either not given the telephone number or it was not documented in the patients’

notes as being given.

13

Essential Equipment

2 patients required equipment to be installed in their home prior to discharge 1

patient had the equipment installed. 1 did not but was still discharged as it was to be

installed later that day.

6. Conclusions

None of the sample case notes included a fully completed checklist and there were

variances across the areas with regard to the percentage of notes that had a partially

completed check list or no checklist. The checklist is a very useful tool detailing the

steps that need to be taken in the first 24 hours after admission and at least 24 hours

prior to discharge.

In order for the implementation of this tool to be successful, the checklist needs to be

adopted as a standard inclusion in patients’ notes. Full completion of the checklist

would also help to rectify the obvious lack of documentation relating to the steps

taken when planning for and at the point of discharge. However if the checklist is to

be adopted as standard, it would need to be amended to include options for patients

who have been admitted to hospital for end of life care (2 patients in the sample were

admitted to hospital for end of lifer care, hence the audit results showed it was not

applicable to utilise the checklist or set a date for discharge).

The checklist also lacks an option for patients who have an irregular discharge, i.e.

when they decide against medical advice to discharge themselves from hospital. 1

patient in the sample took this option against medical advice and refused to wait until

their medication was ready or to sign an irregular discharge form. There was clear

documentation of this episode in the patient’s record. It would be beneficial to

include an option for irregular discharge within the checklist.

There were variances in the setting of a planned date of discharge within 12 hours of

admission throughout the CHP, some areas engaged with this policy guideline more

than others. However in some areas where medical staff set the date, at times,

nursing staff find medical staff are not always willing to do this at an early stage.

Therefore in certain areas there is a need to discuss this further with medical staff

and to encourage nursing staff to set a date for discharge if it is not done by medical

staff within 12 hours of the patient’s admission to hospital.

14

There was disparity in the patients categorised by nursing and medical staff as being

‘at risk’ within the data sample in relation to who the auditor identified ‘at risk’ using

the categories previously stated. This could be due to the fact that the nursing and

medical staff assessed the patients whereas the auditor gained the information from

the case notes. It could also be from a reluctance to categorise someone ‘at risk’

due to the further assessment and intervention which would be required for the

patient.

It was encouraging to note the 4 patients who were identified as ‘adults with

incapacity’ 3 had a power of attorney and the steps had been taken to appoint one

for the remaining patient.

No patients were given the information leaflet within 24 hours of admission; this could

be due to a lack of knowledge of this need or lack of supplies of the leaflets. This

should be followed up with each area.

Referrals to others were in most cases done timeously.

The lack of documented evidence of the steps taken at least 24 hours prior to

discharge was very apparent. It was obvious in some cases certain steps must have

been taken as the patient could not have been discharged within them but these

steps had not been documented. If something has not been documented it is taken it

has not been done and this is a very important point that needs to be raised with

nursing staff in all areas.

In relation to education and training the ATD policy states there will be a programme

of awareness raising, education and training, an education package will be available

for all relevant staff and ATD training will be provided for all NHS health staff involved

in patient care. Results from the audit have shown there has not been the same

structured approach to education and training in every area. An education booklet is

available to staff however not all nursing staff have received training on the ATD

policy let alone all staff involved in patient care. There seems to have been a ‘cart

before the horse’ implementation of the policy and then training and it is only obvious

that staff will not engage completely with the policy when they have not yet

completed education and training on it.

15

It is recommended useful lessons may be learned if the education and training was

evaluated in relation to the implementation of and engagement with the policy.

The case notes were audited retrospectively and the general questions put to nursing

staff within the period mid January to mid February and it was encouraging to note

there seemed to be a general increase with staff awareness of and engagement with

the policy, and its utilisation in practice.

7. Recommendations:

1. Finalise the audit report and disseminate audit findings to each area

2. Locality Managers/ Clinical Services Managers and Clinical Directors for

each hospital must take responsibility for improving compliance with the

standards of the policy and practice must be audited on ongoing basis

3. Locality multi agency groups, which include public representatives,

established to implement the new model of care must take responsibility for

monitoring compliance with the policy

4. Locality Managers and Clinical Directors to identify how they can

engage GPs at local level to participate more effectively within the

Extended Care Teams

5. Senior Charge Nurses must ensure that the checklists are completed at

appropriate times for every patient admitted to hospital in Argyll and Bute

6. Senior Charge Nurse to ensure that every patient has planned date of

discharge set within 12 hours of admission – this is to be done by the

multidisciplinary team

7. Individual patient assessments must identify risk factors in relation to

health and/or social factors and anticipatory care plans developed as

indicated within the policy.

8. All relevant information must be communicated with patients/carers and

families, both verbally and in written form where appropriate prior to

discharge from hospital

9. All staff must complete the education programme by the end of August 2012

10. Amend checklists to include suggested changes

11. Follow up audit to be carried out in November 2012

16

Appendix 1

General questions: 1. Are there Multi Disciplinary Team meetings on the ward?

yes / no

2. How often do these take place?

weekly /twice /weekly /daily /other /none

3. Are there daily board rounds on the ward?

yes / no

4. Who attends these meetings? (please highlight those who attend)

Ward senior nurse / GP / AHPs / Social work / Community nursing / other…………..

5. How many registered nurses work on the ward? 6. What is their whole time equivalent? 7. How many registered nurses participated in the ATD training?


Item : 11.1

Modernisation of Mental Health Services Update Report

Report by John Dreghorn

The CHP Committee is asked to: • Note current key issues and progress against the action plan

1. Background The following report provides an update on the implementation of the modernisation of mental health services in Argyll & Bute.

2. Progress Report

Project Management As previously reported, Crawford Cumming was appointed to the role of project manager through Hays Recruitment Agency. This will be reviewed at the end of stage 1 with a view to making a direct appointment on a fixed term basis for the stage 2 and construction phases.

External Advisors Stage 2 appointments are still to be made through the SFT framework of approved contractors. This is likely to take place in October following completion of the stage 1 report.

Capital Project Approvals Timetable Following a review in early August of the work requirements to deliver an OBC in time to meet the approvals programme, the Mental Health Project Director and Capital Project Director concluded that it would not be possible to achieve the previously agreed deadlines with any confidence of producing a robust and convincing business case.

In light of this we advised the Hubco representatives that the approvals timetable would require to be amended, resulting in a 3 month delay in achieving stage 1 approval. While this is regrettable, it was clear from the progress that had been made to date in terms of design development that there was some doubt about Hubco’s ability to deliver a stage 1 report containing sufficient detail to support an OBC. We have agreed a revised stage 1 submission date of 5th October, which should allow sufficient time for: a review of the report by our external advisors including independent testing of the financial model; and its inclusion within the OBC. The revised approvals timetable is as follows:

• CHP Committee - 31 October 2012 • NHS Highland Asset Management Group (AMG) - 20 November 2012 • NHS Highland Board - 4 December 2012 • Scottish Government Capital Investment Group (CIG) - 15 January 2013

Inpatient Services The bed compliment has reduced by 2 to 38 beds following the discharge of 2 long term patients from Tigh na Linne

The inpatient services modernisation group has been merged with the community services modernisation group to ensure consistency of approach to the modernisation work and to promote a greater level of integration of the two parts of the service. This will include having common documentation which follows the patient, and access to a common IT patient record system as MiDIS is rolled out. The group continues to work closely with the Scottish Recovery Network (SRN) with audits of Scottish Recovery Indicator (SRI 2) taking place across a number of teams/departments.

Staff Redeployment As previously reported the next group of staff to be redeployed will be Admin & Clerical. The planned establishment has been revised taking account of the transfer of the Clinical Psychologists into the Community teams. This staff group was previously centrally managed and had centralised admin support.

Over the next 2 months it is expected that the establishment will be set for: Estates, Hotel Services, Laundry and Stores. Following this, new job descriptions will be produced and AfC banded prior to staff redeployment taking place later this year.

New Posts - Guided Self Help Workers (GSHW): Interviews took place in August and these posts have

now been appointed to. - Clinical Psychology: Older Adult/Neuropsychologist job description agreed and awaiting

AfC banding. - CBT Practitioners: All posts now recruited - Primary Mental Healthcare Workers (PMHCW): All post now appointed - CMHS Posts: All new nursing and support worker posts have now been appointed. Admin

posts will be appointed during September/October

B u d g e t - 2012/13 Cost Improvement Plan (CIP): Nil new to report this month - Bridging: The closure of Tigh na Linne later this year remains the key component of the bridging calculation. The previously reported bridging requirement of £500k for 2012/13 remains unchanged. - Projected Operational Funding Gap: The projected operational funding gap remains unchanged at £188k, however it is anticipated that this will have been reduced as revised establishments for estates and hotel services are confirmed in early September. This gap must be closed by the time of the OBC submission to the CHP Committee at the end of October.

Resettlement Group The commissioning of services to support 3 patients in a group house in Lochgilphead has proven more complicated than anticipated, resulting in a delay in making an appointment. The Councils commissioning team are working to resolve any outstanding issues. It is now expected that it will be November before the support staff are in place to facilitate discharge.

However, progress has been made in discharging or progressing discharge plans for several other longer term patients. Following refurbishment earlier in the year Firgrove is almost ready for use with some final items of furniture on order. This will act as a pre-discharge placement for patients whose discharge arrangements have yet to be finalised, but who are ready for discharge.

New Hospital As reported above the approvals time table has now slipped by 3 months. As yet we have not received confirmation from Hubco with regard to the impact on the overall build programme.

Since the last report the design team have produced 3 new concept designs. The 1st which was produced in July was a development of the original concept design produced in 2011, but it was clear that the site constraints would make that design unsuitable. The 2nd design included the assumption that Tigh na Linne would be demolished. While this addressed some of the site constraint issues it was considered too much of a risk as Tigh na Linne along with the other building on site are being reviewed by Historic Scotland, with the potential to become listed. The 3rd concept design was issued on 20 August and will be reviewed on 22 August by a number of project and service representatives. If accepted as an accurate interpretation of the design brief, this concept design will then be fully developed to a stage C level to allow it to be fully costed. See floor plans and site plan below.

One issue which will need to be resolved over the next 2 months is access to land adjacent to Tigh na Linne, which is currently leased to the Mid Argyll PFI company. This land is unused at present but under the control of the PFI company. The CLO are reviewing the contract and early contact has been made with the PFI company to advise them of our interest in developing this land.

Community Mental Health Service (CMHS) The Community Service Operational Guidelines which was developed by project senior nurse last year is being reviewed with council representatives with the aim of agreeing changes which will make this a document which can be adopted by council and NHS staff. This will assist with he ongoing integration of our services.

CMHS Team Base The lack of capital continues to be a problem in both Campbeltown and Dunoon. In both areas the plan is to develop under-utilised areas of the hospital as a base (clinical and administrative) for the CMHS, incorporating NHS and council staff. Both projects require significant capital works. NHS Highland is in communication with CIG representatives regarding the possibility of an early release capital funding based on the future sale of parts of the Argyll & Bute Hospital site. This is reliant on the production of a “site master plan”. We are working with the Scottish Futures Trust (SFT) on this.

3. Summary During July & August there has been a significant amount of progress on the capital project. We are close to agreeing the concept design which will then be fully developed for stage 1 submission in early October.

Unfortunately a number of factors have led to a delay in the development of the OBC which effectively results in a 3 month delay in achieving approvals. It remains unclear whether this will result in 3 months slippage for the overall project.

The community teams are now fully established although there remains some uncertainty regarding when the team bases will be ready in Campbeltown and Dunoon.

John Dreghorn Project Director – Mental Health Modernisation

ARGYLL & BUTE CHP COMMITTEE MEETING Wednesday 29 … · 29/08/2012 · Argyll & Bute CHP Committee...

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Transcript of ARGYLL & BUTE CHP COMMITTEE MEETING Wednesday 29 … · 29/08/2012 · Argyll & Bute CHP Committee...