ARGYLL & BUTE CHP Wednesday 18 February 2015 J03-J07, Mid ...€¦ · a poster campaign on buses....

ARGYLL & BUTE CHP COMMITTEE MEETING

Wednesday 18 February 2015

J03-J07, Mid Argyll Community Hospital, Lochgilphea d

12.30pm - Lunch

1pm - Meeting

Time Agenda Item Title Presenter 1pm 1 Chairman’s Welcome Chair

2 Apologies Chair 3 Conflicts of Interest Chair 1.05pm 4 Minutes of Meeting of 17-12-14 (attached) Chair 1.10pm 5 Matters Arising Chair 6 NHS Highland 1.20pm 6.1 Highland NHS Board –3 February 2015 (verbal) Chair 1.25pm 6.2 Director of Operations Report (attached) Christina West 7 Clinical Governance 1.35pm 7.1 Clinical Quality & Patient Safety Report (attached) Pat Tyrrell 1.50pm 7.2 Infection Control Report (attached) Pat Tyrrell 2.10pm 7.3 Public Health Report (attached) Elaine Garman 8 Financial Governance George Morrison 2.25pm 8.1

8.2 Report (attached) Revenue Budget Proposal 2015/16 (attached)

2.50pm 9 A&B HSCP Integration Update (attached) Stephen Whiston

10.30am – 12.30pm – Committee Members Development S ession

• Children’s Services and Early Years Collaborative – Patricia Renfrew, Consultant Nurse, Children & Families / Liz Strang

• Launch of Dementia Friends Scotland in Argyll and Bute – Pat Tyrrell, Lead Nurse

3pm 10 10.1 10.2

Mental Health - Modernisation Project Update (attached) - Escort/Transfer Service Audit Report (attached)

John Dreghorn Gillian Davies

3.20pm 11 Renal Dialysis Service (attached) Stephen Whiston

3.35pm 12 Staff Governance

12.1 PDP/R & eKSF Implementation Update (attached) Sally Munro

3.45pm 13 Performance Management 13.1 Delayed Discharge Update (verbal) Pat Tyrrell

3.50pm 14 Papers for Noting Chair - Partnership Forum Minute of 18-12-14 (attached)

3.55pm 15 AOCB Chair

16 Details of Next Mee ting :

To be advised.

4pm Public Session Chair

Argyll & Bute CHP Committee 18 February 2015

Item : 4

DRAFT MINUTE OF MEETING OF THE

ARGYLL & BUTE CHP COMMITTEE

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

Training Room,

Cowal Community Hospital, Dunoon

17 December 2014 – 1pm

Present

Mr Robin Creelman, Chairman, Argyll & Bute CHP Ms Christina West, Chief Officer, Health & Social Care Partnership/ Interim Director of Operations, 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 Elaine Wilkinson, Non-Executive Member Councillor Elaine Robertson, Argyll & Bute Council Representative Councillor John McAlpine, Argyll & Bute Council Representative Councillor Anne Horn, Argyll & Bute Council Representative Mr Alastair McLaren, Argyll Voluntary Action Mr Duncan Martin, Chairman, Public Partnership Forum

In Attendance Apologies

Mr George Morrison, Head of Finance Mr Stephen Whiston, Head of Planning, Contracting & Performance, Argyll & Bute CHP Ms Gaye Boyd, Interim Head of HR Mrs Sheena Clark, PA to Interim Director of Operations - Minute Secretary Ms Elizabeth Reilly, Area Dental Committee Representative Dr Michael Hall, Clinical Director, Argyll & Bute CHP Mr David Ritchie, CHP Communications Manager Mr Cleland Sneddon, Executive Director, Community Services, Argyll & Bute Council Ms Dawn Gillies, Staffside Representative Ms Elizabeth McMillan, Staffside Representative Mr Michael Roberts, Vice-Chair, Public Partnership Forum

1. CHAIRMAN’S WELCOME The Chairman welcomed everyone to the meeting. 2. APOLOGIES Apologies for absence were noted. 3. CONFLICTS OF INTEREST There were no conflicts of interest noted.

2

4. MINUTE FROM PREVIOUS MEETING on 22 AUGUST 2014 P6 - Risk Management – Incidents : last paragraph – Councillor McAlpine asked about the requirement for Police involvement to support staff to administer drugs to disruptive patients. With the above amendment the Minute of the meeting on 22 October 2014 was accepted as an accurate record. The Committee: • Approved the content of the Minute of 22 October 2014, with the amendment noted.

5. MATTERS ARISING Risk Management – Incidents – Police involvement to support staff to administer drugs to disruptive patients. Ms Tyrrell advised that she will discuss this further with Mr Dreghorn and advise Councillor McAlpine accordingly. Review & Redesign of Hospital, Community & Care Services in Kintyre – Mr Whiston advised that the CHP is working with the Scottish Health Council to finalise the template for assessment of the service change. The Committee: • Noted the update. 6. NHS Highland 6.1 Highland NHS Board – 2 December 2014 Mr Creelman referred to discussions at the recent meeting which highlighted the Board’s confidence in NHS Highland achieving a break-even position for 2014/15. The Highland Quality Approach - Rapid Process Improvement Work carried out in a number of departments is achieving significant positive results in timesaving for staff and patients and contributing to both improved services and efficiency savings. The Committee: • Noted the update. 6.2 Director of Operations Report Ms West provided a summary of the points detailed in the paper which reported on the ongoing business of the CHP. Integration - Health & Social Care Partnership - The public consultation for the draft integration scheme closes at 12 noon on 23 December 2014. Details of the consultation, newsletter, and public engagement events are available on the NHS Highland website. There will be continuing engagement with staff and the public during 2015. Reshaping Care for Older People (RCOP) – The consultation period has been extended to end January 2015 and the outcomes will inform the wider strategic plan and the key priorities

3

for year 1. CHP representatives have attended community council meetings to discuss how and why services need to change and to encourage public opinion and comment. Positive public feedback has been received from the meetings and the information provided. Conversation cafes are planned as part of the engagement and involvement approach. Mid Argyll – Cara Ward in MACHICC remains closed on an interim basis due to staffing pressure and is under constant review, with the Core Management Team receiving regular updates. The ongoing work following the announced Healthcare Inspection of MACHICC in July continues. The recruitment process for remote and rural GPs continues, with national adverts on TV and a poster campaign on buses. Lochgilphead Medical Practice has received some interest and has undertaken some initial informal discussions with potential candidates. Kintyre – Public consultation meetings have taken place across Kintyre to engage the public in proposed changes to GP services. There have been some recruitment difficulties to the vacant GP post in the Kintyre Medical Group, with service continuity being provided through locums GPs and the substantive part-time GPs taking on additional hours. There has been an extension to the operating hours of the Extended Community Care Team (ECCT) and the vacant team lead post has been advertised internally. Islay & Jura - Islay hospital buildings are being reviewed by a multidisciplinary group with public representation. The optimal site is to be agreed for the location of a Macmillan end of life care room and relatives’ overnight room. Proposals are being considered for further development to improve the space, provision and configuration of the hospital and the feasibility of including dental facilities in the hospital. Cowal Mental Health - successful recruitment to the Community Psychiatric Nurse and Cognitive Behavioural Therapy posts has been completed.

Wards & Day Therapy Centre - refurbishment works have been completed in the Hospice Day Therapy Centre, to include for example, therapeutic treatments. A dementia friendly environment has been created in the admissions ward, including a quiet area, an orientation board and appropriate furnishings, music and television programmes. Bute – a Bute Option Appraisal Group convened and agreed scope to include NHS and Social Work and local Care Home and Housing. This will form a subgroup of the local Reshaping Care for Older People. Oban, Lorn & Isles Mull & Iona – an action plan detailing the work to be progressed will be presented for agreement at the next meeting of the Review Group on 16 December 2014. Following approval by the Review Group an out of hours rota using local and other GPs is being populated and will be ready for implementation in January 2015. The Working Group led by Dr Richard Wilson is key to the success of the project and the development of a service model for day time GP services to enable successful recruitment to the vacant GP posts. Port Appin Out of Hours Services – following notification by the GP in Port Appin of his intention to opt out of hours services by no later than 1 August 2015, public engagement

4

drop in events were held in Port Appin and Lismore with representatives from NHS and Scottish Ambulance Service. The CHP will be looking to extend the current out of hours service based at Lorn & Islands hospital to cover the service need of 3 geographical areas as well as to develop and enhance community resilience. Dental – Negotiations have started with a new prospective leaseholder for Oban Dental Access Centre. Mr Morrison clarified that the rental cost is not an issue in concluding an agreement but the viability of a business case requires to be affirmed. Decontamination Unit – NHS Highland Consultant Microbiologist is leading the discussions with the manufacturer to address the current challenges with compliant water testing. The Belford Hospital decontamination unit has been utilised to ensure service continuity. Pain Service – the CHP continues to be challenged with the provision of the pain service, with associated waiting time breaches. Work is ongoing with the Planning Department and Locality Teams to resolve the issues. The Committee: • Noted the content of the report. 7 Clinical Governance 7.1 Clinical Quality & Patient Safety Report Ms Tyrrell summarised the detail in the report. Incidents - a total of 506 incidents were reported in Quarter 2 of 2014/15. Cowal & Bute – 73, Helensburgh – 20, Mid Argyll & Kintyre – 285, Oban, Lorn & Isles – 120 outwith Highland – 8. The top 3 categories of incidents in Argyll & Bute were falls, violence and aggression and pressure ulcers. There were 4 incidents with major and extreme consequence resulting in Significant Event Reviews. Two RIDDOR reportable incidents were recorded in quarter 2. Complaints – the overall number of complaints received in Argyll & Bute remains relatively low, with the grades of the majority recorded as either low or medium. The top three issues identified are staff attitude/behaviours, procedural issues and clinical treatment. The performance in quality of the responses has improved. Skill improvement workshops with managers are being arranged for early 2015. Ms Tyrrell will provide a breakdown of spread analysis of complaints in the next report to the Committee. Clinical Quality Indicators – the overall compliance set out for each of these indicators is very good. Scottish Patient Safety Programme (SPSP) - Lorn and Islands Hospital - Issues with SEWs recording over the past few months are attributed to bank staff and students not recording

5

the action on the SEWs charts. There is evidence within the patient records of actions being taken and the issue of correct recording is being addressed.

Mortality reviews are up to date and summary report will be available for next CHP Committee. Further training in carrying out the mortality reviews will be provided by SPSP Lead for ANPs and consultants within the hospital.

Community Hospital Spread Plan - due to capacity issues it has not yet been possible to progress the planned spread of SPSP bundles and improvement methodology to Mid Argyll Hospital. A meeting to identify how this can be progressed in both Mid Argyll Hospital and Victoria Hospital, Rothesay will be scheduled for January 2015. In the meantime there is shared learning across the community hospitals with a number of SPSP elements being adopted. Ms Tyrrell will provide a further update at the next meeting of the Committee. Healthcare Environment Inspectorate (HEI) - the 16 week progress report on the action plan which followed the HEI inspection of Mid Argyll Hospital was submitted to HEI on 2 December 2014. Most of the actions have now been completed. A meeting is scheduled with NHS Greater Glasgow & Clyde, to include CHP infection control representation, to discuss concerns highlighted in laundry processes and what quality control measures are in place to identify unfit laundry. Robin emphasised the requirement to identify a representative from patient/public involvement to be involved in developing the improvement action plan. Older People in Acute Hospitals (OPAH) - Lorn and Islands Hospital had its first inspection (unannounced) by HEI of the standards for older people in acute hospitals. The inspectors spent two days in the hospital on 3 and 4 December 2014 and visited each of the 3 inpatient wards as well as A&E. They carried out a range of observational and documentation audits as well as interviewing staff and patients across all areas. The initial verbal feedback identified many areas of strength which included how well patients were cared for, the quality of staff interactions, the completion of assessments, protection of mealtimes and quality of food, access to pressure relieving equipment and patient feedback Areas for improvement included completion of DNA CPR forms, awareness of Adults with Incapacity Act, care planning and completion of Medicines Reconciliation forms, better signage outside of the wards and implementation of the delirium care bundle. These areas had previously been identified by the local team and actions were already in place. The draft report will be received on 14 January 2015; the report and plan is to be submitted by 22 January 2015 with the final report is to be published on the website on 10 February 2015. This was the first OPAH inspection in Argyll and Bute; the CHP will take the opportunity to make sure that there is learning from this and that good practice and areas for improvement are shared with all hospitals. Vale of Leven Hospital Public Inquiry Report / Aberdeen Royal Infirmary: Short Life Review of Quality and Safety - both of these recently published reports have been reviewed through the Argyll and Bute Clinical Quality and Patient Safety Group meeting in December and small review group will meet to identify improvement actions required in Argyll and Bute to address lessons learned through these reviews and recommendations. Argyll & Bute Operational Health and Safety Plan - CHP Health and Safety Managers in conjunction with NHS Head of Health and Safety have undertaken a review of performance against the existing Operational Health and Safety Plans.

6

Integration of Health and Social Care in Argyll and Bute - Following initial guidance being issued by Scottish Government to provide an overview of the key elements and principles that should be reflected in the clinical and care governance processes implemented by Integration Authorities, a workshop session took place on 15 December 2014 to begin the development of framework and mechanisms to deliver clinical and care governance in the new Argyll and Bute Health and Social Care Partnership. The Committee: • Noted the content of the report. 7.2 Infection Control Report Ms Tyrrell provided an update of the current status of healthcare associated infections (HAI) and infection control measures in Argyll & Bute and NHS Highland. NHS Highland is currently off trajectory to meet the Clostridium difficile (CDI) target but on trajectory to meet Staphyococcus Aureus Bacteraemia (SAB) target; this position remains changeable. Currently NHS Highland are on “red” in terms of the SAB quarterly report but “green” in terms of this year’s number of infections against the trajectory. There have been no cases of SAB since February 2014 in Argyll & Bute. Current initiatives are concentrating on infections associated with vascular devices and catheters as well as working to reduce blood culture contamination rate. 8 patients were diagnosed with CDI in Argyll & Bute since April 2014, one while an inpatient in Lorn & Islands Hospital and the seven remaining developed CDI in the community. Work continues within the infection control group to review any incidence of infection and to scrutinise the surveillance data to identify any learning points and trend analysis. There is also a focus on working with community staff to enhance the prevention of CDI in community settings. The Infection Control and Prevention team and the Health and Safety team are working in collaboration with other key members to ensure NHS Highland is prepared to care for a potential Ebola case, i.e. equipping of units with personal protective equipment. Details of referral pathways and guidance is available. This is a high priority and as a result is creating a significant pressure on team resources. In order to mitigate some of the pressure, a nurse from the re-deployment register has been appointed to assist with this work. ICNET (infection control software programme) integration with Argyll and Bute, and Greater Glasgow and Clyde has not yet occurred due to ongoing discussions around governance and work is underway to move this work forward. There was 1 confirmed case of Norovirus in November in Cowal Community Hospital, affecting patients and staff, resulting in the closure of the hospital to admissions for 5 days. Another outbreak in early December affected residents and staff in a care home in Oban resulting in the care home being closed to admissions. It is due to re-open at the time of this report.

The Committee: • Noted the content of the report.

7

7.3 Public Health Annual Report Ms Garman referred to the circulated paper which advised on Alcohol Brief Interventions (ABI) and Violence Against Women (VAW). Ms Garman advised that whilst there has been much coordinated work on ABIs over the years there has been less so on violence against women within Argyll & Bute and this is currently being rectified. Alcohol Brief Interventions The HEAT 4 target (now standard) for Alcohol Brief Interventions (ABI) is aimed at reducing the consumption of hazardous and harmful drinkers. The annual target for ABI delivery in Argyll & Bute is 1066. A minimum of 90% of the target delivery must come from the priority settings of Primary Care (GP practices and NHS), Maternity and A&E and this has been reinforced to localities. A maximum of 10% of delivery can be counted from non-priority settings. The HEAT standard is due to end in March 2015 but there will continue to be a requirement to report ABI delivery through Health Promoting Health Service returns and possibly through a separate return. At present Argyll & Bute ADP is significantly below trajectory for the HEAT 4 target. Between 2011 and 2014 a total of 279 people have been trained to deliver ABI within Argyll & Bute. In addition there were a significant number of staff trained prior to 2011 and several staff have been trained online or outside Argyll & Bute. If each trained member of staff delivers only four ABI we will exceed our target. The main challenges are : • staff capacity and encouraging each trained member of staff to deliver ABIs and

report delivery. • encouraging GP practices to increase their delivery in the final quarter of the year. • developing an appropriate reporting system. • ensuring all ABIs reported can be counted. Ms Wilkinson suggested that the involvement of the 3rd sector could assist in the delivery of ABIs and Ms Garman agreed that this could be further considered and discussed. Violence Against Women There is no Government target for VAW work. It is most clearly a partnership issue although there are specific actions that individual organisations need to do to improve response to women at risk from harm. Policy and guidance work is being undertaken across all sectors to raise awareness of VAW and to support and advise staff and managers on appropriate responses to reports of VAW. Extensive work has also been carried out to identify options for training which is key to rolling out the policies and guidelines. It was agreed that the VAW profile requires to be raised in the appropriate CHP forums. Councillor McAlpine highlighted the availability of gambling facilities in some deprived areas which can impact on vulnerable families and contribute to public health issues. Ms Wilkinson commented that input into dealing with these concerns should also be part of the GIFREC agenda.

8

The Committee: • Noted the positions on Alcohol Brief Interventions and Violence Against Women. 8. Financial Governance 8.1 Finance Report Mr Morrison provided an update to the circulated paper and advised that at end November 2014, Argyll & Bute CHP recorded an overspend of £33,000. This is a favourable movement of £231,000 on the overspend of £264,000 recorded at the end of October and demonstrates a significant improvement arising from the actions of managers to contain and reduce expenditure.

He reported that in discussion with the Health Board, the CHP has agreed to take action to further reduce planned spending over the remainder of the financial year and indicated that the expected yield from this action will be £0.5m which, if achieved, will result in Argyll & Bute CHP achieving a year-end position of £0.25m underspent.

It was noted that in addition to pressure on budgets from savings targets, there are a number of in-year cost pressures causing budget overspends, as detailed in the report.

Mr Morrison advised that in 2015/16 the funding uplift received from the Scottish Government will be 1.8% (£2.75m). Against this there are a number of existing cost pressures and expected cost increases which require to be funded. The recurring savings requirement in 2015/16 is expected to be in the region of £5.3m, with one factor contributing to this being the presumption of a £2m contribution to close the gap with NHS Greater Glasgow & Clyde. He explained that the NRAC share is population based and NHS Highland was underfunded by £12m in 2014/15, £3m of which related to Argyll & Bute. It is expected that NHS Highland will receive increased funding in 2015/16 to at least partly address this underfunding.

The Committee:

• Noted the year-to-date financial position.

• Noted the requirement for management action to support the Board in achieving a year-end break-even position.

9 Argyll & Bute Health & Social Care Partnership In tegration Scheme Mr Whiston referred to the circulated papers submitted to the NHS Highland Board as an update on the Argyll & Bute Health & Social Care Partnership. He advised that the Scottish Government have accelerated the submission date to early January 2015 of the draft Integration Scheme, which is a constituted document under statute and picks up the key issues of responsibilities of the Integrated Joint Board (IJB), which will be accountable for the delivery of services. The Integration Scheme must be approved by Scottish Ministers before the IJB may legally form. Approval of the Scheme will be restricted to those matters which are prescribed for inclusion and any future changes will require the scheme to be resubmitted following further consultation. Following approval by NHS Highland Board on 2 December and to comply with the revised timescale, the public consultation on the draft integration scheme will be for a period of 4½

9

weeks, ending 23 December, following which the draft Integration Scheme will be submitted to the Scottish Government in early January 2015 for approval. It is also a requirement to have a Strategic Plan in place to enable delegation of resources to the IJB. It is acknowledged that due to the consultation period, review and sign off by the Board and the Council, the timescale for completion of the strategic plan is approximately 9 months, commencing in January 2015. It is acknowledged that the IJB will be legally constituted on 1 April 2015 and the Board and the Council will need to agree interim governance arrangements until resources are legally delegated to the IJB, following agreement of the Strategic Plan. The Committee: Noted the content of the documents submitted to the Highland NHS Board on 02-12-14. 10 Mental Health Modernisation Update Ms West highlighted key issues and progress against the action plan as detailed in the circulated report. Project Management - as the capital project proceeds towards the completion of hub stage 1 and the completion of the Outline Business Case (OBC), the need for additional project management support to deliver the OBC by mid January has been identified. Options to support the project team have been agreed. Inpatient Services - Current staffed bed compliment is 26 and recent pressure on beds has been noted.

The reduction in patient numbers in IPCU (currently 4), has further highlighted pre-existing concerns regarding the viability of IPCU as a stand-alone unit, leading to a review of the options available and the decision to merge IPCU with Succoth Ward. This will improve the clinical environment and provide a safer model of care for patients and staff. NHS Highland’s Asset Management Group met in November and approved £295k capital funding to convert an area within Succoth to function as the IPCU. The work will be tendered in January and commencement in Feb/March. Work is expected to be completed by end of May 2015. Supported Transfer of Detained Patients – the initial review of the audit of patients transfers from January 2014 produced in September showed a significant increase in the number of patients detained and requiring supported transfer when compared to 2013. A review of the incident reports associated with this service shows a high number of incidents from 2 areas and the majority being due to transport problems (mainly SAS). Further work including a review of activity from July to November, plus an analysis of questionnaires received from staff, partner organisations; service users and carers, will add move evidence to this review. It is anticipated that a range of options to improve this service will be developed once the evidence from the review has been considered by the Programme Board. The outcome of the analysis will be detailed in the next report to the Committee. The Committee: Noted current key issues and progress against the action plan.

10

11 Staff Governance 11.1 PDP/R & eKSF Implementation Update Ms Boyd reported that the CHP currently has 14.40% of all staff (19.19% excl bank) with reviews and personal development plans signed off in e-KSF for this financial year. The rolling 12 month figures for Argyll & Bute CHP (from 1 October 2013 - 30 November 2014) show that 42.49% of all staff have had reviews completed (56.62% excl bank). It is acknowledged that considerable efforts will have to be made across the CHP to raise the level of activity of reviews, which need to be viewed as worthwhile by staff and managers/reviewers. The focus will continue to be on managers/reviewers ensuring quality of the process which is also considered by the Staff Governance Committee. Historically the period from December–March usually records higher activity than other months but managers are encouraged to schedule reviews in a planned manner throughout the year to spread the workload and ensure a higher proportion of staff have reviews carried out. A quality survey trialled in September (using survey monkey) indicated good levels of satisfaction in relation to the review process (by reviewees), the survey will be conducted pan Highland in April 2015. Concerns continue to be highlighted by a number of staff, particularly those on low hours, or on bank contracts, who have difficulty in accessing the eKSF software and their records due to either a low level of confidence on computer use, or difficulty in being able to find a suitable computer in their workplace on which they can log-in. Further work will have to be carried out in operational units to identify and provide PCs for access, and also to address training needs. Following a number of focus groups held across Scotland, a number of staff suggestions for improvement will inform the review of KSF in Scotland :

• Review and simplify the content of the core dimensions • Develop consistent guidance and resources with an ‘improvement focus’ • more clarity on links with appraisal including values, behaviours and service led

objectives This work will be carried forward nationally and be completed by 31 March 2015. The contract to deliver the e-KSF system was due to end in March 2014 pending the introduction of the replacement system Oracle Performance Management (OPM), hosted within eESS (employee information system). Due to delays with the new system, e-KSF has continued to be used and will continue until March 2016.

The Committee : • Noted the current position which shows an overall decline in PDP & R meetings taking

place. • Noted the need to re-invigorate this in practice and use it to support and direct staff

development in line with CHP and NHS Highland objectives. • Noted the need to ensure that regular annual reviews and PDPs continue for all staff,

including bank staff. • Noted that the eKSF software licence has been extended to March 2016.

11

12 Performance Management 12.1 Delayed Discharge Update Ms West reported 12 delayed discharged, 10 <4 weeks and 2 >4 weeks : • 3 - due to adults with incapacity processes • 5 – due to a delay in care at home arrangements being in place • 2 – due to delay in completion of community assessments • 1 – due to a health equipment issue • 1 – due to family disagreement re. discharge arrangements. Councillor Robertson expressed concern regarding the shortage of carers and the need to encourage people into the employment of the care sector. It was noted that Argyll College offers training courses to assist and support access to a career sector. A review of funding for carers is also required. There is also a need to discuss this issue in community settings to encourage rural community resilience in the care of the elderly. Councillor Robertson recorded her thanks to staff who participated in the RCOP consultation and engagement events with community councils.

13 Papers for Noting

a) Vale of Leven Hospital Enquiry Report – Executive Summary b) Aberdeen Royal Infirmary – Short Life Review of Quality & Safety c) Notes of Clinical Quality & Patient Safety Group – 09-09-14 d) Integration Newsletter – Dec 14 e) Reshaping Care for Older People – Survey

https://www.surveymonkey.com/s/Reshaping_Care

f) NHSH Quality Awards Nomination Process 14 AOCB There were no items for discussion. 15. DATE, TIME & VENUE FOR NEXT MEETING :

Wednesday 18 February at 1pm, J03-J07, MACHICC, Lo chgilphead

The Committee : Noted the verbal update and comments.

The Committee : Noted the content of the circulated papers.


Item : 6.2

Argyll & Bute CHP Director of Operations Report – F ebruary 2015 Report by : Christina West, Interim Director of Op erations The CHP Committee is asked to:

• Note the content of this report Introduction The Director’s report highlights a range of issues in brief that feature in the ongoing business of the CHP and that are not the current focus of formal papers presented and discussed as substantive items at the CHP Committee meeting. Integration Information on integration and public engagement events are available in the NHS Highland website on the link below. http://www.nhshighland.scot.nhs.uk/OurAreas/ArgyllandBute/Pages/HealthandSocialCareConsultation The integration scheme was formally submitted to Scottish Government in January 2015. This document will provide the framework for the Integration Joint Board to be legally constituted, once passed in statute, this is expected to be in April 2015. Mid Argyll, Kintyre & Islay (MAKI) Mid Argyll The remote and rural project for Mid-Argyll is progressing with the amalgamation of Lochgilphead Medical Practice and Inveraray Practice. 3 GPs have been recruited to ensure appropriate cover in both practices. The OOHs service will be provided from Lochgilphead, with support from Nurse Practitioners based in the hospital, and the community nursing team working to 20.30 hours. A fixed term business manager was appointed to support the administrative aspect of the merging of 2 practices, and work is ongoing in progressing the IT infrastructure. The remote and rural project has acknowledged the triple duty aspect of GPs working in these roles, and a week-long training course has been designed and delivered in Lochgilphead, for all doctors working in non-bypass community hospitals to ensure skills are maintained. A further one week course is planned for September 2015. A review of the remaining continuing care dementia in-patient beds is in progress, with a multi-disciplinary team being identified, to undertake comprehensive assessments of the patients. This information will be used to inform the next steps of the review. Kintyre The Kintyre remote and rural project has recently progressed to an agreed model. Campbeltown Medical Practice will assume responsibility for in-patient care and out of hours services for the entire peninsula, while maintaining their own in-hours GMS work. This model will be supported by Nurse Practitioners based in the hospital and the community nursing team working until 21.30 hours. Campbeltown Practice has successfully recruited 1.5 wte GPs to support this model.

2

The practice in Carradale, currently a single handed practice, will maintain responsibility for in-hours GMS work, and in-patient care will transfer to Campbeltown Practice. Kintyre Medical Group (KMG) will maintain in-hours GMS work, while out of hours and in-patient care will transfer to Campbeltown. Work is currently on-going with KMG to consider options to support the GPs in-hours GMS work, within the remaining resource, across the 3 sites. Work is ongoing to implement an infrastructure of IT and communications to support this cross site working. Public events have been arranged in March to ensure effective communication with the population across Kintyre. It is anticipated this new model could be fully implemented by 1 May 2015. Islay & Jura The Islay and Jura Service Review Implementation Group continues its work to develop safe and sustainable services to the Island populations. The 3 practices on Islay are now operating under a principle partner model, with Drs Pickering and McTaggart as the principle partners, while maintaining services from the 3 practice sites of Bowmore, Port Ellen and Port Charlotte. They are in the process of recruiting further GPs to join their team and provide a triple duty service covering in-hours, out of hours, accident and emergency and hospital care. Work is ongoing to implement an IT infrastructure to support this model. Discussions are ongoing with the GPs on Jura to support them with the service for Jura.

Work is ongoing to move towards an integrated nursing team for the islands. This would see nursing staff working across both the hospital and community to ensure seamless care for patients and develop a flexible sustainable nursing workforce. The next step will be to include social workers, Allied Health Professionals, generic support workers and home carers to develop a larger integrated care team Capital plans are being drawn up to provide 2 dental chairs within the hospital footprint. This would eliminate the use of the existing dental facility being provided in a portacabin. Some redesign of existing services will need to be implemented to enable this to proceed, but it is recognised that the existing dental facilities require significant upgrading and an affordable solution is required. Cowal & Bute / Helensburgh & Lomond Reshaping Care for Older People (RCOP) : 8 Conversation Cafes have taken place across the localities as part of the RCOP & Integration engagement and consultation process. Children’s Executive : The Locality Practice Forum has worked well this year delivering staff sessions across Health, Education and Social Work. Cowal Mental Health : The Team is approaching full establishment after a period of significant staff gaps with the Acting Team Lead continuing to provide leadership locally. Cowal Community Hospital Wards & Day Therapy Centre : following the completion of the refurbishment works, the official opening of the Hospice Day Therapy Centre is on 7 March 2015.

3

Oban, Lorn & Islands Reshaping Care of Older People Services Update : Work with this project continues, and the locality will be looking at ways to use the Integrated Care Fund to progress with initiatives.

The community nursing service is currently undergoing redesign with a move to one team with a corporate caseload for Oban and Lorn area. This will ensure effective team working and peer support.

The Day Hospital Service Redesign has been completed, with patients now referred direct to the Extended Community Care Team for follow up and assessment within the community.

Consultant Services : The locality has a full complement of consultant surgeons. Dr Jorge Cabo has resigned from his post as Consultant Physician with effect from January. Service continuity will be provided by a locum physician pending recruitment to a substantive post. GP Services : The Mull Health Care Review Group approved the CHP proposal to move to an integrated GP service covering Tobermory and Bunessan at their latest meeting. The CHP will now progress to recruiting salaried GP’s and progressing with this new model.

The interim out of hours service for Salen and Tobermory Practices on Mull is now provided by one GP based in the PCEC in the hospital in Craignure. This is working well to date and the rota is populated until June.

From 9 February 2015 out of hours services for Port Appin and Lismore are being provided from Oban PCEC. Pain Service : challenges in the provision of the pain service in Argyll & Bute CHP continue and work is being undertaken with the Planning Department to resolve the issues. Discussions include consideration of input from physiotherapy and psychology to develop and support the service. All new referrals are being administered through Oban to ensure equity of service. Currently the waiting time for pain is 48 weeks.

Audiology Services : discussions are ongoing to provide support to the department due to staffing pressures. Fire : the fire compartmental work at Lorn & Islands Hospital is due to commence on 27 February until mid May 2015. During this time the hospital will reduce its overall bed capacity by 18 beds. Contingency plans have been explored and agreed both within the hospital and with other agencies. A press release has been issued to advise the public of the work being undertaken.

Alcohol and Drugs Partnership (ADP)

On 4 November 2014 Argyll and Bute Council entered into a fixed price outcome based contract with Addaction Scotland for community based adult addiction services which would complement the existing statutory sector services. The purpose of this contract was to provide holistic, person centred and recovery orientated care and support for people affected by addictions within the area of the Alcohol and Drugs Partnership. The service had previously been delivered by five local providers. Concerns have been raised regarding service continuity and that existing service users do not know how to access the new services in Argyll and Bute

4

It was agreed on 18 December 2014 by the ADP Executive to ask Argyll and Bute Council to offer to extend the contracts of the existing service providers till 31 January 2015, in combination with Addaction commencing service provision on 1st January 2015 in line with their contractual requirement. The purpose of this one month extension was to respond to service user concerns, address any potential concerns about accessing services over the festive holiday period and provide time for improved communication and clarity of access for service users in the local areas. The cost of this extension was circa £30k which was met by the ADP. Addaction is providing services in Oban, Dunoon, Islay, Mid Argyll, Kintyre, Helensburgh and on Bute. Addaction has confirmed that its staff are in a position to provide the relevant services throughout the entire partnership area. Both Addaction and the joint Health and Social Work Team (ABAT) are available to service users across the authority in order to provide addiction services as required. The ADP Executive Group decided that additional communications should be undertaken, which included adverts in every local paper, which would further mitigate any remaining risk of people being unclear how to access services locally. The ADP took out advertising space in all local newspapers week commencing 2 February signposting service users to where they can action addiction services in Argyll and Bute. A chronology of the commissioning process has been prepared and reviewed by Legal Services within Argyll & Bute Council. There has been no formal challenge by any tenderer in relation to the commissioning process. From a contractual perspective the Council has in place a binding contract with Addaction which is now beyond the stand still period for challenge by unsuccessful tenderers. Service Users have been sent information of the additional option of accessing services from a supplier of their choice by accessing Self Directed Support. SDS is a requirement of the Addaction contract. The ADP Executive Group discussed the potential advantages and risks of an extension to contracts for a further three months. Concerns were expressed regarding further confusion, lack of clarity re local providers and an impact on the staff TUPE arrangements if contracts were extended. The information presented to the Executive Group provided sufficient reassurance that Addaction are actively providing a service across all areas of the Partnership. Service continuity for service users was the reason for the 1 month extension and this has been adequately addressed over the past month. As of the 1st of February 2015 Addaction will be the sole adult community services provider of the ADP.

The actions taken by the ADP and Addaction have ensured that there is now service continuity

and that a provider was in place to offer services across Argyll and Bute from 1st January 2015.

The offer of a one month extension, accepted by three of the existing service providers across the areas of Argyll and Bute in which they provided services, complemented the services offered by the incoming provider and provided reassurance that there was no gap in service for service users during the transition. In turn it allowed written assurances to be received from the existing providers that their service users had been communicated with regarding the new contract arrangements. Argyll and Bute Council and the ADP are currently working with Audit Scotland as part of our commitment to support people across Argyll and Bute affected by drug and alcohol issues.

1

Argyll and Bute CHP Clinical Quality and Patient Sa fety Report Report by Pat Tyrrell, Lead Nurse and Fiona Campbel l, Clinical Governance Manager

The CHP Committee is asked to:

• Note the contents of the Clinical Quality and Patient Safety Report.

1. CONTRIBUTION TO THE BOARD’S CORPORATE OBJECTIVES The vision of the Highland Quality Approach is:

• Better Health – improving the health of the population • Better Care – enhancing the experience of care for individuals • Better Value – controlling the per capita cost of care

In order to achieve this, the key elements of the Quality Strategy have been adopted: Safe There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. Effective The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Person-Centred There will be mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrate compassion, continuity, clear communication and shared decision-making

Argyll & Bute CHP Committee18 February 2015

Item : 7.1

2

2. RISK MANAGEMENT 2.1 Adverse Events FIGURE 1: TOTAL NUMBER OF ADVERSE EVENTS PER MONTH IN ARGYLL AND BUTE JAN-DEC2014

FIGURE 2: TOTAL NUMBER OF ADVERSE EVENTS BY CATEGOR Y AND LOCALITY OCT-DEC2014

171 163175 180

189174

161 161

188

151170

134

0

50

100

150

200

Jan

2014

Feb

2014

Mar

2014

Apr

2014

May

2014

Jun

2014

Jul

2014

Aug

2014

Sep

2014

Oct

2014

Nov

2014

Dec

2014

Argyll & Bute

0 20 40 60 80 100 120 140

Fire

Medication (including vaccines)

Violent, Aggressive, Disruptive …

Category by Locality/Divison

Cowal and Bute Helensburgh

Mid Argyll, Kintyre & Islay Oban, Lorn and Isles

A total of 455 adverse events were reported during Quarter 3 which is a decrease from previous quarters: Quarter 1 – 543 Quarter 2 - 510 Quarter 3 – 455 Locality Breakdown: Cowal & Bute – 72 (15.8%) Helensburgh – 15 (3.3%) Mid Argyll & Kintyre – 243 (53.4%) Oban – 125 (27.5%)

The top 3 category of adverse events were falls, V&A and pressure ulcers. By locality: Cowal & Bute – transfer/discharge (14), falls (11), V&A / Sharps (6) Helensburgh – falls (3), pressure ulcers (3), medical device (2) Mid Argyll – falls (59), self harm (38), V&A (25) Oban – falls (44), medication (14), pressure ulcers (11)

3

FIGURE 3: TOTAL NUMBER OF VIOLENCE AND AGGRESSION A DVERSE EVENTS JAN-DEC2014

FIGURE 4: TOTAL NUMBER OF FALLS ADVERSE EVENTS JAN -DEC2014

FIGURE 5: TOTAL NUMBER OF FALLS WITH HARM ADVERSE E VENTS JAN -DEC2014

24

3329

4043

25 25

34 34

10

15 16

0

5

10

15

20

25

30

35

40

45

50

Jan

2014

Feb

2014

Mar

2014

Apr

2014

May

2014

Jun

2014

Jul

2014

Aug

2014

Sep

2014

Oct

2014

Nov

2014

Dec

2014

Violence & Aggression

42

2528

4046

54

42

23

3337

43

34

0

10

20

30

40

50

60

Jan

2014

Feb

2014

Mar

2014

Apr

2014

May

2014

Jun

2014

Jul

2014

Aug

2014

Sep

2014

Oct

2014

Nov

2014

Dec

2014

All Patient Falls (harm & no harm)

13

8 9 1012 11 12

6 710

17

8

0

5

10

15

20

Patient Falls with Harm

A total of 41 violence and aggression adverse events were reported Cowal & Bute – 6 (14.6%) Helensburgh – 1 (2.4%) Mid Argyll & Kintyre – 25 (60.9%) Oban – 9 (21.9%)

A total of 114 patient falls with an outcome of harm and no harm were recorded. Cowal & Bute – 10 (8.8%) Helensburgh – 3 (2.6%) Mid Argyll & Kintyre – 58 (50.9%) Oban – 43 (37.7%)

35 of the 114 patient falls had an outcome of harm. Cowal & Bute – 3 (8.5%) Helensburgh – 1 (2.8%) Mid Argyll & Kintyre – 20 (57.1%) Oban – 11 (31.4%)

4

FIGURE 6: TOTAL NUMBER OF HOSPITAL ACQUIRED PRESSUR E ULCERS JAN -DEC2014

FIGURE 7: TOTAL NUMBER OF PRESSURE ULCERS IN COMMUN ITY JAN -DEC2014

FIGURE 8: TOTAL NUMBER OF MEDICATION ERRORS JAN -DE C2014

1

7

2

0

1

2

3

1

6

3

5

3

0

1

2

3

4

5

6

7

8

Hospital Acquired Pressure Ulcers

7 9 96

11

2 4 4 6 74

105

1015

Jan

20

14

Fe

b 2

01

4

Ma

r 2

01

4

Ap

r 2

01

4

Ma

y 2

01

4

Jun

20

14

Jul 2

01

4

Au

g 2

01

4

Se

p 2

01

4

Oct

20

14

No

v 2

01

4

De

c 2

01

4

Patients Developing

Pressure Ulcers in the Community

18

47

96

4 5 57

13 1310

0

5

10

15

20

Medication Errors

11 hospital acquired pressure ulcers were reported. Cowal & Bute – 1 (9.1%) Mid Argyll & Kintyre – 6 (54.5%) Oban – 4 (36.4%) All of these were Grades 1 and 2 Pressure Ulcers, appropriate actions were taken to prevent further damage

12 patients were being treated by primary care teams after discovery of the ulcer(s) in the community. Cowal & Bute – 2 (16.7%) Helensburgh - 2 (16.7%) Mid Argyll & Kintyre 6 (50.0%) Oban – 2 (16.7%) Three of these were Grade 3 pressure ulcers and have been reviewed using Root Cause Analysis. TV nurse is working with local teams to improve early identification and prevention

36 medication errors were recorded. Cowal &Bute – 5 (13.9%) Helensburgh – 1 (2.8%) Mid Argyll & Kintyre – 16 (44.4%) Oban – 14 (38.9%)

5

FIGURE 9: OUTCOME OF ADVERSE EVENTS BY LOCALITY OCT – DEC 2015

FIGURE 10: OUTCOME OF ADVERSE EVENTS BY LOCALITY OC T – DEC 2015

74 1406 4616 25

26

33 756 162 31 4

0 50 100 150 200 250 300

Oban, Lorn and Isles

Locality/Division by Outcome

Incident with no injury, harm or ill health to a person or the service

or the organisation

Near miss (incident prevented)

1

0 0 0 0 0

1 1 1

0

1

0

0.2

0.4

0.6

0.8

1

1.2

RIDDOR Reportable

The outcome of the adverse events reported was noted as: No harm / injury – 266 (58.5%) Near miss – 49 (10.8%) Harm / Injury – 130 (28.6%) Death – 0 Property damage - 10 (2.2%)

There were 2 RIDDOR reportable adverse events in Quarter 3. Cowal & Bute – staff fall resulting in a >7 day sickness absence. Helensburgh – staff moving and handling injury resulting in > 7 day absence.

6

2.2 Significant Event Reviews (SERs) TABLE 1: SIGNIFICANT EVENT REVIEW MEETINGS HELD IN QUARTER 3 No. Case Action Taken Learning/Issues to

be Shared/ Escalated 1. Breach in vaccine cold

chain.

Incident occurred in a GP Practice. Fridge temperature outwith normal range and failure in temperature monitoring systems

- Refreshment of Cold Chain Policy for all staff - Review of fridge temperature monitoring systems - Improved communication between community and primary care staff - Audit of PGD compliance - NES training programme for all staff undertaking immunisation

-Importance of adhering to NHSH Medicines Cold Chain (Refrigeration and Cold Storage Policy) -Ensuring that there is a clear system in place with responsibilities for fridge temperature monitoring assigned to named individuals and that staff undertaking immunisations check that temperatures have been recorded.

2. Transfer of Patient under Mental Health Act to England without the permission of the Scottish Government

- Appropriate authorities informed and legal advice sought - Formal documented risk assessment specific to transfer to be carried out prior to transfer -Develop Easy Read guide on requirements for transfer of patients under Mental Health Act -Improve communication between Consultants and Medical Records -Pursue funding for adapted vehicle for transfers

3. Ambulance en -route to Acute Hospital had to divert to community hospital as patient’s condition deteriorated. Patient died following admission to A&E.

- Improve access to GP Vision system -Improve information sharing between GPs and SAS to support effective emergency transfers

GPs to leave written information with patients along with contact numbers for SAS

7

No. Case Action Taken Learning/Issues to be Shared/ Escalated

4. Delay in Child Protection

referral being instigated from A&E

- Improve assessment and history taking in A&E - Provide clinical supervision for all A&E staff - Develop forum for A&E SCNs -Ensure compliance with Child Protection training - Make sure all staff are aware of guidelines

TABLE 2: SIGNIFICANT EVENT REVIEWS DECLARED IN QUAR TER 3. No Case Actions Taken Lessons to Share

1. Complaint about care received by person with dementia This complaint was subject to a SER. Review of the patient’s care revealed that were a number of areas where improvements were required across the pathway of care. The outcomes of the review and the response to the complaint are still in the process of being compiled.

Report, Action Plan and response to complaint currently being written. An update will be provided in a future report

A report is to be provided to the Patient Centred Care Experience Improvement Group to ensure that learning from the patient’s experience is shared widely.

2. Concerns regarding Child Protection processes A complex complaint was received regarding the way matters were dealt with and the impact on the family.

The complaint is currently being investigated and the SER meeting date has been arranged.

Learning identified through the investigation of this complaint and the SER will be included in a future report.

3. FEEDBACK 3.1 Complaints TABLE 3: ARGYLL AND BUTE COMPLAINT PERFORMANCE REPO RT

ARGYLL AND BUTE

Expected Number

No complaints received 7 Withdrawn Number simple

Simple - achievement against 20 days 80%

Simple - achievement against 40 days 100% Number complex Complex - achievement against 40 days 100% Number further correspondence received Further correspondence - achievement against 20 days 80% Number of high risk complaints received 2

FIGURE 11: NUMBER OF COMPLAINTS RECEIVED JAN 2014

8

TABLE 3: ARGYLL AND BUTE COMPLAINT PERFORMANCE REPO RT

AMBER RED AUGUST SEPT OCT

8 - 9 10 and over 7 3 4

0 1 0 4 2 3

70 - 79 %

69 % and under 0% 0% 33%

90 - 99 %

89 % and under 50% 0% 100%

3 0 1

90 - 99 %

89 % and under 67% n/a 0%

0 0 1

70 - 79 %

69 % and under n/a n/a 0%

3 4 and over 0 0 0

FIGURE 11: NUMBER OF COMPLAINTS RECEIVED JAN 2014 – JAN 2015

OCT NOV DEC JAN

4 4 9 10 0 1 3 2

33% 0%

100% 0% 1 0

0% 0%

1 0

0% n/a

0 1

FIGURE 12: GRADE OF COMPLAINTS FROM JAN 2014

FIGURE 13: TOP 3 COMPLAINTS ISSUES JAN 2014

The overall number of complaints received in Argyll and Butealthough there was an increase in Q3 either low or medium. The top three issues which are identified in complaints are related to staff attitudes/behaviours, procedural issues an Our performance in Argyll and Bute in responding to complaints within the target timescales requires improvement. While we have improved both the quality of the investigation and the written response to complaints, the timescales ilengthened. In order to address this and to identify actions which will enable speedier responses managers will receive further training and support.

9

FIGURE 12: GRADE OF COMPLAINTS FROM JAN 2014 - JAN 2015

FIGURE 13: TOP 3 COMPLAINTS ISSUES JAN 2014 - JAN 2015

The overall number of complaints received in Argyll and Bute remains relatively lowalthough there was an increase in Q3 - and the grades of the majority of complaints are either low or medium. The top three issues which are identified in complaints are related to staff attitudes/behaviours, procedural issues and clinical treatment.

Our performance in Argyll and Bute in responding to complaints within the target timescales requires improvement. While we have improved both the quality of the investigation and the written response to complaints, the timescales in which the process is completed have lengthened. In order to address this and to identify actions which will enable speedier responses managers will receive further training and support.

remains relatively low- and the grades of the majority of complaints are

either low or medium. The top three issues which are identified in complaints are related to

Our performance in Argyll and Bute in responding to complaints within the target timescales requires improvement. While we have improved both the quality of the investigation and the

n which the process is completed have lengthened. In order to address this and to identify actions which will enable speedier

10

4. QUALITY AND SAFETY 4.1 Clinical Quality Indicators (CQIs) Appendix 1 contains three tables showing the latest available results for the standards CQIs for Pressure Ulcers, Falls and Food, Fluids and Nutritional Care. The overall compliance set out for each of these indicators is very good. Audit of compliance with each of the standards is carried out within the wards on a monthly basis. Recent external audit carried out in one ward to quality assure this process has identified some significant discrepancies in findings. In order to assess the extent of this problem we will undertake external audits of each ward in Argyll and Bute during February and March 2015. 4.2 Scottish Patient Safety Programme (SPSP) Lorn and Islands Hospital Appendix 2 contains the latest outcome trend data related to SPSP outcomes in Lorn and Islands Hospital. There has been an increase in raw mortality rate for Q3 - mortality reviews are being carried out to identify any potentially preventable factors.

Work on the Sepsis and Venothromboembolism pathways continue with fairly good results.

5. EXTERNAL REVIEW / INSPECTION

5.1 Older People in Acute Hospitals (OPAH) Lorn and Islands Hospital in Oban had its first inspection (unannounced) by HEI of the standards for older people in acute hospitals. The inspectors spent two days in the hospital on December 3rd and 4th 2014. The report and action plan are included as Appendix 3 to this report. The unannounced inspection covered Ward A (surgical), Ward B (medical/high dependency unit), and Ward I (rehabilitation/stroke/palliative care). The inspectors looked in particular at the standards for the following:

� treating older people with compassion, dignity and respect � screening and initial assessment � person-centred care planning � safe and effective care.

During the inspection, they spoke with staff and patient and carers. They observed what happened in the wards, looking at how staff interacted with patients and what happened at mealtimes. They also received completed questionnaires from 12 patients and two from family members, carers or friends and reviewed 12 patient health records to check the care that they observed was as described in the care plans. They looked at screening and initial assessment for dementia and cognitive impairment, food, fluid and nutrition pressure area care, falls and medicines reconciliation.

11

Overall they found many areas of good practice in Lorn & Islands Hospital which included:

• The psychiatric liaison team work well with staff in the hospital and were spoken highly of by ward staff.

• Multi-disciplinary team meetings between hospital and community staff ensure that care is individualised and is focused on meeting the needs of patients and/or carers.

• Relatives and carers are encouraged to be involved in care, for example at mealtimes.

• Ward staff go to the kitchen prior to meals to check menus and meals for all patients. The inspectors also noted that they saw positive interactions between staff and patients and that staff were actively seeking ways to improve the patients’ experience. Of the 12 patients who completed the questionnaire:

• 100% stated the quality of care they received was good • 92% stated that they get help, if required with eating and drinking, and • 83% stated they had been given clear information about their condition and

treatment The inspectors also noted a number of areas for improvement and these included:

• Where assessments prompt that further action is required, such as referral to specialist services, it should be evident from the patient health records that this has taken place.

• There is a lack of person-centred care plans in place for cognitive impairment, nutritional care, prevention of falls and pressure area care based on the outcome of the assessment.

• Documentation was not always legible, dated or signed. Some of the documentation in use was poor quality photocopies of assessments which made them difficult to read.

5.2 Joint Inspection of Health and Social Work serv ices for Older People in Argyll and

Bute Under Section 115 of the Public Services Reform (Scotland) Act 210, together with regulations made under 2010 Act, the Care Inspectorate and Healthcare Improvement Scotland will jointly be inspecting the provision of health and social work services in the Argyll and Bute community planning partnership areas commencing Monday 27 April 2015. The inspection plans of both the Care Inspectorate and Health Improvement Scotland, approved by Ministers, sets out a commitment to implement a new scrutiny model for the multiagency inspection of adult services that is:

• targeted, proportionate and risk based; • provides public assurance that services are delivering quality outcomes; • informed by assessed needs, rights and risks; • open and transparent; • focuses of continuous improvement and development; • evaluates the consistency of outcomes for people who are supported by health and

social services across Scotland; and

12

• reduces the scrutiny landscape by incorporating sampling of regulated services as part of the model of scrutiny.

This process will support rigorous, fair and objective assessment and inspection of the care of older people and how they are supported by health and social care services to remain in their own homes or in a homely setting. This is consistent with the proposals for the integration of health and social care systems currently being taken forward by the Scottish Government. The inspection report, which will contain graded evaluations, will be published, on the Care Inspectorate and Health Improvement websites following the inspection. There will be an opportunity to provide comment on factual accuracy prior to publication. Advance information comprising Partnership Position Statement; supporting evidence / documentation; and case information, in order that records can be selected for case file reading are required to be submitted to the Inspection Team by Wednesday 04 March 2015. In summary, the Inspection is a 24 week process from notification to provision of draft report and includes:

� Scrutiny of Position Statements and Evidence � Case File Audit – 100 individuals � Staff Survey � Interviews with service users, unpaid carers, staff, groups representing unpaid carers

and advocacy Inspectors will be on site the weeks beginning Monday 27 April; Monday 25 May and Monday 8 June 2015.

6 HEALTH AND SAFETY 6.1 Lone Working The Health and Safety Team in conjunction with the NHSH Violence and Aggression Manager is conducting a series of lone working audits. Initially these are targeting team leads who were assessed as being in the high risk category following completion of a lone working questionnaire. The aim of the audits is to establish how teams are currently managing lone working risks. Once this is established, team leads will be given assistance to develop control strategies and protocols to manage the risk. 6.2 Monitoring of Risk Assessments The risk assessment monitoring exercise undertaken across the CHP has now ended, 87% of all team leads completed the monitoring. The purpose of this exercise was to identify if the team leads had produced risk assessments for their team activities. The table below details the findings.

13

TABLE 4: RISK ASSESSMENT MONITORING: % COMPLETION Location % of team

lead responses to the monitoring exercise

% of teams with any risk assessments

% of teams with no form of risk assessments

% of completed risk assessments against a notional final total

Cowal 100% 84% 16% 65% Helensburgh 100% 100% 0% 97% MACHICC 100% 69% 31% 68% Kintyre 100% 41% 59% 36% Lorn and Isles 100% 62% 38% 53% Bute 100% 86% 14% 86% Islay 54% 43%* 57%* 31%* A&B Hospital 45% 60%* 40%* 50%* A&B CHP Total

87% 68% 32% 61%

* Figures derived from the percentage returned, which is not at 100% The final analysis indicates that the CHP has completed 61% of the required ‘general’, activity/ task based risk assessments. Departments such as Dental, OT, Medical records, Dietetics, Podiatry and X-ray demonstrated consistent completion of risk assessments across each locality. The results of the monitoring exercise show that the CHP has achieved the first target, of 60% completion, as set out within the NHSH Operational Health and Safety Plan. Of the 68% of teams that had risk assessments, 75% were completed during the last few months of the monitoring exercise. A detailed report has been provided to the Director of Operations and Clinical Service Managers and will be tabled at the March CHP Operational Health and Safety Group to discuss recommended actions. 7.0. FIRE SAFETY 7.1 Fire Risk Assessments Fire risk assessments carried out by the CHP Risk Advisor, Fire Safety, using the 3i system continue to progress. Garelochhead, Kilcreggan, Campbeltown, Islay, Lorn and Islands, Dunoon, Rothesay, Mid Argyll, Mull and Iona Community Hospital, Helensburgh VICC, Rothesay Annexe, Rothesay GP Practice, Dalmally, Taynuilt, Inveraray, Furnace, Tarbert Muasdale, Coll, Colonsay, Port Appin, A&B IPCU & Succoth, Aros & Residencies are now complete and have been issued. Action plans are being prioritised locally. Annual audits have been completed for Garelochhead and Kilcreggan Health Centres & Campbeltown, Islay, Lorn & Islands and Cowal Hospitals. A number of action plans still require to be completed by duty holders. Audit requests have been made to MACHICC & Rothesay and completed action plans and dates to visit are awaited from duty holders.

14

7.2 Compartmentation Survey (Interim works) Interim compartmentation work has been completed at Cowal Community Hospital, which has reduced the inpatient risk considerably. Weekly compartmentation meetings around the proposed works for Lorn & Islands Hospital are taking place. Works scheduled to commence 02 March. This will have a significant impact on the hospital’s clinical environment and plans are being developed in partnership with social work and primary care to manage the interim position where there will be reduced bed capacity available from March until May 2015. Funding for work in Campbeltown & Islay has been agreed. 7.3 Training Classroom fire safety training is offered across the CHP, in addition to the on-line LearnPro fire safety module. During 2014, classroom training was delivered in Islay, Lorn & Islands, Argyll and Bute, Cowal and Rothesay Hospitals. Duty holders are responsible for arranging and requesting delivery of training sessions by the Risk Advisor, Fire Safety, to ensure that all staff receive training as per the NHSH statutory & mandatory training prospectus V5.1. 7.4 Fire Incidents In Dec there was only 1 fire alarm attendance reported by Scottish Fire and Rescue Service (SFRS) - an apparatus fault at L&I. Unwanted Fire Alarm Signals (UFAS) are reported via Datix, all are investigated and actions identified to minimise recurrence. From the 01 December the fire service will be conducting more detailed root-cause analysis reports for all UFAS. 7.5 Fire Service Audits The SFRS audit of Rothesay Victoria was carried out on 5th Feb 2015.

15

APPENDIX ONE: CLINICAL QUALITY INDICATOR COMPLIANCE SCORES Table 3: CQI Rates: % compliance with standards for Pressure Ulcer Prevention

16

Table 4: CQI rates: % compliance with Standards for Falls Prevention

17

Table 5: CQI Rates: %compliance with Standards for Food, Fluids and Nutritional Care

APPENDIX TWO: SCOTTISH PATIENT SAFETY PROGRAMME, LO RN AND ISLANDS HOSPITAL, OBAN LORN AND ISLANDS HOSPITAL SPSP OUTCOME MEASURES FIGURE 14: RAW INPATIENT MORTALITY FIGURE 15: CRASH CALL R

FIGURE 16: MEDICINES RECONCILIATION

18

APPENDIX TWO: SCOTTISH PATIENT SAFETY PROGRAMME, LO RN AND ISLANDS HOSPITAL, OBAN

AND ISLANDS HOSPITAL SPSP OUTCOME MEASURES

FIGURE 14: RAW INPATIENT MORTALITY FIGURE 15: CRASH CALL R ATES

FIGURE 17: SAB RATE

Unannounced Inspection Report – Care for Older People in Acute Hospitals

Lorn & Islands Hospital | NHS Highland

This report is embargoed until 10.00am on Tuesday 10 February 2015

3–4 December 2014

kathryn.bell2

Text Box

APPENDIX 3

CONFIDENTIAL – DRAFT REPORT

Healthcare Improvement Scotland Unannounced Inspection Report (Lorn & Islands Hospital, NHS Highland): 3-4 December 2014

2

Healthcare Improvement Scotland is committed to equality. We have assessed the inspection function

for likely impact on equality protected characteristics as defined by age, disability, gender

reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex,

and sexual orientation (Equality Act 2010). You can request a copy of the equality impact assessment

report from the Healthcare Improvement Scotland Equality and Diversity Officer on 0141 225 6999 or

email [email protected]

© Healthcare Improvement Scotland 2015

First published February 2015

The publication is copyright to Healthcare Improvement Scotland. All or part of this publication may be

reproduced, free of charge in any format or medium provided it is not for commercial gain. The text

may not be changed and must be acknowledged as Healthcare Improvement Scotland copyright with

the document’s date and title specified. Photographic images contained within this report cannot be

reproduced without the permission of Healthcare Improvement Scotland.

www.healthcareimprovementscotland.org

mailto:[email protected]



3

Contents

1 Background Error!

Bookmark not defined.

2 A summary of our inspection 6

3 What we found during this inspection 8

Appendix 1 – Areas for improvement 20

Appendix 2 – Details of inspection 23

Appendix 3 – List of national guidance 24

Appendix 4 – Inspection process flow chart 25

Appendix 5 – Terms we use in this report 26



4

1 Background

In June 2011, the Cabinet Secretary for Health, Wellbeing and Cities Strategy announced that Healthcare Improvement Scotland would carry out a new programme of inspections. These inspections are to provide assurance that the care of older people in acute hospitals is of a high standard. We measure NHS boards against a range of standards, best practice statements and other national documents relevant to the care of older people in acute hospitals, including the Clinical Standards Board for Scotland (CSBS) Clinical Standards for Older People in Acute Care (October 2002). Our inspection process is focused on the three national quality ambitions for NHSScotland, which aim to ensure that all care is person-centred, safe and effective. The process includes a planned NHS board visit which allows them to highlight areas of good practice and also areas where improvements could be made. The NHS board visit is then followed up by an inspection to each acute hospital in the NHS board area. We also look at outcomes relating to one or more of the following areas on each inspection:

treating older people with compassion, dignity and respect

screening and initial assessment

person-centred care planning

safe and effective care

managing the return home, and

leadership and accountability.

We are working closely with improvement colleagues in Healthcare Improvement Scotland to ensure that NHS board teams are given appropriate support to deliver improvements locally and to share and learn from others. During our inspections, we identify areas where NHS boards:

must take action in a particular area, or

should take action in a particular area.

If we tell an NHS board that it must take action, this means the improvements we have identified are linked to national standards, other national guidance and best practice in healthcare. A list of relevant national standards, guidance and best practice can be found in Appendix 3. If we tell an NHS board that it should take action, this means that, although the improvements are not directly linked to national standards, guidance or best practice, we consider the care that patients receive would be improved.

About this report

This report sets out the findings from our unannounced inspection to Lorn & Islands Hospital, NHS Highland on Wednesday 3 and Thursday 4 December 2014. This report summarises our inspection findings on page 6. Detailed findings from our inspection can be found on page 8.



5

The inspection team was made up of three inspectors and a public partner. One inspector led the team and was responsible for guiding them and ensuring the team members agreed about the findings reached. A key part of the role of the public partner is to talk with patients about their experience of staying in hospital and listen to what is important to them. Membership of the inspection team visiting Lorn & Islands Hospital can be found in Appendix 2. The report highlights 9 areas of good practice and 12 areas for improvement. You can find all areas for improvement from this inspection in Appendix 1 on page 20. The flow chart in Appendix 4 summarises our inspection process. More information about Healthcare Improvement Scotland, our inspections, methodology and inspection tools can be found at http://www.healthcareimprovementscotland.org/OPAH.aspx

http://www.healthcareimprovementscotland.org/OPAH.aspx



6

2 A summary of our inspection

Lorn & Islands Hospital is a 66 bed general hospital located on the southern outskirts of Oban providing acute and community services within the area. We carried out an unannounced inspection to Lorn & Islands Hospital on Wednesday 3 and Thursday 4 December 2014. We inspected the following areas:

ward A (surgical)

ward B (medical/high dependency unit), and

Ward I (rehabilitation/stroke/palliative care).

Before the inspection, we reviewed NHS Highland’s self-assessment and gathered information about Lorn & Islands Hospital from other sources. This included Scotland’s Patient Experience Programme, and other data that relate to the care of older people. We also carried out a NHS board visit to NHS Highland on Tuesday 18 November 2014. Based on our review of this information, we focused the inspection on:

treating older people with compassion, dignity and respect

screening and initial assessment

person-centred care planning, and

safe and effective care.

On the inspection, we spoke with staff and used additional tools to gather more information. In all wards, we used a formal observation tool and the mealtime observation tool, where appropriate. We carried out nine periods of observation during the inspection. In each instance, members of our team observed interactions between patients and staff in a set area of the ward for 20 minutes. We also carried out patient interviews and used patient and carer questionnaires. We spoke with seven patients during the inspection. We received completed questionnaires from 12 patients and two from family members, carers or friends. As part of the inspection, we reviewed 12 patient health records to check the care we observed was as described in the care plans. We looked at screening and initial assessment for:

dementia and cognitive impairment

food, fluid and nutrition

pressure area care

falls, and

medicines reconciliation.

During the inspection, 79% of the screening and initial assessment documentation we checked was completed correctly.



7

Areas of good practice

We noted areas where NHS Highland was performing well in relation to the care provided to older people in acute hospitals. This included:

The psychiatric liaison team work well with staff in the hospital and were spoken highly of by ward staff.

Multi-disciplinary team meetings between hospital and community staff ensure that care is individualised and is focused on meeting the needs of patients and/or carers.

Relatives and carers are encouraged to be involved in care, for example at mealtimes.

Ward staff go to the kitchen prior to meals to check menus and meals for all patients.

Areas for improvement

We found several areas which require further improvements to be made for the care of older people. Examples of some of these include the following.

Where assessments prompt that further action is required, such as referral to specialist services, it should be evident from the patient health records that this has taken place.

There is a lack of person-centred care plans in place for cognitive impairment, nutritional care, prevention of falls and pressure area care based on the outcome of the assessment.

Documentation was not always legible, dated or signed. Some of the documentation in use was poor quality photocopies of assessments which made them difficult to read.

What action we expect the NHS board to take after our inspection

This inspection resulted in 12 areas for improvement. A full list of the areas for improvement can be found in Appendix 1 on page 20. We expect NHS Highland to address all the areas for improvement. The NHS board must prioritise those areas where improvement is required to meet a national standard. The NHS board has developed an improvement action plan, which is available to view on the Healthcare Improvement Scotland website and the NHS board website for 16 weeks. After this time, the action plan can be requested from Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org/OPAH.aspx We would like to thank NHS Highland and in particular all staff at Lorn & Islands Hospital for their assistance during the inspection.

http://www.healthcareimprovementscotland.org/OPAH.aspx



8

3 What we found during this inspection

3.1 Treating older people with compassion, dignity and respect

Across the wards inspected, we saw positive interactions between staff and patients and patients were referred to by their preferred name. We observed no use of inappropriate language by staff during in any of the wards we visited. All wards inspected were mixed sex wards with patients being cared for in single-sex bays or single rooms. All rooms had en-suite toilet facilities available with ward access to baths/showers. The wards were bright and smelled fresh. However, corridors in some wards were cluttered with various pieces of equipment. Information about clinical quality indicators (CQIs) and a range of condition specific information leaflets was display for patients and visitors. Patients had access to fluids, with the exception of some patients in ward I. Personal items such as hearing aids and glasses were seen to be used. The wards appeared calm with buzzers being answered promptly. There was no personal information on display above the patients bed or in public areas. Large whiteboards that provided specific patient information for staff were only in areas accessible to staff only. We observed patients wearing either their own clothes or night wear. We discussed with staff what they would do if a patient was admitted with no night clothes or clean clothes. Staff told us that they would routinely phone either the next of kin or place of residence, for example a nursing home, to ask if additional clothing could be brought in. If necessary, hospital nightwear would be provided for patients to wear until the additional clothing was brought in. We saw evidence of multidisciplinary team working within all wards inspected, with teams seen working well together. Staff were actively seeking ways to improve the patients’ experience. For example, in ward A they had reviewed the patient’s journey for those attending for endoscopy. A test of change was carried out to reduce the number of moves between departments and people seeing the patient. This has resulted in a more streamlined journey for the patient and reduced the number of handovers required. We observed that it has received positive patient feedback.

Patient and relative comments

We spoke with seven patients during the inspection. The majority of patients we spoke with considered their treatment and care as being good and they felt that clinical and nursing staff engaged well with them when discussing their treatment. However, a few respondents to the patient questionnaires felt they did not feel involved with the care plan nor was this explained to them. Some patients we spoke with said that they felt that the response to the nurse call could be quite slow and once initial response was made, getting the help they needed could be delays to undertaking the required assistance. Of the 12 patients who completed our questionnaire:

100% stated the quality of care they received was good

92% stated that they get help, if required with eating and drinking, and

83% stated they had been given clear information about their condition and treatment.



9

Through our carer and visitor questionnaires, family members, carers and friends had the opportunity to give us their opinion of the hospital. 100% of the 3 people who completed the questionnaire stated that:

‘Staff take the time to get to know the person I am visiting, as a person.’

‘The quality of care the person I am visiting receives is very good.’

‘Staff listen to my views and opinions about the care and treatment of the person I am visiting.’

Patients commented positively through our surveys and interviews.

‘Hospital excellent in every way.’

‘I have found everyone very helpful and very understanding. Due to my age (85) I don't like to bother anyone or cause too much trouble, but I have never felt that in Ward A at all. Staff chat away to me and make me feel worthy again. I cannot fault anyone at all. I have been here for two weeks at this point today and might be here a further two weeks. They have made me feel very welcome and nothing is too much trouble.’

Carers and relatives also commented positively in our surveys and interviews.

‘The staff could not have been more helpful.’

‘Patient is very pleased with the food he receives in the hospital.’

‘All staff have been fantastic with my mother from cleaning staff all the way up, making her feel welcome and looking after her very well. Nothing seems to be too much trouble.’

3.2 Screening and initial assessment

Outcome 1:

The patient is supported to return home (or to a homely setting or care service) or if necessary admitted directly to the correct ward (in this or other appropriate hospital).

Ensuring older people are screened and assessed appropriately on arrival at hospital, including medicines reconciliation. Where initial assessment and screening identifies care needs, a multidisciplinary team completes a detailed assessment without delay. Once the assessments are completed, admission or discharge occurs promptly.

NHS Highland’s self-assessment states that a full patient assessment is carried out on admission which includes:

mobility

food fluid and nutrition

medication

cognition

falls, and

pressure ulcer risk.



10

The assessment findings inform the ongoing care plans. NHS Highland however, acknowledged that documentation is an area for improvement and highlight in the self-assessment that: ‘The revised nursing documentation and associated training, which is due to commence in December 2014, will support this improvement. As part of the implementation of NHS Highland’s revised standardised nursing record and care planning documentation an augmented audit tool is being developed to audit compliance with documentation of all assessments and reviews undertaken and will give a more holistic approach to auditing the older person’s hospital experience.’ During the inspection, documentation was not always legible, dated or signed. Some of the documentation in use was poor quality photocopies of assessments which made them difficult to read.

Do not attempt cardiopulmonary resuscitation

Do not attempt cardiopulmonary resuscitation (DNACPR) relates to the emergency treatment given when a patient’s heart stops or they stop breathing. Sometimes medical staff will make a decision that they will not attempt to resuscitate a patient. This is because they are as sure as they can be that resuscitation will not benefit the patient. For example, this could be when a patient has an underlying disease or condition and death is expected. When this decision is made, opportunities should be taken to have honest and open communication to ensure patients and their families are made aware of the patient’s condition. However, in some cases, clinical staff may decide not to share this information as they feel it may cause too much distress for the patient and their families. During the inspection, we reviewed four DNACPR forms; only one was fully completed. The remaining three forms either did not have review dates or did not state who the form had been discussed with. There were no entries in the medical notes to state why it had not been discussed with the patient.

Dementia and cognitive impairment

During the inspection, cognitive assessment was recorded using the 4AT screening tool in 10 out of 12 patient health records. One patient was assessed using the Mini Mental State Examination (MMSE). One patient’s medical condition meant that cognitive assessment on admission was not a clinical priority. However, there appeared to be no consideration given to if the person could consent to medical treatment or plans to complete cognitive assessment as the patient’s condition improved. It was noted that where the 4AT was completed indicating a possible cognitive impairment, this did not prompt any further assessment of cognition or assessment of capacity to consent to treatment.

Nutritional care and hydration

We were told that each patient has a nutritional assessment carried out, along with nutritional screening using the Malnutrition Universal Screening Tool (MUST). This tool calculates the risk of malnutrition and should be completed within 24 hours of admission. During the inspection, we reviewed 12 patient health records for nutritional care. We found that eight MUST’S had been completed within 24 hours of admission. It was not clear when the MUST assessments were carried out as there was no space for recording the time of screening. It was not stated in any of the assessments if the patient’s height and weight had been measured, estimated or reported. It was unclear how the weight loss component of the MUST was calculated as there was no space on the form to record

http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=121




11

the patient’s usual weight. This can impact on the accuracy of the MUST assessment and medical prescribing for a patient. It will also be unclear if a patient is experiencing weight loss while in hospital. Eight out of 10 patients had re-screening carried out within the weekly timeframe. However, they were not signed by the person carrying out the assessment due to lack of space or prompt on the form for a signature. Nutritional assessments were present in 11 out of 12 patient health records. However, they were always fully or accurately completed. For example, recording a person’s likes, dislikes, assistance required or special requirements.

Falls assessment

A detailed falls assessment document was present in 11 out of 12 patient health records viewed. However, it did not always reflect the individual assessment of the person and appeared more a tick box assessment. For example, the assessment included a cognitive assessment using the 4AT, but this did not reflect if this was a new impairment or if the person had a known impairment, such as delirium or dementia. They also did not always record if the person had a fear of falling. However, it was clear from the NHS Highland board visit that the board is moving towards using the Scottish Patient Safety Programme (SPSP) falls bundles which are being embedded in the inpatient documentation. This will include five screening questions which will identify patients who are more vulnerable to falls and trigger a more detailed assessment by a multidisciplinary team.

Pressure Area Care

NHS Highland’s policy states that all patients within Lorn & Islands Hospital must have a preliminary pressure ulcer risk assessment (PPURA) completed within 6 hours of admission. During the inspection it was noted that nine out of 12 patients had a completed PPURA. Following the PPURA, it was identified that two out of five patients required a more detailed assessment using the adapted Waterlow assessment and both had this carried out. In one of the patient’s health records it could not be established when the initial assessment had been carried out as they had been transferred from another area and the Waterlow assessment could not be found. There was, however, evidence of ongoing assessment since transfer into the inspected ward.

Medicines reconciliation

The Chief Medical Officer (CMO) (2013)18 states that when a patient is admitted to hospital for more than 24 hours, medicines reconciliation should take place. This should include a documented record of the patient’s details and whether they have any allergies. Any medicines prescribed to the patient should only be listed after checking with two or more sources. This can be the patient, a carer, GP, pharmacy or a printed GP letter. There should also be a medicines plan for each medicine to indicate if the medication is to ‘continue’, ‘stop’ or ‘be withheld’. It should be clear who has completed the form and there should also be evidence of a pharmacist review. The medical admission document contains a medicines reconciliation page which contains a list of patient medication and allergies on admission to hospital. These were present in all records viewed. However, they were not always fully or accurately completed. For example, it was not clear when these were completed as they were not all dated, timed and signed. It was not evidenced where the drug information had been obtained from as the boxes identifying source of information were not ticked. Although there were columns to identify medications stopped or withheld, there was no clear identification if a medicine was to continue. There was also no evidence of pharmacy review. In one patient health record, only the patient’s demographics and allergy status were completed. In the other three patient



12

health records, none of the medicines reconciliation forms were completed within 24 hours of admission and the signature of the person completing the form was missing.

Area of good practice

■ Staff at Lorn & Islands Hospital reviewed the patient’s journey for those attending the endoscopy department. This reduced the number of moves between departments and was a more streamlined journey for the patient.


1. NHS Highland must ensure clinical staff consistently comply with the national policy on do not attempt cardiopulmonary resuscitation (DNACPR).

2. NHS Highland must ensure that all older people, who are being treated in accident and emergency or are admitted to hospital, are assessed within the national standard recommended timescales. This includes cognitive impairment, nutritional assessment and pressure ulcer care.

3. NHS Highland must ensure that medicines reconciliation is undertaken within 24 hours of admission to hospital in accordance with the Chief Medical Officer (CMO) (2013)18.

3.3 Person-centred care planning

Outcome 2:

The patient (and their carer, if appropriate) is consulted and involved in decisions about their care.

Ensuring that all care is person-centred and that care plans are developed with the involvement of the patient and their carer, if appropriate.

NHS Highland’s self-assessment states that patient assessments and care plans are developed on admission to hospital in collaboration with patients and/or carers and families. This is a dynamic process that involves ongoing re-assessment and evaluation throughout the period of hospital stay and takes into account changing needs. However, in the notes viewed, the care plans in use were not person centred, individualised and did not provide sufficient detail to guide care. For example, there were no plans in place for a patient who required assistance after having a stroke. It was not clear how the patient’s needs in terms of hygiene, toileting, moving or eating and drinking would be met. They were not updated to reflect ongoing care or changes in the patient’s condition. Staff spoken with stated that the nursing handover, including the handover sheet, is used to communicate care needs to staff on duty. We were told daily board rounds with the multidisciplinary team meetings (both hospital and community staff) take place in each hospital. This allows the team to discuss care needs and progress in order to evaluate and plan care. We observed these during the inspection. These facilitate a more co-ordinated approach to ensuring that care plans are individualised and are focused on meeting the needs of patients and/or carers. NHS Highland recognised that the nursing documentation was an issue. The board stated that it plans to introduce new documentation by the end of January 2015. This will be based



13

on the principles of the nursing process (assessment, care planning, care implementation and evaluation) and the Roper Logan and Tierney Activities of Daily Living Model of Nursing. All wards inspected stated that relatives and carers are encouraged to be involved in care where they wished, for example at mealtimes. There was also evidence in the nursing and medical notes of discussions with families to inform assessments and plans for future treatment.

Care planning for patients with cognitive impairment

Where the 4AT identified a possible cognitive impairment, there were no care plans found to guide care, treatment and management of patients.

Care planning for food, fluid and nutrition

Care plans were in place for patients identified as at risk of malnutrition. The care plans clearly recorded where a referral had been made to the dietitian or that charts were being used to monitor food and fluid intake. However, no care plans were found for patients requiring special diets or needing prompting or assistance to eat and drink.

Care planning for patients who are a falls risk

The falls care plan included prompts for referrals for further assessment, such as medicines review or cognitive assessment. Although these actions were signed as completed by nursing staff, there was no evidence of communication or recognition by medical and pharmacy staff to demonstrate that action had been taken.

Care planning for people with pressure ulcers

Where a risk of pressure ulcer damage was identified, it was not clear due to the lack of care plans what interventions were in place for example, what type of mattress or frequency of the patient’s position being changed. It was unclear how the frequency of SSKIN bundle (skin, surface, keep moving, incontinence, nutrition) was determined. We saw five wound charts and treatment plans in place. However, one did not detail the grade of pressure ulcer but did however detail the aim of the dressing (such as healing or protection).


■ Multidisciplinary team meetings between hospital and community staff that care is individualised and is focused on meeting the needs of patients, relative and carers.

■ Relatives and carers are encouraged to be involved in care, for example at mealtimes.

Area for improvement

4. NHS Highland must ensure that patients have person-centred care plans in place for cognitive impairment, nutritional care, prevention of falls and pressure area care based on the outcome of the assessment.



14

3.4 Safe and effective care

Outcome 5:

The patient, with dementia (or cognitive impairment), experiences care that is tailored to meet their individual needs and promotes their mental wellbeing.

Ensuring that:

care for older people with dementia (or cognitive impairment) meets the Scottish Government Standards of Care for Dementia in Scotland, and

guidelines on use of medication for the behavioural and psychological symptoms of people with dementia and/or delirium are available to all staff.

Dementia and cognitive impairment

NHS Highland recognised in its self-assessment that further work is needed to guide staff on the investigation, treatment and management of people with delirium. It was noted during the inspection that the 4AT has been embedded in NHS Highland for initial assessment. However, where the 4AT identified a possible impairment, it did not prompt further assessment or referral, for example an assessment of capacity to consent to treatment or referral for a more detailed assessment of cognition. Two patients were documented as having dementia despite having no formal diagnosis before admission and no referral to old age psychiatry or other specialist team for diagnosis. This demonstrated a lack of understanding of delirium and cognitive impairment and of the NHS Highland pathway to guide care. However, NHS Highland is currently testing the delirium bundle in Caithness Hospital before implementing it in other areas of the board. During our board visit to NHS Highland, we noted evidence that dementia training was becoming widespread across the NHS board and there is evidence that future training needs were being addressed. There is good use of video-conferencing to support and promote training. Stress and distress training had already begun across the NHS board with evidence of more training in the pipeline. There has been overall enthusiasm from staff wishing to attend the training and no difficulties in staff being released for training, demonstrating a definite commitment from the NHS board.

Adults with incapacity

The adults with incapacity (AWI) form is used to authorise treatment for patients who are unable to consent to treatment themselves. When people who have lost the capacity to make decisions about their welfare are admitted to hospital, it is important to know if they have an appointed power of attorney or guardian. This is someone who is appointed to make decisions on another person’s behalf when they are unable to do so themselves. We saw three AWI forms but only one medical note had a documented assessment of capacity to consent to treatment. None of the certificates were correctly completed to reflect that the principles of the AWI Act were being followed. Examples include the following:

One certificate did not state the proposed interventions or demonstrate that it had been discussed with the patient’s family who it was stated had legal power of attorney. The certificate recorded the incapacity as being due to advanced dementia, although we found no evidence of the patient having dementia diagnosed.

Another certificate stated the intervention as being for ‘fall and sore at sacral area and spinal abrasion’. It stated that the incapacity was due to dementia despite the patient having no recorded diagnosis of this either before admission or during admission to hospital. It was noted during a previous admission that the patient had a diagnosis of delirium and was to be seen as an outpatient for further assessment of cognition and it



15

was not clear what interventions had taken place. The AWI form did not reflect a plan of care for the patient.

When power of attorney is identified it is recognised good practice to obtain a copy of the document to verify that the attorney has the power granted to consent to treatment on the patient’s behalf. One patient health record stated that a relative had power of attorney, but there were no checks made to establish what powers were held. Another patient health record did not reflect information from an admission a couple of months previously which that stated that the son held power of attorney. No checks were made and there was no photocopy of the document in the patients health record. This could result in decisions being made without the legal power to do so. For example, by not consulting the legal decision maker, or by obtaining consent from someone who does not have the legal authority to give consent. NHS Highland recognised in its self-assessment that priority needs to be given to increasing the number of staff accessing education materials available for AWI and that there is a need to improve engagement of medical staff for AWI completion.

Environment for people with dementia and cognitive impairment

Some wards had improved the environment to make it more dementia friendly by using:

picture and word door signs for bathrooms and toilets.

clocks, and

contrast colour in some areas.

NHS Highland has 25 Dementia champions across 4 acute hospital sites. Within Lorn & Island hospital, they have undertaken environmental audits using a recognised environmental audit tool. The findings are currently being reviewed with an action plan to address the issues identified.

Liaison psychiatry service

During our board visit to NHS Highland, we were told that there was good support from the mental health and liaison psychiatry teams in the assessments of patients. Staff on the wards told us that they could access the psychiatry old age liaison team through referral and that they valued this service.


■ NHS Highland’s commitment to providing education and training within the Promoting Excellence framework.

■ NHS Highland providing support to staff through the mental health and liaison psychiatry teams in the assessment of patients.


5. NHS Highland must ensure that where the 4AT score indicates a possible impairment, guidance should be available to staff to prompt further assessment, management and treatment. This should include guidance for referrals to any specialist teams for follow-up.

6. NHS Highland must ensure current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented. In order to do so, all staff who



16

have a professional role in the implementation of the legislation must receive training appropriate to their role.

7. NHS Highland must ensure systems are in place to record key personal information, such as power of attorney, about people with dementia or other cognitive impairments. This information should be used and be shared with staff involved in the care of the patient.

8. NHS Highland must ensure improvements to the ward and hospital environment are carried out to make it more suitable for people with dementia and cognitive impairment.

Outcome 6:

The patient’s status is maintained or improved and appropriate food, fluid and nutrition is provided in a way that meets their individual needs.

Ensuring care for older people meets the NHS Quality Improvement Scotland Clinical Standards for Food, Fluid and Nutritional Care in Hospital.

From the patient health records reviewed, it was clear if a referral to the dietitian had been made following the completion of the MUST. However, where advice had been given, it did not appear to have been consistently acted on or reflected in the plan of care. For example:

A patient had been referred to the dietitian who carried out an assessment of the patient and left instructions for ward staff to commence food record charts and dietary supplements. However, the food recording chart did not have entries for all meals and the supplement recording chart was not always completed to reflect that the supplement had been given or taken. There was evidence of ongoing dietetic input as this patient continued to lose weight.

A patient was admitted to the hospital on 15 September 2014 following a stroke. The nursing record stated that the patient was not alert enough for a swallow test on 17 September 2014, but a referral was sent to a speech and language therapist. There was no evidence of further attempts by nursing staff to carry out a swallow test. The patient was seen by the speech and language therapist on 22 September 2014, who advised a feeding tube insertion, which was done on 23 September 2014. The dietitian was also contacted to advise on a starter feeding regime. The patient had been ‘nil by mouth’ for 8 days before receiving any nutrition. On discussing with the senior charge nurse, we were told that ward staff would only pass a nasogastric tube if the patient had been nil by mouth for 5 days. Staff were not aware of any starter feeding regime protocol held within the ward to start nutritional support over weekends or public holidays.

Management and provision of nutrition and hydration and protected mealtimes

All the wards inspected stated that the ward handover and/or the safety brief is used to communicate which patients require special diets or assistance with meals. During the inspection, the wards inspected stated that protected mealtimes were in place to reduce non-essential interruptions during mealtimes to make sure that eating and drinking are the focus for patients without unnecessary distractions. We saw posters on display to explain protected mealtimes and to indicate when meals would be served. The approach to mealtime preparation varied between the wards inspected. Meals were given out on a timely manner to ensure correct temperature. In one ward, the auxiliary staff appeared to co-ordinate the meals and described how they visit the kitchen an hour before meal times to ensure that every patient has ordered a suitable meal. This ensures that new



17

patients to the ward can choose their meal rather than be given one ordered by another patient. However, not all patients were given a choice of hot or cold drinks with their meal. Many patients were not helped to prepare for their meal and some were not sitting in a safe eating position. We did not see patients being offered hand hygiene but there were hand wipes on patient lockers. Staff told us that could obtain any adaptive aids required through the occupational therapy department. During the inspection, we did not observe any patients who required assistance. In the other ward inspected, a member of staff is the co-ordinator for that mealtime. The role involves ensuring ward staff serve patient meals in a timely manner and that patients are given the appropriate help. Patients are also prepared for their meal, for example helping them out of bed or making sure they are in a comfortable position to eat in bed. We observed patients being offered hand hygiene before meals were served.

Menu and provision of snacks

In all wards inspected, picture menus were available for patients. Staff stated that they could get hot meals during kitchen opening hours for patients who had missed mealtimes. All ward kitchen areas had a supply of snacks available including yogurts for patients with swallowing difficulties. Wards routinely gave patients tea and toast during the evening. Although, one ward did state that due to safety issues, it did not have access to a toaster.

Food and fluid balance charts

Food and fluid balance charts are used to record how much patients are eating and drinking when there are concerns about their intake and output. Charts may be requested by medical staff, dietitians, speech and language therapists or started by nursing staff and food and fluid balance charts were in use but they were completed inconsistently in the wards inspected. Charts were not always completed throughout the day, totals were not calculated and it was not clear how they were informing future decisions or care.


■ Ward staff go to the kitchen before mealtimes to check menus and meals for all patients.

■ All ward kitchen areas had a supply of snacks available, including yogurts.


9. NHS Highland must ensure that that patients’ intake of food and fluid is accurately recorded, monitored and that necessary action is taken if a patient’s intake is inadequate.

10. NHS Highland must ensure that a consistent approach to mealtimes is implemented on all wards and staff co-ordinate the meals appropriately.

Outcome 7:

Where avoidable, the patient does not fall during their stay in hospital.

Ensuring a systematic process is in place to assess older people for the risk of falling (which includes medication review) and individualised controls are implemented to prevent falls or reduce any risk to a minimum.

NHS Highland has a detailed falls assessment which includes information on cognitive impairment, medication, visual impairment and other factors such as appropriate footwear and environment. We saw the detailed assessment had actions ticked as completed, but



18

there was no evidence of medication review or referral to medical staff or specialist team when a new cognitive impairment was identified. There was evidence of referral to physiotherapy and occupational therapy and there was re-assessment where a person’s condition had changed or they had fallen during the admission to hospital. Where a risk was identified and safety measures, such as bedrails were in use, there was evidence of a risk assessment being carried out to ensure their safe use. Ward B has recently been provided with pressure alarms to alert staff to when a person has got out of their bed or chair. There were no risk-assessments in place to inform the decision for use or a care plan to monitor the effectiveness of the intervention. Staff also told us that patients may require a higher level of staff observation to maintain safety. Although this may be appropriate to keep the patient safe, it should also consider the impact on the patient of limiting their freedom to move. Consideration should be given to the Mental Welfare Commissions Rights, Risks and Limits to Freedom (Good Practice Guide, March 2013, page 29). The ward handover and safety brief are used to communicate which patients are at risk of falling. The CQI for falls is fully embedded within NHS Highland and all wards had a completed falls safety cross on display. NHS Highland’s self-assessment states that there are plans to phase out the CQI and replace it with the four SPSP falls bundles by the end of 2015. NHS Highland has also identified that they need to link falls and dementia work more closely.


■ The CQI for falls is fully embedded within NHS Highland, with all wards having a completed falls safety cross on display.


11. NHS Highland must ensure that it considers the Mental Welfare Commissions Rights, Risks and Limits to Freedom (Good Practice Guide, March 2013, page 29) to ensure that the individual’s’ human rights are met.

Outcome 8:

Where avoidable, the patient does not acquire a pressure ulcer during their stay in hospital. If they are admitted with a pressure ulcer their care is tailored to their needs.

Ensuring care for older people is delivered in line with the NHS Quality Improvement Scotland Best Practice Statement for the Prevention and Management of Pressure Ulcers, so patients can be identified as being at risk of a pressure ulcer and receive care to minimise the risk, including access to a local wound care formulary.

NHS Highland self assessment states that reporting pressure ulcer incidence is done by completing the pressure area safety cross and through the electronic incident reporting system. All pressure ulcers are recorded on the incident reporting system. In the wards inspected, safety crosses were utilised and CQI’s were displayed, however on some wards the safety cross was not always kept up-to-date. For example, in one ward one day was coloured green to indicate no pressure ulcers. However, in the patient health records, it was noted that the patient had been transferred from another ward with a pressure ulcer, which should have been reflected in the day being coloured amber. During the NHS Highland’s board visit, we were told that a SSKIN bundle is implemented if the Waterlow score is 15 or greater. There was evidence in the notes examined of SSKIN



19

bundles being in place and being well completed. However, due to the lack of care planning, we cannot be assured that the care being given to patients is appropriate.

Specialist pressure relieving equipment

During the NHS Highland board visit, we were told that wards have access to specialist pressure relieving equipment, such as cushions, heel protectors and mattresses to help prevent pressure ulcers. All wards used electric profiling beds and, if required, had access to high specification mattresses and pressure relieving equipment. Most staff were aware of how to obtain pressure relieving equipment during normal working hours. However, not all staff knew how to obtain this equipment out-of-hours. During the inspection, we saw specialist mattresses and cushions in use. However, due to a lack of personalised care plans, it was difficult to establish if the patient was on an appropriate surface.

Tissue viability service

We were told that NHS Highland has a specialist tissue viability service and that it can be accessed by telephone or an online referral system. This includes the e-clinic, where staff can email photos of wounds and receive online advice. Staff were aware of how to access this service and we saw evidence of referral to this service in the patient health records.


■ E-clinic service where staff can email photos of wounds and receive online advice.


12. NHS Highland must ensure that when a SSKIN bundle is implemented, a care plan is in place which identifies all the patient’s individual needs in relation to preventing and managing pressure ulcers and clearly demonstrates how those needs are to be met.



20

Appendix 1 – Areas for improvement

Areas for improvement are linked to national standards published by Healthcare Improvement Scotland, its predecessors and the Scottish Government. They also take into consideration other national guidance and best practice. We will state that an NHS board must take action when they are not meeting the recognised standard. Where improvements cannot be directly linked to the recognised standard, but where these improvements will lead to better outcomes for patients, we will state that the NHS board should take action. The list of national standards, guidance and best practice can be found in Appendix 3.

Screening and initial assessment

Outcome 1

NHS Highland:

1 must ensure Clinical staff consistently comply with the national policy on DNACPR (see page 12). This is to comply with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Integrated Adult Policy – Decision Making and Communication (Scottish Government, May 2010) & SGHD/CMO(2014)17.

2 must ensure that all older people, who are being treated in accident and emergency or are admitted to hospital, are assessed within the national standard recommended timescales. This includes cognitive impairment, nutritional assessment, and pressure ulcer care (see page 12). This is to comply with Clinical Standards for Older People in Acute Care, Standard 2, Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2, NICE guideline 161 (falls) and Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 2.

3 must ensure that medicines reconciliation is undertaken within 24 hours of admission to hospital in accordance with the SPSP (see page 12). This is to comply with Scottish Government Health Directorate, (CMO) (2013) 18.

Person-centred care planning

Outcome 2

NHS Highland:

4

must ensure that patients have person-centred care plans in place for cognitive impairment, nutritional care, prevention of falls and pressure area care based on the outcome of the assessment (see page 13). This is to comply with Standards of Care for Dementia in Scotland, page 15, Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 2.7 and Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 4.



21

Safe and effective care

Outcome 5

NHS Highland:

5 must ensure that where the 4AT score indicates a possible impairment, guidance should be available to staff to prompt further assessment, management and treatment. This should include guidance for referrals to any specialist teams for follow up (see page 15). This is to comply with Clinical Standards for Older People in Acute Care, Standard 2.

6 must ensure current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented. In order to do so, all staff who have a professional role in the implementation of the legislation must receive training appropriate to their role (see page 15). This is to comply with Adults with Incapacity (Scotland) Act 2000 Part 5 – Medical treatment and research.

7 must ensure systems are in place to record key personal information, such as power of attorney about people with dementia or other cognitive impairments. This information should be used and be shared with staff involved in the care of the patient (see page 16). This is to comply with Standards of Care for Dementia in Scotland, page 26.

8 must ensure improvements to the ward and hospital environment are carried out to make it more suitable for people with dementia and cognitive impairment (see page 16). This is to comply with Standards of Care for Dementia in Scotland, page 26.

Outcome 6

NHS Highland:

9 must ensure that that patients’ intake of food and fluid is accurately recorded, monitored and that necessary action is taken if a patient’s intake is inadequate (see page 17). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 3.6.

10 must ensure that a consistent approach to mealtimes is implemented on all wards and staff co-ordinate the meals appropriately (see page 17). This is to comply with Clinical Standards for Food, Fluid and Nutritional Care in Hospitals, Criterion 4.



22

Outcome 7

NHS Highland:

11 must ensure that consideration is given to the good practice guidance on Mental Welfare Commissions Rights, risks and limits to freedom. This is to ensure that the individuals human rights are met (see page 18). This is to comply with 1.5.3 Human Rights Act, 1998 and the Mental Welfare Commissions Rights, risks and limits to freedom (Good Practice Guide March 2013 page 29).

Outcome 8

NHS Highland:

12 must ensure that when a SSKIN bundle is implemented, a care plan is in place which identifies all of their individual needs in relation to preventing and managing pressure ulcers and clearly demonstrates how those needs are to be met (see page 19). This is to comply with Best Practice Statement for the Prevention and Management of Pressure Ulcers, Section 4.



23

Appendix 2 – Details of inspection

The inspection to Lorn & Islands Hospital, NHS Highland was conducted on Wednesday 3 and Thursday 4 December 2014. The inspection team consisted of the following members: Ian Smith Senior Inspector Irene Robertson Inspector Kenny Crosbie Inspector Ken Barker Public Partner



24

Appendix 3 – List of national guidance

The following national standards, guidance and best practice are relevant to the inspection of the care provided to older people in acute care.

Best Practice Statement for Prevention and Management of Pressure Ulcers (NHS

Quality Improvement Scotland, March 2009)

Clinical Standards for Food, Fluid and Nutritional Care in Hospitals (NHS Quality Improvement Scotland, September 2003)

Clinical Standards for Older People in Acute Care (Clinical Standards Board for Scotland, October 2002)

Dementia: decisions for dignity (Mental Welfare Commission, March 2011)

Health Department Letter (HDL) (2007)13: Delivery Framework for Adult Rehabilitation - Prevention of Falls in Older People (Scottish Executive, February 2007)

National Standards for Clinical Governance and Risk Management (NHS Quality Improvement Scotland, October 2005)

Mental Welfare Commission - Rights, Risks and Limits to Freedom (Good Practice Guide, March 2013, page 29).

Scottish Intercollegiate Guideline Network (SIGN) Guideline 86 – Management of Patients with Dementia (SIGN, February 2006)

SIGN Guideline 111 – Management of Hip Fracture in Older People (SIGN, June 2009)

Standards of Care for Dementia in Scotland (Scottish Government, June 2011)



25

Appendix 4 – Inspection process flow chart

This process is the same for both announced and unannounced inspections.



26

Appendix 5 – Terms we use in this report

Terms and abbreviations

AWI adults with incapacity

CMO Chief Medical Officer

CQI care quality indicator

CSBS Clinical Standards Board for Scotland

DNACPR do not attempt cardiopulmonary resuscitation

MMSE Mini Mental State Examination

MUST Malnutrition Universal Screening Tool

PPURA Preliminary Pressure Ulcer Risk Assessment

SIGN Scottish Intercollegiate Guidelines Network

SPSP Scottish Patient Safety Programme

SSKIN skin, surface, keep moving, incontinence, nutrition


How to contact us You can contact us by letter, telephone or email to:

find out more about our inspections, and

raise any concerns you have about care for older people in an acute hospital or NHS board.

Edinburgh Office | Gyle Square | 1 South Gyle Crescent | Edinburgh | EH12 9EB

Telephone 0131 623 4300

Email [email protected]

www.healthcareimprovementscotland.org

The Healthcare Environment Inspectorate, the Scottish Health Council, the Scottish Health Technologies Group, the Scottish Medicines Consortium (SMC) and the Scottish Intercollegiate Guidelines Network (SIGN) are part of our organisation.

mailto:[email protected]

Improvement Action Plan

NHS Highland

Lorn & Islands Hospital

Care for older people in acute hospitals inspection

Inspection Date: 3 and 4 December 2014

File Name: Lorn and Isles Inspection Report Improvement Plan Jan15 Version: 0.3 Date: January 28th 2015

Produced by: Healthcare Improvement Scotland/NHS Highland Page: Page 1 of 14 Review Date:

Circulation type (internal/external): Internal & External

1

Improvement Action Plan Declaration

It is essential that the NHS board’s improvement action plan submission is signed off by the NHS board Chair and NHS board Chief Executive. It is the responsibility of the NHS board Chief Executive and NHS board Chair to ensure the improvement action plan is accurate and complete and that a representative from Patient/Public Involvement within the NHS board has been involved in developing the improvement action plan. By signing this document, the NHS board Chief Executive and NHS board Chair are agreeing to the points above.

NHS board Chair NHS board Chief Executive

Signature: Signature: Full Name: GARRY COUTTS Full Name: ELAINE MEAD Date: 29th January 2015 Date: 29th January 2015


NHS Highland







2

Ref: Action Planned Timescale to meet action

Responsibility for taking action

Progress Date Completed

1.

SCREENING AND INITIAL ASSESSMENT OUTCOME 1:

NHS Highland must ensure Clinical staff consistently comply with the national policy on DNACPR

1.a 1.b 1.c

Reissue guidance and briefing sessions for all staff SCNs to audit records on weekly basis CSM will carry out overall audit and report results at end February

February 28th 2015

Hospital Clinical Services Manager

Guidance for all staff has been reissued. Clinical Director has briefed medical staff. Further briefings will be delivered during February. SCN audits have commenced.


NHS Highland







3




2.

SCREENING AND INITIAL ASSESSMENT OUTCOME 1: NHS Highland must ensure that all older people, who are being treated in accident and emergency or are admitted to hospital, are assessed within the national standard recommended timescales. This includes cognitive impairment, nutritional assessment, and pressure ulcer care

2.a 2.b

SCNs will audit records on weekly basis to ensure that all assessments are completed within the agreed timescale Implement SBAR report to communicate between A&E and wards where initial assessments have not been completed

February 28th 2015


SCN audits of records has commenced and actions taken to address identified areas for improvement. SBAR tool has been introduced. CSM audit of records to commence in February 2015


NHS Highland







4




2.c

CSM will audit sample of patient records on monthly basis to monitor compliance with standards for assessment and will report to A&B Quality Care in Hospitals Group

3.

SCREENING AND INITIAL ASSESSMENT OUTCOME 1:

NHS Highland must ensure that medicines reconciliation is undertaken within 24 hours of admission to hospital in accordance with the SPSP

3.a 3.b

Pharmacists will sign medicines reconciliation form in addition to Kardex Reinforce for junior doctors need to complete forms in out

January 30th 2015 January 30th

Hospital Senior Pharmacist

Pharmacists have commenced signing the Medicines reconciliation forms after checking. Junior


NHS Highland







5




3.c

of hours, including weekends

Re-audit compliance at end of February and report to A&B Quality Care in Hospitals Group

2015 Feb 2015

doctors reminded of their responsibility and included in briefing for new doctors

4.

PERSON CENTRED CARE PLANNING OUTCOME 2 NHS Highland must ensure that patients have person-centred care plans in place for cognitive impairment, nutritional care, prevention of falls and pressure area care based on the outcome of the assessment

4.a 4.b

Deliver training and practice support for staff in person centred care planning and implementation of new documentation SCNs to identify senior nurse in each team to audit quality of person centred approach to assessment and care planning on an ongoing basis

January 30th 2015 February 8th 2015


Initial training for staff has been carried out. New documentation now being implemented within the hospital for new patients. Senior staff nurses still to be identified.


NHS Highland







6




4.c CSM will carry out further audit, observational study and patient/carer interviews and report in February 2015

April 30th 2015

5.

SAFE AND EFFECTIVE CARE OUTCOME 5 NHS Highland must ensure that where the 4AT score indicates a possible impairment, guidance should be available to staff to prompt further assessment, management and treatment. This should include guidance for referrals to any specialist teams for follow up

5.a 5.b

Implement delirium bundle starting in Emergency Department (ED)and then spread throughout the hospital Audit staff awareness and compliance and report to A&B Quality Care in Hospitals Group

March 31st 2015

Consultant Nurse - Dementia

Elements of the bundle have been implemented in ED. Further staff training and guidance will be delivered prior to spread of bundle across LIH


NHS Highland







7




6.

SAFE AND EFFECTIVE CARE OUTCOME 5 Must ensure current legislation to protect the rights of patients who lack capacity is fully and appropriately implemented. In order to do so, all staff who have a professional role in the implementation of the legislation must receive training appropriate to their role

6.a 6.b

Deliver training for all staff in Adults with Incapacity Act and its application within hospital settings Audit case records on monthly basis to monitor compliance with the requirements of the Act and report to A&B Quality Care in Hospitals Group

February 10th 2015 February 28th 2015

Consultant Nurse- Dementia

All nursing and medical staff have been briefed on requirements. Further training dates set for staff to take place in January.


NHS Highland







8




7.

SAFE AND EFFECTIVE CARE OUTCOME 5 NHS Highland must ensure systems are in place to record key personal information, such as power of attorney about people with dementia or other cognitive impairments. This information should be used and be shared with staff involved in the care of the patient

7.a 7.b 7.c

Deliver training for all staff in Adults with Incapacity Act and its application within hospital settings Ensure that all staff identify, communicate, share and record information on Power of Attorney for people with cognitive impairment Audit and report compliance with these requirements

January 30th 2015 February 28th 2015 February 28th 2015


Training for staff has been scheduled to take place in January. All staff have bee briefed about need to improve information identification, sharing and recording related to PoA.


NHS Highland







9




8.

SAFE AND EFFECTIVE CARE OUTCOME 5 NHS Highland must ensure improvements to the ward and hospital environment are carried out to make it more suitable for people with dementia and cognitive impairment

8.a 8.b

Develop action plan to address areas for improvement identified through audit of environment and include time lines and leads. Progress will be monitored through A&B Quality Care in Hospitals Group Carry out further review with local Dementia Action Group and Alzheimer Scotland

January 30th 2015 March 30th 2015


Recommendations identified from the audit using King’s Fund tool and action plan is being prioritised with senior nurses and estates staff. Discussions have taken place with local dementia Action Group who are keen to be involved.


NHS Highland







10




9.

SAFE AND EFFECTIVE CARE OUTCOME 6 NHS Highland must ensure that that patients’ intake of food and fluid is accurately recorded, monitored and that necessary action is taken if a patient’s intake is inadequate

9.a 9.b 9.c

Ensure that all wards are aware of, and have access to NHS Highland’s guidance for nasogsatric feeding Ensure that all staff understand the starter regime following swallowing assessment Implement ongoing audit and monitoring systems within each ward of fluid balance and food and fluid charts

December 2014 December 2014 January 30th 2015


Guidelines are available in each ward and further staff briefings have been delivered. SCNs developing systems for ongoing monitoring of food and fluid charts.


NHS Highland







11




9.d Provide update report on improvements to A&B Quality Care in Hospitals Group

March 30th 2015

10.

SAFE AND EFFECTIVE CARE OUTCOME 6 NHS Highland must ensure that a consistent approach to mealtimes is implemented on all wards and staff coordinate the meals appropriately

10.a 10.b 10.c

Implement mealtime co-ordinator role for every ward Reinforce need for hand hygiene for all patients at key times, including mealtimes

Carry out observation audit of practice within each ward

February 28th 2015 December 2014 February 2015

Clinical Services Manager

Work underway to implement mealtimes co-ordinator in each ward. Briefing for staff on making sure that patients have access to appropriate hand hygiene facilities at correct times.


NHS Highland







12




11.

SAFE AND EFFECTIVE CARE OUTCOME 7 NHS Highland must ensure that Consideration is given to the good practice guidance on Mental Welfare Commissions Rights, risks and limits to freedom. This is to ensure that the individuals human rights are met

11.a

Develop and implement Standard Operating Procedure to be followed by staff when using safety measures within the hospital to keep patients safe

February 28th 2015

Lead Physiotherapist


NHS Highland







13




12.

SAFE AND EFFECTIVE OUTCOME 8 NHS Highland must ensure that when a SSKIN bundle is implemented, a care plan is in place which identifies all of their individual needs in relation to preventing and managing pressure ulcers and clearly demonstrates how those needs are to be met

12.a 12.b

Train all staff in use of SSKIN Care Bundle to inform individual patient care plans Audit case records to ensure that care plans are being appropriately completed and reviewed. Monitor through A&B Quality Care in Hospitals Group

February 28th 2015

Senior Nurse- Tissue Viability

Training underway for staff and changes in practice being monitored.


NHS Highland







14

1

INFECTION CONTROL REPORT Report by Pat Tyrrell, Lead Nurse, Argyll and Bute CHP 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. Contribution to Board Objectives One of the Board key objectives 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. 3. Summary

TABLE 1 SHOWS NHS HIGHLAND INFECTION PREVENTION & CONTROL TA RGETS AND PERFORMANCE DATA

Group Target NHS Scotland

NHS Highland

Clostridium difficile

Age 15 and over New Target 32.0 (100,000 OBDs) to be achieved by 03/15

42.1 July-Sept 2014

40.0 July-Sept 2014

Red

40.6 Oct-Dec (not yet HPS validated data)

Red (not yet validated)

Staphylococcus aureus bacteraemia

Age 15 and over 24.0 (100,000) AOBDs

32.3 July-Sept 2014

24.7 July-Sept 14

Red

21.94 Oct-Dec (not yet HPS validated data)

Green (not yet validated)

Hand Hygiene 95% 95% 96% Green Cleaning 90% 95%

96.3% Green


Item 7.2

2

Group Target NHS Scotland

NHS Highland

Estates

90% 97% 97.5%

Green

Source: - Health Protection Scotland/ISD/Local data. NHS Highland Clostridium difficile case data (not yet validated by HPS) identifies the position as of 15th January 2015 as, 78 cases (60 cases age 65 and over, and 18 cases aged 15-65years ) against target of 78 by end of March 2015. Based on previous monthly data we estimate the predicted number of cases will be 94 by 31st March 2015. NHS Highland SAB case data (not yet validated by HPS) identifies the position as of 15th of January 2015 as, 44 cases against target of 60 by end of March 2015.The Board remains on trajectory to meet this target. NHS Highland will not meet the Clostridium difficil e target and remain on trajectory to meet the SAB target. .

4. Challenges

• To support all clinical staff in hospitals and the community in the prevention and

reduction of Clostridium difficile infections. • The Infection Control and Prevention team and the Health and Safety team are working

in collaboration with other key members to ensure NHS Highland is prepared to care for a person who potentially has Ebola infection. This is a high priority and as a result is creating a significant pressure on team resources.

• To reduce MSSA bacteraemias by engaging all clinical staff in hospitals and the community in initiatives to prevent and reduce invasive device/healthcare related infections.

• ICNETs (infection control software programme) integration into Argyll and Bute has not yet occurred. Ongoing discussions between ICNET, NHS Highland and Greater Glasgow and Clyde continue around the integration of ICNET and the overall infection prevention and control governance structure. Work is underway to move this work forward however whilst we await the integration of ICNET there is a risk that human factors might result in errors and delays in infection control information being received due to the reliance on the transfer of data manually.

5. Risks Achieving the SAB HEAT target and reducing the incidence of further CDI cases.

3

Argyll and Bute CHP Healthcare Associated Infection Report –

February 2015

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

1. Staphylococcus aureus (including MRSA)

1.1 Staphylococcus aureus bacteraemia target NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, S taphylococcus aureus bacteraemia (including MRSA) cases are 24.0 cases or less per 100,000 acute bed days. For NHS Highland this means no more than approximately 60 cases in year April 2014 ending March 2015. 1.2 Trends National data published by Health Protection Scotland identifies that NHS Scotland Staphylococcus aureus bacteraemia incidence rate July to September 2014 was 32.3 per 100,000 acute occupied bed days (AOBDs), compared to 30.7 per 100 000 AOBDs in the previous quarter. NHS Highland’s SAB incidence rate for July –September 2014 was 24.7 and in October – December 2014, there were 14 Staphylococcus aureus bacteraemia cases, (12 MSSAs & 2 MRSAs) with an incidence rate of 21.94 per 100,000 acute occupied bed days (not yet validated by HPS). It should be noted that whilst there are fluctuations in the quarterly rate of SABs, currently NHS Highland is on “green” in terms of the SAB quarterly report, and in terms of the HEAT target trajectory. Based on annual data, NHS Highland remains the second best performing Board in Scotland for Staphylococcus Aureus bactereamias against comparable Boards (excluding National Waiting Times Centre and non-mainland Boards).

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

47

FIGURE 1: FUNNEL PLOT OF S. AUREUS BACTERAEMIA RATE S FOR ALL NHS BOARDS IN SCOTLAND AGAINST ACUTE OCCUPIED BED DAYS (X100 000) , 1 APRIL 2014 TO 30 JUNE 2014

FIGURE 2: NHS HIGHLAND STAPHYLOCOCCUS AUREUS BACTERAEMIA CUMULATIVE CASE NUMBERS YEAR ON YEAR SINCE 2010.

0

10

20

30

40

50

60

70

April May June July Aug Sept Oct Nov Dec Jan Feb March

Cum

ulat

ive

Cas

e N

umbe

rs

2010-11 2011-12 2012-13 2013-14 2014-2015 Heat Target to 31-3-15

5

FIGURE 3: QUARTERLY ROLLING YEAR STAPHYLOCOCCUS AUREUS RATES PER 100,000 ACUTE OCCUPIED BED DAYS FOR HEAT TARGET MEASUREMENT

TABLE 2 SHOWS THE CUMULATIVE TOTALS FOR SAB WITHIN ARGYLL AN D BUTE CHP FOR THE YEARS SINCE 2009-2010 UNTIL JANUARY 2015 Hospitals 09/10 10/11 11/12 12/13 13/14 14/15 Lorn and Islands, Oban 8 3 0 5 5 0 Victoria Hospital, Rothesay 1 1 0 0 0 1 Mid Argyll Hospital, Lochgilphead 0 1 0 0 0 0 Argyll & Bute Hospital, Lochgilphead 0 0 0 0 0 0 Campbeltown Hospital 0 0 0 0 0 0 Mull and Iona Community Hospital 0 0 0 0 0 0 Islay Hospital, Bowmore 0 0 0 0 0 0 Cowal Community Hospital, Dunoon 0 0 0 0 0 0 There has been one case of SAB in Victoria Hospital , Rothesay since the last report. Enhanced surveillance to identify cause is being un dertaken and will be reported through Infectoion Control Group. 1.3 Current Initiatives

• As of the 1st of October the Infection Control and Prevention Team have begun collecting data for the national enhanced Staph.aureus surveillance database. All NHS Boards will be providing data from their enhanced surveillance to this database, which will provide an epidemiological national perspective.

• The focus for interventions continues to concentrate on infections associated with invasive devices (lines which are inserted into a person to allow access for treatment or monitoring).

0

5

10

15

20

25

30

Apr 12 - Mar 13

Jul 12 -Jun 13

Oct 12 -Sept 13

Jan 13 -Dec 13

Apr 13-Mar 14

Jul 13 -Jun 14

Oct 13 -Sept 14P

Jan 14 -Dec 14

Apr 14 -Mar 15

Actual Performance Target

.

Apr 12 - Mar 13

Jul 12 - Jun 13

Oct 12 - Sept 13

Jan 13 - Dec 13

Apr 13- Mar 14

Jul 13 - Jun 14

Oct 13 - Sept 14(P)

Jan 14 - Dec 14 (P)

Apr 14 - Mar 15

Actual Performance 21.8 21.4 25.0 25.1 25.4 23.4 22.9 22.6 Trajectory 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0

Target 26.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0 24.0

6

2. Clostridium difficile

2.1 Clostridium difficile HEAT Target NHS Boards are required to further reduce healthcare associated infections so that by year ending March 2015, the rate of Clostridium difficile infections (CDI) in patients aged 15 and over is 32.0 cases or less per 100,000 total oc cupied bed days . For NHS Highland that means no more than approximately 78 cases in the year ending March 2015. 2.2 Trends National data published by Health Protection Scotland (HPS) identifies that during Q3 2014, an incidence rate of 42.1 cases per 100 000 acute occupied bed days was reported for NHS Scotland, this represents an increase of 50% compared to the previous quarter when 27.9 cases per 100 000 acute occupied bed days were reported. Seasonality has been observed, whereby the pattern in overall quarterly rates in both age groups in 2014 and in the previous four years shows rising incidence rates in Q2 and Q3 followed by a drop over Q4 and Q1. Despite the observed seasonality, the overall pattern of year-ending rates still shows a steady decline across NHS Scotland in both age groups over the same period. NHS Scotland Clostridium difficile infection (CDI) in patients aged 15 -64 years July - September 2014 was 42.1 per 100,000 bed days. NHS Highland’s rate for the same period was 40.0 per 100,000 bed days. When comparing the year-ending September 2013 data with year-ending September 2014 data, the trend analysis for NHS Highland shows a statistical decrease in our cases of CDI in the 15 – 64 years age range, and no significant change in the age range of 65 years and over. It should also be noted that a significant number of incidences (to date 15 cases) reported by NHS Highland to HPS may relate to the care and management of patients identified previously with CDI. As patients who carry the CDI organism may experience relapses in their symptoms over time (i.e. have further episodes of diarrhoea), which necessitates a repeat sample being taken, outside of the 28 day exclusion criteria. October – December 2014, there were 24 cases of Clostridium difficile infection in patients aged 15 and over with a rate of 40.6 per 100,000 occupied bed days (not yet validated by HPS). 5 cases aged 15-64 years and 19 cases aged 65 years and over. NHS Highland Clostridium difficile case data (not yet validated by HPS) identifies the position as of 15th January 2015 as, 78 cases (60 cases age 65 and over, and 18 cases aged 15-65years; of which 15 cases have been associated with known CDI patients having a relapse in symptoms) against target of 78 by end of March 2015. Based on previous monthly data the predicted number of cases will be 94 by 31st March 2015.

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 within the 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

FIGURE 4: FUNNEL PLOT OF CDI INCIDENCE RATES IN PATIENTS AGED OVER 65 YEARS FOR ALL NHS BOARDS IN SCOTLAND, JULY-SEPTEMBER 2014.

HG = Highland FIGURE 5: FUNNEL PLOT OF CDI INCIDENCE RATES IN PATIENTS AGED 15 – 64 YEARS FOR ALL NHS BOARDS IN SCOTLAND, JULY-SEPTEMBER 2014.

HG = Highland

Argyll & Bute CHP Committee Date of Meeting: February 2015

8

FIGURE 6: NHS HIGHLAND CLOSTRIDIUM DIFFICILE INFECTION CUMULATIVE CASE NUMBERS AGE 15 YEARS AND OVER YEAR ON YEAR SINCE 20 10.

TABLE 3 SHOWS THE CUMULATIVE CD TOXIN POSITIVE CASES IN EACH ARGYLL AND BUTE CHP HOSPITAL FOR THE YEARS SINCE 2009 UNTIL JANUARY 2015

Hospitals 09/10 10/11 11/12 12/13 13/14

14/15

Lorn and Islands Hospital, Oban 0 1 2 1 4 2

Cowal Community Hospital, Dunoon 3 1 2 2 4 0

Victoria Hospital, Rothesay 3 0 1 0 1 0

Mull and Iona Community Hospital 0 1 0 0 0 0

Argyll & Bute Hospital, Lochgilphead 0 0 0 0 1 0

Mid Argyll Hospital, Lochgilphead 0 0 1 0 0 0

Campbeltown Hospital 0 0 1 1 2 0

Islay Hospital, Bowmore 0 0 0 0 0 0 TABLE 4 SHOWS THE CUMULATIVE CD TOXIN POSITIVE CASES IN ARGYLL AN D BUTE COMMUNITY FOR THE YEARS SINCE 2009 UNTIL JANUARY 2015

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

13/14 14/15

North and West Unit

Reported as CHPs

22 8

South and Mid 21

6

Argyll & Bute CHP 2 4 2 2

7

10 (7 pts)

0

20

40

60

80

100

120

Cum

ulat

ive

Cas

e N

umbe

rs

2010-2011 2011-20122012-2013 2013-20142014-2015 Heat Target to 31-3-15


9

3. Hand Hygiene

3.1 Hand Hygiene Reporting Each Board is now responsible for monitoring and reporting hand hygiene compliance data. With effect from April 2014, percentage compliance of each staff group will be reported in the bimonthly report to the Board. 3.2 Trends NHS Highland Hand Hygiene Rolling Monthly Audit Programme continues across all clinical areas sustaining 99% compliance in November and 96% in December 2014. Figures for Argyll and Bute are contained within the report cards in Section 2 –all areas are achieving the compliance target of 95%. 4. Cleaning and the Healthcare Environment

4.1 Current Rates The monthly cleaning and estates audits as per the National Cleaning Services Specification demonstrated 97% compliance in November and 96% in December 2014 for domestic monitoring and 99% for estates monitoring in November and 98% in December 2014. The results for each hospital in Argyll and Bute are included within the charts in section 2 of the report.

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


10

5. HEI Inspection programme From the beginning of January 2015, the Healthcare Environment Inspectorate (HEI) will be introducing inspections of antimicrobial stewardship to all community hospital inspections. The inspectorate has been working with the Scottish Antimicrobial Prescribing Group (SAPG) and the “Association of Scottish Antimicrobial” Pharmacists (ASAP) to ensure robust inspection is implemented to meet Scot MARAP 2 (2014) and SAPG guidance. Inspectors will be looking for clear evidence of antimicrobial management teams’ stewardship of community hospitals, and availability and implementation of antimicrobial policies. Community hospital inspections will continue to be announced, with four weeks’ notice, and visits to these hospitals will focus on the four questions relating to antimicrobials listed below. • Are NHS board policies for antimicrobial prescribing available, in date and reviewed as a minimum every 2 yrs? • Are ward staff able to explain who they seek advice from on good antimicrobial stewardship? • Are ward staff aware of antimicrobial policies relevant to their ward and able to access them? • Is there a system in place for use of alert/restricted antimicrobials? (if used) As part of the inspection the HEI team may also request to meet with the Antimicrobial Management Team (AMT) to seek assurance on questions relating to AMT structure, meetings, reporting etc and antimicrobial education. This would only be necessary if they have not inspected these elements during an acute hospital visit in the past year.

6. Outbreaks/Incidents

6.1 Norovirus

Norovirus is a highly infectious virus that causes outbreaks in the community, healthcare and care settings every year. To help reduce the risk of outbreaks in hospitals, care settings and the wider community, members of the public who think they have norovirus are again being asked to ‘Stay at Home’ until at least 48 hours after any symptoms have passed. As norovirus is so infectious, it is important that everyone plays their part in reducing outbreak risks. To do this, hospitals may suspend access to particular wards to protect patients, staff and visitors from norovirus.

Norovirus has a distinctive seasonal pattern and nationally an increase in confirmed or suspected cases has been reported over this quarter.

Norovirus outbreaks associated with Argyll and Bute CHP

10 Nov 2014 - 14 Nov 2014 Cowal community Hospital Norovirus suspected

26 Oct 2014 – 18 Nov 2014 Struan Lodge Norovirus suspected

22 Nov 2014 – 11 Dec 2014 North Argyll House Norovirus suspected

18 Dec 2014 – 05 Jan 2015 Morar Lodge Norovirus confirmed


11

7. Ebola preparedness

Viral haemorrhagic fevers (VHF) are severe and life-threatening diseases caused by a range of viruses. Most are endemic in a number of parts of the world, most notably Africa, parts of South America (Bolivia, Venezuela, and Brazil) and some rural parts of the Middle East, the Balkans, South Russia and Western China. Currently there is much attention on the VHF virus, Ebola. Ebola’s geographical distribution is Western, Central and Eastern Africa.

Transmission to the first case (known as the index case) is likely to have been through contact with infected animals. Person to person spread is through contact with infected blood and body fluids via a mucous membrane, open wound, or needlestick injury. There is no evidence either circumstantial or epidemiological that aerosol (through the air) transmission occurs.

In the UK, the likelihood of a patient presenting with Ebola is minimal, however most patients who could have VHF are likely to present to Accident and Emergency departments either directly or via their general practitioner.

NHS Highland continue to work under the guidance produced by Health Protection Scotland, based on the Advisory Committee on Dangerous Pathogens guidance September 2014, on the ‘Management of Hazard Group 4 viral haemorrhagic fevers and similar human infectious diseases of high consequence’; to ensure key staff are aware of their role in the risk assessment of potential patients, and the subsequent actions to take. This resolve was tested on the evening of the 29th December 2014, when the On Call Consultant Microbiologist was informed by a General Practitioner that there was a possible case of Ebola within NHS Highland. The patient, who was a visitor to Highland, had returned recently from Sierra Leone. Local and national guidance was followed successfully, and after further consultation with clinical colleagues in NHS Grampian, it was decided that the patient was High Risk for Ebola. The NHS Highland Health Protection Team, in conjunction with Scottish Ambulance Service colleagues, made arrangements for the patient to be transferred to the Regional Infectious Diseases Unit in Aberdeen, as per agreed protocols. Advice was also sought from Health Protection Scotland & Scottish Government. The transfer was accomplished successfully on 30th December. Blood sampling of the patient was achieved whilst en route by NHS Highland staff to expedite diagnosis. Subsequent testing at the Scottish Reference Laboratory in Edinburgh showed the patient was in fact not infected with Ebola. Following this local and national debriefs have been held, in order to share learning.

The Ebola Preparedness Short life working group continues to meet to ensure NHS Highland guidance remains up to date and reflects lessons learnt from national and international experts. This meeting is chaired by Dr Mills, Lead Infection Control Doctor and has a wide range of members from business continuity, health and safety, operational units, and health and social care groups. All operational units have conducted a ‘walk through exercise’ to identify where potential Ebola patients would be cared for, and ‘table top exercises’ have been conducted to ‘test’ resilience. Personal protective equipment is in place throughout NHS Highland, and training on the use of PPE continues to be undertaken.

8. Decontamination

Issues affecting the water quality for the washer disinfector in the endoscopy decontamination unit in Lorn and Islands Hospital have now been resolved and all scopes are being decontaminated within the unit.


12

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 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.


13

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.


14

24

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

CSM Clinical Services Manager

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

HEI Healthcare Environment Inspectorate

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

SCN Senior Charge Nurse

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

25

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 Date of meeting: 18 February 2015

Item 7.3 Public Health Report by : Alison McGrory, Health Improvement Principal on behalf of Elaine C Garman, Public Health Specialist The CHP Committee is asked to: • Note the service updates. • Ensure ongoing commitment to the preventative approach to health improvement,

especially in light of the Integrated Care Fund. • Consider their role in improving the health of Argyll and Bute’s people.

1 Background and Summary This paper provides an update on a number of requested health improvement topics. This is framed within an update on the wider health assets approach to health improvement. The paper includes:

• Asset Mapping • Social Prescribing • Smoking Cessation • Child Health Weight • Adult Healthy Weight and Physical Activity • Dental Health

Argyll and Bute Community Health Partnership has a good track record in investing in community led health improvement and in balancing this with the delivery of national health improvement priorities. The Integrated Care Fund, with its emphasis on a preventative approach, brings further opportunity for investing in health improvement services over the coming year. 2 Main body of report ASSET MAPPING Current thinking in health improvement suggests healthy people arise from healthy communities, eg by being active and building social networks, and from the increased self-confidence and efficacy that subsequently arises. This is known as “salutogenesis” or an “assets based approach”, it involves engaging local communities in finding out what health issues matter to them, responding to what they want and enabling co-production of new services. It also involves removing boundaries and not looking at health deficits, such as smoking or obesity in isolation from the social determinant of health. A key element of an assets approach is an awareness of what services and resources exist in local communities to support healthy living and giving consideration to how people find out about these assets. There is impetus to map assets and resources in Scotland with national direction for this, for example from ALISS (A Local Information System for Scotland – www.aliss.org) and from Living it Up. Local asset mapping has taken place following a partnership approach between NHS, local authority, third sector and community representatives. A working group has been meeting for over 12 months. More than 4,000 community assets have been identified and the current phase of activity involves uploading them online. Work is also underway to encourage

2

partners to promote their activities online and there are significant opportunities for joint working with the local service ABAN (Argyll and Bute’s Advice Network). Properly mapped assets can be used in a number of ways:

• Informal signposting for the wider public • Social prescribing for people less able to access services • Staff better able to find other services for their client group

SOCIAL PRESCRIBING Social prescribing can benefit specific population groups, such as, people with common mental health problems or frequent attendees of primary care services. It recognises wider social determinants of health. Social prescribing is defined as: A mechanism for linking patients in primary care with non-medical sources of support within the community. These might include opportunities for arts and creativity, physical activity, learning, volunteering, mutual aid, befriending and self-help, as well as support with, for example, benefits, debt, legal advice and parenting problems. Health Scotland 2007 We have some good practice with social prescribing in Argyll and Bute, for example Oban and Lorn Healthy Options (LOHO) and Argyll Active. The Many Conditions, One Life guidance from the Joint Improvement Team for utilising the Integrated Care Fund, contains the following recommended action: introduce local volunteers and new roles in GP practices to simplify access to local sources of community support, including support for unpaid carers. This will be pursued by locality ICF implementation groups and should be considered at forthcoming locality workshops looking at services for people with multi-morbidities. SMOKING CESSATION The HEAT target from the Scottish Government for smoking cessation changed in April 2014 to measure quit rates over a 3 month period rather than the previously measured 1 month period. 40% of these quits should come from the most deprived SIMD areas. The Highland wide trajectory is to achieve 582 quits during 2015 - 2016. Due to the small numbers a trajectory is not provided for Argyll and Bute CHP. From April - June 2015 there were 79 recorded 3 month quits from an expected 146. This has been tabled at the Improvement Committee. All NHS Boards are underperforming on this target. One reason for underperformance may be under reporting of people who quit with support from community pharmacies following the implementation of the new pharmacy contract in July 2014. NHS Highland launched a revised smoke-free policy in December 2014 and is counting down to having smoke free grounds across all sites by the end of March 2015. As part of the Scotland-wide initiative, the smoke-free policy aims to guarantee everyone entering NHS Highland premises, vehicles and grounds, has the right to breathe air free of tobacco smoke. Smoke-free grounds should have been in place throughout Scotland since 1st January 2008 but this has not always been the case. A key issue for the local implementation of this policy relates to managers and staff reminding people who smoke of the policy and enforcing the policy requirements if required. Another important aspect is within acute admissions providing advice and support for smokers, for example, nicotine replacement therapy. Smoking cessation throughout Argyll and Bute is largely delivered by GP practices, with the exception of Kintyre and Bute. This arrangement has evolved over some 3 years as smoking cessation advisors have left post and there have been difficulties recruiting new staff. From April 2015 a new payment arrangement for practices, based on per head of population, will be implemented. This is resulting in some practices receiving a lower payment and some receiving a higher payment.

3

CHILD HEALTHY WEIGHT Fit-ness was an 8 week multi-agency programme on Bute delivering healthy weight interventions with children and their parents. The aim of the programme was to ensure: family fun; healthy diet awareness; increased physical activity; enhanced parent/child attachment; and improved mental health and well-being. The programme was delivered on Sunday afternoons, 34 primary school pupils regularly attended along with 22 parents. The programme was successful in tackling the child healthy weight agenda in an innovative, novel and fun way. Families reported the variety of activities and motivation of the team delivering the programme encouraged them to come back each week, also inspiring four families to sustain a more active lifestyle beyond the programme, for example, by children attending swimming lessons, participating in active schools events and parents attending additional exercise classes. This activity won a Cosla Bronze Award. An innovative event took place in the autumn of 2014 in Campbeltown to engage the whole community in promoting healthy and sustainable food messages. Partners included NHS Highland, schools, families and local food producers and the lead was the social enterprise Inspiralba. Funding was provided from the Scottish Government’s Food for Thought programme with an additional £1,000 from the NHS healthy weight budget. Local primary schools identified a lead teacher who developed lesson plans with a range of activities including visiting local food producers. The festival culminated with a performance of the Barrowband which was attended by 120 parents and children. These 2 events are excellent examples of partnership working and co-production being used to address the causes of childhood obesity i.e. inactivity and unhealthy food choices. There have been challenges in Argyll and Bute in delivering HEAT target interventions, however further work has taken place across all schools on community wide healthy eating under the curriculum for excellence. Plans are being developed to ensure the 2015-16 budget is invested as early as possible in the new financial year to co-produce local services in other communities. ADULT HEALTHY WEIGHT INCLUDING PHYSICAL ACTIVITY A structured 4 tier, menu-based weight management pathway, with clear routes into and out of each tier has been in place in Argyll and Bute since 2013. A dedicated dietitian oversees the pathway and this is seen as being instrumental to the success of the service. Tier 1 is community based activity for the general population and funding has been provided to a number of initiative such as the food festival described above. It is recognised there is much more potential for action in tier 1. Tier 2 is primary care based support for people who wish to address their body weight with one-to-one or group support provided via the Counterweight programme. Counterweight is also available in tier 1 by self-referral. More than 30 practitioners are now trained to deliver Counterweight from a range of settings including local authority, NHS and third sector. Since April 2014, 76 people have participated in Counterweight bringing the total to 160 since the programme began. Counterweight takes place in a range of NHS and community locations including Dunoon Carers Centre, Atlantis Leisure Centre and Centre 81 in Garelochhead. Tier 3 is triaged care for specialist support for behavioural change therapy and has the option of Counterweight Plus. Twenty five people have been referred into this tier in 2014/15 including 2 from tier 2 which provides reassurance that the tiered approach and triage system is working. Tier 4 is consultant led care and to date there have been no referrals for bariatric surgery from the Tier 3 service. It is considered that there is transferable learning from adult healthy weight management that would benefit the approach to child healthy weight.

4

In January 2015 the Community Planning Partnership launched a new position statement on physical activity. This is a partnership policy that is owned and actioned by the Health and Wellbeing Partnership. Further details can be found here: www.healthyargyllandbute.co.uk/physical-activity-strategy/ There are seven target areas in the new strategy: 1. Maintain provision of physical activity within & beyond the school gate. 2. Facilitate greater levels of physical activity within the workplace. 3. Maintain provision of physical activity within recreational or leisure settings that are inclusive and accessible to all. 4. Support physical activity for older adults and those with long-term conditions. 5. Enhance the promotion of physical activity within healthcare settings. 6. Promote and maintain environments which support rather than hinder physical activity. 7. Facilitate greater partnership working and effective communication. DENTAL HEALTH The National Dental Inspection Programme continues and measures decay free experience in primary teeth of P1 children. Results are:

• Argyll & Bute CHP 75.8% • Highland 70.1% • Scotland 68.2%

Although this is an improvement, 25% of our children still experience tooth decay and the negative impact of this disease. The HEAT 9 target required at least 60% of 3 & 4 year old children in each SIMD quintile to receive at least two applications of fluoride varnish per year by 2014. Minimum rate by Health Board SIMD quintile:

• Argyll & Bute CHP 23.8% • NHS Highland 14.9% • Highland H&SCP 10.8%

All Health Boards in Scotland recognised from the outset that it would be challenging to achieve this target. Argyll and Bute CHP has made steady progress over time, showing children living in SIMD quintiles 1, 2 &3 respectively as 56%, 44.4% & 38.2%. A final report is expected late February or March this year. An oral health and smoking cessation DVD was developed and produced from funding received via the Health and Wellbeing networks in Cowal and Bute. The DVD was recognised for awards by the British Heart Foundation and the Scottish Dental Awards. National Programmes Childsmile Core, Nursery and School and Practice are being delivered throughout A&B CHP. Smile4life is being delivered and supported with partner agencies. A training programme is currently being delivered to staff supporting homeless clients in localities throughout Argyll and Bute CHP. This training offers knowledge, skills and resources for staff and their clients, e.g. toothbrushes, toothpaste, oral health advice, contact numbers of local dental services and named staff that can support access to dental services.

5

CaringforSmiles training package is being delivered to staff in the carehome setting as well as hospital wards and support agencies. A newly developed SCQF training programme was delivered to a carehome worker in Kintyre as part of a national pilot and she was successful in achieving the foundation level with 2 credits. The national perspective is this training package will be delivered in all Health Board areas, improving knowledge and skills of staff looking after our older population living at home and in the carehome setting. 3 Recommendations The CHP Committee should:

• Continue leadership support for the upstream preventative approach in line with recommendations from the Christie Commission.

• Ensure the potential to improve health is achieved by appropriate investment of the Integrated Care fund.

4 Contribution to Board Objectives These obviously do change from time to time but the link at the moment to the corporate objectives is: http://intranet.nhsh.scot.nhs.uk/Resources/Templates/Documents/Quality%20Objectives%202012-14.doc 5 Governance Implications The example below is from a paper on health promoting health service – you would write whatever the implications are for your topic.

• Staff Governance: the report calls for staff to embrace the ethos of every healthcare

contact is a health improvement opportunity, which will have training and customer care implications for staff

• Patient and Public Involvement: the report should ideally be widely discussed with patients and the public to ensure full implementation of its recommendations

• Clinical Governance: the report calls for health improvement to be set out in care pathways

• Financial Impact: the report contains no specific resource requirements, but does support interventions aimed at reducing use of hospital-based health care which may result in cost savings

6 Risk Assessment Risk assessment is not required for anything in this paper. The risk of not achieving the smoking cessation target has been recognised and tabled at the Improvement Committee. 7 Planning for Fairness Planning for Fairness has not been done. Reducing health inequalities is inherent in public health interventions and this is always considered during service planning.


Item : 8.1 FINANCE REPORT REPORT BY : George Morrison, Head of Finance, Argyl l & Bute CHP The CHP Committee is asked to; • Note the year-to-date financial position • Note the requirement for management action to support the Health Board in achieving a

year-end break-even position 1. Year-to-date Position For the nine months ended 31st December 2014, Argyll & Bute CHP recorded an overspend of £38,000. This is a slight deterioration of £5,000 from the overspend of £33,000 recorded at the end of November. It is concerning that the overspend increased in December when there is an expectation that the CHP will deliver a year-end underspend. The in-month deterioration was caused by increasing expenditure on prescribing, individual patient treatments/care packages and locum GPs, all of which offset the benefit achieved through improved spending controls elsewhere. Table 1 below provides details of budgetary performance across Argyll & Bute CHP for the first nine months of the financial year.

Table 1: Financial performance by budget at 31 st December 2014 Year to Date

Budget Annual Budget £’000

Budget £’000

Actual £’000

Variance £’000

Forecast Outturn

Oban, Lorn & Isles Locality 20,061 14,948 15,316 (368) (485) Mid Argyll, Kintyre & Islay Locality 17,322 12,940 13,172 (232) (338) Mental Health In-Patient Services 7,618 5,594 5,557 37 100 Cowal & Bute Locality 12,824 9,573 9,370 203 300 Helensburgh & Lomond Locality 4,793 3,616 3,591 25 50 Salaried Dental Service 3,750 2,783 2,608 175 230 Other Clinical Services 5,893 3,721 3,657 64 200 General Medical Services 15,786 11,746 11,917 (171) (206) Prescribing 17,207 12,997 13,397 (400) (500) Dental, Ophthalmic & Pharmacy 8,052 6,116 6,116 0 0 Services from NHS GG & C 51,602 37,525 37,525 0 0 Commissioned Services 4,287 3,190 3,290 (100) (240) Resource Release 4,609 3,457 3,457 0 0 Depreciation 2,682 1,991 1,991 0 20 Management & Corporate 9,123 6,991 6,876 115 144 Budget Reserves 1,291 600 0 600 1,000

Total Expenditure 186,900 137,788 137,840 (52) 275 Income (1,272) (988) (1,002) 14 25 Net Budget Position 185,628 136,800 136,837 (38) 300

Expected Yield from Management Action 400

Forecast year-end outturn 700

2

2. Analysis of significant cost pressures There are 5 budgets which are reporting significant overspends. These are; Prescribing - £400k overspent Oban, Lorn & Isles Locality - £368k overspent Mid Argyll, Kintyre & Islay Locality - £232k overspent General Medical Services - £171k overspent Commissioned Services - £100k overspent The main causes of these overspends are noted below; i) GP Prescribing This budget was increased by 1% (net of savings) however costs have risen by 4% on last year. This is due partly to an increasing elderly population and partly to increases in certain drugs being prescribed by some practices. ii) Oban, Lorn & Isles Locality Medical consultants - £220k due to locums covering vacancies and sickness absence Surgical consultants - £82k locum costs and visiting urology service Audiology Services - £27k use of agency staff to cover sickness absence Mull Community nursing - £25k excess pay costs – due to maternity leave cover Telecomms - £20k costs arising from new BT contract Laboratory services - £19k mainly due to increased pay costs Porters and Drivers - £17k ongoing excess staffing iii) MAKI Locality Kintyre Medical Group - £92k use of agency locums Islay Hospital Nursing - £39k bank nursing and near patient testing consumables Islay Catering - £26k excess staffing costs Campbeltown Telecomms - £19k costs arising from new BT contract Campbeltown Hospital - £18k near patient testing consumables iv) General Medical Services The main cause of the GMS budget overspend is locums covering vacant practices in Inveraray, Port Charlotte and Bunessan plus maternity leave cover in several practices; Rothesay, Lochgoilhead, Oban and Tighnabruaich. v) Commissioned Services Huntercombe/The Priory - £119k increased volume of referrals SAMS - £59k referrals for decompression treatment Golden Jubilee Hospital - £46k increased referrals for cardiac surgery It is worth highlighting that the CHPs forecast year-end underspend is dependent on several budget underspends, slippage of £1m on budget reserves and further management action which has yet to be delivered to offset these overspends.

3

3. Cost Improvement Programme As part of the 2014/15 budget setting exercise we agreed to a £3.4m recurring savings plan. Table 2 below summarises progress towards achievement of these recurring savings in the current financial year.

Table 2: Argyll & Bute CHP Cost Improvement Program me 2014/15

Recurring Savings Targets Responsible Manager

Target £' 000

Declared Achieved

£' 000 Shortfall

£'000

Oban, Lorn & Isles - 575 69 506 Mid Argyll, Kintyre & Islay L Paterson 514 151 363 Mental Health Services J Dreghorn 219 219 0 Cowal & Bute V Hamilton 381 49 332 Helensburgh & Lomond V Hamilton 147 58 89 CAMHS J Dreghorn 13 7 6 Child Health C West 5 5 0 Learning Disabilities J Dreghorn 16 16 0 Community Dental Services E Reilly 20 20 0 Prescribing F Thomson 511 380 131 Lead Nurse P Tyrell 30 27 3 Public Health E Garman 32 32 0 Practitioner Services J Robinson 6 0 6 Director of Operations C West 23 23 0 Finance & Procurement G Morrison 21 21 0 Human Resources G Boyd 15 5 10 E-Health S Whiston 34 0 34 Planning & Performance S Whiston 10 6 4 Pharmacy Management F Thomson 11 11 0 Commissioned Services C West 121 121 0 Displaced Staff C West 69 26 43 Depreciation G Morrison 590 590 0 Income G Morrison 37 37 0

Totals 3,400 1,873 1,527 At the end of December, there was a shortfall of £1.527m against the agreed recurring savings target. It is clear from the table that limited progress has been made in some areas with regards to achieving savings. This shortfall against the savings plan carries forward into 2015/16 and increases the scale of the financial challenge next year. 4. Forecast Outturn I am now forecasting a year-end underspend of £700,000 for Argyll & Bute CHP. This comprises £500,000 to be achieved from general fund budget underspends plus an additional £200,000 forecast underspend on the ADP budget which has recently been identified. I am concerned about the CHPs ability to deliver a £500,000 underspend on general fund budgets due to ongoing pressures in prescribing, care packages and locums. There will need to be a significant effort from managers in the remaining weeks of the financial year to contain and reduce expenditure if the forecast £700,000 underspend is to be achieved.


Item 8.2

ARGYLL & BUTE CHP FINANCE DEPARTMENT 2015/16 REVENUE BUDGET REPORT BY GEORGE MORRISON

The CHP Committee is asked to;

• Note and approve the calculation of the 2015/16 rev enue budget

• Approve the content of a £4.0m savings plan to achi eve a balanced budget

1. Summary of 2015/16 Revenue Budget The funding uplift available to Argyll & Bute CHP in 2015/16 is £4.835m. This comprises two elements;

• a general 1.8% funding uplift of £2.745m • a “move to NRAC parity” uplift of £2.090m

Against this, detailed analysis of existing cost pressures and forecast cost growth in 2015/16 has been assessed at £8.835m. Table 1 below summarises this position and tables 2 to 5, provided later in the paper, provide a detailed analysis of cost pressures and forecast cost growth.

Table 1 : Revenue Budget Summary

£ ' 000 £ ' 000 Cost Pressures and Forecast Cost Growth Savings shortfall from 14/15 [table 2] 1,469

Cost pressures from 14/15 [table 3] 724 Provision for cost increases [table 4] 3,370 Approved and Anticipated Commitments [table 5] 3,272

8,835 2015/16 Funding Uplift 1.8% on Unified Budget funding 2,745 NRAC uplift 2,090

4,835

Budget deficit/Required savings programme [table 6] 4,000

In summary, forecast cost growth exceeds the available increase in funding by £4.0m. There is therefore a need to implement a £4.0m savings plan in 2015/16. Experience in recent years has demonstrated the difficulty of delivering large scale savings. Indeed in 2014/15, the recurring savings plan of £3.4m is likely to be underachieved by almost £1.5m and, as the shortfall carries forward, this is a contributory factor to the size of the savings target in 2015/16.

2

Table 2 : Savings Shortfalls from 2014/15

Target

Declared

Shortfall 2014/15 Savings Targets £ ' 000 £ ' 000 £ ' 000 Oban, Lorn & Isles 575 69 506 Mid-Argyll, Kintyre & Islay 514 151 363 Argyll & Bute Hospital 219 219 0 Cowal & Bute 381 79 302 Helensburgh & Lomond 147 58 89 CAMHS 13 7 7 Child Health 5 5 0 Learning Disabilities 16 16 0 Community Dental Services 20 20 0 Prescribing 511 380 131 Commissioned Services 121 121 0 Practitioner Services 6 0 6 Director of Operations 23 23 0 Finance & Procurement 21 21 0 Human Resources 15 5 10 E-health 34 28 6 Planning & Performance 10 6 4 Pharmacy Management 11 11 0 Public Health / Health Promotion 32 32 0 Lead Nurse 30 28 3 Displaced Staff 69 26 43 Depreciation 590 590 0 Income 37 37 0 Totals 3,400 1,931 1,469

Table 3 : Cost Pressures from 2014/15

Service Cost Pressures in 2014/15 £ ' 000 Comment ABAT 37 Nursing posts in Kintyre and Bute Near patient testing consumables 50 Increased use in all hospitals Dunoon N3 upgrade (ehealth) 15 Recurring costs relating to infrastructure investment Prescribing 269 Forecast year-end overspend (in excess of unachieved savings target) Communications 114 Increased costs arising from implementation of BT contract Mull OOH 120 Arising from GP opt out Custodial Healthcare 70 Cowal & Helensburgh out of hours costs GJNH - Cardiac & Cardiology Services 49 Increased activity

724

3

Table 4 : Provision for cost increases Base Uplift

On existing budgets ; £ ' 000 % £ ' 000 Pay awards @ 1% 51,401 1.0

514

Incremental Drift 0.2

100 Employers pension cost increase 1.4

720

Rates 984 1.8

18 Travel & Subsistence 1,554 0.0

0

Business to Business Contracts 2,287 1.0

23 OOH's / Availabilty / Daytime 342 1.0

3

Energy – Electricity / Gas / Oil 2,060 1.8

37 Resource Transfer 4,560 1.8

82

Depreciation 2,427 1.0

24 Prescribing 17,207 4.0

688

Hospital drugs 1,964 1.8

35 Service Input SLAs 4,429 1.0

44

GG&C Patients' Services SLA 51,580 1.8

928 Other Commissioned Services 4,275 1.8

77

PFI Contract 1,837 1.8

33 General Supplies inflation 8,429 0.5

42

Expenditure subject to specific allocations 6,708 0.0

0 General Medical Services 15,754 0.0

0

Primary Care non-cash limited services 8,052 0.0

0 Income Budgets (1,830) 0.0

0

184,021

3,370

Table 5 : Approved and Anticipated Commitments

Proposal £ ' 000 Comment GG&C in-patient, day case & out-patient services 2,000 Contribution to claimed £5.6m funding gap GG&C Homecare Drugs 100 Expensive anti TNF drug developments GG&C Beatson Satellite Clinic 70 Approved WoS development GG&C Sexual Health Services at Sandyford 68 Relates to services which were not previously charged GJNH - Cardiac Services 66 Forecast activity growth in single ventrical and cardiac

bypass procedures GJNH - Cardiology Services 338 Updated model reflecting activity growth agreed by WoS

DoFs NSD service developments 50 Cochlear activity, upgrade HDU beds to PICU, additional

adult renal transplant activity Commissioned Services - New Care Packages 250 Growth in approved new care packages Child Protection Services - increased contribution 20 Core Team 28/2/14 - paper 10 (year 2 of 3) Diabetic Retinopathy Screening 4 Core Team 2/5/14 Teleneurology clinics - Oban & Campbeltown 7 Core Team 24/10/14 Development of an obstetric ultrasound service 120 Core Team 22/12/14 Development of audiology service 20 Core Team 22/12/14 Strategy for autism 20 Core Team 30/1/15 - limited provision Change Fund recurring investments 89 Shortfall against resource released from bed closures Depreciation costs arising from 14/15 capital programme 50 Based on 14/15 capital investment

3,272

4

3. Savings Plan 2015/16 The key issue is the requirement to achieve savings of £4.0m. Table 6 below contains details of proposals to achieve these savings. The table contains some difficult proposals. It includes a general 3% savings target against budgets plus additional measures to reach the required target.

Table 6: Savings Plan 2015/16

Recurring Savings Targets (@3%)

Responsible Manager £ ' 000

Oban, Lorn & Isles Locality Marie Law / Lorraine Paterson 596 Mid Argyll, Kintyre & Islay Locality Lorraine Paterson 514 Argyll & Bute Hospital - Mental Health Service John Dreghorn 221 Cowal & Bute Locality Viv Hamilton 382 Helensburgh & Lomond Locality Viv Hamilton 142 Other CHP-wide Clinical Services Various 64 Prescribing Fiona Thomson 516 Commissioned Services Christina West 128 Depreciation George Morrison 74 Management and Corporate services Various 116 Public Health/Health Promotion Elaine Garman 34 Lead Nurse Pat Tyrell 35

sub total 2,823 Additional Measures Discontinue HCHS payments to GP practices 366 Restrict RT uplift to 1% 36 Income 25 Reduce mental health bridging 300 Review of budget reserves - recurring saving 250 Slippage on budget reserves - non-recurring saving (Increase from £300k) 200

Grand Total 4,000

The CHP Committee is asked to consider these proposals and approve them to achieve a balanced revenue budget for 2015/16. George Morrison Head of Finance Argyll & Bute CHP 10th February 2015

1

NHS Highland Board 3 February 2015

Item 5.1 ARGYLL AND BUTE HEALTH AND CARE PARTNERSHIP – UPDATE Report by Christina West Interim Director of Operations/ Chief Officer On behalf of Deborah Jones, Chief Operating Officer The Board is asked to:

• Note completion of the consultation on the Argyll and Bute HSCP Integration Scheme.

• Note and approve the disestablishment of Argyll and Bute CHP and the transition arrangements recommended

• Note the commencement of the process to establish the Strategic Planning Group • Note the continuation of the staff communication and engagement and community

events relating to Integration for January 2015 1 Background and Summary The purpose of this paper is to provide NHS Highland Board with a progress report on the action undertaken to establish the Argyll and Bute Health and Social Care partnership (HSCP) since its last meeting. The Board at its 1st April 2014 meeting endorsed the integration model as “Body Corporate” for the Argyll and Bute Health and Social Care partnership and confirmed the scope of service inclusion at its 5th June 2014 meeting. 2 Argyll and Bute HSCP Establishment Update

2.1 Integration Scheme Consultation on the Argyll and Bute HSCP Integration scheme is now complete in total there were 44 responses from members of the public and stakeholders. This low response rate is unfortunate but predicted, due to the fact this is a statutory instrument and thus not easy to understand, plus the relatively short timescale to respond in order to comply with the SGHD timeline for approval.

2.2 Disestablishment of Argyll and Bute CHP- Transition Arrangements

As referenced at the last board meeting, following the issuing of Scottish Government provided guidance on the disestablishment of CHPs as at 31st March 2015, there is a need to put in place interim arrangements until the resources can be legally delegated to the Argyll and Bute HSCP Integrated Joint Board (IJB). NHS Highland, having considered the risks, and to meet the clinical and care governance and financial accountability requirements, an Argyll and Bute Governance Committee will be established which will be a new subcommittee of the Board.


Item : 9

2

The Argyll and Bute council transition arrangements will be through its existing Community Services Committee.

The end of these transition arrangements must be by the 31st March 2016 as dictated by statute or sooner once resources can be legally delegated to the Argyll and Bute HSCP Integrated Joint Board (IJB).

2.3 Argyll and Bute Shadow Integration Joint Board

The Argyll and Bute HSCP Shadow Integration Joint Board will retain responsibility for the following:

• Production of the Argyll and Bute HSCP Strategic Plan • Oversight of the integration transition arrangements regarding:

o Health and Care Governance (Quality and Safety) o Health and Social Care Workforce and partnership arrangements o Financial Governance o Organisational Development o Patient and Carer engagement and involvement arrangements

The IJB therefore has no responsibility at this time for day to day operational services. 2.3 Strategic Planning Group The Scottish Government has now issued the final guidance in relation to 3 year strategic plans and shadow IJBs are now being asked to enact this and confirm their programme for producing their plans. The table below outlines the timetable for this:

Production of Strategic Plan- Indicative timetable; Item Task Time Scale 1 Establish Strategic Planning Group- Membership,

ToR, Governance Jan/Feb 15

2 Prepare proposals about matters the strategic plan should contain

End of Mar 15

3 Consult the Strategic planning group on proposals End of April 15 4 Produce first draft of plan for SPG consideration End of June 15 5 Consult the Strategic planning group first draft End of July 15 4 Prepare second draft of Strategic Plan End of August 15 Consult the Strategic Planning Group and wider

stakeholders on Strategic plan ( 3 months) End of November 15

5 Prepare final strategic plan End of December 15 6 A&B HSCP approved by IJB and SGHD go live date

agreed, delegated responsibility passed to IJB Feb 2016

7 A&B HSCP Go Live April 2016

Work is now commencing to establish the strategic planning group (Appendix 1 outlines its membership from the guidance) and commence its work. The National Steering Group for Strategic Commissioning has suggested that a good plan should be based around the established strategic commissioning cycle and should:

3

• Identify the total resources available across health and social care for each care

group and for carers and relate this information to the needs of local populations set out in the Joint Strategic Needs Assessment (JSNA)

• Agree desired outcomes and link investment to them • Assure sound clinical and care governance is embedded • Use a coherent approach to selecting and prioritising investment and

disinvestment decisions • Reflect closely the needs and plans articulated at locality level

2.4 Staff and Public Engagement

The series of public and staff engagement events commenced in December and are continuing with 8 staff events planned for this month. These events/sessions arranged in a conversation café style give staff and members of our communities the opportunity to have an informed “local conversation” about current services and issues and the benefits and outcomes to be achieved (see inserted national outcome indicators) as a result of integration, to inform the local transformation in health and care service delivery required. To date 52 members of the public have participated in these cafes and once complete a report on findings and issues will be considered by the programme board and project team to inform future communications events. Supporting the Communications and Engagement process a dedicated Integration programme website has now been set up hosted by Argyll Voluntary Action and this can be found at http://www.healthytogetherargyllandbute.org.uk/

3 Contribution to Board Objectives This is a significant area of policy development for both the Council and NHS Highland as it is a legislative requirement which both partners will need to comply with fully. 4 Governance Implications 4.1 Corporate Governance

The new Partnership will be established by a statue agreement. In particular the governance and accountability arrangements will impact on the current arrangements and

http://www.healthytogetherargyllandbute.org.uk/

4

standing orders of both partners. Dependent on the detail within the Integration Scheme there may be further corporate and legal implications for both partners. 4.2 Financial The revenue and capital budgets of the specified council and NHS services will form part of an integrated budget for the new Health and Social Care Partnership to manage. The exact details regarding management and accountability etc will be defined in the course of the integration programme. 4.3 Staff Governance If the anticipated model of integration is taken forward, the majority of staff contract arrangements will be unaffected however there will be substantial changes to the operational and strategic management arrangements for all staff. Staff are integral to the success of the new Health and Social Care partnership and significant effort will be made to ensure staff are fully involved and engaged in the process Looking forward there are implications for a variety of staff roles and responsibilities, notably management and support services. Some of this is a continuum of the work already underway but others are also opportunities as identified by the Christie report regarding rationalisation, redesign and review of service as a consequence of integration of health and social care. There are also opportunities for staff co-location and professional and team development. Organisational Change Policy will underpin the approach to be taken supported by workforce planning and development strategies. Presentations to key Committees such as Staff Governance Committee, Area Clinical Forum and Professional Executive Committee will be scheduled into the engagement and consultation process in both organisation, as well as face to face discussions and awareness sessions for staff providing them with opportunities to influence and shape partnership arrangements. 4.4 Planning for Fairness: EQIA scoping exercise will be undertaken if required once the service model and its operational arrangements have been identified. Once again lessons learned from North Highland partnership process will be applied. 4.5 Risk The process of integration introduces a large number of risks for the partners. The project is reviewing and updating its formal risk register: - Governance - Finance and Resources - Performance Management and Quality - Human Resources - Integrated IT - Engagement and Communications - Organisational Development - Equity - Programme and timescale

5

The risks around integration are formally recorded on NHS Highlands SBAR and the integration programme will put in place a formal action plan to address and mitigate these risks. 4.6 Clinical Governance There are a number of implications including clarification over pathways, roles and accountabilities in the new structure which will require to be detailed and implemented through the course of the integration programme. Notwithstanding this the integration model will be required to be safe, effective and evidence-based. There will be a need to build significant clinical engagement and consensus across the localities in the partnership catchment area. 5 Engagement and Communication This major service change will require the Partnership to put in place a comprehensive public involvement and engagement process in establishing the new arrangements for PFPI in the partnership. The intention of the communication and engagement approach is to focus on Person Centred Care and outcomes demonstrating how services will improve by integration. This will be the core of both public and staff engagement and consultation. A comprehensive communication and engagement has been developed and will be a discrete project work stream with members drawn from staff, the public and management, supported by SGHD designated funding for communication and engagement. Christina West Interim Director of Operations Argyll and Bute CHP

6

Appendix 1 – Argyll and Bute HSCP Strategic Planning Group Prescribed Membership Integration Authorities are obliged to establish a Strategic Planning Group for the area covered by their Integration Scheme for the purposes of preparing the strategic plan for that area. The group must involve members nominated by the Local Authority or the Health Board, or both. In effect, this provides for the partners who prepared the Integration Scheme, and are party to the integrated arrangements, to be involved in the development of the strategic plan. In addition, the Integration Authority is required to involve a range of relevant stakeholders. These groups must include representatives of groups prescribed by the Scottish Ministers in regulations as having an interest. The table below identifies the initial membership for the Strategic Planning Group. Representative Other Chief Officer HSCP 1 At least 1 member of NHS Highland Board 1 At least 1 Elected member of Argyll and Bute Council 1 Health Professionals (GP, Consultant RGH & MH, AHP, Nurse) 5 Social Care Professionals 2 Users of Health and Social Care 2 Carers of users of Health and Social Care 2 Commercial providers of health care 0 Non-commercial providers of health care 1 Commercial providers of Social care 1 Non-commercial providers of Social care 1 Non-commercial providers of Social housing 1 Third sector bodies within the Local Authority carrying out activities related to health or social care

1

Locality Representatives * 4 Representative of NHSGG&C * 1 Total 24 * Note The policy statement issued in December 2014 made provision for representatives for localities and neighbouring Boards to be represented. The views of localities must be taken into account with the Integration Authority required to identify the most appropriate person to represent each locality on the Strategic Planning Group. Local flexibility is allowed, so that an individual can represent more than one locality. As Argyll and Bute CHP main provider for secondary care services is NHSGG&C a representative is also identified for the group.


Item: 10.1

Modernisation of Mental Health Services Update Repo rt –

January 2015 Report by John Dreghorn

The meeting 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 Governance The next meeting of the MH Programme Board is on 10 April 2015. The Capital Project (Bundle) Board met on 5 February 2015.

•••• Project Management Donna Mackay, who previously worked as part of the project team until March 2014, has rejoined the team to assist with the production of the Outline Business Case (OBC). Work on the OBC is progressing well and should be completed by mid February for submission to the Asset Management Group (AMG), NHS Highland Board, and Scottish Government Capital Investment Group (CIG) during March and April.

•••• Inpatient Services Current staffed bed compliment is 26.

Patient numbers in the IPCU continue to fall – currently 2 patients. Progress is being made on the design of the new IPCU area within Succoth Ward. Tendering of the work is expected to take place in February, with an anticipated commencement date on site of March 2015 and a completion date of end June 2015.

Management met with staff representatives on 27th January to address staff concerns regarding the transfer of the service into Succoth Ward.

• New Posts Nil new to report.

•••• Recruitment

There is currently 1 Consultant Psychiatrist vacancy (Dementia/Old Age Psychiatry). This post has proven very difficult to recruit to as there have been no applicants from the last 2 adverts. The post is being covered by a locum.

Gillian Davies was appointed as the Consultant Nurse for Mental Health in Argyll & Bute in December.

Theresa Sinclair was recently appointed as the Senior Charge Nurse for Argyll & Bute Hospital.

•••• Budget: The inpatient mental health service has achieved its cost improvement target for 2014/15, and is expected to end the year within budget, despite some significant cost pressures in IPCU nursing and Psychiatry.

•••• Resettlement Group Work is progressing well to find suitable placements for the 3 remaining long term patients.

•••• New Hospital Project “The Bundle”: The stage 1 pricing report was issued at the start of January. This initial report indicated that the projected cost of the new Hospital and support services building would be £10.782 million. This is £317k higher than the cap set in the New Project Request (NPR). However, this includes £150k for work to resolve the water supply issues which may not be required and £125k in fees that have already been paid. Further work to bring the total with the NPR cap will take place over the next few weeks in preparation for submission of the OBC to the AMG in March. However, our bundle partners have a more significant pricing problem to address. Inverurie Health Centre’s pricing report is currently showing £3.5 million over the NPR cap. This will require intensive work over the next few weeks to bring it back in line with the NPR.

Enabling Funds: As previously reported £192k has been allocated by the Scottish Government to support works which require to be undertaken before the new hospital construction work commences. Plans for the demolition of Tigh na Linne and the Estates Department workshops are now progressing again after a delay of several months. A further bat survey has taken place and a demolition date is still to be identified. The Architect and contractor are in discussion with the Council’s planning department to ensure that all of the planning conditions have been met before the work commences. Demolition is expected to take 6 weeks to complete.

Scottish Water issued the water impact assessment report in early January. Further meetings with Scottish Water will take place to address the issues identified in the report.

•••• Supported Transfer of Detained Patients An audit of patient transfers from January 2014 will be reported at the next Programme Board in April. The initial report produced in September showed a significant increase in the number of patients detained and requiring supported transfer when compared to 2013, however, data for the 2nd half of the year suggests that this may have been a normal peak in activity as the total transfers for the year is close to the average for the previous 3 years. An analysis of questionnaires received from staff, partner organisations; service users and carers, will be included in the report to the Programme Board.

•••• Service User & Carer Involvement Regular meetings of the Service User and Carers Reference Groups continue on a two monthly basis.

•••• Psychological Therapies NHS Highland along with the other NHS Boards is required to report on waiting times for Psychological Therapies from December 2014. As previously reported, Argyll & Bute has had significant challenges in achieving the 18 week TTG target for 90% of those referred. Further work to validate our data took place up to 16th January. It was reported that the CHP achieved 89.2% for the December reporting period. This target will remain challenging, but with the recruitment to the Cowal & Bute posts we should see the waiting times reducing over the coming months.

3. Summary This month’s report again highlights the ongoing work to deliver the new mental health hospital for Argyll & Bute. The stage 1 report while over the NPR cap is close enough that we should be able to bring it within the cap without compromising the overall design of the building. The main barrier to this project progressing is the significant affordability gap for our partner project in Inverurie. As things currently stand, that project will not be approved as the pricing report is £3.5 million over the NPR cap.

MH Service Modernisation Update Report January 2015 (1) J. Dreghorn Page 2 of 2

Argyll & Bute Committee 18 February 2015

Item : 10.2 ESCORT/TRANSFER SERVICE AUDIT REPORT, MENTAL HEALTH – ARGYLL AND BUTE CHP Report by : Gillian Davies, Consultant Nurse (Mental Health) on behalf of John Dreghorn, Programme Director, Mental Health Modernisation, Argyll and Bute CHP. The CHP Committee is asked to:

• Note the content of the paper

1. Background

There is a requirement from the Code of Practice within the Mental Health Care and Treatment Act (Scotland) 2003 to make provision in the Psychiatric Emergency Plan to facilitate the safe/rapid transfer of patients who have been detained under the MHA(s). In 2003 all community hospitals within Argyll and Bute CHP were given access to a place of safety for mental health patients. An options appraisal process in 2013 was undertaken and the preferred option was to establish a designated escort and transfer service from the Argyll and Bute Hospital in January 2014. This service currently operates with two additional staff members on shift from 10am-10pm, seven days a week to facilitate the safe and rapid transfer of patients detained under the Mental Health (care and treatment) Act 2003 from their local communities to the Argyll and Bute Hospital in Lochgilphead. Transport for this service is provided by the Scottish Ambulance Service (SAS).

A review of the service was requested and a three-phased approach to evaluate the service was undertaken. This included an initial review of the 34 submitted datix incident reports and thereafter a stakeholder and service user/carer questionnaire was undertaken across Argyll and Bute CHP. The final phase to the review included focus group discussions with staff groups within the localities and in-patient services. The results will be discussed in further detail within this paper. Admissions under detention from Localities Januar y to July - 2013/2014

Locality January - July 2013 January - July 2014 Oban, Lorn and the Isles 7 18 Cowal and Bute 5 18 Mid-Argyll 3 1 Kintyre and Islay 1 2 Total 16 39

The recent Mental Welfare Commission Annual Report (2013-2014) report that there is a 3 percent rise in all new episodes of compulsory treatment since the inception of the MHA (S) in 2003. There has been no downward trend in the use of emergency detention from 2005 and within NHS Highland along with NHS Dumfries and Galloway and Greater Glasgow and Clyde having the highest use of emergency detention. There is a rise noted in the use of emergency detention in the very young and very old. (MWC, 2014). Interestingly thirty nine percent (15 patients) detained were known to in-patient services and fifty-four percent (21 patients) were known to out-patient services. Patients detained under an Emergency Detention Certificate are required to be reviewed within 12 hours by the RMO to assess the continued need/criteria for ongoing detention under the Mental Health Act.

2

On average patients detained under Section 36 (Emergency Detention Certificate) the average length of stay from this period is 28 days. Seven patients received care, treatment and subsequent discharge within seven days. Fourteen patients continued to receive care and treatment under Section 44 (Short-term Detention Certificate) and only four patients required continued to require detention under a compulsory treatment order (Section 64). A further comparison of all admissions under detention to mental health services from August to December on both years was also undertaken: Locality August - December 2013 August – December 2014 Oban, Lorn and the Isles 11 3 Cowal and Bute 10 10 Mid-Argyll 1 2 Kintyre and Islay 1 5 Out of Area 0 2 Total (Aug -Dec) 23 22 Overall Admissions via Mental Health Act (S) 2003

39 (in 2013)

61 (in 2014)

Days Detained under EDC after admission Number of Days Cowal and Bute Oban, Lorn and the Isles

One Day 6 Patients 2 Patients Two Days 1 Patient 3 Patients Three Days 1 Patient 1 Patient Total 8 6

There was an increased demand for requests admission on the following days: Admission Days to Argyll and Bute Hospital – MHA (S cotland) 2003 Day Oban, Lorn and

the Isles Cowal and Bute Mid Argyll Kintyre and Islay

Monday 1 1 0 0 Tuesday 4 3 0 1 Wednesday 3 0 1 1 Thursday 3 3 0 0 Friday 4 7 0 0 Saturday 2 3 0 0 Sunday 1 1 0 0 Total 18 18 1 2 SAS Delay Recorded Via Datix Incidents Day Oban, Lorn and

the Isles Cowal and Bute Mid-Argyll Kintyre and Islay

Monday 1 2 0 0 Tuesday 1 1 0 0 Wednesday 0 2 0 1 Thursday 0 2 0 0 Friday 1 7 0 0 Saturday 0 1 0 0 Sunday 0 0 0 0 Total 3 15 0 1

3

Fifty-five percent (19 reports) of incidents recorded via Datix relate to transport/SAS difficulties. The completion of escorts and transfers on the same day often proves challenging due to a number of reasons (geographical location/ferry access/SAS changeover and provision of the ambulance for the escort etc). It should also be noted that there is a reported shift changeover of the ambulance service around 1800 hours in the evening and that the latest departure time from the hospital is 1800 hours for the Cowal locality At times there has been difficulties in completing escorts and transfers on the same day due to the lack of availability of ambulances to provide this service and often resulting in an incomplete transfer the same day, whereby the patient has then required to be remain in the place of safety overnight and transfer facilitated the next day. This has occurred on at least six occasions for both Cowal and Bute Community Hospitals. Additional pressures on the service relate to five requests for multiple transfers on the same day from different localities, again SAS availability was cited as the difficulty for facilitating these on two occasions. Over the 212 days of the audit cycle (January to July 2014) there were three reported incidents of the escort team not being able to facilitate the transfer within the shift. Despite maternity leave, vacancies and sickness absence the escort service has continued to be provided from the Argyll and Bute Hospital. The ‘off-duty’ has also been reviewed for this period and it is recognised that a short-fall in the provision of the dedicated (10am-10pm shift) was recorded on a few occasions only due to unplanned sickness absence, however on these occasions the provision of the escort service was still provided. In more recent weeks there has been significant pressure on the service due to unplanned sickness absence/staffing and clinical demand. Datix Incident Reports - Themes The Datix incident reports were reviewed between January and July 2014, there were a number of issues raised in each report relating to mental health transfers, these included:

• Communication • Verbal Aggression towards Staff • Lack of availability of Scottish Ambulance Service/Transport Difficulties • Staffing • Medication • Request for transfer out with window for escort team

Oban, Lorn and

the Isles Cowal and Bute Mid- Argyll Kintyre and

Islay Communication 1 4 0 0 Verbal Aggression towards Staff

1 1 0 0

SAS Transport/Transfer

3 15 0 1

Use of Pool Car/Porter

1 5 0 1

Staffing 0 4 0 0 Medication 1 0 0 0 Request out with transfer window

0 3 0 0

Use/Issues with Place of Safety

2 13 0 1

Total 9 45 0 1

4

Organisation of Escort/Transfer and Current Shift P atterns It is noted that through Datix incident reports and collation of the data from the in-patient services that there is some confusion and lack of communication around the organisation of the escorts and where the responsibility lies in organising transport etc. It is also noted at times there is a lack of support or awareness of the current escort and transfer policy from SAS control. This often results in non-provision of an ambulance for the escorting team from the Argyll and Bute Hospital which has resulted in utilising the use of a porter/pool car for the escort team to arrive at their destination. Escorts and the ambulance are organised and booked by the on-call page carrier in the Argyll and Bute Hospital it is noted that when this is undertaken it can take around on average 15 minutes of the page carrier (on-duty trained nurse) shift to facilitate and organise the escort. However, it has been noted that when there are additional difficulties, issues and challenges arranging transport it can take the page carrier up to 3 hours to organise/facilitate the escort and communicate with the locality. It should also be noted that there is a reported shift changeover of the ambulance service around 1800 hours in the evening and that the latest departure time from the hospital is 1800 hours for the Cowal locality. There is also a report of three transfers/discharges being cancelled from Succoth Ward due to lack of availability of ambulances/personnel within SAS to facilitate this. From August to late November 2014 there has been a significant reduction in Datix incidents reports raised in relation to the escort and transfer service, a total of three reports only raised. In-patient staff within the Argyll and Bute Hospital have expressed some concerns around the effectiveness of the existing escort and transfer shift pattern and have made some suggestions to this. This would include working the traditional day-shift pattern, but remain dedicated to the escort service with an additional component of an ‘on-call’ system until 10pm each evening effectively extending the escort period to 15 hours per day. However it is noted that there are some challenges to operating this system in relation to Agenda for Change ‘on-call’ arrangements and the European Working Time Directives (compensatory rest periods). Risk Assessment/Available Information The safety of the patient and escort team undertaking the escort is paramount. It is a requirement of the current policy that the on-call page carrier and duty doctor at the Argyll and Bute Hospital seek to obtain the relevant information on the patient’s current mental state and risk factors to enable a safe decision is made around staffing/medication etc prior to the escorting team being despatched from the Argyll and Bute Hospital. The completion of the Sainsbury level 1 risk assessment is requested by the referring doctor/professional however this has not been completed or received on the majority of admissions to mental health services. On discussion with stakeholders there was reference to the lack of availability of written referral letters and risk assessments on receipt of patients to the service or the escort team. 2. Questionnaire and Focus Group Discussion - Analy sis The stakeholder questionnaire was developed in response to the themes highlighted in the incident reports; areas for improvement were also sought. There were 88 responses received via survey monkey to the stakeholder questionnaire. Reponses were received from

5

a variety of stakeholders across community and in-patient services. Interestingly approximately 36% of the respondents were unaware of the current escort and transfer policy within Argyll and Bute CHP. Sixty Four percent (64%) of respondents to the questionnaire have had direct involvement or engagement in the escort and transfer of patients under detention since January 2014. Some areas of concern recorded relate to the following areas:

• Transport • Communication between departments and referrers • Geographical/Rural Location • Staffing • Current Shift Pattern (in-patient service) • Place of Safety • Escort Service • Time of Referral • Availability/lack of current risk assessment

Some further analysis of the results relates many of the concerns around the availability and access to community mental heath services out of hours and at weekends. Additional points raised were around the availability of local staff to support and care for patients. Confidence of staff to care for patients with a mental health condition/presentation within the community hospital setting was also highlighted. The island populations have expressed some concern around the time required to complete the transfer to in-patient services and the lack of availability of a place of safety within the Island of Tiree? On enquiry sixty three respondents have not made the use of video-conferencing facilities to assess/support patient care from the locality to the in-patient service in Lochgilphead. At present not all clinical areas have access to a video-conferencing facility within their environment to support patient assessment in this manner. When asked about what has supported and worked well to support the safe escort and transfer of patients detained under the MHA (S) 2003, stakeholders confirmed the following:

• Patient known to services. • Escort occurred and completed within transfer hours. • Support and Communication from The Argyll and Bute Hospital (In-Patient)

services, Community Mental Health Team, Local Police, General Practitioners, Informal carers and Local Authority staff.

• Access to Transport. • Access to a current care plan, crisis/wellness plan and risk assessment.

Seventy two percent (26 respondents) did report an increased confidence in supporting the care and treatment of patients with mental health challenges in local community hospitals following some training and development. It is noted that one local community hospital has adapted their approach and undertaken regular staffing briefs on shift which has proved successful in the patients care and treatment. Areas for Improvement Stakeholders have expressed some thoughts on improvements/developments to the service that would further support safe and effective transfer of patients detained under the MHA (S) 2003, these include:

• Extended hours/improved access to the patient transfer team • Increased access to Community Mental Health Staff for support

6

• Increased Communication between departments • Regular review with CMHS with patients known to attend local community

hospitals on a frequent basis • Access to Care Plans – In particular (crisis/wellness plans) • Crisis Response Team/24 hour service for Escort and Transfer • Access to Video Conferencing equipment in clinical areas • Reliable/Available Transport, and the possibility of using Helicopter transport

from island communities • Ambulance to be provided from the locality to prevent delays however there

are challenges to the provision of ambulances being supplied from an Island destination

• Improved Staffing within Accident and Emergency Departments/Community Hospitals in particular staff who have mental health experience would be helpful

• Development of local standard operating procedures within localities to support care and treatment of patients with mental health challenges in the place of safety/local community hospital/medication

• Completed Risk Assessments and Referral information on admission etc,, • Training and Development in mental health care and treatment for local

community hospital staff and stakeholders 3 Contribution to Board Objectives Improvement and Change Delivering Integrated Care Delivering Person Centred Care Delivering Safe and Effective Services Delivering Efficient Services 4 Governance Implications • Staff Governance Staff are supported and appropriately trained to support a safe escort and transfer service. • Patient and Public Involvement Service user and carer opinion was sought through the use of a specific developed questionnaire. This was available in paper and electronic format. Carer opinion was sought through the service user. This was administrated through the Community Mental Health Teams to limit distress. Unfortunately the response to the 19 questionnaires distributed has been extremely poor (5%), however the electronic survey will remain open for an extended period. • Clinical Governance To continue to review, learn and develop the service in response to lessons learned. • Financial Impact The service continues to be provided from Argyll and Bute Hospital 10am-10pm, seven days per week, with two additional staff rostered per shift. The use of additional staff/pool car to support escort/transport may also incur some additional financial support. Additional staffing with overnight stays in local community hospitals for patients have occurred in this seven month period. This has resulted in some additional financial impact for the localities. Should

7

the escort and transfer hours be extended to provide an ‘on call’ period this would incur an additional cost. 5 Risk Assessment Escort/Transfer service currently on mental health modernisation risk register. 6 Summary The initial findings of this review suggest that there is a significant increase in admissions and requests for escort and transfers of patients detained under the mental health care and treatment act in the period January to July 2014. However, this increase in demand is not maintained in the remainder of 2014. In total there have been 61 admissions of patients detained under the mental health act (Scotland) 2003 to mental health services. The majority of the admissions are from the Oban, Lorn and Isles/Cowal and Bute Localities. A large proportion of the patients detained are already known to mental health out-patient services. It would appear that there are significant challenges in the obtaining transport via the Scottish Ambulance Service to complete same day transfers within the current shift pattern of the escorting service. This has resulted in patients remaining in the designated place of safety overnight or the escort team using alternative modes of transport and staff to facilitate the transfer on the same day. There appears to be more requests for admission/detention on a Friday/Saturday from Oban, Lorn and the Isles and Cowal and Bute. The majority of SAS delays occur within the Cowal and Bute Locality occurring on a Friday. The on-call page carrier at the Argyll and Bute Hospital is responsible for co-ordinating the escort, it is noted that due to the delays and difficulties of some escorts this has occupied the staff member for around 3 hours of their shift. Eighty eight replies were received from the stakeholder questionnaire via survey monkey; unfortunately the response from the service user and carer questionnaire has been very limited. However the response period has been extended by clinical governance to provide an opportunity for feedback to be received after the submission of this report. From the stakeholder survey and focus group feedback, there are areas of specific concerns relating to the escort and transfer service these include:

• Communication between departments and referrers • SAS Transport availability and access • Geographical/Rural Location/Island Support and Access • Staffing (local community hospital – mental health trained staff) • Current Shift Pattern (in-patient services) • Places of Safety • Lack of local Standard Operating Procedures (mental health) • Out of Hours service/access • Time of Referral • Lack of availability of completed risk assessments

While there is some recognition that the current escort and transfer service works wells this is largely due to the escort occurring and being completed within the transfer shift pattern of both in-patient and SAS personnel and transport is available to facilitate this. Additional supporting factors of successful transfers include evidence of good communication between all relevant departments and access to current crisis/wellness plans and risk assessments. Recent training and development along with a shift in clinical practice has also supported effective care and treatment of patients in local community hospital settings.

8

Stakeholders have also provided areas for improvement which focus around the following areas:

• Improved and extended access to CMHS, • Increased communication, • Access to crisis/wellness plans and risk assessments. • Reliable/Available transport available from localities with the consideration of

helicopter transfer from island localities, • Improved staffing within Community Hospitals/Accident and Emergency

departments of staff with mental health training, • Further training and development • Access to Video Conferencing facilities within the clinical areas.

Gillian Davies Consultant Nurse (Mental Health) Argyll and Bute CHP 8th December 2014 (Updated 10th February 2015)


Item No: 11

Update on the Kintyre Dialysis Project Report by Kristin Gillies, Service Planning and Pe rformance Manager

1 Introduction:

As part of a practice/professional development project one of the Dialysis Nurses at the Vale of Leven (VOL) renal Dialysis unit undertook a project to examine if there was a service model to provide hospital dialysis locally for Kintyre residents who were undertaking a 6 hour round trip 3 times a week for renal dialysis. Through changes in practice and the support of the specialist team in NHSGG&C she identified that an innovative hub and spoke outreach community unit could be provided at Campbeltown hospital. Her initial work identified that it may be possible to put 2 dialysis chairs in the small dayroom within the hospital. The local community and a number of Kidney Dialysis voluntary groups expressed their immediate support to fund the capital and staff training costs to establish the unit in the hospital. In addition the West of Scotland renal planning group endorsed the proposal as a pilot to be evaluated after 1 year examining patient experience, suitability, safety and quality of service. NHS Highland had conducted a previous review of dialysis provision across the Argyll and Bute in 2012/13 area and had concluded that it was not a priority at that time to establish a local unit in the area. However, it planned to review the need for this in 2015/16. The innovative nature of the community outreach model, the enthusiastic support of the community and stakeholders and the support of NHSGGC re clinical networks and decision support and the loan of 2 dialysis chairs led the Argyll and Bute CHP to consider the merits of this proposal including how to fund the revenue costs of the unit (staff, maintenance, consumables etc) The proposal for a Hub and Spoke model of a community hospital renal Dialysis service within the CHP was presented to the Core Management Team in September 2014 and after considerable deliberation a decision was made to undertake a pilot within Campbeltown. It is important to highlight that this new Unit in Campbeltown is a pilot for Argyll and Bute and we will evaluate the service after one year from when it commences (Summer 2015). The evaluation will consider the clinical outcomes for patients, accessibility, service demand and utilisation, patient satisfaction and the financial implications.

The table below provides a breakdown of the patients within Argyll and Bute who currently receive Dialysis outside the CHP.

The CHP Committee are asked to:

• Acknowledge the progress so far within the project. • Acknowledge the costs and the risks within the project. • Confirm the continued commitment to build the Dialysis Unit in Campbeltown. • Note and agree the recommendations on how to move forward.

2

Table 1: Number of patients in Argyll and Bute receiving Hos pital Dialysis in January 2015

A&B Patients by Hospital Dialysis Location No. of Patients

Oban - Belford 1

Taynuilt – Vale of Leven 1

Campbeltown – Vale of Leven 2

Isle of Gigha – Vale of Leven 1

Helensburgh – Vale of Leven 3

Rothesay – Inverclyde Royal 3

Dunoon – Inverclyde Royal 1

Total 12

2. Update on the Pilot

2.1 Nurse training - The Nurses have commenced their training programme. The training comprises of 4 weeks intense training in Stobhill Hospital Dialysis Unit and then continued training in the Vale of Leven Hospital where the Campbeltown patients currently dialyse. It was decided that the Campbeltown patients should not meet the Nurses until the Nurses were of a level so that no confidence was lost in abilities / skills and knowledge. There has not been a time limit put on the second part of the training as it will take as long as the Charge Nurse at the VoLDGH Dialysis Unit feels is necessary to sign off their competencies. It is anticipated that funding for the training will be from the British Kidney Patient Association of up to £45,000 (confirmation of grant is expected in March). 2.2 Location of the Unit – . As the project developed it was realised that the initial proposed location, within the small Dayroom on the Acute ward, would not be big enough or suitable to meet all the clinical and operational specifications for the Dialysis Unit. This change was driven from infection control guidelines about spacing between the machines and chairs and separation of patients from the general acute ward patients to minimise the risk of compromising their health through exposure. In November, the first Architect plans were presented and this confirmed that the day room on the acute ward was too small to house the 2 dialysis chairs and supporting furniture and would meet quality/control of infection standards. Fortunately an alternative location had been identified on the acute ward (which due to the needs of patients and risk management meant the unit had to be located there). The new location offered a number of additional benefits including:

• addressing the infection control guidelines about spacing between the machines and chairs,

• discrete separation of patients from the general ward • The opportunity of providing a separate entrance for dialysis patients minimising the

risk of compromising their immune system. • Future proof provision by providing a fit for purpose facility

3

2.3 Construction timescales–

The following programme has been identified to build the unit:

19/01/15: - 4 weeks for drawings, tender package and lodgement of Building Warrant. This period also includes sign off from NHS Fire Officer, Infection Control and Stobhill.

16/02/15: - 3 weeks out to tender

9/03/15: - 1 week for tender report and client acceptance

16/03/15: - 2 weeks CDM preparation by Contractor (Health and safety Preparation)

30/03/15: - 10 weeks on site build

A total of 20 weeks to completion. Estimated time of completion early June 2.4 Capital Costs With the identification of the alternative location and the increased size and specification for the unit the cost has invariably increased from the original estates estimate of £40,000. The current scheme cost as estimated by the quantity surveyor is detailed in Table 2 below. Table 2: Description of the project build costs

Description Cost £ Quantities Surveyor build Cost £82,000 Fees (12.5%) £10,250 VAT £18,450 Total £110,700

2.4 Project Capital Funding

The CHP has received donations into the endowment fund as detailed in Table 3 below

Table 3: NHS Highland Campbeltown Dialysis Endowmen t fund

Transaction Total Campbeltown Dialysis Campaign Group £50,000 Transplant Life UK £10,000 Various donations by public £2036.42 Architects Fee -£1533.60 Total £60502.82

The Campbeltown Dialysis Campaign Group has been very successful in fund raising for the project to date and it is understood that they have raised a further verbally reported at the £50,000 and that they continue to fund raise to support the local provision of this unit.

4

2.5 Revenue costs

The CHP has committed to meeting the revenue costs of the Dialysis Unit. Below is a table detailing the indicative costs in year 1. (See note)

Table 4: Estimated Annual Costs to the CHP (based o n the information available at the time) Source Argyll and Bute CHP Commissioning Acco untant.

Estimated Annual Costs £ WTE Salary Cover Total Comment

Band 3 0.6 13,000

2,900

15,900

Band 5 0.6 4,600

4,600

GGC Technician 4 visits per annum 4,000

4,000 Cost from GGC

Supplies 3 patients per annum 22,500 £7.5k per patient

Total 17,000

7,500

47,000

Note:

Salary costs based on 14/15 AfC pay scales

Due to a insufficient detail being made available on the running costs of the unit, e.g. overhead costs

such as electricity, domestic services, catering, clinical waste uplifts, it is not yet possible to

provide a full costing. The final total annual running cost of the unit is expected to be higher than

that above. It is advisable that any reliance on the above estimate should be made with this caveat.

2. 6 Revenue Funding - Highlands and Islands Trave l Scheme.

Currently the Renal Transport is provided by the British Red Cross and this is paid for through the Highlands and Islands Travel scheme.

Kintyre Patient Cohort Cost £

Campbeltown patients £38,000

Gigha patient: £34,000

Total £72,000

This budget will be devolved to the CHP in April 2015 and has been identified as the source of funding for the running costs. It should be noted there will remain a call on transport for patients to the unit and also into Glasgow for regular review and should their condition deteriorate and they require a more specialised level of renal dialysis

5

3. Current Project Status

Since the start of the project updates have been provided to the Dialysis Campaign group on the progress and developments in the project including all the changes to the project as well as alerting to them to the increase in costs.

On Tuesday 20th January, the Project Manager met with the Campaign group to further update them on the progress. At this meeting the group were shown the costs from the QS and explained in detail the source of the increase in cost and how the final costs would be known once the tenders had been returned. The PM on behalf of the CHP expressed her regret that the estimated cost had risen but felt there was broad acknowledgment and understanding from the group as to the reasons why and subject to receipt of responses to the tender this would be within budget.

The group were asked to donate the rest of their funds (in excess of £50,000) to allow the build to progress. The Campaign Group pointed out that the year 2 capital cost to purchase the chairs and machines from NHSGG&C was to come from the balance of their funds. The group requested that the year 2 costs of £38,000 for the chairs and the machines were discussed with Glasgow and the Core Team to look at any possible extensions of the loan or funds from the NHS to purchase this.

Unfortunately, before any of these actions could be progressed the Chair of the Campaign group issued a press statement and was interviewed by the media presenting a picture that the CHP had unilaterally changed the remit and scope of the project and was expecting the community to raise more money to meet the increased costs.

It was not apparent at the meeting on the 20th January that the rest of the group wanted this press communication because they had directed the Project manager to issue a press release to the local paper detailing the progress on the project, why the location of the unit had changed and the indicative costs increased in a controlled and informative way, to keep the public engaged with the project.

It is of concern that this action may have damaged the working relationship between the group and the CHP, when previously there has been a strong and developing partnership working arrangement with significant progress on the pilot.

The other funding partners, British Kidney Federation, have expressed their concern at this turn of events but have publicly indicated their continued support of the project and the project management process undertaken by the CHP.

This has understandably raised a degree of anxiety and concern among the 3 patients in Kintyre who are looking forward to receiving their dialysis locally as well as uncertainty within the local nursing team who have committed to providing the service.

6

4. Project Risks

Project Progress/Risk Dash Board (Traffic Light Rep ort)

Item Status & Traffic light colour Notes

1 Drawing up the plans

Craig Hotchkiss and Stewart Nicholson drawing up tenders and building warrant

Require the tenders to be returned to provide definitive costs of the build. Risk over having enough money to progress if costs differ from the QS estimates.

2 Training On track - Staff training commences 19th Jan

3 Funding for training No formal confirmation from the BKPA re funding the training. Hospital funds being used in the interim then planned to be refunded. Money required for backfill.

-KG had verbal assurances re funding but until formal notification there is a risk to the project. Training will be stopped after 8 weeks if funding not secured from BKPA.

4 IT Infrastructure Need an update / confirmation of timescales

-SERPR is required to be installed within the Unit. Stephen Morrow and Julia Little working on this.

5 Funding from Community

£50,000 has been donated to the hospital but this is not enough to allow building to commence.

KG in discussion with the campaign group re additional funds. Once Tenders are back the group will have indicative final costs and will give a better understanding of whether project can proceed.

5. Next Steps and conclusion

The Argyll and Bute CHP management team at its meeting on the 30th January restated its commitment to ensure the interests of the Kintyre dialysis patients remain at the centre of the project by ensuring a high quality, safe and fit for purpose unit is in place. To this end we have immediately:

• Contacted the patients to reassure them • Restated our commitment to seeing the project delivered as per the timetable. • Restated our commitment to meet the revenue consequences of the project • Continued to support release of staff for training • Progress the actions agreed with the Dialysis fund raising group as detailed • Upon receipt of tenders agree the cost to build the unit and fund raising target and if

necessary identify any other sources of capital funding

Christina West Director of Operations has spoken to the Chair of the Campaign Group re stating the commitment and actions as above and stating she will meet with the Dialysis Campaign group and other stakeholders to ensure the project remains on track.

7

At the same time the CHP has issued a press statement clarifying the position and next steps, acknowledging and recognising the huge contribution by the local community in fund raising to date requesting they continue their efforts. It is disappointing and frustrating that this situation has arisen when there has been a tremendous level of fundraising undertaken by the community and when the group had previously been happy with the progress made so far.

The main driver for this whole project is to ensure the patients have a safe and quality service which prevents them having to travel to Glasgow 3 times a week for treatment. The CHP remains committed to achieving this aim so as to ensure this pilot has the best chance of being a success.

6. Governance Implications

Financial: There are likely to be financial implications when implementing this facility but funding sources have been identified within to meet the ongoing revenue costs.

Staff Governance: Ongoing staff governance implications picked up within the wider project / implementation with NHSGG&C and A&B CHP.

PFPI: Ongoing public involvement as part of the wider Implementation project

Clinical Governance: Clinical pathways have governance implications which are factored into the project and provided in partnership with NSHGG&C.

Equality and Diversity: Reduce the inequity of geography in providing hospital dialysis services for this cohort of patient.


Item : 12

PDP/R AND e-KSF IMPLEMENTATION 2014/15 Gaye Boyd, Interim Head of HR 1. BACKGROUND AND SUMMARY The Argyll and Bute CHP has progressed over previous years in working towards achieving the NHS Highland target that ALL Agenda for Change staff have a review against a Knowledge and Skills Framework (KSF) post outline, with at least 80% of reviews being carried out and recorded online using the web based system, e-KSF. However, in this current period there is a marked decline in the number of reviews recorded in the rolling 12 month period and the management team in the CHP recognise the need to recover and improve on this position. There is normally a marked increase in the ‘in year’ reviews completed between Jan and March each year and work is ongoing to ensure that the higher level of reviews are carried out in this period It should be noted that prior to implementation of e-KSF, there was no systematic way of knowing which staff had a regular review. NHS Highland is now in the position to be able state exactly the number of staff who have had reviews, that these follow the same process, and that staff are actively involved. The evidence is being used by staff as support for Continuous Professional Development (CPD) and re-registration. In addition it allows for Mandatory and Statutory training to be included in every staff members’ PDP, which raises the profile and acts as a record enabling measurement of the levels of completion of required training across the organisation. The target remains that 80%, at any time, of all staff have a KSF review completed and recorded on e-KSF at least annually.

The CHP Committee is asked to:

• Note the current position and need to accelerate completion of reviews and PDPs taking place and use it to support and direct staff development in line with CHP and NHS Highland objectives

• Note the need to ensure that regular annual reviews and PDPs continue for all staff, including bank staff

• Note that the eKSF software licence has been extended to March 2016 • Recognise the governance issues related to carrying out and recording reviews

with staff

2 Sally Munro Workforce Development Facilitator 04-02-15

2. MONITORING PROGRESS 2014/15 The position across NHS Highland at 31 January 2015 is as follows (Extract from e-KSF 31-01-15): Area All AfC

staff Reviews

signed off % of AfC staff (all)

% of AfC staff

(excl bank)

% of AfC staff(all) In last 12 months

%of AfC staff in last 12

months (Excl bank)

Argyll and Bute CHP

1955 441 22.56 31.03 37.70 51.86

Corporate Services 745 124 16.64 17.37 46.44 48.46

West 949 107 11.28 15.69 33.72 46.92 Mid Highland 534 92 17.23 21.10 32.40 39.68 North Highland 890 168 18.88 25.26 40.90 54.74 Raigmore Hospital 3350 563 16.81 23.99 35.46 50.62 South Highland 651 93 14.29 17.78 36.10 44.93 I The CHP currently has 22.56% of all staff (31.03% excl bank) with reviews and personal development plans signed off in e-KSF for this financial year. This time last year the CHP had 29.67% signed off within the financial year. The total percentage for NHS Highland is 17.8% (23.48% excl bank posts). The rolling 12 month figures for A&B CHP (from 1 February 2014 to 31 January 2015) show that 37.70% of all staff have had reviews completed (51.86 % excl bank). This should be 80% and be maintained at that level.

3. PLAN FOR 2015-16 An e-mail has been circulated to the Partnership Forum and all managers highlighting the ongoing use of e-KSF until 2016 and implementation of Oracle Performance Management. This has also included updated guidance for managers as to how they can use e-KSF to identify reviews due, and progress in completion of these. It is important to note that completion of annual reviews and personal development planning is a key part of achieving staff governance standards, and also relates to clinical governance in terms of ensuring staff are receiving the development required to maintain and develop their skills and ensure ongoing service improvement. It is the actual review that is most important so that staff have a conversation with their line manager at least once a year about how they are performing in the job, what they are doing well, what training and development they may need and how they can contribute to service improvement with their team in the coming year. The electronic system is only the tool for recording this for the individual (for CPD evidence etc, the manager/reviewer, and the organisation). The electronic system may change but the principles of review remain the same. 4. 2015/16 Contract for e-KSF AND e:ESS As previously indicated the contract to deliver the e-KSF will continue until March 2016. Boards have been asked to prepare for a transition to the Oracle Performance Management (OPM) hosted within Eess (employee information system) which will include a roll out plan,

3 Sally Munro Workforce Development Facilitator 04-02-15

guidance and training packages but until then the existing e-KSF system should continue to be used for the planning and process of reviews and personal development planning until OPM is ready . 5 CONTRIBUTION TO BOARD OBJECTIVES The achievement of the target is in line with the NHS Highland Board objectives. 6 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. 7. IMPACT ASSESSMENT The KSF and e-KSF processes are impact assessed at National level and will be monitored as part of overall staff engagement measures. Gaye Boyd Interim Head of HR Argyll and Bute CHP NHS Highland

Argyll & Bute CHP Committee

18 February 2015 Item : 14

ARGYLL & BUTE CHP PARTNERSHIP FORUM MINUTE OF MEETING HELD on 18th December 2014 in Aros Boardroom

Present: Gaye Boyd (GB) Interim Head of HR Helen Duthie (HD) Unison Ian Duff (ID) Unison Julian Gascoign (JG) Risk/Health & Safety Manager Pat Tyrrell (PT) Lead Nurse Alastair Craig (AC) Senior Management Accountant By VC Elizabeth McMillan (EM) Unison (Co Chair) Dawn Gillies (DG) Unison (Co-Chair) Lorna Low (LL) Royal College of Midwives Sally Munro (SM) Workforce Development Facilitator Viv Hamilton (VH) Locality Manager B C H & L Charlie Gibson (CB) Personnel Officer Adam Palmer (AP) Employee Director NHSH Donnie Cameron (DC) CSM Kintyre

Apologies: Christina West (CW) Interim Director of Operations Colin Crawford (CC) British Dental Association Angela Dewsnap (AD) Personnel Officer Fiona Broderick (FB) Unite Stephen Whiston (SW) Head of Planning Contracting & Performance Donald Watt (DW) Clinical Services Manager OLI Billy Staley (BS) Information & Projects Manager David Ross (DR) Head of Estates Kathie Graham (KG) Interim Clinical Services Manager Cowal and Bute Kate Dumigan (KD) Royal College of Nurses John Dreghorn (JD) Project Director - Mental Health Modernisation Project

In attendance Pam Cremin (PC) Workforce Planning & Development Manager NHSH Ray Stewart (RS) Senior Quality Improvement Lead NHSH Helen Robertson (HR) Raigmore AHP Lead/NDP Project Manager NHSH

Minutes: Rose MacVicar (RM) HR & Planning Contracting & Performance

Item Subject Action 1 Welcome and introductions

Due to technical issues during the meeting and DG advising she had to leave the meeting at 3.30pm, both DG and GB chaired the meeting at different intervals. GB welcomed all to the meeting and asked all for introductions. GB advised that as before the meeting will be recorded to enhance the accuracy of the minute of the meeting.

2

Item Subject Action 2 Everyone Matters 2020 vision

a) PC presented an overview of the Delivering Everyone Matters 2020 Workforce Vision and Implementation Plan 2015-16.

Everyone Matters Workforce Visioning is a workforce set of processes to support

each of the Scottish Government’s 2020 workforce vision. Consultation was held throughout Scotland to engage staff regarding the content of the Everyone Matters Implementation plan and how Health Boards should be taking this forward.

Everyone Matters Workforce Implementation Plan is made of the following five actions:-

• Healthy organisations culture • Sustainable workforce • Capable workforce • Integrated workforce • Effective leadership and management.

Local delivery plans will be used as the primary method of reporting. NHSH have compiled an Action Plan – Everyone Matters:2020 Workforce Vision Implementation Framework and Plan 2014 – 15 containing an update on Progress. Information contained in the document comes under the headings of :-

• Actions for Boards • Current State • Actions Planned • Additional Actions Required • Workforce Lead

PC advised that she is undergoing the processes of engaging with partnership forums within NHSH, Management teams and other professional groups within NHSH to ensure that actions within the plan are accurate and to offer the opportunity to submit any additional comments or actions they would like to be included. Unfortunately not all members of the Partnership had received copy of the plan and could therefore not refer to the document at the meeting. PC advised that she will forward a copy of the document for onward circulation. Members are asked to take the opportunity to view the plan and forward any comments to PC.

b) RS presented an overview of iMatter documentation which was circulated prior to the meeting.

Implementation of iMatter will take place over the next three years commencing in January 2015. Actions and Timescales for Boards were detailed on page 8 of the circulated report. iMatter will be used as a measuring tool for staff engagement/staff experience. NHSH have used the Staff Surveys as a basis for action. It was noted that although the plan will be rolled out throughout NHSH, the start date for A & B will be delayed until any impact from the formation of the HSCP is ascertained.

PC/RM All

3

Item Subject Action 2 Everyone Matters 2020 vision

iMatter continued A & B HSCP may have to consider revising/adapting the implantation plan so that any local authority staff who become part of an Integrated Teams can participate in the staff survey thus providing a fuller picture of the service involved. It is hoped that of implementation of iMatter will commence in A & B in October 2015. Feedback will be given via HPF.

Questions arising from presentation:- a) PT advised as part of the Quality and Safety Review carried out earlier this year in

the OLI locality one of the actions identified within the plan would be a test on iMatter. There may be implications for the CHP if we are unable to action. PT further advised that she is due to report back to the Clinical Quality and Patient Safety group in February. Are still keen to explore if at all possible prior to the Integration.

RS advised that iMatters will take 3 years to be fully implemented. This does not mean that everything else will stop around team development, culture and behaviour. It should be seen as ongoing work and used as a measurement tool which allows management and staff to identify areas we need to focus on. It was noted that DW is due to submit the report for OLI. PT advised she will arrange a meeting with DW to discuss and will liaise with RS or AP. It was also noted that staff side representation will require to input.

b) VH. Wished to ascertain if directly employed Child & Families staff in North

Highland are excluded from the process.

RS advised - currently yes.

PT

3 Musculoskeletal redesign HR advised that the NHS Highland Allied Health Professionals Musculoskeletal redesign programme process is underway. Currently the services are about to implement the MAT Services which is due to go live Highland wide on 12th January. Anyone who has muscular or joint problem can contact NHS 24. The person will then be taken through a specific screening tool with a call handler who will identify if people are of a low, medium or high risk of developing chronic conditions. Those who are identified as low risk are screened and directed towards NHS Inform webpage where Apps for download and visualising exercise are available. If the person is of medium risk they will be referred back to NHS Highland. Hub will be used to reduce waiting times and to maximise use of capacity. When Hub is implemented staff will be able to take bookings for new patient referrals and appointments for those who want to opt back in for treatment. For information MATS stands for Musculoskeletal Advice and Triage service. When PMS is in place consistently across the patch staff will be able to use e-vetting to screen referrals. Complexities have been noted around PMS particularly due to reporting to AHP Waiting times and Waiting standards. Implementing of the systems will be carried out in a phased manner commencing with Raigmore then rolling out to other areas. Staff information leaflets, posters and cards for patient information have been issued to all of the GP practices across Highland. NHSH will be holding public awareness campaigns via newspapers, press releases with details of service in the near future. All the leaflets are on the intranet AHP page site.

4

Item Subject Action 4 Minutes of the meeting held 4th September

Under matters arising from Minute held on 6th November “ID advised that the Estates staff have been displaced”. ID advised that this should be amended to read Integrated Equipment Service staff. With this amendment the minute was accepted.

RM

5 Matters arising from the minute not included on the agenda a) Payment of Unsocial Hours While on Leave.

GB advised that concerns were raised and discussed at the Terms & Conditions meeting in November. It was confirmed that the three months prior to change would be used as a reference period although locally that could be amended if it is felt necessary. HD advised that reference periods had been identified in OLI though the particular identified timescale did not include a public holiday. Rather than using a reference period, the three month period after the change (with any on-call included) should be used so as to ensure that all staff are treated consistently.

GB advised that T & C sub group had advised that they were uncomfortable this reference period could be changed locally. It was agreed that the 3 months would be standard unless it wasn’t reflective of a shift pattern. HD has been unsuccessful in trying to ascertain what has been happening in other areas of NHSH re outstanding payments. GB had contacted Payroll re payments to staff based in Dingwall. Payroll staff advised payments were identified using a trawl of staff. Payroll staff will contact SCNs to ascertain which reference period they used as a basis.

For the benefit of all GB advised that extra hours definition is any time worked that is not contractual i.e. anyone working above their contracted hours is classed as extra hours but if contracted even on a temporary basis that becomes contractual hours (e.g. someone picking up extra hours) GB further advised:- • Enhancements when staff are on annual leave and sick leave have been dealt

with locally. NHSH are taking the approach that we have to review all staff’s rotas and calculate would have been paid had the staff member been working during periods of sick leave/annual leave. NHSH will use a reference period of three months prior to the change (2008).

• Issues re extra hours. Nationally that is being looked at by STAC who have

formed a SLWG and they will advise what the guidance will be. It was agreed by the Partnership that the three month period as detailed previously is used in all areas and can only be changed by agreement or if the period is not reflective of the normal working pattern.

b) Integrated Equipment Service

It was noted that the Integrated Equipment Service update is carried to January to allow DR to join the meeting. ID voiced his disappointment and raised concerns and that no update has being available for the Partnership over the past 6 months due to DR unavailability to attend the meetings. GB advised that she has spoken to DR who has confirmed that he will join the

5

Item Subject Action 5 Matters arising from the minute

b) Integrated Equipment Service continued meeting in January. It was agreed that it may be helpful if a list of queries regarding the IES be compiled and forwarded to DR prior to the meeting in January.

c) Structure of Forum

Quoracy and representation was discussed and it was agreed that further discussion be held under AOCB.

Matters arising (included on the agenda) a) Dress code policy

PT advised on the two specific queries tabled at the last meeting:- • Bare Below Elbows - Requirement for clinical areas. Within the policy it advises that staff delivering direct clinical care should adopt bare below the elbows recommendation and do not wear long neck ties. During the Health Care Environment Inspectorate Inspectors visit to MACHICC in July 2014 the Inspectorate identified two members of staff who were in one of the wards, were not bare below the elbows. Incident was discussed at the NHSH Infection Control Improvement Group and it was noted that this requirement had not been included in the policy. For the avoidance of any ambiguity the recommendation of the Infection Control Improvement Group is that all staff entering ward/clinical areas should be bare below the elbows. Potential is that when any staff who enter a ward/clinical area may have to interact with a patient (possibility someone may fall or an event and may have to respond to the issue urgently). All managers need to be mindful if going into clinical areas that they must ensure they are bare below the elbow PT advised that she has liaised with Catherine Stokoe (NHSH Infection Control Manager) re this and although bare below elbows is an unofficial directive from NHSH the intention is that it will be incorporated when the Policy is updated in September 2015.

b) Footwear – full enclosed and made of wipeable material. Any footwear with holes are not acceptable within clinical areas. Within the policy it is clear that staff footwear must be appropriate to ensure a safe environment for staff and patients. Staff should wear plain, soft soled shoes which cover and protect the foot and the toes. Trainers which have venting holes or clog type shoes which are not fully enclosed are not appropriate for wear in clinical areas as blood or body fluids can spill and staff may become exposed to possible infection. Similarly if the shoes are not made of a wipeable material will be unable to decontaminate the footwear. Discussions were held on the material and composition of the footwear. PT advised that all footwear must conform to the specifications of the guidance standards contained in the policy and, in terms of health and safety, should be non slip soled. JG advised that Porters and Catering staff must wear protective toe capped shoes in order to prevent any injury from dropped items. LL asked if consideration could be given to issuing all staff with appropriate

RM

6

Item Subject Action 5 Matters arising (included on the agenda) - Dress code – Footwear continued

footwear as part of the uniform supplied – this would take away all risks or misunderstanding about what staff can wear as the plan is open to interpretation on what is deemed suitable.

PT advised in view of the current financial position provision of appropriate footwear to staff would be seen as an unnecessary requirement and would entail a massive cost to the organisation. If staff need further specific guidance PT will provide pictorial examples of what appropriate footwear is acceptable at the next meeting of the Partnership.

HD asked if consideration could be given to combining the Dress Code and Uniform Policy as there appears to be discrepancies. For the avoidance of any misunderstandings it would be beneficial for all staff if recommendations were contained in one policy. PT agreed to flag up these concerns. DC raised issue of midwives wearing own clothes and possibly inappropriate footwear thus running the risk of contamination or injury whilst working in the community. PT advised DC to contact her PA and request this to be included in the discussions for the next Infection control meeting.

c) Reduction in Supplementary Staffing

PT presented an overview of the establishment reviews in in-patient settings. It was noted that there appears to be some difficulties with communications and the processes. Meetings to discuss findings and recommendations will be held. In turn this will be compiled into a report which is to be completed by the turn of the year then tabled at Core Management in January. AC advised that requirements for any additional resource in areas will need to be forwarded to Head of Finance by 9th January to ensure inclusion in next year’s financial plan. As an action AC will flag up the item with Head of Finance. PT advised that paper will not be prepared/finalised until end of January but will provide a summary/bullet points information for Head of Finance. It was agreed that further discussion on Reduction in Supplementary Staffing be held at the next Partnership Forum

d) Staff Governance SLWG – GB advised that meeting is to be arranged for early January. It was noted that the Staff Survey results were issued yesterday. Feedback at Partnership Forum meeting in January.

PT PT DC AC PT Agenda item GB/SM/ DG

6 Health and Social Care Integration Workstreams are continuing to progress work on agenda. DG advised that she had VC to the last Joint Board meeting unfortunately signal was poor highlights from the meeting as follows:-

• Christina West has been appointed as Chief Officer of the Health & Social Care Partnership (HSCP) (commenced in post as from 1st December 2015)

• Programme Manager update was presented by Allen Stevenson • Discussed updates and representation at all workstreams

7

Item Subject Action 6 Health and Social Care Integration continued

GB advised • Work is being progressed on the management structure for the HSCP.

Structure has been drafted and has to be concluded by the 5th January • Public events are ongoing

VH advised that the Project Team, senior managers and staff side reps of both organisations are engaging with public re document and integration in general. It was noted that the further staff events are being held in January. The format for these events will be in a slightly different manner to those previously. Staff will have the opportunity to have discussions around key principles and integration. It was noted that CW hopes to attend every event.

Discussions were held on the Workstreams Feedback from staff being that they are not aware of what is going on in the workstreams. Staff side have discussed how to communicate with members locally in terms of what is happening within the workstreams. It was agreed that communication and engagement of staff at all levels is paramount and must ensure that information on how to access information on integration and events are widely advertised/available. Although there is an integrated newsletter available it was agreed that it may be beneficial for a short summary from the workstreams to be tabled at Partnership meetings.

7 Finance Update a) CHP

AC presented an overview of Finance Report for the eight month period ending 30th November 2014. Copies of the report were circulated prior to the meeting. It was noted that the overspend has moved from a previous figure of £264,000 to a overall position of £33,000 – a very favourable move demonstrating a significant improvement arising from the actions of the Managers taken to contain and reduce expenditure. In the main month 8 budgets achieved a break even or underspend. The only exception being General Medical Services which continues to record overspends due to use of locums but this is expected due to vacancies and various leave within practices. Overall position is improving and there is confidence that the CHP will achieve an underspend in the current financial year. It is important to note that the savings have been achieved by non recurring measures and there are concerns around the recurring savings plan in the scale of the shortfall on the recurring savings plan. Table 2 gives a break down of Cost Improvement Plan 2014/15

The CHP have a £3.4m savings target for 2014/15. At this point of the financial year the CHP has achieved a savings of £1,806m leaving a shortfall of £1,594m. The projected shortfall will require management action to reduce spending thus enabling the CHP to break even at the end of the financial year. Managers are urged to continue to review their savings programmes and to

8

Item Subject Action 7 Finance Update continued

achieve or declare what can be achieved as soon as possible. Without any movement in the savings this will place a significant budget pressure onto next year’s budget. The balance of outstanding savings will feed into the savings for the financial plan for next year along with various increases for costings - growth, inflation and approved management spend during 2015 -16. The overall CHP position is improved and continues to move in the right direction. Finance paper will be tabled at the Core Management meeting on Monday. This includes an outlook for 2015/16. Various expected costs pressures – growth, pay awards, and other local and national cost pressures show a potential financial gap in region of £5m+. By having a shortfall in this year’s savings target of 1.6m this will become part of this £5m gap. CHP continue to encourage managers to implement action/savings plans and to review possible expenditure. AP asked if the inclusion of the payment of GG&C is included in the projection for payment. AC advised that discussions are continuing with GG&C re payments and is unable to clarify further at the moment in time. NRAC payment. AC advised that previous reports have highlighted the fact that the population is declining in A & B. Payments made via the Arbuthnot formula will reduce as a consequence of this. A & B also has an aging population which will place other pressures on the budget. Arbuthnot formula payment was 29.86%. This has now reduced to 29.04%. This appears to be a relatively small percentage movement but entails a very large sum of money which will have a significant impact on the available budget whilst trying to maintain the same level of service or to retain the same level of infrastructure. The CHP is beginning to see the fruits of the actions that have been taken to save costs throughout the year. We will have to carry on with the work being mindful that next financial year will carry similar and increased savings requirement. Recurring deficit needs to be addressed. Learn to live within our means on a recurring basis.

b) Overview of NHSH financial position – copy of Chief Executive’s paper was circulated prior to meeting. Content of which was noted including the part that Argyll & Bute CHP has to and continues to play in achieving the Board’s overall financial position.

AP advised that NHSH consider every decision and every potential spend before commencing to ensure that NHSH achieve the targets by March 2015. Reductions have been noted during the year though gap still needs to be addressed. NHSH will continue to focus on safety and quality of services for all patients.

c) Email from Interim Director of Operations (copy of which was circulated prior to the meeting). Content was noted as follows:-

• Workforce Monitoring will now be held on a monthly basis. All posts have to be

fully scrutinised at locality level with only essential posts being submitted by Locality Managers.

9

Item Subject Action 7 Finance Update continued

• all use of agency, bank, excess, part time hours and overtime to cease unless deemed essential and signed off by a senior manager.

• Spending on supplies and services to be restricted to essential purchases only. • Staff travel and accommodation costs should be restricted where possible with

increased use of vc being adopted. Car share where possible. • Quality of patient care and should not be comprised in any way.

Proposal of using suggestion box for staff (which had already been raised at Co-chairs meeting by EM) was discussed. After discussions it was agreed that a sealed suggestion box be located in each site. Each locality will appoint a member of staff to take ownership. Contents are collated and submitted to the Partnership Forum for consideration. All staff assured that comments submitted are valued and that we are willing to take cognisance of their input. Subgroup to be formed to consider the suggestions – membership to be agreed. Thereafter a newsletter could be issued giving details of the suggestions submitted.

Agenda Item

8 Highland Partnership Forum AP presented an overview of the meeting held on 12th December. The following was noted:-

a) Smoke free policy Verbal update given. Draft Policy has been circulated and discussed at a number of forums. In accordance with the Scottish Government directive aim is to have smoke free sites no later than 1st April 2015. No smoking will be allowed anywhere within sites e.g. in garden spaces or within vehicles. Mental Health Hospitals and care homes in North Highland are exempt from the policy. Sites have already started working towards this date. It was noted that all buildings within NHS Highland smoke free since Jan 2008. HD raised issue of E-cigarettes. It was noted that they are included in the ban. It is acknowledged that these are unregulated, but advised that staff and patients are using these as a method to stop smoking.. AP decision was based on Public Health and Government information. There is an element about normalising people not smoking on sites and anyone using an e-cigarette looks as if they are “smoking”. In terms of supporting in-patient who are suffering from nicotine withdrawal replacement therapy is available. NHSH will have to ensure patient documents issued advised that there is a no smoking policy in sites and offer details of how dispensing of nicotine replacement therapy can take place for them.

b) Pre-retirement survey. A survey was conducted recently in NHSH in terms of looking for information, support and guidance when planning retirement. A number of staff advised that pre-retirement courses were a good idea and would like to have reinstated. Discussions were held and courses will be reinstated. These will be widely dispersed as possible (to include A & B). Management clear that attendance at the courses should not be in work time. Staff should utilise annual leave or days leave given within phased retirement. Evening classes may also be available. NHSH are planning to set up courses during 2015 more information will follow in due course. Any suggestions on the format for these courses would be welcomed. c) Financial position discussed d) Summary of HQA paper which was tabled at the Board meeting on 2nd

December. e) iMatter

10

Item Subject Action 8 Highland Partnership continued

f) Hard and Soft Facilities Management Work ongoing Scotland wide. Following up possible implications for NHSH

g) Input on eHealth Strategy h) Approved new policies on Short term secondments. Documents on intranet in

near future. Policies apply to transfer of social care staff i) TOIL policy – to be tabled for further discussions j) Consultation on draft pensions regulations which come into force on 4th

January 2015. Significant changes come into force in April 2015. Programme of work in terms of awareness raising, sending out information, presentations if and where possible between now and April and beyond. Programme not yet in place though initial notification has been made via payslips. Ensure staff are aware how changes may affect them come 1st April 2015.

GB advised that she is aware that posters are already available and can A & B have copies to circulate. Noted query for staff regarding Policies for Adult care which has been posted on the intranet under policies. Need to indicate that the new policy excludes staff in A & B.

9 Argyll & Bute Committee GB advised that the Committee met on 17th December – carry forwarded discussion to the next minute of the Partnership.

10 Modernisation of Mental Health Services Update As JD was unable to attend the meeting GB presented an overview of the report which was tabled at the Committee meeting as follows:- a) Programme Board met on 17th October. b) In-patient services bed compliment within ICPU is falling - 4 patients currently.

This figure is due to reduce further to 2 patients in January 2015.

Decision to merge ICPU and Succoth wards which will be taken forward in 2015 with work expected to be completed by May 2015. HD asked if this would involve any changes in staffing levels. GB advised that it has not been confirmed as part of the discussions for establishment review. If discussions are to be held ensure that staff side are involved and identify if any organisational change steps are required.

c) Vacant post for Consult Psychiatrist is proving difficult to recruit to – post is

currently being covered by locum. d) Cowal and Bute continuing to experience problems due to vacancy in clinical

physiology although noted that the CTB post was filled in November.

11 Workforce Planning and Development a) HCSW

SM advised that the CHP continues to struggle with Induction and completion of the Code of Conduct carried out for new staff within the three month period from commencement in post. Managers are reminded that this is mandatory for all staff who are not regulated or part of profession. Since the commencement 2011 new staff were employed . 26 of the staff achieved within timescale. A number of staff have eventually completed but this process took a considerable amount of time to achieve and still have 60 staff who are yet to complete. Requirements were set by the Government to ensure public protection and safety of patients and must not to be seen as a tick box exercise. As an organisation we must be able to record that we have given the staff the required induction.

11

Item Subject Action 11 Workforce Planning and Development continued

a) HCSW Code of Conduct has also been in place for existing staff from 2012. 95% have signed remaining 5% = 37 people mainly in OLI and MAKI. It is noted that this not only bank staff as approximately half of the figure are permanent staff who should have read and signed off. Some more work required to this push within localities. GB advised that this is a poor reflection on the development of staff. Need to emphasise to all that this should happened within the 3 month period and to ensure that the new member of staff the correctly induction into the organisation.

b) eKSF. SM target remains at 80% of all staff have a review completed and recorded on eKSF. Best achieved in past was 65% permanent staff (figure increased if exclude bank staff). Figures at end of November have advised that we have only achieved 14% of staff having had a review completed and this is disappointing as we are now at the month 8 stage. When comparing the figures to Highland, the overall figure is 12%. Our end of year position in April 2014 was 46% of all staff having had a review completed and recorded on eKSF. If we were to have the same amount of activity from now until end of year it is predicted that we will achieve 42% therefore highly unlikely that we will be over 50%. Major concerns is 50% of staff not having a review – which is the important part not necessary the recording of the process. SM further advised monitoring of the rolling twelve rolling month period is continuing. This system indicates the how the process is embedded in day to day practice. Within the report it was noted that 47% of staff having had a review completed and recorded. This equates to a marked decline in the overall process. Given this trend and the likelihood of continuing to record a decline over the rolling year the CHP will fail to reach or be close to the 80% target. We are aware that the process is not the easiest to use but it has been in place for some time. The contract has been extended to the end of 2016 and should encourage staff and managers to use. Reviewing the KSF in NHS Scotland Report on Focus Group Findings was circulated for information. Report considered what lessons have been learned on usage of eKSF and how it can be improved. Outcomes from the Report will be considered and taken onboard for the replacement for eKSF - Oracle Performance Management (OPM). OPM has not been completely designed as yet hence the continuation of the eKSF contract until 2016. OPM has simpler outlines and more focused on review rather than the evidence and will sit under the eESS systems. GB advised that the report content is positive and notes that staff are positive about the process. eKSF will remain operational until March 2016. As an organisation we need to recover from the decline in reviews and be more proactive not just to April 2015 but continuing on under the new system. GB reminded all that eKSF is the system used by the organisation. Reviews should be done at least once per year. The most important part of eKSF is the opportunity for staff and line managers to discuss any issues or career developments/training.

12

Item Subject Action 11 Workforce Planning and Development

b) eKSF continued 14% is a very low figure for completion. Staff must be seen as the organisation’s main resource. The processes of systems like eKSF should offer development opportunities and staff governance standards. Staff are encouraged to be more proactive and if they have not had their review to seek an opportunity to arrange a meeting with their line manager for their eKSF. Where possible opportunities taken to share and replicate best practice in use of and recording of eKSF throughout the CHP. It was noted that there continues to be an amount of negativity around the process. Staff struggle to see the relevance of eKSF and that the process has nothing to offer them. Issues of access to computers and computer literacy remains to be addressed at local levels.

c) Redeployment GB presented an overview of the Redeployment registers Current Redeployment register. It was noted that 40 members of staff are on the register at the present time. Main changes noted in the CB H & L area with the addition of 3 band 2s and 1 band 6. In MAKI figures reduced to 3 employees - band 6 successful matched, band 3s have reduced to 0.7 and additional band 2. OLI and Mental Health services remain as previously reported. Secondary Register There has been no movement on this register with 33 employees currently remaining on the register. DG asked the Partnership to take cognisance that the Joint Trade Union Partnership and HR workstream is looking at redeployment. GB advised that in the main this does not change the process for redeployment for CHP staff. Further discussion is still to be had around how we manage that policy going forward following Integration as we will also have Local Authority staff to consider. Redeployment has been discussed in the HR workstreams. Membership is made aware that NHS hold a register containing a priority list of staff for redeployment. The register remains confidential, as cannot be shared at the moment (no details of base or bands are advised).

Discussions where then held on the amended PIN guidelines for NHS staff on fixed term contracts. It was noted that the minimum duration fixed term – 3 months maximum is 2 years. When staff are approaching the end of a fixed term contract a meeting with their line managers should take place. Where possible this should be held 12 weeks prior to end of contact. Within the new PIN guidelines some flexibility has been given for this time scale changes – the maximum period of remains at 12 weeks though if staff are on a 3 month fixed term contract this could be arranged for a different point e.g. half way through the contract. During the approach to the end of the contract HR will offer support to maximise opportunities for other employment within the organisation. There is no guarantee of employment and employee will leave on the date given for the end of the fixed term contract.

13

Item Subject Action 11 Workforce Planning and Development

d) Redeployment continued GB advised that this process is already implemented in A & B. HR have a database of fixed term contracts. Ensure managers are meeting with employees at least 12 weeks before end of contract and staff are placed on redeployment register at that point. HD asked if staff on fixed term contracts are entitled to come under the redeployment similar to permanent staff. GB advised that staff on fixed term contracts have no protection and will be at a lower priority than to those undergoing organisational change.

Staff on fixed term contracts continuing after 2 years have the right to redundancy payments. Managers need to be mindful after 4 years becomes a permanent status of employment.

12 Organisational Change a) CHP and Locality Organisational Change Group

Last meeting of the group was held on 15th December. GB advised that are still awaiting some job descriptions from Agenda for Change. When job descriptions are returned will be able to move on to mapping and matching of staff and posts. In the meantime VH and GB will conduct 1 -1s with the remaining staff members who are at risk in terms of the redesign. When process began there were 11 members of staff were involved. This has now reduced to 3 due to turnover, staff moving on, leave posts etc.

It was noted that Phase 1 is almost complete and continue to move forward with Phase 2.

Staff side representation on the group. As EM is retiring in December a replacement staff side representative will be required. DG advised that she is happy to continue in the meantime but would welcome consideration by another staff side rep.

Next meeting due to be held early February.

b) MAKI – arranged meeting was cancelled due to overrun of WFMG. c) BCH&L copies of minute of 5th November were circulated prior to the meeting.

CG advised that the main discussions held were around ToR and Health Social Care Integration. Due to time restraints most agenda items were carried to the next meeting. HD noted that an extra ordinary meeting was requested to discuss the Integrated Equipment Service. IES is discussed in the OLI group and would not expect CBH&L group to be making any decisions. CG – advised that discussions centred around a member of staff approaching CSMs with concerns regarding the IES. CSM was not aware that redesign was taking place hence the need for information/discussion. It was noted that sharing of the minutes of Locality Organisational Change Groups

GB/VH

14

Item Subject Action 12 Organisational Change continued

and Partnership Forum were seen as a vita source of information for all staff.

d) OLI – meeting was cancelled – next meeting in January 2015. e) Radiography

GB reported that 5.6 WTE posts indentified as part of the redesign had been approved at WFM. Have appointed 7 people but have not filled the complete 5.6 vacancy –further advert to be placed. Have been successful in recruiting to the Band 7post.

Representation from the staff to be invited to the next meeting to present an overview It was noted that there is also two vacancies within the CHP.

13 AOCB a) Smoke free policy – as discussed previously under HPF b) HQA Awards - email was circulated round all users for information (document

circulated prior to the meeting for information). Are looking for nominations and notice to be cascaded as widely as possible. Car sharing and proposal for e diary - proposal tabled by EM. Local authority operates a car sharing system. Given the financial climate is this something we could consider and look to explore within CHP. It was noted that some areas have booking system for pool cars on the intranet but not available on all sites. It was agreed that a member of Hotel Services management be invited explore discuss scheme further. AP advised that NHSH devised a system for sharing car journeys to work (details available on the intranet – under heading of Kessock Bridge road works link into Highland.liftshare.com. Noted the scheme is independent of the health board or local authority) Health & Local Authority staff using NHS pool cars within integrated teams discussed for information will be required to see if any difficulties arise.

It was agreed that subject would need further discussions and will be included as an agenda item at the next meeting of the Partnership.

c) Consultation on Proposals to introduce Duty of Candor for Health and Support care staff. (documents as circulated prior to the meeting for information). It was noted that comments to be submitted by 5th January.

d) On behalf of the Partnership forum GB wished to thank Elizabeth McMillan for

her contribution over the years to the work of the Partnership and expressed best wishes to EM on her retirement.

e) As the CHP will no longer be in existence as from 1st April 2015 discussions

were held on how the work this group presently undertakes and the issues that are discussed are absorbed and reflected within the Integrated Partnership Forum. It was agreed that item will need fuller discussion and will be included in the agenda for the meeting in January.

f) SLAs

CG advised that he is involved in the repatriation of SLA38 and SLA45 and will provide an update for next meeting of the group.

Agenda item Agenda item Agenda item

14 Close GB thanked all for attending and brought the meeting to a close.

15

15 Next meeting to be held on 22nd January 2015 in Aros Boardroom at 12.30 p.m. Subsequent meeting 5th March 2015 in Aros Boardroom at 12.30 p.m.

Provisional dates undernoted are for further meetings in 2015 and may be subject to change following formation of Health & Social Care Partnership on 1st April 2015. 16th April 28th May 9th July 27th August 8th October 26th November

For admin purposes. All papers for discussion must be forwarded to RM 7 days prior to the meeting. To facilitate the VC Bridge please advise RM if you wish to VC at least 7 days prior to the meeting.

Glossary A & B Argyll & Bute ABC Argyll & Bute Council B &C Bute and Cowal CHP Community Health Partnership GG&C Greater Glasgow and Clyde H & L Helensburgh and Lomond HPF Highland Partnership Forum HR Human Resources HSCP Health & Social Care Partnership HQA Highland Quality Approach OLI Oban Lorn and Isles MAKI Mid Argyll Kintyre and Islay NHSH National Health Service Highland PF Partnership Forum PVG Protecting vulnerable Groups SAS Scottish Ambulance Service SCN Senior Charge Nurse SLWG Short Life Working Group STAC Scottish Terms and Conditions Committee SPS Scottish Patient Safety WFM Work Force Monitoring

ARGYLL & BUTE CHP Wednesday 18 February 2015 J03-J07, Mid ...€¦ · a poster campaign on buses....

Documents

Transcript of ARGYLL & BUTE CHP Wednesday 18 February 2015 J03-J07, Mid ...€¦ · a poster campaign on buses....