Board of Directors Meeting, 31 Jnauary 2011
                                                                                      Agenda Item 6


                              Meeting on 31 January 2011

                         Quality and Safety Committee Report

1. Purpose of report

1.1    To inform the Board of key issues arising in relation to quality and safety.

2. Provenance

2.1    This report is sourced from discussions arising from the Quality & Safety Committee
       meeting of 6 January 2011 and those reports received by the Committee.

3. Assurance Framework

3.1    A number of risks were reviewed that were contained within the Assurance

             It is noted that S3 Supervision will now appear as a regular item on the
              Quality and Safety agenda.
             S9 CQC registration - plans in place around this to provide Board assurance
              via regular reporting.
             SU3 and SU10 – any quality and safety implications in sustaining the
              2010/11 financial plan will be considered.
             T1 and T2 - Delayed transfers of care – appropriate updates are provided to
              the Board and there is a clear planned programme of work underway.
              Complex work is being undertaken in the Adult Clinical Directorate to
              enhance care pathways, overall plans will be presented to the Trust
              Management Board later in January.

3.2    Other risks were reviewed and noted. The number of risk scores have been
       reduced after review in December, these include the risk scores in S4 and S5
       concerning Clinical Audit and Clinical Governance. These reduced in relation to the
       continuing embedding of quality and safety within the new clinical directorate

3.3    The Balance Score Card noted that the seven day follow-up plan is in place in order
       to achieve our target by the end of the year. Attention was drawn to the problems
       arising when people are admitted from out of area. Social Care indicators were
       reviewed, particularly around waiting times for assessment, copies of care plans
       and regular reviews. Work is underway to ensure that these issues are addressed.

3.4    The challenges around managing a reduced target in sickness absence were

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                                                         Board of Directors Meeting, 31 Jnauary 2011
                                                                                       Agenda Item 6

4. CQC Condition Around Supervision and Appraisal

4.1     Supervision – the figures available at the time of the meeting demonstrated that we
        had not met the target of 90% by the end of December, as expected. There are
        strategies in place to manage this and bring the trajectory back on track.

4.2     It had been noticed that feedback regarding CQC visits from staff and assessors
        had been generally positive with extremely positive feedback received from St
        John’s Court. Melrose feedback had not been as positive, but the CQC agreed with
        the Trust’s report and actions against this. No major concerns have been
        highlighted to the Trust. It is anticipated that the CQC will inspect prisons later this

5. Reports From Sub Committees

5.1     Serious Untoward Incident Group – it was noted that the roll-out of reporting all
        incidents electronically is underway and this transition should be completed by the
        end of the month, when all reports should be submitted electronically. The first draft
        of a trial run of trends analysis was shared with the Quality and Safety Committee.
        This work will be further developed although data quality could not be assured.
        Early indications would suggest there are no major trends within our mortality data.
        The current RCA position was noted, NHS Devon are aware of our progress with
        RCAs and resources are being deployed to ensure that we meet our backlog in as
        timely a manner as possible.

5.2     Safeguarding Committee (including Child Protection and Vulnerable Adults Annual
        Report and Annual Declaration)

5.2.1   This report was presented and the Committee was reminded of their statutory
        responsibility to report on systems and processes to safeguard children. It outlined
        the core elements needed in terms of internal governance and multi-agency
        processes. The Trust continues to have representation on the Devon and Torbay
        Safeguarding Boards.

5.2.2   95% of staff have now completed level one e-learning as of the end of December
        2010. The priority for the oncoming year is training at level two and three. A further
        module has been developed with a timeframe for eligible staff to complete this.

5.2.3   Section 11 Audit – this is an annual requirement as part of the Children’s Act. It was
        noticed that the progress made by the Trust was commended in last year’s

5.3     Adults Safeguarding Report - Serious Case Reviews – an individual management
        review has been completed and services were judged as good. Key points noted
        were that further improvements need to be made around training for Safeguarding
        Adults. A number of serious case reviews have been commissioned with more
        expected. The Trust will have a role to play in these. Safeguarding reports are to
        be presented to the Board for ratification and approval for onward submission,
        where appropriate.

5.4     Infection Control and Outbreak Report – the report was noted.

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                                                      Board of Directors Meeting, 31 Jnauary 2011
                                                                                    Agenda Item 6

5.5    Information Governance Committee – recent incidents regarding information
       governance, learning will be by Root Cause Analyses into incidents before reporting
       recommendations with actions back through Quality and Safety Committee.

5.6    Clinical Effectiveness Group Report – this was received and noted. Work is
       ongoing to ensure that the Trust has the best systems in place to deliver on NICE
       Guidance requirements.

5.7    Quality Accounts - Work is underway to put together this year’s return from the
       Trust. The areas of priority are care planning, patient experience and slips, trips
       and falls. It was agreed that in future Quality Accounts would move further up the

6. NHS Southwest Quality and Safety Improvement Programme

6.1    It was noted that the Strategic Health Authority will meet with the Trust on the 19
       January 2011 to start to make an assessment of our current patient safety
       programmes. This will kick off a series of learning events around a number of
       different workstreams involving frontline staff. A number of Devon Partnership NHS
       Trust staff form part of the faculty of the NHS Quality and Patient Safety
       Improvement Programme – these include four of the Patient Safety Officers and the
       Co Medical Director, who is also the Clinical Lead for the programme.

7. Quality Hotspots

7.1    A piece of work was presented about the work that has been undertaken within our
       Gender Dysphoria Service. There has been good engagement in the improvement
       programme and further progress will be reviewed in March to identify any
       outstanding issues or problems which may still need to be resolved.


8.1    The Trust is awaiting publication of investigations into four homicides committed by
       people using services within the Trust. These investigations are being undertaken
       by HASCAS. The Trust has a consolidated homicide action plan in place which is
       already addressing issues that have been identified prior to this publication.

9. GP Engagement Report

9.1    It was noted that engagement responses are increasing as GPs become more
       confident that actions are being addressed. C2C groups continue to develop and
       are helping to understand the influence of commissioning interests of GPs. A
       number of people are identified at key points and work continues to enhance our
       engagement with our GP colleagues.

10. Recommendations

10.1   Members of the Board are asked to receive the report and note its contents.

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                                                  Board of Directors Meeting, 31 Jnauary 2011
                                                                                Agenda Item 6

Prepared by Dr Helen Smith, Co Medical Director
Presented by Dr David Somerfield, Co Medical Director
Date: 24 January 2011

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