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Assynt House
Beechwood Park
Inverness, IV2 3BW
Telephone: 01463 717123
Fax: 01463 235189
Textphone users can contact us via
12 May 2010 Typetalk: Tel 0800 959598
www.nhshshighland.scot.nhs.uk
MEETING OF NHS BOARD CLINICAL GOVERNANCE COMMITTEE
Tuesday 18 May 2010 at 9.15am
Board Room, Assynt House, Inverness
AGENDA
9.15 1 WELCOME / APOLOGIES
9.20 2 EMERGING ISSUES
9.25 3 MINUTE OF MEETING HELD ON 9 FEBRUARY 2010 (attached)
The Committee is asked to approve the Minute
9.30 4 MATTERS ARISING
4.1 Update on previously raised emerging issues
4.1.1 Interim arrangements to cover Head of Clinical Governance & Risk
Management’s leave
The Committee is asked to note the current position in relation to
outstanding investigations and other emerging issues
9.40 4.2 Review of Committee’s Effectiveness
Report by Internal Audit and Action Plan (previously circulated)
The Committee is asked to note the report and agree the areas for
action
10.10 4.3 Clinical Governance Committee Action Plan – Update
Report by Lesley Anne Smith, Head of Clinical Governance & Risk
Management (attached)
The Committee is asked to note progress against the action plan.
Working with you to make Highland the healthy place to be
5 ASSURANCE AND ACCOUNTABILITY
10.10 5.1 Clinical Governance Committee Annual Report 2009 – 2010 (attached)
The Committee is asked to approve the content of its Annual Report
2009 – 2010 for submission to the Audit Committee on 25 May 2010.
10.15 5.2 Clinical Governance Committee Draft Work Plan 2010 – 2011
(attached)
The Committee is asked to discuss and agree its work plan for 2010 –
2011.
10.25 5.3 Clinical Governance Forum Update
Report of meeting held on 3 March 2010 (minute attached) and on 17
May 2010
The Committee is asked to note the report of the meeting held on 3
March 2010 and the current position in relation to issues previously
identified.
5.4 Infection Control Issues
10.35 5.4.1 Clinical Governance and Infection Control Structures and Reporting
Arrangements
Report by Heidi May, Nurse director (to follow)
The Committee is asked to consider and agree the structures and
reporting arrangements
10.50 5.4.2 Health Facilities Scotland Control of Infection Report
Report by Heidi May (to follow)
The Committee is asked to note progress against implementation of
the report’s recommendations
11.00 5.5 Slips, Trips and Falls – Development of Falls Prevention Strategy
Report by Iain Macritchie, Rehabilitation Coordinator, on behalf of
Judith Catherwood, Associate Director (AHPs)
The Committee is asked to:
Note the report
Note the rolling out of the MORSE Risk Assessment Training for
identifying those at risk of falling in the In-Patient settings of NHS
Highland
Endorse the early completion of this roll out and its link with Clinical
Quality Indicators
Endorse the need to change staff and population attitudes (which
wrongly perceive falls in our hospitals, care homes and
communities as inevitable and not preventable) by supporting the
robust implementation of the Falls Prevention and Bone Health
Strategy and anticipating a reduction in the number of injurious falls
across NHS Highland
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Encourage the early identification of those who have fallen and
been taken to an emergency department
Encourage the Board-wide implementation of good Fracture
Liaison practice in order to prevent subsequent falls with escalating
severity of fracture
Specify any additional actions pertaining to Clinical Governance
arising from the report
11.15 5.6 Information Governance
Verbal update by Mirian Morrison, Clinical Governance and
Development Manager
The Committee is asked to note the position
11.20 5.7 Complaints Policy and Procedures
Report by Lesley Anne Smith (attached)
The Committee is asked to approve the attached Complaints
Management Policy and Procedures
11.30 5.8 Pregnancy and Newborn Screening Programmes in NHS Highland:
Annual Reports 2008 and 2009
Report by Sally Amor, Child Health Commissioner/Public Health
Specialist on behalf of Margaret Somerville, Director of Public Health
and Health Policy (attached)
The Committee is asked to:
Note the attached Pregnancy and Newborn Screening Programmes
Annual Report for 2008 and 2009
Note the key issues and issues that have been identified in the
preparation of this report with regard to quality assurance and
clinical governance
Endorse the report and the proposals for future annual reports to
be presented to the Clinical Governance Committee in the autumn
to allow for the presentation of a full year of data from the preceding
year
6 SAFE AND EFFECTIVE CARE
6.1 NHS Quality Improvement Scotland (NHS QIS)
11.40 6.1.1 Forthcoming NHS QIS Review Visits
Verbal Report by Mirian Morrison
The Committee is asked to note progress in preparations for the NHS
QIS reviews.
6.1.2 Update on recent review visits
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11.45 (a) Clinical Governance and Risk Management Standards Review
Verbal report by Lesley Anne Smith
The Committee is asked to note the report of the NHS QIS visit on
10/11 March 2010.
11.55 (b) Food, Fluid and Nutrition
Report by Judith Catherwood, Associate Director (AHPs) and
Executive Lead for Food, Fluid and Nutritional Care
The Committee is asked to:
Note progress with implementation of the FFNC standards in
Hospitals within NHS Highland
Note NHS Highland’s local report from the QIS visit from March
2009 which was published in February 2010 along with the national
overview
Note the publication of Health Facilities Scotland national report in
March 2010 on Boards’ implementation of the National Nutrition
Specification, NHS Highland’s compliance rate of 89.5% and future
plans to improve our compliance with the specification
Note progress towards achievement of the targets, standards and
national nutrition specification across NHS Highland
Endorse the priorities for future work to ensure NHS Highland
complies with the FFNC standards and the National Nutrition
Specification
12.05 6.2 Risk Management Steering Group
Report of review of the Group’s structure and remit
Verbal update by Lesley Anne Smith
The Committee is asked to note the position
12.15 6.3 Surgical Profiles – progress against action plan (attached)
Report by Lesley Anne Smith
The Committee is asked to note the submission of the updated Action
Plan
12.25 6.4 NHS Highland Response to Mid Staffordshire NHS Foundation Trust
Reports
Report by Lesley Anne Smith (attached)
The Committee is asked to discuss the recommendations made by
the Independent Inquiry and consider what further actions may be
required by NHS Highland in response to these
7 HEALTH, WELLBEING AND CARE
There are no items under this heading, the report on the Independent
Advisory and Support Service having been deferred to the next meeting
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12.40 8 FOR INFORMATION (attached)
a) North Highland CHP Clinical Governance & Risk Management
Group minutes of 26/01/10
b) Mid Highland CHP Clinical Governance & Risk Management Group
minutes of 10/03/10
c) Raigmore Hospital Clinical Governance & Risk Management Group
minutes of 20/01/10 and 17/02/10
d) Risk Management Steering Group minutes of 18/03/10
e) Area Drug & Therapeutics Committee minutes of 20/01/10
f) Maternity Services Committee minutes of 15/02/10
g) Information Governance Committee minutes of 19/04/10
The Committee is asked to note the Minutes
9 ANY OTHER COMPETENT BUSINESS
10 DATE OF NEXT MEETING
The next meeting of the Committee will be held on Tuesday 17 August
2010 at 9.15am in the Board Room, Assynt House
13.00 CLOSE OF MEETING
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