Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 18, Annex 1 evidence those recommendations which were believed to apply and to respond appropriately. He confirmed that Trusts were co-operating and sharing their individual approaches, which was helpful for all. Mr Lindsay briefed the Committee on two inquest case studies and the key issues arising from these. The Committee discussed these, in broad terms. In the context of operational and staffing pressures, Mr Wilkins queried the point at which a service may be withdrawn in the interests of patient safety D and the legal position of doing so. Mr Lindsay stated that there was no guidance or definitive answer to this difficult question and it would depend on the circumstances. However, conscientious monitoring and an ability to audit actions and evidence careful decision-making would be crucial. The broader point was the pressure in the system going forward and Trust Boards must be cognizant of this. R 44/13 Review of CQC Outcome 21: Records A In setting the context for this review, Mrs Schwarz stated that health records had been an issue of longstanding concern to the Audit Committee and to the F Safety & Quality Committee, which was currently overseeing progress with compliance. The review being undertaken today had been scheduled as a result of known focus by the Care Quality Commission (CCQ) and as part of the Committee’s rolling programme to review the process to test assurance of outcomes declaring compliance. The current status of this outcome was compliance but with T moderate concern. Mrs Schwarz thanked Mr Lindsay for attending and he left the meeting. Penny Taylor, Head of Clinical Systems Governance, attended for this item. Mr Thomas stated that that this standard was very broad and covered more than health records. An inspection in 2012 by the CQC and a subsequent mock inspection in March 2013 had identified concerns with the security of case notes on wards, updating notes in a timely manner and with Treatment Escalation Plans (TEP) not being completed consistently in respect of DNAR. Dr Williams asked Mr Thomas how confident he was that the actions in place would ensure compliance. If the CQC inspected today, would they find the Trust compliant? Assurance could not be given on this point and Mr Budge stated that the CQC had been asked if they were able to identify other similar organisations who exhibited best practice. Mrs Raikes asked when the Trust would be compliant. Mr Budge stated that when the CQC submitted the formal report of their inspection it was likely that the Trust would be given between thirty and sixty days to comply. Some of the issues were not unique to the Trust and whilst they were features of working in a busy environment, they also concerned culture, which took longer to shape. Overall, the actions would take 3
Item 18, Annex 1 time to embed and Mr Budge would ensure that the Head of Assurance undertook a further review. Mrs Schwarz queried progress with DNAR recording. Dr Mayor stated that it was challenging to ensure this conversation was undertaken sensitively and comprehensively. Dr Williams acknowledged this could be an issue in MAU but it must be comprehensively resolved in the subsequent patient pathway. Dr Mayor was meeting with junior doctors to ensure that D patient notes were clearly annotated when the conversation had not been had. Mr Budge suggested that the Safety & Quality Committee set a timescale for a further audit and then track progress. Dr Mayor stated that TEP was an issue for the wider health community to address and that, overall, the solution lay outside the Trust. Mr Baber suggested seeking and adopting best practice from other trusts who had complied with this standard. R There were no further questions. The Committee noted the assessment of compliance with moderate concern and the limited assurance provided by the actions identified. The Board would receive updates via the Safety & Quality Committee. A Penny Taylor left the meeting. 45/13 Counter Fraud Annual Report 2012/13 46/13 The Committee noted F this document. There were no questions. Internal Audit Annual Report 2012/13 Mr Glover gave an overview of the report and is contents. The Committee discussed two issues of concern, the delay to the PACS project implementation T and the deferral of the Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation inspection. PACS Mr Thomas updated the Committee on developments at the PACS Project Board which had taken place the previous day. On the Committee’s recommendation it had been decided to defer the scheduled go-live date for three months and to extend the existing provider’s contract for the same timescale as there was insufficient assurance on the speed at which historical images could be accessed. The maximum financial exposure to the Trust would be c£60k plus costs associated with extending the life of the Project Board. Dr Williams queried the degree of confidence Mr Thomas had that a delay of three months would be sufficient to solve the problem. Mr Thomas explained the size and complex nature of the project and contractual arrangements, which involved dealing with sub-contractors under Connecting for Health (C4H). The situation was aggravated by 4
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Trust Board Friday 5 July 2013, 9.0
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Members of Plymouth Hospitals NHS T
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Item 3 observer. The Chairman requi
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Item 3 Board oversight of contribut
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Item 3 the Board next month. • Th
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Item 3 been involved and there was
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Item 3 continuing to build. Mr Babe
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Item 3 to Norovirus, Professor Lewi
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Item 3 • Careful communication of
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Item 3 • Approved the writing off
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Updated: prior to July Board Item 4
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Updated: prior to July Board Item 4
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Item 8 Quality Impact Assessment Pa
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Item 8 3.2 Quarterly Summary Hospit
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Item 8 4.4 Monthly Proportion of Pa
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Item 8 Inpatient falls are currentl
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Item 8 REI signage PALS were contac
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Item 8 Complaints received listed b
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Item 8 The graphs below illustrate
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Item 8 5.5 Friends and Family Test
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Item 8 1. Pressure Ulcers (EoC) 2.
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Item 8 Observations The essence of
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Item 8a SUMMARY REPORT Trust Board
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Annex 2 Item 8a Summary of Serious
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Item 9 Key Recommendations The Trus
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Item 9 Effective Care (Section B2 o
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Item 9 Description 31 days from 'de
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Item 9 4.6 Non Elective Activity is
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Item 9 Summary of performance excep
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Item 9 Ensure that all patients adm
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Item 9 Forecast Significant progres
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Item 9 Update on previous actions C
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Contents EXECUTIVE SUMMARY D FINANC
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B1 Safe care Description Hospital S
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Response Rate Recommender Score B3
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B5 Other safety & quality metrics D
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C2 Non-Elective Activity Descriptio
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C4 Referral To Treatment (RTT) Desc
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C6 Other access & activity metrics
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D2 Cost improvement programme (CIP)
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D4 Cash Management Description Revi
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E1 Staffing numbers Description Est
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E3 Sickness absence PERFORMANCE IND
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Risk Rating F2 Monitor's Financial
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Item 10 DETAILED REPORT Trust Board
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Item 10 4. Key Issues for the Board
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Item 11 SUMMARY REPORT Trust Board
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Item 11 DETAILED REPORT Trust Board
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Item 11 • Challenge in respect of
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Item 11 Over the past two years, me
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Page 109 and 110: Item 12 Next Steps 1. Conversation
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Page 113 and 114: Item 12 EDS Grades and E & D Object
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Page 117 and 118: Item 12 3.6 The workforce is suppor
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Page 121 and 122: Item 13 Telephone conversations.
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Page 125 and 126: Item 14 SUMMARY REPORT Trust Board
Page 127 and 128: Item 15 incident investigations to
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Page 131 and 132: Item 15, Annex 1 • Top three issu
Page 133 and 134: Item 15, Annex 1 The Chair asked SS
Page 135 and 136: Item 16 COMMITTEE MINUTES Finance,
Page 137 and 138: Item 16 pay and staffing, highlight
Page 139 and 140: Item 16 • PACS contract - likely
Page 141 and 142: Item 17 Terms and Conditions of Emp
Page 143 and 144: Item 17, Annex 1 29/2013 Minutes an
Page 145 and 146: Item 17, Annex 1 31/2013 Francis Re
Page 147 and 148: Item 18 SUMMARY REPORT Trust Board
Page 149 and 150: Item 18 Next Steps The Audit Commit
Page 151: Item 18, Annex 1 Matters arising 4/
Page 155 and 156: Item 18, Annex 1 Payroll & Expenses
Page 157 and 158: Item 18, Annex 1 The Committee note
Page 159 and 160: Item 18, Annex 1 Going Concern Revi
Page 161: Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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