COUNCIL OF GOVERNORS AGENDA · 2017-12-11 · and the Trust would also be working with Ernst &...

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COUNCIL OF GOVERNORS 7 December 2017 12.30pm – 2.30pm

Board Room, Aintree Lodge

AGENDA d = document v = verbal p = presentation

No Item Reference

Preliminary Business – Chairman

12.30 1. Apologies for Absence

To note the apologies

CG17-18/026 (v)

2. Declarations of Interest

To receive declarations of interest in agenda items and/or any changes

to the register of governors’ declarations of interest pursuant to

Standing Orders

CG17-18/027 (v)

3. Minutes from the last meeting (18 October 2017)

To approve the minutes from the last meeting and discuss any matters arising:

CG17-18/028 (d)

Overview

12.40 4. Strategic Update

Chairman/Chief Executive

To note

CG17-18/029 (p)

1.00 5. Lead Governor Report

To note

CG17-18/030 (d)

Quality & Performance Management

1.10 6. Assurance on Key Indicators:

• Quality & Safety

• Finance & Performance

Non-Executive Directors

CG17-18/031 (p)

Internal System of Control

1.40 7. Key Issues & Assurances

• Audit

Non-Executive Director

CG17-18/032 (p)

Governance

1.55 8. Governor Committees:

Committee Chairs

• Membership Committee (1 November 2017) for noting

• Quality of Care Committee (15 November 2017) for noting

CG17-18/034 (d)

Concluding Business

2.10 9. Any Other Business

Chairman

CG17-18/035 (v)

10. Date and Time of Next Meeting:

20 March 2018 in the Board Room at 5pm

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Council of Governors

Wednesday 18 October 2017 5:00pm

Board Room Aintree Lodge

MINUTES

Present: Neil Goodwin - Chairman (Non-Executive Director)

Tracey Barnes - Public Governor

Sharon Bird - Public Governor

Elaine Carter - Public Governor

Jennifer Ensor - Public Governor

Ray Humphreys - Public Governor

Tony Kneebone - Pubic Governor

Pamela Peel-Reade - Public Governor (Lead Governor)

Rosemary Urion - Public Governor

Helen Frankland - Staff Governor (Nursing)

Lorraine Heaton - Staff Governor (AHPs) (Deputy Lead Governor)

Kerry McManus - Staff Governor (Other)

Paul Cummins - Appointed Governor (Sefton Council)

Barbara Hunter-Douglas - Appointed Governor (Edge Hill University)

John Wilding - Appointed Governor (University of Liverpool)

In Attendance: Tristan Cope - Medical Director

Joanne Clague - Non-Executive Director

David Fillingham - Non-Executive Director

Michael Games - Corporate Governance Manager

Sue Green - Director of People & Corporate Affairs

Tim Johnston - Non-Executive Director

Caroline Keating - Associate Director of Corporate Governance/Board

Secretary

Tanya Lewis - Corporate Governance Officer

Kevan Ryan - Non-Executive Director

Angie Smithson - Integration Programme Director

Steve Warburton - Chief Executive Officer

Beth Weston - Chief Operating Officer

Apologies: Mike Bowker - Public Governor

Tony Byrne - Public Governor

Jim Ford - Public Governor

Colin Maher - Public Governor

Rose Milnes - Public Governor

Julie Naybour - Public Governor

Andrew Swift - Staff Governor (Medical)

Dianne Brown - Chief Nurse

Ian Jones - Director of Finance & Business Services

Mandy Wearne - Non-Executive Director

2 members of the public were in attendance

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Aintree University Hospital NHS Foundation Trust

Minutes: Council of Governors’ Meeting 18 October 2017 2/7

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Preliminary Business

CG17-18/016 Apologies for Absence

The apologies were noted as above.

CG17-18/017 Declarations of Interest

There were no declarations of interest.

CG17-18/018 Minutes from the last meeting (15 June 2017)

The minutes from the previous meeting held on 15 June 2017 were approved as an

accurate record.

Matters Arising:

Exit Interviews

Pamela Peel-Reade, Lead Governor, sought and received assurance that during the exit

interview process staff received valuable feedback regarding their performance. Sue

Green, Director of People & Corporate Affairs advised that the Policy and guidance

contained a summary on retention including valuing staff.

Overview

CG17-18/019 Strategic Update

The Chairman advised the meeting of the following matters:

• Aintree/Royal Liverpool Merger – The Outline Business Case (OBC) was to be

presented to the Boards of Aintree and Royal Liverpool & Broadgreen University

Hospitals NHS Trust (RLBUHT) at the end of October 2017 for approval. Pending

approval, work would commence on engagement with Governors as well as

developing the Full Business Case and preparation for the Competitions & Markets

Authority process. The Chairman reinforced the importance of Governors’

engagement in the next part of the process.

• Care Quality Commission (CQC) Inspection – The unannounced CQC inspection

had begun on 3 October 2017 with approximately 50 inspectors in attendance over a

four day period. They had visited 3 key areas: Medicine, Surgery & Anaesthesia and

End of Life Care. The CQC had interviewed over 140 staff members from across the

Trust. Focus Groups had also been undertaken with Consultants, Matrons and

Governors and the Well-Led element of the inspection was taking place on 25/26

October 2017. Informal feedback had been provided to the Trust and immediate

action plans had been instigated to address any concerns raised. The Trust

continued to provide information to the CQC as per their data requests. The final

report was expected early in the New Year.

• Liverpool Community Health (LCH) – NHS Improvement (NHSI) had announced

that Mersey Care NHS Foundation Trust had been appointed as the provider for

community services in Liverpool. Services would begin to transfer from Alder Hey

Children’s NHS Foundation Trust to Mersey Care with effect from 1 November 2017

with the full transfer expected to be completed by April 2018.

• Accident and Emergency Department (AED) Performance – the Trust remained

challenged on its performance and had been ranked as category 3 (can improve with

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support). Work was continuing with ECIP to improve the Trust’s internal processes

and the Trust would also be working with Ernst & Young to improve current

performance. Furthermore, a review was being undertaken of out of hospital demand

and capacity to ensure that appropriate pathways were in place to discharge patients

safely. The Council was advised that A&E performance and patient flow were the

biggest challenges facing the Board and was a major focus of discussion at Board

meetings and would continue to be over the coming months.

• Visit from Secretary of State – a session had taken place with front line staff on 11

October 2017 with the Secretary of State for Health. The feedback from the event

had been positive and the opportunity had been taken to explain the pressures and

challenges being faced by the hospital as well as the steps being taken to improve

the position.

Members of the Council then sought and received clarification in relation to the following

matters:

• The Trust was receiving a contribution towards the fees for the work being

undertaken by Ernst & Young

• The benefits to be derived from having Mersey Care as the sole provider for

community services in Liverpool and Sefton

• Plans to merge the commissioning groups had fallen through. The Trust would

continue to work with the CCGs and Mersey Care to ensure safe packages of care

were put in place

• The plans in place to support staff well-being during the winter months. It was

explained that a health and well-being plan was in place to allow staff to access

services at different levels given the impact that sickness absence had on all staff.

The Council noted the update.

CG17-18/020 Lead Governor Report

Pamela Peel-Reade, Lead Governor, presented the report which highlighted the wide-

range of activity both internally and externally being undertaken by Governors during the

period and highlighted the following:

• The Organ Donation Memorial Opening Event in September 2017 which had been

well attended by staff and family members

• The Aintree Champions Excellence (ACE) Panel which highlighted the high

standards required to attain the status and the positive impact it had on the staff

• The session with the Secretary of State for Health that provided an opportunity to

showcase Aintree’s achievements.

Tracey Barnes, Public Governor, commented on her experience at the ACE Panel

meeting for ward 15 and the rigorous process undertaken. She advised that she had

spoken to staff on the ward, reviewed documentation and received a brief presentation.

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She was delighted to award the staff for their sustained performance.

Barbara Hunter-Douglas, Appointed Governor, requested that the Corporate

Governance Team be acknowledged for the effort devoted to organising and facilitating

Governor Meetings and other development sessions.

The Council noted the report.


CG17-18/021 Assurance on Key Indicators

Quality & Safety Kevan Ryan (Non-Executive Director), member of the Quality Committee, gave a

presentation on assurance on key indicators relevant to quality which covered the key

areas of focus, where on-going assurance is received and where assurance is sought on

areas of concern. He highlighted the main areas of focus including actions arising from

Serious Incidents and the increase in the level of incident reporting, progress against the

Quality Strategy, improved compliance in Medical Revalidation, improved referral rates in

Organ Donation, concerns over the failure to act on test results, increases in the level of

infections, particularly C.Difficile cases and the reviews undertaken on the Safeguarding

service and subsequent action plans put in place. An overview was also provided on the

Trust’s performance against the main clinical quality indicators.


matters:

• The process for recruitment and the length of time taken between the stages of

recruitment. It was noted that key performance indicators (KPIs) were provided to

the Divisions to track the recruitment process and a deep dive was planned next

month with a view to breaking down the stages to improve the process. The KPIs

were distributed to the Divisions on a monthly basis

• Management of the numbers of Ready for Discharge patients and the monitoring of

stranded patients (i.e. those patients in hospital for longer than 7 days)

• Patients re-admitted to hospital within 28 days. It was noted that work was being

undertaken to more accurately track these but often the readmission related to a

separate health condition to that previously treated, although every effort was made

to ensure that patients were discharged safely to avoid them being readmitted with

the same condition

• The potential for staff to provide pro-active health advice to patients prior to

discharge. Reference was made to staff providing information for smoking cessation,

alcohol consumption and obesity.

The Council noted the presentation. Finance & Performance Joanne Clague (Non-Executive Director), Chair of the Finance & Performance

Committee, gave a similar presentation on assurance on key indicators relevant to

finance and performance. This covered the aspects of the Corporate Performance

Report relevant to the Committee’s remit, the concerns with Emergency & Acute Care

performance, the Transformation Deep Dives and the challenges experienced in

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achieving efficiencies, and the financial position including the bids submitted to the

regulators to continue with the Trust’s capital programme. An overview was also

provided on performance against the financial and activity indicators, including access to

services and workforce targets.


matters:

• The bid submitted for the capital loan to support the Trust’s capital programme to

maintain quality services and refurbishment of the environment in which they were

performed. It was noted that the interest rate for the loan would be low in

comparison to commercial loans

• The continued work on enhancing relationships between Departments and A&E to

aid better patient flow and improve the number of discharges

• The impact on the Trust being a major trauma centre coupled with the increases

seen in attendances at A&E, increased bed occupancy and the level of patient acuity

and dependency increasing. It was explained that this had been factored into the

modelling and planning but the increased level of A&E attendances was

unprecedented and directly contributed to the pressures and challenges being faced

by the Trust

• The progress made against the output from the results of the Staff Survey 2016/17

by the Divisions.

The Council noted the presentation.

Internal System of Control

CG17-18/022 Key Issues & Assurance (Audit)

Tim Johnston (Non-Executive Director), Chair of the Audit Committee, gave a

presentation which covered the key areas of assurance relating to the internal systems

of control. Some of the areas the Committee had reviewed related to the progress made

on Sickness Absence Management processes as well as consideration of the internal

audit reports on Safeguarding and Working Time Regulations. Other key areas of focus

for the Committee for 2017/18 included a deep dive into Cyber Security and the planned

approach for a deep dive into the Clinical Audit Plan.


matters:

• The duty of care undertaken by the Trust and the processes in place to ensure that

shift patterns were commensurate with staff and ward requirements

• The impact of Cyber-attacks on the Trust and the various systems and processes in

place to ensure that the Trust remained as protected as possible. The Trust also

had disaster recovery protocols in place as well as a back-up and recovery process.

Regular communications were issued to staff on cyber security to raise awareness.

The Trust, as a major trauma centre, had also submitted a bid with NHS Digital for

cyber resilience funding

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• Work was being undertaken on long term absences in conjunction with Occupational

Health with a view to reducing overall absence rates.

The Council noted the presentation.

Governance

CG17-18/023 Governors’ Development Day (4 October 2017)

Pamela Peel-Reade, Lead Governor, thanked the Corporate Governance Team for

arranging the programme and facilitating the Development Day. She added that the day

was very informative and that the subsequent development programme report provided

ample opportunities for Governors to enhance their knowledge and experience of

activities within the hospital.

The Council approved the Development Programme.

CG17-18/024 Governor Committees

Membership Committee – 8 May 2017

The Council of Governors received the report of the Committee which was taken as read

and noted. Pam Peel-Reade, Committee Chair, made reference to the Get Involved with

Aintree Group which was scheduled to meet in November 2017 and asked Council

members to provide some fresh ideas with which to engage with the Group so that they

remained active and involved. She also made reference to the new Membership Stand

which would be made available to any Governor who wishes to promote membership at

any event they attend or inform the Committee of events that other governors may wish

to attend.

The revised terms of reference for the Committee were approved.

Quality of Care Committee – 17 May 2017

The Council of Governors received the report of the Committee which was taken as read

and noted. Sharon Bird, Committee Chair informed the Council that discussion had

taken place on the Quality Strategy and concerns were raised regarding the level of

pressure ulcers as well as the increasing numbers of C.Difficile and MSSA cases.

However, the Committee had been assured that there had been no lapses in care. The

Committee had also welcomed the inclusion of the Sepsis Trolley in A&E.

The revised terms of reference for the Committee were approved.

Concluding Business

CG17-18/025 Any Other Business

In closing the meeting, the Chairman stated that the challenges for the NHS and within

Aintree University Hospital would make it increasingly more difficult to deliver safe quality

services. The Board was fully aware of the unrelenting pressure on the workforce and

would give due consideration to investing in services in order to maintain hospital

standards. There was every expectation that winter would be challenging but a great

deal of work had been undertaken to plan and prepare for the months ahead.

Further updates would continue to be provided at Board meetings, Governor feedback

sessions and at the next Council meeting.

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Date and Time of Next Meeting

Thursday 7 December 2017 in the Board Room Aintree Lodge at 12.30pm

The meeting closed at 6.50pm Chair’s Signature: Date:

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Report from the Lead Governor

Report to Council of Governors

Date 7 December 2017

Committee Name Council of Governors

Chair’s Name & Title Pamela Peel-Reade, Lead Governor

Core Governor Activity

• Attendance at Board meetings and Board Feedback sessions with the Chairman

• Director Walkabouts – Tony Kneebone, Colin Maher and Jim Ford have participated

• Quality of Care Committee – 15 November 2017

• Membership Committee – 1 November 2017

• Quarterly Informal Council of Governors – the meeting on December 4th was attended by ten

Governors. Kevan Ryan attended and spoke about his career, what inspires him, what he feels he

has achieved and the things he has yet to achieve as a Non Executive Director at Aintree. On the

agenda was a discussion of the Governor Development Programme and ‘Information Overload’.

• Board Session on Emergency Care, November 29th – Sharon Bird, Lorraine Heaton and Pamela

Peel-Reade were invited to attend the Ernst and Young presentation on the findings from Phase 1,

the Diagnostic Report into Aintree’s Emergency Care and Flow Improvement. An oral report will be

provided at the meeting.

• Board-Governor Session, November 29th – the planned session on the proposed merger with the

RLBUHT was attended by thirteen Governors.

Governor Development

• Buddy Clusters have been introduced to mentor and support the five most recently elected public

Governors, and to forge relationships and small networks within the Council so strengthening our

teamworking. Meetings are ongoing, their frequency and focus are at the discretion of each cluster

host.

• Governor Induction at Liverpool Heart and Chest Hospital took place on November 9th which was

facilitated by Ann Utley (Luscient Ltd)– Ray Humphreys and Jenny Ensor attended and the positive

feedback from the event has been circulated. The slide presentation which accompanied the day

and the group work on Holding to Account has also been circulated to all Governors.

Wider Trust Activity

• Staff Induction each month – Staff Governors are taking it in turn to make a brief presentation on

membership to new staff on their first day in the Trust and the Membership Leaflet is now included in

every induction pack. When a Staff Governor is unavailable the Lead Governor or her Deputy step

in. The aim is to provide the essential facts of the Governor-Member accountability relationship and

set the seed of membership engagement in the minds of new staff.

• Aintree Volunteer Induction each month – this is an opportunity for Governors to recruit members

from amongst people who are already committing time and loyalty to the Trust, and also to engage

with them, hear their ‘stories’ and recognise the contribution they make to the smooth running of the

hospital. Tony Byrne and Sharon Bird lead on this, Ray Humphreys is also supporting this activity,

and of course any Governor is welcome to attend.

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• Workstream – Tony Kneebone continues to be involved in the Catering Food Quality Group.

• Proud of Aintree Awards, October 27th – Twelve Governors attended and were able to use the very

enjoyable evening as an opportunity to meet and speak to some of the staff who were being

recognised for their outstanding achievements.

• DME Event on Ward 30 October 31st – Sharon Bird and Jenny Ensor attended – please see Notes

below at Appendix 1

• Fab NHS Change Week, Showcase Event, November 14th – Jenny Ensor attended – please see

Notes below at Appendix 1

• Health & Wellbeing joint event by Sefton CVS, Macmillan, Sefton CCG and the hospital, November

24th – Jenny Ensor attended. The event was well attended. There were stalls for general information

from Macmillan staff, advice about wigs and post mastectomy bras, advice on diets, yoga and

exercise. The event finished with a most interesting talk from Aintree's Consultant Clinical

Psychologist.

• PLACE Inspections, November 7th - Kerry McManus participated in this inspection. December 5th –

Tony Kneebone participated in this inspection.

External Activity

• Health Awareness event at Fazakerley Health and Wellbeing Forum, November 17th. The event is a

regular, popular community event supported by LCC and Age Concern. Advice from a range of

services and organisations was available and this time included the Stroke Association and Healthy

Homes – Pam Peel-Reade attended.

Lead Governor Activity

• Lead Governor Network – Pam Peel-Reade attended a meeting in London of 22 of the 40 or so Lead

Governors in this national, informal group on November 15th. Items on the agenda for discussion

included the following: NED/Governor relations; Attendance at Part 2 Board meetings; FT Values;

Patient Interface; Relationship of the network with NHS Providers and possible formation of an

association; Organisational takeover and merger; Governor Induction and Development; Continuity

and corporate memory; Length of Governor terms of office. Notes of the meeting will be circulated to

all Governors.

Recommendation

The Council of Governors is asked to note the report.

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Appendix 1

DME Event on Ward 30 October 31st - Notes

Sharon Bird and Jenny Ensor

This was a “Book and Cake" sale to raise money to support their Christmas parties. This year it is

planned to hold a party on each of wards 30, 32, 33, and 34. This will avoid the less mobile patients

having to move wards to enjoy the party.

We were then shown around the DME and Stroke Unit by Lisa Roberts, Clinical Business Manager

DME/Stroke Unit. We were very impressed by what we saw of a bright, patient / family friendly unit that

meets the complex needs of their patients. We also heard that they have held a DME/Stroke "Listening

Week" of inpatient experience of being in the unit which showed positive results.

We came away from the visit reassured that the unit is a place where the staff enjoy their work and

ensure that their patients receive the best of care.

Fab NHS Change Week, Showcase Event, November 14th – Notes

Jenny Ensor

I attended 4 or 5 presentations at the Change Week Showcase event.

The most interesting were:

• The psychological effects of wearing pyjamas all day. Staff throughout the hospital were invited to

take part. The experience of those staff wearing pyjamas and the reactions of colleagues to them

were interesting but a feeling of vulnerability by the wearers was universal

• Physiotherapist. Studied the rate of deconditioning of muscle tone in cases of prolonged inactivity

and therefore the importance of exercise, pre- and post-operation.

• Nutritionists. Looked at the importance of correctly balanced nutrition and rehabilitation across a

number of medical conditions.

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Council of Governors

7 December 2017

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Strategic Update

• Autumn Budget Statement

• Aintree/Royal Liverpool merger

• Care Quality Commission Inspection

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Assurance on Key Indicators

Mandy Wearne, Non Executive Director

Joanne Clague, Non Executive Director

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Key Areas of Assurance

Quality

Key Areas of Focus On-going Assurance Assurance sought on

areas of concern

Serious Incidents including

Incident Reporting

Inpatient Falls C.Difficile Infections

Learning from Deaths Ophthalmology Results to Action

7-Day Services

Patient experience CQC Inspection

Quality Strategy 2017/18 Corporate Performance

Report - KPIs relating to

Quality

Level of Risk for capacity and

Ready for Discharge patients

Risk Register Aintree Assessment &

Accreditation Framework

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Clinical Indicators

2016-17 TARGET 2017-18

Q1

2017-18

Q2

2017-18

M7

2017-18

Target

Trend

27 C-DIFF (Trust attributed) 12 19 4 No more than 46

1 MRSA 1 0 0 None

PRESSURE ULCERS

61 - Grade 2 17 17 5 No more than 57

6 - Grade 3+ 5 0 0 None (with identified

lapses in care)

98.2% PATIENT SAFETY

THERMOMETER

97.5% 98.2% 99.0% Better than national

average

31 SERIOUS INCIDENTS 6 5 4 Improve on 16/17

MORTALITY

107.26 - SHMI 107.26 105.79 105.79 Within expected range

94.22 - HSMR 97.93 95.29 96.17 Less than 100

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Key Areas of Assurance Finance & Performance

Key Areas of Focus On-going Assurance Assurance sought

on areas of

concern Corporate Performance Report Winter Plan Review of Referral to

Treatment data

Emergency & Acute Care

Quality Efficiency & Productivity Capital Programme

Transformation Deep Dives

- Theatre Utilisation

- Workforce

- Non-Pay

Annual Business Plan Priorities

Finance

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Finances & Activity

2016-17 TARGET 2017-18

Q1

2017-18

Q2

2017-18

M7

2017-18

Target

Trend

£2.181m REPORTED

SURPLUS / DEFICIT

-£2.650m -£4.015m -£4.665m -£6.842m

3 RISK RATING 3 3 3 Plan

£9.961m CASH £9.701m £11.844m £11.827m Plan

£11.577m CAPITAL £1.554m £2.278m £2.641m Plan

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Access (1)

2016-17 TARGET 2017-18

Q1

2017-18

Q2

2017-18

M7

Target Trend

AED 95% by March 18

RTT 92%

CANCER

- 2 Week 93%

- 31 Days 96%

- 31 Days surgery 94%

- 31 Days drugs 98%

- 62 Day classic 85%

- 62 day screening 90%

- Breast symptomatic 93%

- Consultant upgrades 85%

DIAGNOSTICS <1%

STROKE 80%

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Access (2)

2016-17 TARGET 2017-18

Q1

2017-18

Q2

2017-18

M7

Target Trend

OPERATIONS

CANCELLED

<0.8%

PATIENTS

READMITTED

WITHIN 28 DAYS

All

OUTPATIENTS

CANCELLED

<5%

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Workforce

2016-17 TARGET 2017-18

Q1

2017-18

Q2

2017-18

M7

Target Trend

95.6% ATTENDANCE RATES 95.82% 95.87% 95.88% 96.0%

73.9% APPRAISALS 77.7% 74.19% 73.89% 85%

67.1% MANDATORY TRAINING 76.40% 75.80% 73.94% 85%

426 VACANCIES 415 316 341 n/a

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Key Areas of Assurance

Internal System of Control (Audit)

Kevan Ryan, Non Executive Director

Key Areas of Focus On-going Assurance Assurance sought on areas

of concern

Internal Audit Reports

- Working Time Regulations

- Emergency & Acute Care

- NHS Supply Chain

- 4Action

Risk Management Strategy

Cyber Security

Counter Fraud

Losses & Compensations

Clinical Audit – Plan for Deep Dive

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Membership Committee Report: Council of Governors 18 October 2017 1/1

Membership Committee Report


Date 20 March 2018

Committee Name Membership Committee

Date of Committee Meeting 1 November 2017

Chair’s Name & Title Tony Byrne – Public Governor

Summary of Meeting

• Tony Byrne, chaired the meeting and provided an update regarding the promotion of membership. It

was the intention to set up the Membership Stand in the Elective Care Centre (ECC) to engage with

members to promote membership and the role of the Governors. Once a date had been agreed the

relevant Departments within ECC and all Governors would be informed. The Committee agreed that

the first date would act as a pilot to gauge interest from the members and then further dates would

be agreed.

• An update was provided on the Get Involved with Aintree Group. The Committee had been asked to

provide ideas regarding interesting activities to ensure that the Group remained engaged. It was

agreed that approval be sought to share the Divisional Patient Experience Action Plans with the Get

Involved with Aintree Group.

• The Membership Strategy Implementation Plan was reviewed and an update was provided. It was

noted that consideration was to be given to the re-assignment of tasks at the next meeting.

• Discussions were held regarding Focus on Health Events and whether there was any value in re-

introducing the events. Consideration was given to exploring the use of the support groups and

health awareness weeks within the Trust for Governors and members to attend and it was agreed to

take this forward. The Committee also agreed that it was not appropriate for Focus On Events to be

re-introduced given the current pressures on the hospital and the proposed merger and would focus

its efforts on the Get Involved with Aintree Group.

Recommendation


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Quality of Care Committee Report


Date 7 December 2017

Committee Name Quality of Care Committee

Date of Committee Meeting 15 November 2017

Chair’s Name& Title Sharon Bird

Summary of Meeting

Patient Experience – Visiting and Friends and Family Test (FFT)

The Committee received a presentation on the current position and future plans for Patient Experience

which highlighted the following matters:

• From April 2017 Aintree’s FFT has been measured against local Trusts as opposed to national and

regional outputs

• In October 2017 the Trust piloted automated feedback via voice mail and text on 15 wards and

outpatients department. The output is currently being evaluated

• Inpatient satisfaction scores consistently scoring above or within 3% of local averages with 95.4% of

patients scoring the FFT question positively. A&E Department has seen a sustained increase in

patient satisfaction

• Flexible Visiting had been implemented which resulted in the development of a Visitors’ Charter

setting out the expectations of visitors and staff during visiting times. The Charter has been

displayed throughout the organisation and leaflets available on wards. Overall responses received

on the revised visiting times had been largely positive. The Charter was distributed to Governors at

the meeting for information purposes

• A patient & family shadowing project had been developed that enables the ‘shadower’ to observe the

care experience from the patient’s and family’s perspective. It was a direct, real time observation of

patients and families as they move through each step of the care experience in any healthcare

setting.

The Committee was advised that there was an opportunity for Governors to be involved in the

shadowing project and to contact the Corporate Governance Team in the first instance if they wished to

do so. The Committee sought and received assurance that proactive patient experience was being

undertaken and this was triangulated with the information from the complaints team and incident

reporting to ensure that improvements could be made where appropriate. The Committee was further

advised of the variety of measures and reporting in place which included both internal and external

audits with action plans developed accordingly.

Quality Strategy Year 3 Delivery Plan – Quarter 2 (Q2) 2017/18

The Committee reviewed the results for Q2 and the following matters were discussed:

• Hospital Acquired Pressure Ulcers: There had been five grade 3/4 hospital acquired pressure

ulcers during April to September 2017 against a target of zero. The Committee sought and received

assurance that the cases had been spread across the Trust and not in one particular area. Had this

been the case, the Tissue Viability Nurse would do a deep dive, investigate trends and assess

training needs.

• Critical Medicines: a Clinical Governance Pharmacist had commenced in post and the Medicines

Safety Group had been re-instated to help improve practices. Furthermore, the Weekly Meeting of

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Harm reviews medication incidents and the Committee was advised that incidents in this regard were

monitored closely by the Medicines Safety Group and the Safety & Risk Executive Led Group with

lessons learnt fed back to the relevant areas. Some concern was expressed about omitted

medicines but the Committee was advised that the pharmacists do a reconciliation but this can only

be performed if the trust has the patient record with the medicine history.

• Hip & Knee Replacement: concern was expressed on the number of patients who did not have their

temperature taken within 1 hour prior to surgical incision and the Committee was advised that the

team had investigated the pathway and there had been no trends or issues identified.

• Pneumonia: The Committee was concerned about the numbers of patients not receiving antibiotics

within 4 hours of arrival and was advised that whilst the Trust was not achieving the required target

the numbers of patients involved was proportionately small compared to the overall patients treated

and so the mortality outcomes were below the ‘as expected range’. However, it was acknowledged

that further work needed to be undertaken to improve performance.

• Hip Fracture: The Committee was advised that the Trust remained challenged against the criteria to

achieve the standard and that there was a national issue to recruitment to posts in this area.

Aintree Assessment & Accreditation (AAA) Framework – Q2 2017/18

The Committee received the report which provided an overview of the AAA assessments during Q2 and

the following matters were highlighted:

• There had been 13 assessments completed during Q2 with 13 ACE Wards, 16 Green

Wards/Departments, 4 Amber Wards/Departments and 0 Red Wards/Departments

• The framework was to be updated for 2018 to refresh the standards based on the new Key Lines of

Enquiry (KLOE) published by the Care Quality Commission (CQC)

The Committee was advised that the AAA was looked upon positively by staff who were engaged at

every stage of the process.

Trust Mortality Report

The Committee received the report which highlighted the following:

• SHMI was reported at 105.79 for the period April 2016 to March 2017 and was in the “as expected”

range

• HSMR was also in the “as expected” range at 95.27 for the period July 2016 to June 2017

• SMR was reported as “better than expected” at 94.15 for the period July 2016 to June 2017

• The crude in-hospital death rate had improved in August 2017 and reported at 2.52%

• The 12 month rolling crude mortality rate has decreased and is 2.99%

The Committee was advised that the Trust had a high crude palliative care coding rate compared to

other organisations in the North West. This had been investigated and the Trust was found to have a

large number of patients in comparison to others and was deemed to be achieving best practice

standards with no themes identified.

Recommendation


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COUNCIL OF GOVERNORS AGENDA · 2017-12-11 · and the Trust would also be working with Ernst &...

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