1. CLINICAL GOVERNANCE Presentation for Assembly of Governors Thursday 15 December 2011

2. CLINICAL GOVERNANCE REVIEW Review produced in November 2010 set out to: –Reduce the number of corporate committees –Improve accountability of the committee and sub committees –Strengthen overall governance arrangements

3. CLINICAL GOVERNANCE REVIEW As a result: –Number of corporate committees reduced – with a stronger focus on corporate areas supporting/ going out to operational divisions –Revised terms of reference / work plans –Clinical Governance dashboard- reflecting ‘Ward to Board’ indicators –Increase ‘synthesis’ of data across quality themes. –Strengthened of membership of committee

4. KEY PRIORITIES (ANNUAL PLAN 2011) Management and prevention of violence training Reducing the severity of assaults Implement new electronic risk management system Strengthen safeguarding arrangements Developing the use of outcome measures Implementation of RIO – patient information system Real time feedback systems Improve physical health care support

5. CQC (Care Quality Commission) Reviews –‘ Responsive’ review: January 2011 –Themed review: July 2011 –MHA reviews: On going process (reflecting previous role of MHA Commission) On going compliance issues: –Prison Healthcare (internal monitoring)

6. RESPONSIVE REVIEW 3 sites, inpatient and community teams –Solihull Wards & Lyndon Clinic –Zinnia: Lavender ward and CMHT –Reservoir Court and Older People CMHT Four standards (outcomes) reviewed –Major concern: Safeguarding process –Moderate concerns for other standards

7. RESPONSIVE REVIEW Key Issues identified: –Excellent staff – Overall felt they saw very good examples of team working and professional staff. –Mixture of positives and negatives. –Concerns raised over Physical Health care – particularly in relation to the consistency of approaches –Solihull A&E – concerns were raised over arrangements at Solihull Hospital for patients in need of emergency care –Safeguarding procedures – concerns that thresholds for escalating safeguarding concerns were not clear / clearly understood

8. RESPONSIVE REVIEW Key Issues identified continued: –DOLS training – concern of a lack of awareness of DOLS process –Specific Concerns in relation to Lavender ward relating to: Staffing levels – staff did not feel that they were safe Clinical Supervision –Concerns over notifications (to CQC) and how these are classified.

9. THEMED REVIEW All 3 PICU units: July 2011 –1 unit – Fully compliant –1 unit – moderate and minor concern –1 unit – 2 moderate and 2 minor concerns

10. ISSUES ARISING FROM CQC VISITS CQC approach is to reflect what is seen (and said on the day). There is little triangulation Issues have arisen which could have been predicted reflecting: –The effectiveness of the team –‘Transparency of purpose’ (i.e. are all staff focused on priorities, ensuring risks are escalated) –On going issues / concerns which are not addressed These have informed the Quality strategy…

11. MHA VISITS Function of CQC which was formally separate as part of Mental Health Act commission Role is to review compliance with requirements of the MHA; BUT, CQC is demonstrating much closer working and correlation between MHA and regulation requirements

12. QUALITY STRATEGY Setting a common framework for quality improvement across the organisation. Which is clearly understood at all levels of the organisation Reflecting the Monitor Quality Governance framework ‘Ward to Board’ monitoring

13. QUALITY STRATEGY Incorporated projects : –Nursing Strategy –Nursing metrics (monthly quality monitoring) –Quality support team / visits –Integrated dashboard reporting –Essence of care

14. Quality Support Teams – Scheduled Visits Annual schedule of visits to all clinical teams – inpatient and community. Teams of 3 – senior professional or manager (8b); a peer reviewer (Band 7) and a service user/carer representative Core Aspects of Service reviewed: Welcome; Respect and involvement of people who use our services; Consent to care and treatment; Suitability of staffing; Safeguarding and safety; Quality and management Serious concern(s)? Yes Visit lead notifies Team/Ward Manager, SDM, Lead Nurse and Clinical Director immediately and escalates to Executive Officer, then…. No Visiting team complete report and forward to Head of Compliance and/or Corporate Lead Nurse Decision on outcome EXCELLENT Zone management notified. Governance team roll out learning to other areas POSITIVE Zone management team notified. Notification may be displayed in service area CONCERNING Zone management team notified. Required to remedy, further visit planned UNACCEPTABLE Local management notified, urgent remedy and assurance required. Further visit planned Quarterly summary report of all visits prepared by Governance team for Quality and Safety Committee

15. Quality Support Teams – Ad Hoc Visits Head of Compliance monitors Ward and Team performance and liaises continuously with corporate departments – i.e. HR, complaints, risk management Information emerges which indicates there may be concerns(s) about a particular area of service Serious concern(s)? Yes Ad hoc visit arranged to service area. 8b (or above) plus another professional. Visit not announced and focuses on identified area of concern. Generally short of no more than one hour duration. No Visiting team complete report and forward to Head of Compliance and/or Corporate Lead Nurse Quarterly summary report of all visits prepared by Governance team for Quality and Safety Committee Visit lead notifies Team/Ward Manager, SDM, Lead Nurse and Clinical Director immediately and escalates to Executive Officer, then…. Report relates solely to areas of concern identified pre-visit and documents findings (unless others become evident during the course of the ad hoc visit.) If findings indicate serious concerns then zone management team are required to remedy situation and provide assurance. Follow up unannounced visits may be arranged depending on whether the identified concerns were found to be valid.

16. COMPLIANCE FUNCTION New function within the Governance umbrella (recently appointed) Compliance team will: –Provide support to teams to maintain compliance –Improve overall intelligence, liaison and correlate information and issues being raised by the CQC –Develop arrangements for monitoring non compliance and reviewing teams

17. LOOKING FORWARD Internal (continuing issues): –Prison Governance arrangements –Compliance with CPA (Care Programme Approach) –Safeguarding

18. LOOKING FORWARD National: –NICE quality standards –National outcomes framework –Quality Accounts – increased profile of quality –Mid Staffs review