SOUTH EASTERN HEALTH & SOCIAL CARE TRUST Minutes of a meeting of the Governance Assurance Committee held on Wednesday 19 September 2018 at 12.00 noon in the Boardroom, Trust Headquarters, Ulster Hospital PRESENT: IN ATTENDANCE: APOLOGIES: Dr M Briscoe, Non-Executive Director (Chairman) Ms N Patterson, Director of Primary Care, Older People & Executive Director of Nursing Mrs M Weir, Director of Human Resources & Corporate Affairs Mr B Whittle, Director of Children s Services & Executive Director of Social Work (via video conference) Mrs Catherine McKeown, Head of Internal Audit, BSO Miss I Low, Assistant Director, Risk Management and Governance & Board Secretary Miss J Turner, Executive Support Services Manager Mr N Brady, Non-Executive Director, Chairman, Audit Committee Mr M Mawhinney, Non-Executive Director Mr C McKenna, Chairman of Trust Board Mr J Patton, Non-Executive Director (Lead for Safeguarding) Mr H McCaughey, Chief Executive Ms R Coulter, Director of Planning, Performance & Informatics Mr N Guckian, Director of Finance and Estates Mr C Martyn, Medical Director Mr S McGoran, Director of Hospital Services Ms B Mongan, Director of Adult Services & Prison Healthcare ACTION CHAIRMAN S BUSINESS The Chairman welcomed Mrs McKeown to the meeting. Dr Briscoe, on behalf of members, wished to record thanks and appreciation to Mrs O Neill for her contribution as a Non-Executive Director to the Trust Board and as a member of this Committee. Mrs O Neill had resigned from her term of office wef 7 September 2018 as she had been successful in being appointed to a post in another organisation which unfortunately meant there may be a conflict of interest with her role as Non-Executive Director within the Trust. Communication has been made with the Department of Health regarding a replacement and a response is awaited. Members noted that Ms Coulter and Mr McGoran had both planned to attend today s meeting. However, due to unforeseen circumstances both Directors were called away at short notice to other pressing work commitments and were unable to attend the meeting. Technically the meeting was not quorate (ie, minimum of 5 members at the meeting) however Dr Briscoe decided to 1
proceed with the business of the meeting as there were no items requiring formal decisions to be made. 1.0 DECLARATION OF POTENTIAL CONFLICT OF INTERESTS WITH ANY BUSINESS ITEMS ON THE AGENDA Dr Briscoe invited members to declare any items of potential conflict of interests with business items on the agenda. None were received and the business of the meeting proceeded. 2.0 MINUTES OF THE PREVIOUS MEETING HELD ON 13 JUNE 2018 The minutes of the previous meeting held on 13 June 2018, having been previously circulated, were taken as read and agreed as a true and accurate record, subject to the following amendment: Insert: Present: Ms N Patterson, Director of Primary Care, Older People and Executive Director of Nursing. Members noted that Ms Patterson was inadvertently listed under both In attendance and Apologies and not the Present section. 3.0 MATTERS ARISING FROM THE MINUTES For action/discussion There are no items for action/discussion. For information/noting 3.1 Update D-Nav issue Members noted that communications continue with relevant parties and the Department of Health regarding provision of this service. It was confirmed on 25 April 2018 that the contract would continue with the company for a minimum of 12 months. The Royal College Review report is awaited. 3.2 Update Inquiry into Hyponatraemia Related Deaths (IHRD) Members were advised that this item was discussed in detail at the last Governance Assurance Committee (GAC) meeting held on 13 June 2018 and again at the Safety, Quality Improvement & Innovation Committee (SQIIC) on 14 September 2018. The Trust s IHRD Oversight Committee is responsible for taking forward the work associated with the Inquiry. Further updates to the GAC will be provided as and when there are developments. Non-Executive Directors (Mr Patton, Ms O Hagan and Mrs Minford) have been nominated to participate in work streams/sub groups and they have been invited to induction days to brief them on their role in this work. 2
3.3 Update on future assurance arrangements for organisational controls to replace the former Controls Assurance Programme Discussion on the above item was included at item 5.2 below. 3.4 Update Draft Report on Board Assurance Framework and Corporate Risk Register 2018/19 Miss Low reported that above report was approved by the GAC at its meeting on 13 June 2018 and subsequently endorsed at the Trust Board meeting held on 21 June 2018. Miss Low advised that she had provided Dr Briscoe with a copy of the Report of the Regional Review of MLUs as requested at the last meeting which was carried out by the Leadership Centre. 3.5 Update BHSCT Neurology Lookback Exercise Members noted that the Trust continues to participate in tele conference calls as and when required in relation to the above matter. In addition, the relevant documentation, requested by the Solicitor to the Inquiry, is being collated and will be submitted by the due date. 3.6 Update replacement for AS/NZ standard Members received, for information, a copy of a paper which had been circulated with the papers for the meeting outlining the background work to the development of a proposal for a HSC Regional Model for Risk Management (including a Regional Risk Matrix). In presenting the paper, Miss Low advised that in order to get agreement to the proposal across all HSC organisations listed in the paper, she had attended the Chief Executives Forum on Monday 17 September 2018. The outcome of that meeting was agreement by the Chief Executives Forum to endorse the proposal for a HSC Regional Model for Risk Management (including a Regional Risk Matrix). A short discussion ensued and Miss Low addressed the queries raised by members. Members were also advised that the proposal had been previously presented to, and approved by, the Corporate Control Committee at its meeting on 18 July 2018. Following a short discussion, members endorsed the proposal presented by Miss Low at the meeting. Members agreed it was a good example of collaborative work and Mrs Weir thanked Miss Low for leading, across the region, on this work. 3
4.0 NEW BUSINESS ITEMS For action/discussion 4.1 Update End of Year Accountability Review meeting held on 1/8/18 Members received, for information, a copy of the minutes of the above meeting which were circulated with the papers for the meeting. In the absence of Mr McCaughey at the meeting, Miss Low provided a short update as provided by Mr McCaughey. Miss Low said that the accountability meeting went well. She advised there were no significant concerns raised at the meeting by the DoH. Discussions centred around Transformation work, Winter Pressures and Resilience Plans, Finance for 2018/19 and 2019/20, Cyber Security; and Dunmurry Manor. In reviewing the minutes of the meeting, Dr Briscoe sought further clarification on the undernoted matters:- Mr McCaughey highlighted some risks associated with the deliverability of expenditure plans for transformation monies. Dr Briscoe enquired if there was flexibility for Trusts to utilise the allocation in areas other than those designated for transformation, such as domiciliary care or mental health? In response, Mrs Weir stated that Trusts are required to inform the Department if the allocation will not be utilised within the specified timeframe and if unable to spend the allocation is returned to the DoH. The recruitment process for a number of posts, identified against transformation funding, has commenced. A briefing on this issue is provided to EMT on a weekly basis. Single Employer for Junior Doctors. Dr Briscoe enquired about the strengths and weaknesses of this proposal. In response, Mrs Weir stated that work was carried out on this issue within the last two years. It is an attractive option for junior doctors. However, the challenge arises around the Responsible Officer role. Discussions are taking place, on a regional basis, about the feasibility of this role being undertaken by NIMDTA. A Task and Finish Group has been established and it is anticipated it will report out in August 2019. The model of a single employer for junior doctors has been implemented in areas of England and in Scotland. In relation to the opening of the Transition Ward, Dr Briscoe enquired if this was intended as a permanent facility. In response, Ms Patterson stated it was an 4
extension of the Discharge Lounge. There are currently 10 beds open in the Transition Ward and, due to ongoing pressures, it will be permanent for the foreseeable future. Financial Outlook: Dr Briscoe noted the minute relating to the Financial Outlook, Richard Pengelly provided an update on the financial position for 2018/19, advising that although the Department of Health budget has received a measure of protection compared to other Departments, the projected funding is not sufficient to maintain existing services. For information/noting 4.2 Update Mid Year Assurance Statement 2018/19 (due 12/10/18) Miss Low reported that the DoH had issued a letter on 28 August 2018 to all ALBs seeking completion of the Mid-Year Assurance Statement by 12 October 2018. Members were advised by Miss Low that the function of this statement is to enable the Chief Executive, as Accountable Officer, to attest to the continuing robustness of the organisation s system of internal governance. Miss Low outlined the process for completion of the statement which would be submitted to the EMT for approval in the first instance, prior to submission to the Audit Committee meeting to be held on 4 October 2018. IL 4.3 Update Dunmurry Manor Ms Patterson informed members that a the DoH had agreed with the COPNI that a single response to the COPNI report would be issued on behalf of the HSC from the six relevant authorities involved (DoH, SET, BHSCT, SHSCT, NHSCT and RQIA). The response is being finalised and will be submitted by the response date of 1 October 2018. Mr Whittle joined the meeting, via video conference. The Department has commissioned CPEA to carry out an independent review into care failings at Dunmurry Manor Care Home, focusing on the actions of the Health and Social Care (HSC) system. The review will consider HSC responses to issues at Dunmurry Manor and identify lessons to be learned for the future. The current position is that neither the Trust nor RQIA have any concerns regarding the level of quality of care currently being provided to residents in Dunmurry Manor. Dr Briscoe 5
enquired about the residents and their families in Dunmurry Manor. In response, Ms Patterson stated that, following publication of the COPNI Report, she and Mrs Johnston, Assistant Director, Older People, offered to meet with all of the families of current residents. Fifteen families accepted the offer and no concerns were raised with the Trust. At the same time, the Trust wrote to the families of all residents in residential and nursing home accommodation asking them to contact the Trust directly if they had any concerns about quality of care. The small numbers of issues raised are being addressed and none were in relation to Dunmurry Manor. Finally, Ms Patterson reminded members that a criminal investigation has been commenced by PSNI in relation to Dunmurry Manor and the Trust will co-operate with the investigation as and when required. 4.4 Update formation of Short Life group to review and assess the effectiveness of the Trust governance arrangements for services commissioned from the Independent Sector Members received, for information, a copy of the Terms of Reference in respect of the above group. In briefing members, Mr Whittle informed members that correspondence was received from Mr Pengelly (RP 2711), on 30 July 2018, requesting that Trusts should take pre-emptive steps to review and assess the effectiveness of their current governance arrangements and to strengthen them as necessary with a focus on the quality and safety of services commissioned from the independent sector. This matter was discussed at a recent EMT meeting and it was agreed that a short life Task & Finish Group should be established, in order to review and assess the effectiveness of the current governance arrangements. It will be chaired by Mr Whittle and will review the governance arrangements in place with all independent nursing, domiciliary care (including supported living), adult day care, adult placements and independent hospitals/clinics. Mr Whittle then summarised 3 key responsibilities of the group as follows:- To review and assess the effectiveness of the current governance arrangements within the current legal and policy framework; To review the likely impact of any proposed new service provision under the current transformation IPTs that will enhance the quality and safety of the services commissioned from the independent sector; and 6
Recommend proposals to strengthen the current governance arrangements with a focus on the quality and safety of the services commissioned from the independent sector. The group should also consider the recent correspondence from the DoH in relation to Further Assurances on Domiciliary Care, August 2018 (RP2757) and report back to the EMT no later than the end of October 2018. A short discussion ensued. Dr Briscoe said that she had two comments to make in respect of the TOR of the group firstly, she thought it would be useful to include a definition of ISPs in the paper and also to outline the methodology to be used for the review. In response, Mr Whittle stated it is predominantly a desk top exercise, which will be carried out by the Managers who work with the different elements of the independent sector. There is no formal methodology in place for this purpose, in any of the Trusts and no guidance has been issued by the DoH in this regard. Mrs McKeown stated there were a number of Internal Audit reports available, which may be of assistance with the exercise such as Domiciliary Care and Voluntary Care Contracts. Dr Briscoe further enquired if the Trust was required to communicate with the Department on the methodology to be used. Mr Whittle stated this was not required. He also said that the Department is currently undertaking a review of the 2003 Quality, Improvement and Regulation Order, which includes the legislative and policy context. Mr Whittle said that he would review the TOR of the group for consideration by EMT in the light of Dr Briscoe s comments above. Finally, the report of the Short Life Group will be presented at an EMT meeting initially and subsequently at a meeting of this Committee. BW 4.5 Reports on Effectiveness of Corporate Control and SQIIC Members received, for information, copies of the Reports on the Effectiveness of the Corporate Control and Safety, Quality Improvement & Innovation Committees which had been circulated with the papers for the meeting. In presenting the papers, Miss Low briefly summarised the key points within the respective reports which had been presented to, and approved by, the Corporate Control and SQII Committees on the 18 April 2018 and 7 September 2018 respectively. A short discussion ensued. Dr Briscoe noted attendance at the Corporate Control Committee was poor on some occasions. In response, Miss Low stated this issue had also been highlighted to the Committee at the time of the report 7
and appropriate action taken post the meeting. There were no queries with regard to the SQIIC report. 4.6 Schedule of dates for Governance Assurance Committee meetings 2019 Members received, for information, the Schedule of Dates for meetings of the GAC for 2019, for noting in their respective calendars. ALL 5.0 STANDING AGENDA ITEMS For action/discussion 5.1 Update on the Corporate Risk Register 2018/19 Miss Low reminded members that the Corporate Risk Register 2018/19 was approved by Trust Board at its meeting on 21 June 2018. Updates are currently being sought for the position as at 30 September 2018 and this will be reported on at the Trust Board meeting on 28 November 2018. One new item was included on the Register during September 2018 and this was in relation to Transformation Work. It was also noted that all HSC Trusts had added this item to their respective registers. IL 5.2 Update Future Assurance Arrangements for Organisational Controls to Replace the Former Controls Assurance Programme Miss Low gave a brief overview of discussions at the last meeting of the Controls Assurance Project Team held on 6 September 2018. She said that this group will continue to meet however it has been agreed to change the name of the group to the Organisational Controls Assurance Group (OCAG) to reflect the change to the work programme following the formal standing down of the former Controls Assurance Programme by the DoH. There are also a number of new templates/assurance statements for some of the former standards, which will be used with immediate effect. If there is no template available, the former evidence list/s will be used, which may include ISO standards/accreditation in some cases. In addition, Miss Low highlighted that there is now no common scoring system, as with the previous standards. Dr Briscoe enquired about where the responsibility lay for ensuring the standards are fit for purpose. 8
In response, Mrs Weir stated this now lay with the Trust, as the DoH no longer has oversight of the programme. There is no regional agreement on the process, with some Trusts choosing not to measure against the standards in the future. This Trust has taken the decision to continue to monitor against the standards (using both the old and the new templates, as appropriate) and also will probably introduce an assurance statement per standard (as is the case with some of the replacement evidence lists/standards as recently issued by Policy Lead/s, DoH) in order to provide assurance to the Accountable Officer. The production of the baseline assessment will remain as in previous years. During discussion, Mrs McKeown stated she supported the approach being adopted by the Trust. Members acknowledged the benefit of the Trust s approach in this matter and the significant volume of work involved. Finally, Miss Low confirmed the next meeting of the OCAG would be held in early November 2018 to finalise arrangements in terms of the scoring system to be used and the use of assurance statements. A further update will be provided at the next meeting. IL For information/noting 5.3 Minutes of the Corporate Control (18 July 2018) and Safety, Quality & Innovation Committee (20 April 2018) Members received, for information, the minutes of the Corporate Control and the SQII Committees which had been held on the 18 July 2018 and 20 April 2018 respectively. Members noted that there were no issues of concern raised by either Committee. 5.4 Action plans for Corporate Control and Safety, Quality Improvement & Innovation Committees 2018/19 Members received, for information the action plans of the Corporate Control and SQIIC for 2018/19. There were no areas of concern noted and members noted that the majority of items were on target for completion. 6.0 ANY OTHER BUSINESS There was no business under this item. 7.0 DATE AND VENUE OF NEXT MEETING It was agreed that the next meeting of the Committee should be held on Wednesday 19 December 2018 at 12 noon, in the Board Room, Trust Headquarters, Ulster Hospital. IL Minutes Gov Assurance 19 September 2018 9