MINUTES OF RISK MANAGEMENT BOARD
Meeting Room – Eastgate House
30th November 2007
Attendance
Morton Creeger(MC) Non-Executive Director (Chair)
Rob Hurd(RH) Director of Finance
Kathryn Corder(KC)Director of Nursing
Seijel Sukha(SS)Health and Safety Advisor
Lynne Wilson(LW)Facilities Manager
Michelle Nolan(MN)Risk Manager
Mark Masters(MM)Director of Estates and Facilities
Mark Vaughan(MV)Director of Human Resources
Apologies
Kim Harris (KH)Customer Care Manager
Andrew Woodhead(AW)Chief Executive
Fiona Gow (FG)Head of Clinical Governance
Andy Dwyer(AD) Clinical Risk Manager
1.Minutes of the last meeting were agreed as accurate
2. MATTERS ARISING
MC requested that the actions progress columns on the agenda arecompleted so that the table can be easily observed at the meeting rather than leaving it black which would take a lot of time to get through as there are many issues arising. MN agreed that for the next meeting progress will be followed up prior to the meeting.
(Action: MN)
MN reminded the group that the table summarises the action points from previous meetings.
The progress from the last meeting is as follows:
ISSUE / ACTION / LEAD / PROGRESS / MATTER RESOLVEDYES / NO
2. Root Cause Analysis – Medicines Management (2.2) / Log the reasons in to the risk register why the Trust is not able implement the electronic stock control system in Pharmacy. / Rob Hurd / Risk register is regularly updated. / Yes
2. Medication Incidents (3.1.1) / Results from the Pharmacy audits and update of what other Trusts are doing from Pharmacists. / Pharmacists / Report included within papers.
Pharmacists to undertake an audit within two months. / Yes
2. Incident 8025 (3.1.5) / A report regarding the hot water problems on AMU. / Mark Masters / No on-going issues have occurred recently / Yes
2. Medicines Management (3.2.1) / A full report on the medicines management audits to be provided. / Michelle Nolan
Fiona Gow
Andy Dwyer / Audit report within papers / Yes
2. Steven Steps Action Plan (3.2) / Review the current seven steps action plan. / Andy Dwyer
Michelle Nolan / Meeting arranged for 19th December to review action plan / Yes
2. Security and Night Site Visit (10.1) / Update on further three night visits and meeting with Medirest manager regarding competency of security staff. / Michelle Nolan
Lynne Wilson / A night site visit has been completed since the last meeting – fewer issues found.
A programme of quarterly night visits for 2008 has been agreed.
Meetings have been held with Medirest staff and the contract specification has been reviewed. / Yes
2. Security and Night Site Visit (10.1) - continued / Further initiatives
to be introduced during 2008 to ensure that the security systems are more robust.
2. Waste Management (11) / Include weak and underperforming areas regarding waste management on the risk register. / Michelle Nolan
Lynne Wilson / Waste Management Report to be reviewed and key areas to be added to risk register / No
2. Proposed risk awareness training for executives, non executives and senior managers (18) / Look into options for risk awareness training to be provided at senior managers and NAC meetings with a training programme in place. / Michelle Nolan
Andy Dwyer / Action plan for all areas of risk management work to be developed. Work has commenced but not yet completed. Meetings to be arranged to progress this during January 2008 / No
2. Assurance Framework (20) / Review links between the Trusts ten targets and the assurance framework. / Michelle Nolan
David Murrel / The Trusts top ten targets have been linked to the assurance framework / Yes
3.1. Incident Trends / Incident trends to now be presented by dates of incidents rather than incident number or when they were logged. / Seijel Sukha / The trends have not been produced by incident number due to backlog of incidents. This would have not reflected what is actually happening in the Trust / Yes – may be reviewed when inputting of incidents is up to date
3.1 Incident Summaries / Look into options of getting statistics on actions of incidents, progress reports and issues that are now closed. / Seijel Sukha / Problems with scheduler have now being resolved but need to populate the database with e-mail addresses so that reports can be sent out. Dates have been scheduled to populate system during December and January / Yes
4. Claims Update / Add a column in the claims document to show the date the claim was received. / Kim Harris / Column has been added / yes
7. Ulysses Update / Decide whether to move over to the new incident web forms or stay with the old designed ones. / Michelle Nolan
Seijel Sukha
Andy Dwyer / Decision has been made to move over to the new incident web forms. Work is in progress to get these up and running. / Yes
7. Ulysses Update / Scheduled reports are still is not running. Resolve issue with database provider. / Michelle Nolan
Seijel Sukha
Andy Dwyer / Issue has now being resolved and scheduler is working. E-mail addresses for each department to be re-entered in order for reports to be sent.
Dates for e-mail entry have been agreed for December and January / Yes
10. Fire and Security Update / Compile action plans for different areas from night site visits. / Michelle Nolan
Lynne Wilson / Monthly meetings have been scheduled to commence in January. Reports now contain a summary action plan. / Yes
10. Fire and Security Update / Consider option of using Dictaphone whilst undertaking fire risk assessments to speed up process. / Michelle Nolan
Seijel Sukha / Health and Safety Advisor does not feel that this would be helpful. / Yes
12. Legionella / E-mail Morton Creeger on an update within week about legionella issues. / Mark Masters / E-mail sent. Report within papers / Yes
16. Risk awareness training / Develop an annual training schedule detailing risk awareness training for all senior managers and the exec team. / Andy Dwyer
Michelle Nolan / To be linked with annual risk programme. Work has commenced on developing the programme. / No
17. For information, review and approval / Policies for high level meetings to have a front page executive summary included highlighting changes and updates. / Fiona Gow / Board summary sheet to be used / Yes
20. Directorate and Accepted Risk Register / Dates and details on the risk register and accepted risk register are not corresponding with each other. Look into this matter. / Seijel Sukha / Issues have been resolved. / Yes
20. Directorate and Accepted Risk Register / Each director to provide a page summary detailing progress made against their risk registers to include in the annual report. / Michelle Nolan / Annual report will be written in April 2008 / No
20. Directorate and Accepted Risk Register / Add a progress column in the accepted risk register instead of target date so it can be monitored effectively. / Seijel Sukha / Progress column added and risk registers re-scheduled to all directors and CEO. / Yes
3. INCIDENTS
3.1 Summaries (8906 – 9039)
High/medium incident review
Incident Trends
The group reviewed the incident summaries and the trend report.
MC commented on incident number 8986. He expressed concern about key management in this incident and questioned about details of the incident. MM clarified that this type of incident is a one off as new fire panels are being introduced and communication between installers and staff here were not appropriate, which can happen with new projects of this nature.
MC then went on to comment on the incident trends report stating that there has been a significant rise in security incidents. MN agreed and stated that these incidents are mainly to do with security being compromised by people leaving windows, doors open. MN stated that they are trying to encourage everyone, not just security to have ownership of security. MN also informed the group that depending on the security trends they are going to have security themes to focus on each month.
MN stated that they have had another night site visit and feel that the security needs checklists to go through every night. MC agreed that this would be a good idea as it would clarify the security guards role as well. MN and LW to look into compiling a checklist.
(Action: MN & LW)
RH questioned whether either LW or MNhave contract meetings with Medirest as it may be an idea to express concern at these meeting regarding security and maybe draw up a tighter specification with them as to what we expect of their service. LW agreed and stated that she and MN will take this into consideration.
(Action: MN & LW)
KC stated that she was not happy with the first paragraph of the incident trends report as it is indicating that Clinical Governance have no resources to enter incidents. She confirmed that this was not the case and the new administrator is inputting a lot of clinical incidents. KC indicated that the backlog issue should be resolved by the next meeting. The first paragraph was however reported by AD when approached about the backlog. AD to report at the next meeting the reasoning behind this backlog.
(Action: AD)
MN reported that the incident summaries will now also be scheduled out to all ward /department managers as the scheduler is up and running again. MN, SS and AD are going to set up the e-mails over the Christmas period to have this running again.
(Action: MN, SS & AD)
3.2 NRLS Report
The group then went on to look at the NRLS report. MC questioned why there was a big amount reported in March only. KC state that AD has problems reporting by the electronic link and usually only goes through as one big amount and the NPSA are aware of the problems. KC agreed she would ask AD to clarify and explain this in more detail in the next meeting.
(Action: AD)
MC then went onto question the graph comparing the number of reports received from RNOH compared with other organisations stating that this Trust seems to have a high number of reporting compared to other Trusts. MN suggested that the cause of this maybe because RNOH generally has a good reporting culture compared to other Trusts. MC expressed concern that this type of reporting can nevertheless be an area of concern in terms of insurance cover. KC went onto suggest that it maybe near-miss information too rather than real incidents that are being filtered on the graph.
3.3Root Cause Analysis Investigation Updates
MN went over with group the audit report (leading from the RCA involving a death on site incident) included within papers. The audit highlighted good practices such as:
- Fridges are used correctly.
- Blood and urinary agents are stored correctly.
- CD stock balances are checked and signed for every 24 hours.
However areas for improvement were also noted. Weaknesses included:
- Not all areas have a link nurse.
- Not all signatures of nurses authorised to order drugs from Pharmacy form are up to date or present.
- Not all medicines cupboards / fridges / trolleys were secured.
- 40% of fridges have no maximum / minimum thermometer
- Security of keys is an issue.
- There were some gaps in knowledge.
RH questioned whether RCA’s were being fed into the Ulysses database somewhere. MN answered that they were added to the risk registers and actions are followed up through there as well. MC suggested keeping RCA’s a standing agenda item and requested that a table is developed summarising the work that has been undertaken for each RCA.
(Action: MN/AD)
4.0CLAIMS UPDATE
The group reviewed the legal claims overview document and the comparison report from the NHSLA. The report stated that compared to some other Trusts our figures were not that bad. MC questioned what the term ‘legal alert’ meant in the active litigation report. KC stated that she was not sure of the meaning and will ask KH to explain it at the next meeting. MC stated that it might be a good idea to have a footnote at the end of these documents explaining key terms.
(Action: KH)
5.0IT UPDATE
There was no IT update due to the absence of SP.
6.0SOCIAL CLUB LEASING ARRANGEMENTS UPDATE
MM reported that the lease has been determined but s yet to be signed. An invoice has been raised but also has yet to be paid. MM stated that with current situation the social club cannot afford to pay the invoice so we are waiting for some communication from them.
7.0ULYSSES UPDATE
MN attended the annual user’s group meeting, where the new version was introduced. The new version will be installed shortly within the Trust. The new graphics programme looks as if it will be a useful tool for trend reports.
SS has resolved the scheduling problem and dates have been put into the diaries during December and January for MN, SS and AD to re-enter all e-mail addresses in order that incident summary reports can be sent automatically to all departments on a weekly basis.
(Action, AD, MN & SS)
SS has rescheduled all risk register reports to the executive team. These reports will be received on a monthly basis. The three reports directors will be receiving are their Directorate Risk Registers, Accepted Risk Registers and a report on the risks that need reviewing (those risks coming up to their target dates).
SS has added a progress column to the accepted risk register.
8.0INFECTION CONTROL
KC reported that since the last meeting there have been four Clostridium Difficile cases, one in June got missed by Infection Control as they were not informed. There have been no MRSA Bacteraemia cases reported.
KC also reported that the new Infection Control Champion has now been recruited and will be focusing on hand hygiene, training and awareness with consultants. She stated that the department have also been give £100,000 funds for deep cleaning and re-paining wards which will build into more effective infection control.
9.0FIRE AND SECURITY UPDATE
MN reported that night site visits will be undertaken quarterly – dates have been agreed for 2008.
The security survey reports now include a summary action plan at the back of each report so that actions can be monitored more effectively.
The last night site visit was undertaken earlier in the evening than previous reports and fewer issues were found.
The Bolsover survey did not highlight any significant issues. The survey team included a member of the Estates Department who is leading on the Estates related issues.
Coxen and ADU fire risk assessment was reviewed to highlight the amount of work involved in an assessment. ABU assessment is now also completed. The LFEPA inspector has reviewed the assessment format and is happy with the contents and style of the reports.
10. WASTE MANGEMENT
LW reported that she is having monthly meetings with matrons to tackle the issue of waste management. The key issue focused on at the moment is segregating waste in all areas better and reported that she is also working along side the new Infection Control Champion to promote this.
11. LEGIONELLA
MM reported that the Estates Manager and two other Estates employees have been booked on the relevant training and the Trust policy will be reviewed after this. A Building Management system is now in place and can now get a trends profile.
12. NHSLA PROGRESS REPORT
KC reported that after being assessed on 50 categories we have been given a Level 2. KC stated that her team are waiting for a report back from the NHSLA for feedback so we can work towards any grey areas which may have been highlighted. The hard work of the Risk Management Team- FG, MN and AD was highlighted in assisting with the NHSLA assessment preparation.
13. REVIEW OF PROJECTS APPROVED BY THE CAPITAL PROJECTS PLANNING GROUP
The group reviewed the proposed capital projects summary document. RH stated that the funding has been allocated according to affordability and the main themes that are being looked at are health and safety risks, redevelopment and income generating financial impact.
14. REVIEW OF ADEQUACY OF AUDIT PLANS
There were no audit plans to review for this meeting.
15. RISK AWARENESS TRAINING
MN reported that the session for executives was well attended.
A local induction programme for the new Non Executive Director’s must be implemented. Induction templates have been developed for the executive team, Non Executive Director’s, senior managers and Consultants.
A training programme for the executive team and senior managers will be included with the risk management programme which is under development.
(Action: MN)
MN explained that from now on at every meeting two sections from the MaPSaF will be used as a training aid for the executive team. On the agenda items section 4 and 5 were noted to be used as training for this meeting. However, as only two directors were present and the Non Executive Director has come to his end of term it will be postponed until the next meeting.