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Appendix 1

DRAFT WELSH AMBULANCE SERVICES NHS TRUST

Minutes of the meeting of the Clinical Governance Committee of the Welsh Ambulance Services NHS Trust held at 10am on 14 February 2008-02-14

1/08 PRESENT: Ms C Cookson Non Executive Director(Chair) Mr D Evans Non Executive Director Mr M Cassidy Deputy Chief Executive Ms S Jones Director of Unscheduled Care/Clinical Director In Attendance: Ms K Charters Staff Side Representative (Unison) Mrs C Jones PA to Corporate Secretary Mr J Huxley Assistant Corporate Secretary Mr B Roberts Staff Side Representative (TGWU) Mr N Waskett Medical Advisor on GP Services Mr R Whitfield Research & Development Manager

APOLOGIES: Mr A Murray Chief Executive Mr K Webb Clinical Operations Officer Ms T Styles Senior Audit Manager Mr A Jenkins Clinical Governance Lead Ms R Beaumont- Wood Named professional for Safeguarding Children Ms C Powell Clinical Governance Manager Mrs L Meadows Director of Personnel & Development Mr D Jackland Director of ICT/ Estates Mr B Meredith Non Executive Director 2/08 PROCEDURAL MATTERS:

The Chair welcomed Mr J Huxley the Assistant Corporate Secretary, Kath Charters and Bleddyn Roberts, both Staff Side representatives for Unison and UNITE respectively, to the meeting.

RESOLVED: That (1) the appointment of the Chair, membership and confirmation of the

terms of reference of the Committee, which had been approved by the Trust Board in January, be noted;

(2) the minutes of the meeting of the Committee held on 17 December 2007 be confirmed as a correct record and the following matters arising be noted:-

Clinical Governance Feb 08 1

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(a) Minute 7.67 - Contract with St.John Ambulance – it was confirmed that an update of the position would be provided at the next meeting of the Committee.

(b) The paper relating to the ongoing pressures within the South East Region was to be circulated, week commencing 18 February 2008.

(3) an updated report on the contract with St. John Ambulance be

brought to the next meeting of the Committee.

3/08 HEALTHCARE STANDARDS The Committee received a report on the progress with the Healthcare

Standards Improvement Plan( HCSIP) and considered a proposed Healthcare Standards (HCS) Reporting Framework for 2008-09. A report to the North Wales Regional Office (NWRO) had been submitted at quarter three which identified that over 95% of all actions were anticipated to meet the target or had been completed.

Within the Welsh Health Circular (WHC) it recommended that the internal

audit and clinical audit departments should be utilised as part of the mechanisms for validating the HCS self assessment submission. The Deputy Chief Executive and the Director of Unscheduled Care/ Clinical Director agreed to liaise with internal audit about the self assessment. It was also confirmed that Mr R Whitfield, Research and Development Manager, was progressing an audit policy document as part of the delivery of an Annual Clinical Audit Plan.

The Committee identified the need for the role of internal audit to be clarified

and for the Trust to be clear what its requirements were to ensure any effective audit facility was provided to the Trust. Members agreed that looking at other Ambulance Services for best practice in this area could prove beneficial.

In relation to the Reporting Framework, concerns were highlighted around

capacity issues and the Deputy Chief Executive expressed his confidence that the department had benefitted from the experience gained during the year and would satisfactorily meet future challenges.

RESOLVED: That

(1) the HCS exception report for quarter three be noted;

(2) the Reporting Framework be approved; and

(3) the role of internal audit in the context of ensuring that the Trust receives information on pre-determined areas of work, be clarified.


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4/08 SAFEGUARDING CHILDREN UPDATE REPORT

The Director of Unscheduled Care/Clinical Director presented a report on the current progress with the Safeguarding Children work stream which include the first draft of the Safeguarding Children Policy. This draft policy would ultimately be supported by other policy documents within the Safeguarding Children work stream. The report confirmed that a new Safeguarding Team had been established, headed by a ‘Named Professional’, including a Paramedic and specialist Nurse. The Committee were advised that a Safeguarding Children Training Strategy was currently being developed and the lead officer of the Safeguarding Team was currently writing revised notification procedures from the National Public Health Services in relation to the release of information in connection with serious adverse incidents. The revised Child Protection procedures were to go live on 1 April 2008 and it was important that essential staff were fully trained on the new procedures. Furthermore, the lead officer of the Safeguarding Team had been granted membership of the ‘ All Wales Child Protection Procedure Forum and the Welsh Assembly Government Children’s Safeguards Advisory Group. As previously stated, the Policy was very much a first draft and the ‘Named Professional’ had requested comments on the document with a view to revising it again before presenting it to the Committee and the Board in April/May. RESOLVED: That (1) the need for Clinical awareness be addressed, including Volunteer

Car Drivers and the First Responders;

(2) the Named Professional be asked to liaise with the Director of Personnel & Development with regard to CRB checks; and

(3) a revised policy be presented to the next meeting of the Committee incorporating any feedback received.

05/08 CONFIDENTIALITY & DISCLOSURE OF PERSONAL INFORMATION PROTOCOL

Dr Nigel Waskett presented the draft protocol on confidentiality and disclosure of personal information which was based on a similar protocol by the Gwent NHS Trust. The draft protocol had been amended to refer more to the operational activities of the Trust and had been approved by the Welsh Legal Services, with advice from Graham Southway, an expert on confidentiality issues.


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The Committee noted that the protocol would be a dynamic document and would change in the light of experience, lessons learned from adverse incidents reports and future legislative changes. There were, however, practical steps that could be taken in relation to requests for confidential/personal information and ensuring that sufficient expertise and advice was available within the Trust to assist staff to deal with this work. The following were included in the report:-

(a) The Trust Board has appointed its Caldicott Guardian ( Director of Unscheduled Care/Clinical Director) to advise on confidentiality issues; (b) The appointment of an Information Governance Adviser from the ICT Directorate; and (c) Develop a Confidentiality Disclosure Log to be made available on the intranet, coupled with effective monitoring mechanisms and paper back-up systems as appropriate.

The Committee was also advised that this issue had implications for a number of Directorates of the Trust eg ICT, Human Resources, Training and Public and Patient Involvement

Following discussion the Committee identified the following issues which would require further discussion to resolve :- ▪ Facilities on ambulances to keep information locked away; ▪ The consequences of storing information on Laptops; ▪ The procedures in relation to Patient Clinical Records (PCR) within Hospitals; ▪ Training for staff; and ▪ The development of a programme to use clinical records for research.

RESOLVED: That, following further amendments, the protocol referred to the meeting of the Trust Board on 26 March for approval.

06/08 INFECTION CONTROL

The Director for Unscheduled Care/Clinical Director submitted a report updating the Committee on Infection Control. The main focus of the policy, which was currently being drafted, was to identify which areas needed to be updated or changed to ensure that the Trust had met targets set by the Welsh Assembly Government (WAG) and also reflected best evidence based practice. The policy would incorporate a clear two way line of communication to ensure infection prevention and control issues were both highlighted and acted upon. Advice had been sought from a number of internal and external sources.


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It was confirmed the vehicle cleanliness was area of concern in that there were inconsistencies throughout the Service in the time and materials available to undertake the work. It was confirmed that vehicle and station audits would continue on an annual basis and action plans would be produced to ensure improvements were being made. Station level champions would be used to boost communication and education. The infection control policy would be submitted to the next meeting of the Committee in April. RESOLVED: That (1) the Infection Control Policy be brought to the next meeting of the

Committee for referral to the meeting of the Board in May;

(2) a Task & Finish Group be set up to discuss the provision, suitability and cleaning of uniforms;

(3) the National Fleet Manager be asked to investigate the time available and the provision of suitable materials to clean vehicles; and

(4) Station based “Champions” be introduced to promote communication and education highlighting infection issues.

07/08 PROTECTION OF VULNERABLE ADULTS (POVA)

The paper submitted by the Unscheduled Care Directorate set out the main objectives within the POVA work stream initiation document and updated the Committee on progress to date. The report informed the Committee that a process mapping session had been held which looked at the current POVA policy, a re-design of forms currently used within WAST, and introducing a “Training the Trainers” programme to be rolled out throughout each region. This mapping day had produced a series of actions which would now be taken forward. Education, communication and raising awareness were key areas highlighted. London Ambulance Service had done some considerable work in this area and the Committee felt the Trust could benefit from looking at the work they had done. RESOLVED: That (1) the work to date and the progress be noted; and

(2) the Director of Unscheduled Care/Clinical Director be asked to look

at work undertaken by the London Ambulance Service and other appropriate Services.


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08/08 CLINCIAL GOVERNANCE UPDATE

The Director of Unscheduled Care/Clinical Director submitted a report confirming the progress made in relation to the recommendations of the Clinical Governance Support and Development Unit (CGSDU) following its review of Clinical Governance arrangements within the Trust. The eight recommendations had already been identified by the Trust as priority areas and therefore were cross referenced within the Welsh Ambulance Services NHS Trust Programme and the Healthcare Standards Improvement Plan. The recommendations were listed in the report along with a response/commentary for each recommendation. The Trust would continue to work closely with the CGSDU and the National Patient Safety Agency (PASA) to develop improved systems of reporting, to identify the lessons learned and to take action taken to improve patient safety. It was suggested that the JRCALC website would be useful for paramedics and technicians to receive information and ask questions regarding change. Richard Whitfield, Research and Development Manager would hold discussions with the Corporate Communications Manager about establishing this link.

RESOLVED: That the report be noted.

09/08 UPDATE ON ADULT REFUSAL OF TREATMENT

The Director of Unscheduled Care/Clinical Director presented a paper updating the Committee on the Adult Refusal of Treatment/Transport work stream. The need to review the systems and processes by which care was discharged by the Service had been highlighted in Time To Make a Difference. The main aim was to ensure that a robust Clinical Governance led document reflected: ▪ Service user needs; ▪ Respects the right of the competent adult to refuse ambulance treatment/ transport; and ▪ The role of the practitioner in managing diverse issues around the refusal of treatment and delivering care that is clinically effective and meets best practice and professional expectations. The report confirmed the current position which showed that several policies required review to ensure that patients and staff were offered the best evidence based care available. In this context, further work was ongoing to review the process which would inevitably lead to a series of actions and an awareness programme for relevant staff. This area of work would, therefore, be subject to further reports to the Committee.

RESOLVED: That a further report be brought to the next meeting of the Committee in April.


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10/08 COLLABORATIVE WORKING

The Director of Unscheduled Care/Clinical Director submitted a report updating the Committee on the position regarding Collaborative Working in relation to Mental Health Services. A working group had been established and had met bi-monthly to consider safe pathways for mental/suicidal callers. Clear protocols needed to be established to ensure consistency for the client group. The report listed the membership of the working group and confirmed a number of goals to be achieved over the short, medium and long term. An initial task was to increase understanding and support for mental health and well-being and to equip people to respond appropriately. RESOLVED: That the report be noted.

11/08 CLINICAL RISK REGISTER

The Director of Unscheduled Care/Clinical Director informed the Committee that the National Risk and Health & Safety Manager had been commissioned to work with each region to help develop a regional risk register which would feed into the Trust’s Corporate Risk Register. He would also be working closely with the National Patient Safety Agency. RESOLVED: That a further report be brought to the April meeting of this Committee.

12/08 COMPLAINTS/CLAIMS UPDATE RESOLVED:

That the references to complaints and claims during the discussions in previous items of business on this agenda be noted.

13/08 MINUTES AND TERMS OF REFERENCE OF SUB-COMMITTEES AND

WORKING GROUPS

The Assistant Corporate Secretary outlined the need for a comprehensive review of Sub-Committees and Working Groups that were currently associated with the Clinical Governance Committee. This would enable the Committee to decide which bodies should be retained and what information, and in what format should it be presented to future Committee meetings. It was also recommended that the terms of reference of each body be referred to the Committee for approval.


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The minutes of the Patient & Public Involvement (PPI) Sub-Committee were submitted for information. RESOLVED: That (1) a full list of Sub-Committees and working groups be compiled and

considered along with their terms of reference at the next meeting of the Committee; and

(2) the minutes of the PPI Sub-Committee be received. 14/08 ACTION SHEET

RESOLVED: That it be noted that a number of items had been transferred onto the Business Planning Sheet and would be presented to future meetings of the Committee.

15/08 DATE OF NEXT MEETING RESOLVED:

That the next meeting of the Committee be held on 21 April 2008.


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