1. No category

H
Cover Sheet
Meeting:
Report Author:
Board of Directors
Kathy Bray, Board Secretary
Date:
Thursday, 19th December 2013
Sponsoring Director:
Sabrina Armstrong,
Corporate Affairs
Assistant
Director
of
Title and brief summary:
POLICIES AND PROCEDURES - The Board is asked to note that the following policies were approved
at the Weekly Executive Board Meeting since the 13 November 2013.
Action required:
Note
Strategic Direction area supported by this paper:
Keeping the Base Safe
Forums where this paper has previously been considered:
The following Policies and Procedures were approved at the Weekly Executive Board Meeting held
since 13 November 2013.
Governance Requirements:
Ensures consistent approach to policy and procedural document formulation.
Sustainability Implications:
None
1
Executive Summary
Summary:
The following Policies and Procedures were approved at the Weekly Executive Board Meeting held since 13
November 2013.
- Mobile Telecommunications Equipment.
If you would like to receive a copy of the above, please contact Kathy Bray, Board Secretary on 01383
355933 or Kathy.bray@cht.nhs.uk.
Main Body
Purpose:
N/A
Background/Overview:
N/A
The Issue:
N/A
Next Steps:
N/A
Recommendations:
The Board is asked to note the policies approved by the Executive Board since the 21 November 2013
Board of Directors Meeting.
Appendix
Attachment:
There is no PDF document attached to the paper.
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I
Cover Sheet
Meeting:
Report Author:
Board of Directors
Kathy Bray, Board Secretary
Date:
Thursday, 19th December 2013
Sponsoring Director:
Sabrina Armstrong,
Corporate Affairs
Assistant
Director
of
Title and brief summary:
DRAFT QUALITY ASSURANCE BOARD MINUTES - 18 NOVEMBER 2013 - To receive the draft
Quality Assurance Board Minutes from the meeting held on 18 November 2013.
Action required:
Note
Strategic Direction area supported by this paper:
Keeping the Base Safe
Forums where this paper has previously been considered:
N/A
Governance Requirements:
Deliver the Regulations
Sustainability Implications:
None
3
Executive Summary
Summary:
As above
Main Body
Purpose:
N/A
Background/Overview:
N/A
The Issue:
N/A
Next Steps:
N/A
Recommendations:
The Board is asked to receive and note the contents of the draft Quality Assurance Board Minutes from the
meeting held on 18 November 2013.
Appendix
Attachment:
Minutes QAB 18 11 13 - draft.pdf
4
QUALITY ASSURANCE BOARD (QAB)
MINUTES OF THE MEETING HELD ON
Monday 18 NOVEMBER 2013
PRESENT:
Jan Wilson, Non-Executive Director (Chair)
Lesley Hill, Director of Planning, Performance, Estates & Facilities
David Birkenhead, Divisional Director, DATS
Mike Culshaw, Clinical Director, Pharmacy
Barbara Crosse , Medical Director
Sabrina Armstrong, Assistant Director of Corporate Affairs
Juliette Cosgrove , Assistant Director to Medical / Nursing Director
Julie Hull, Director of Workforce and OD
Mark Partington, Director of Operations
Pam Union, Associate Director – Risk Management
IN ATTENDANCE:
Stephanie Jones, PA (Minutes)
Alison Wilson, Head of Estates – Operations and Corporate (presentation)
Martin Griffin, Head of Estates – Corporate Services (presentation)
Julie Barlow, ADD Surgery & Anaesthetics (Matters arising)
Andrew Bottomley, General Manager, Orthopaedics (Matters arising)
Julian Bates, Chief Information Office, HIS (Matters arising)
Helen Marshall, General Manager, Risk Management (Item 4)
PRESENTATION BY THE ESTATES AND FACILITIES DIVISION PATIENT SAFETY AND QUALITY BOARD
Alison Wilson and Martin Griffiths attended the meeting to present the work to date and future
work plan of the Estates and Facilities Patient Safety and Quality Board (PSQB).
Risk Areas:
Asbestos: Removal programme in place and due to be completed by January 2014.
Laminar Air Flow Theatres: Theatre 5 (HRI) had recently failed a laminar air flow test and a
programme for the replacement of the laminar air flow in both Theatre 4 & 5 (HRI) orthopaedic
surgery is being looked at with partner P21. It is hoped a solution will be found by the end of
December 2013 with a view to starting work soon after that. Theatre capacity will be limited during
this period, however Theatre 5 can still be used as a general theatre during the replacement works.
Electrical infrastructure: Capital team looking at a programme to replace switches, transformers and
load sharing. Awaiting confirmation of when this will start.
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Safety & Quality Challenges: on-going work / progress to date:
Health Tech Memorandums (HTMs): on back of CQC report all HTMs reviewed.
Energy, sustainability & waste: Work commenced to develop a Sustainable Development Action
Plan with clear targets to deliver energy efficiency and cost savings. Looking at someone who is
dedicated to carry out this piece of work.
Fire safety: Good progress made since April 2013. Currently working with the ADDs to ensure 100%
compliance on Fire Safety Training Awareness. A piece of is work being undertaken at CRH in
relation to evacuation training. It is hoped some work will be done with the Fire Brigade.
Health and safety: The Health and Safety Action Plan for 2013/14 has been approved at Board of
Directors. Health and Safety training is being rolled out across the Trust. David Sinclair leading on
this. Fire / Health & Safety now included on the prompt list for Leadership Walkrounds.
Emergency planning: New Emergency Planning Officer now in post (Heather Kirk). Statement of
compliance and action plan to go to Board of Directors in December 2013. Current local risks include
Tour De France (July 2014) and Trust Wide evacuation.
Capital Development Projects: Asbestos removal programme on going, mainly at HRI; patient and
staff areas safe. Some asbestos found in old part of CRH within the stone walls which has been
sealed and coated. Lendlease check on an annual basis for asbestos.
Ward 8 upgrade due to be completed by January 2014. Main Entrance upgrade taking longer than
anticipated, but should be completed by the end of January 2014. Acre Mill refurbishment
programme on-going.
Facilities:
Laundry: Service specification issued to Laundry suppliers – tenders have just been received.
Retail Services: Evaluation of 3 tender submissions; Board recommendation end of November 2013.
Portering: Overall aim to provide a better service across the Trust.
Catering: Review of patient menu’s taking place with service users. A report will be presented to
Weekly Exec Board (WEB) mid-January 2014.
Jan Wilson thanked Alison and Martin for their informative presentation.
MAIN MEETING
1. APOLOGIES :
Helen Thomson, Director of Nursing
Keith Griffiths, Director of Finance
Anna Basford, Director of Commissioning & Partnerships
Linda Patterson, Non-Executive Director
Jackie Murphy, Deputy Director of Nursing
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2. MINUTES OF THE LAST MEETING:
Juliette Cosgrove to be added to the list of people present, otherwise the minutes were approved
as a correct record.
ACTION: Stephanie Jones to amend.
3. MATTERS ARISING
Fracture Neck of Femur: Julie Barlow and Andrew Bottomley were in attendance to give an
update on fractured neck of femur in relation to the reported performance on time to theatre,
projected performance and impact and associated risks of loss of the laminar air flow capacity at
HRI theatres. Julie presented a paper and the following was noted:
The standard target of 85% of patients to have surgery within a 36 hour period is the Department
of Health’s recommended level. This has also been set as the Trust’s target. Although this target
has only been achieved in the last 7 months more patient reach theatre within the 36 hour period
against the national average of 71%. The reasons for not reaching theatre vary (i.e. patient not
fit, more urgent cases of trauma).
The loss of laminar flow capacity has not eased the situation and it is anticipated that theatres 4
& 5 (HRI) will be out of action for a total of 12 weeks (6 weeks per theatre) and will not be
available to perform certain surgical procedures that require laminar air flow. This will cause
additional challenges in times of high demand to deliver sufficient procedures within the 36 hour
window.
The following has been put in place to address the risks:
 Delivery of trauma lists on Saturday/ Sunday
 Spinal surgery moved to CRH to create space at HRI
 Maximise usage of Theatre 5 for procedures that do not require laminar flow
 Plan to extend days in Theatre 4.
 Relocating trauma, were possible, to Day Surgery.
Transferring spinal activity to CRH has resulted in fewer laminar theatre sessions available to
deliver elective activity, which has a knock on effect on 18 week RTT compliance. A review of the
theatres will be required over the coming months to mitigate this.
Forecast: Based on activity last year, there is a major challenge ahead. Improved performance
has been seen this year despite an increase in the number of procedures undertaken. The loss of
laminar flow in theatres adds to the risk and the Division are drawing up a plan to address the
risks and looking at the possibility of bringing forward the outsourcing programme and the use of
mobile theatres, however further discussion will need to take place at WEB. The directorate are
planning for a high level of procedures during December 2013/January 2014 with an extra ½
procedures a day, during bad weather this could be increased to 4/5 per day.
Mark Partington reported that the CCGs are due to receive non-recurrent monies in relation to
outsourcing, which would be mainly around orthopaedics. Further discussion would take place at
Planned Care Board on 20 November 2013.
Juliette Cosgrove queried the impact fractured neck of femur cases has on mortality in the
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incidence of cases that wait longer than 36 hours for surgery. This information was unknown and
a mortality review would need to be undertaken. Julie confirmed that they used the British
Orthopaedic association within their dashboard.
Jan Wilson thanked Julie and Andrew for the update.
Clinical Records Management Group: Juliette Cosgrove presented a paper on behalf of Jackie
Murphy to give an update on the current work of the Clinical Records Management Group.
The Terms of Reference, membership and chairmanship for the new Clinical Records Group has
been revisited and is in the process of being signed off by Divisional Directors. The Nursing
Documentation steering group will be aligned to this group. It was agreed the draft Terms of
Reference will need to come to QAB for approval, along with minutes.
It was noted great improvements have been seen in relation to clinical records and improvement
works will continue to be audited. Emphasis needs to be made on sustaining these
improvements and the ultimate solution to this would be the Electronic Patient Records (EPR).
ACTION: - Clinical Records Group Terms of Reference to be submitted to QAB for final approval
- Minutes of the Clinical Records Group to come to QAB.
In relation to the Equality and Inclusion Board, Julie Hull suggested that the CQC may look at
equality in relation to staff and patient records and how the Trust manages them.
A facilitated event should be organised to undertake an overall diagnosis of QAB to check the
necessary quality assurance is being given. Regular deep dives into specific areas of concern
should be arranged using the 3R’s process (Reality, Response, Result).
ACTION: Juliette Cosgrove / Julie Hull to look at pulling together a half day facilitated session
to refocus the activity and role of QAB and to look at what is expected of the Boards/Committees
that feed into it. Juliette/Julie to feed back to QAB in December 2013.
Clinical Coding: Julian Bates gave an update in relation to clinical coding sign and symptoms.
Currently CHFT sign and symptom is slightly higher than peer groups meaning that it has slightly
more patients coded symptomatically rather than a definitive diagnosis (i.e. shortness of breath
rather than asthma all of which can contribute to HSMR figures. An analysis into how clinical
Divisions code has been carried out and variations between Divisions noted. Dr Foster uses the
first episode of care for HSMR. Julian reported that clinical coding is currently being discussed at
a number of forums and Price Waterhouse Coopers (PWC) are currently leading on a piece of
work.
Julie Hull suggested the ‘go see’ approached should be used. A visit to Bradford NHS Foundation
Trust where they are noted to be doing well in relation to coding could be beneficial to see what
can be learnt from them.
QAB asked for further assurance that the problem is being addressed. Julian agreed to get
further information and feedback at a future meeting.
ACTION: - Juliette Cosgrove/Barbara Crosse to meet to discuss how to take forward the
questions raised at QAB which weren’t clarified in the Clinical Coding Sign and
Symptom report.
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- Julian Bates to bring an update to QAB in January 2014.
Improving the Quality of Care and Safety of Patients: Juliette Cosgrove presented the paper
‘Improving the Quality, Care and Safety of Patients’, which had been prepared in response to the
Francis, Keogh and Berwick reports and was presented to the Trust Board in October 2013.
Engagement sessions to allow staff to share their perception of the reality of the Trust had taken
place in relation to the issues identified in the three reports.
Ambitions from Keogh have been cross-referenced with the 9 recommendations from the
Berwick report, which resulted in a defined set of 8 key results upon which staff views were
sought. Each key result aim looked at the reality and the response of staff and was allocated a
Governance lead.
Mark Partington raised concerns that it was unclear on what work has been commissioned as 2/3
pieces seem to be similar. Clarity around this should be sought in order to ensure there is no
duplication and to confirm who is doing what. It was understood that no framework has been
established for this piece of work, although WEB has asked for an action log in order for each lead
to provide an update by January 2014. The next steps will then be outlined by WEB.
The Governments response to Keogh is due on 19 November 2013.
ACTION: Juliette Cosgrove to speak to Anna Basford to check there is no duplication in relation to
the Workstreams and will discuss with Directors.
RCA C.diff Report for Ward 5AD, CRH: An investigation report into the outbreak of c.diff on
Ward 5AD was undertaken following 4 patients identified on the ward as having c.diff between
24 August and 10 September 2013. All four cases were investigated using the RCA process and
reported as a Serious Untoward Incident (SUI). Two of the patients were noted to have the same
strain with the other two having different strains.
Areas of concern were noted to be due to the delay in isolation in all 4 cases. Capacity to isolate
patients to a side room was noted to be an issue, alongside an issue with the bedpan washing
machine. The issue of the lack of side rooms at CRH for isolation has been reviewed, but no
conclusion drawn. Lesley Hill and David Birkenhead to look at possible solutions to move this
forward. The Infection Control standards expected should be made clear to agency staff.
Despite the above incident, it should be noted that we are the second best organisation in the
Yorkshire and Humber region against the ceiling target of c.diff.
The contents of the report were acknowledged by the QAB.
Blood Transfusion Incident Update: The action plan following a blood transfusion incident was
presented. It was noted a new Blood Transfusion Policy is now in place which has been approved
at WEB and was being promoted via Dr Rothwell. The action plan will be monitored by the Blood
Transfusion Committee.
Jackie Murphy and the Blood Transfusion Team to decide whether it is necessary to train all areas
or a smaller group of people who are always available to carry out transfusions – no decision
around this has yet been made.
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David Birkenhead reported the Division are looking at electronic tracking of blood transfusion
(using barcodes and scanner) through business planning.
4. LEARNING FROM EXPERIENCE REPORT
Helen Marshall was in attendance to present the Learning from Experience Report for Q1 & Q2
and gave a summary of the events that have occurred in the two quarters from which the Trust
can learn and make improvements to safety, clinical effective ness and patient experience.
Helen reported that significant improvement had been seen during Q1 and Q2. The following
was noted:
- No new Never Events.
- 15% increase in the number of incidents reported in Q1, which reduced to 3% increase in Q2
compared to the previous year.
- Top 3 areas of Serious Incidents are pressure ulcers, falls and medication errors. It was noted
the number of harm falls had gone down, but the severity had gone up. Allergies were known
to be an issue and a common approach in addressing them across the Trust was needed. A 23%
increase had been seen since last year.
Complaints & Concerns: A 27% increase had been seen in complaints in Q1 and a reduction in all
other areas except CWF in Quarter 2. A decrease was noted in concerns.
ACTION: QAB noted and accepted the contents of the report.
5. HSMR
Barbara Crosse reported the mortality project was going well. Key themes have been drawn up
as part of the action plan and progress was being made with leads identified. Clinical Outcomes
Board (COB) looking at how learning can be disseminated across the Trust. Strategic Exec Board
(SEB) looking at Workforce and in particular who’s available out our hours.
It was noted there had been an increase in crude mortality this month.
ACTION: Juliette Cosgrove to provide a monthly written report in relation to Mortality for QAB to
include dashboard and exceptions.
6. INTEGRATED PERFORMANCE REPORT
Lesley Hill presented the Integrated Quality and Performance report for October 2013 and the
following was noted:
Crude Mortality/SHMI/HSMR: SHMI for April 2012 to March 2013 currently stands at 102.
HSMR year to date data is for April to August 2013 stands at 100 rebased to 108 and represents
improvement from the rebased figure of 111 for the year to date last month. Crude Mortality
has risen for October to above that of October 2012.
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Readmissions within 30 days: Performance now within target for both CCGs.
Fractured Neck of Femur: Continuation of low performance noted. Lack of Theatres 4/5 not
easing the situation.
Stroke: Significant drop in performance noted. Pathway for TIA patients currently being
reviewed.
Patient Flow: Delays in ambulance to A&E handover noted. Two 12 hour trolley waits
experienced in A&E (October) and a RCA was being undertaken. The need for a Standard
Operating Procedure (SOP) is needed to deal with long waits in A&E.
18 Week RTT: Being delivered at Trust level.
DNA rate for first follow up appointments: New SMS reminder service has been launched and
new appointments continue to be made 9-16 weeks in advance starting in Ophthalmology.
Sufficiency of appointment slots: Improvement continues to be seen, however GI, liver and
ophthalmology remain an outstanding problem – focussing on capacity to improve performance.
7. CQC OUTLIER ALERTS / UPDATE
Pam Union reported a new mortality outlier had been received for Peripheral and Visceral
Atherosclerosis. A case note review had been initiated, reviewing 38 sets of notes. A response
back to the CQC by the 6 December 2013 is required. Alex Hamilton and team are dealing with
this. It was understood an earlier warning that this may alert had been picked up from Dr Foster.
Intracranial Injury: A review of the pathway for patients with intracranial injury was
implemented in July 2013. From the review it was identified that some of the patients, who had
sustained serious injury were not suitable for the pathway and were put on the care of the dying
pathway. Another patient not suitable was transferred to Leeds. Further works needs to be
done on promoting the pathway to the Stroke consultants.
ACTION: Juliette Cosgrove / Barbara Crosse to take Intra-cranial pathway to COB to look at
through workstreams.
8. RED INCIDENT REGISTER
Pam presented a paper which outlined the proposed changes to Incident Management at the
Trust in order to comply with the revised National Framework for reporting and learning from
Serious Incidents.
Concerns were noted regarding the difficulty to meet timescales set out in the Framework. Our
process is fit for purpose but the problem is with the output. Investigation skills training will need
to be addressed in order to help sort out this issue.
The Policy requires updating and will need to be approved at WEB by 31 December 2013 and a
separate training package will need to be introduced.
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Red near misses were discussed and where it would be best to document them.
ACTION: Pam Union to look at where Red near misses should be logged and a timescale around
them will be looked at in line with the Policy.
Pam reported that progress had been made on some of the old red incidents. There is a still lot
of work to be done on action plans.
Two new red incidents in relation to two 12 hour trolley waits in A&E (CRH) and a sudden death
were new additions to the Register. The sudden death will be investigated alongside South West
Yorkshire Partnership NHS Foundation Trust (SWYPFT).
It was noted the Register was no longer categorised and Pam agreed to reinstate this.
ACTION: Pam Union to prepare a table to show Red Incidents on STEIS each. To be received by
QAB monthly.
9. NEVER EVENTS
Liz Craig’s report into how the 3 CWF Never Events were handled by the Trust was presented to
the Board of Directors in October 2013. An action plan drawn up by the CWF Division will be
brought to QAB in December 2013. The report had been shared with the Divisions although no
response had been received to date.
ACTION: Pam Union to bring CWF Never Events Action Plan to QAB in December 2013.
10. 12 HOUR TROLLEY WAITS IN A&E (CRH)
Mark Partington gave a verbal update to the Board regarding the two 12 hour trolley waits in
A&E at CRH on 28/29 October 2013. The definition of a 12 hour trolley wait is the time from the
decision to admit and stops when the patient is admitted to a bed. Exceptions are CDU in A&E,
when they are deemed to be admitted.
An RCA report has been undertaken which will be shared with the CCGs and QAB members. A
‘patient story’ in relation to the trolley waits would be received by the Board of Directors at its
November meeting.
The key outcomes for future learning were noted to be around timely escalation and
communication. In this particular case, the escalation process was slow. A more detailed
Standard Operating Procedure (SOP) will be drawn up to address this.
ACTION: Steph Jones to email out the RCA Trolley Waits report to QAB members.
11. PATIENT SAFETY AND QUALITY BOARD SOAPS
The SOAPS from the following Divisional PSQBs were received and noted:
- Surgery & Anaesthetics: 5 November 2013
- DATS: 8 November 2013
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12. NURSING QUALITY INDICATORS
Jackie Murphy’s report into the Nursing Quality Indicators (NQIs) was presented and the contents
noted, along with the Ward League Tables.
13. ANY OTHER BUSINESS
Jan Wilson: Jan raised the issue of staff accessing relatives’ notes and asked for clarity around
this process. It was confirmed that staff do not have a right to access such notes and would be
disciplined accordingly if found doing so.
14. 2014 QAB MEETING DATES
The QAB meeting dates for 2014 were approved.
ACTION: Steph Jones to send out the 2014 meeting dates with the minutes.
15. FAST TRACK MINUTES
The following fast track minutes were received and noted:
 Audit and Risk Committee (public): 22 October 2013 draft
 Trust Safeguarding Committee: 28 October 2013
 Information Governance and Records Strategy Committee: 25 October 2013
16. DATE AND TIME OF NEXT MEETING
Monday 23 December 2013
2pm – 4pm
Discussion Room 2, L&D Centre, HRI
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QUALITY ASSURANCE BOARD
PROPOSED MEETING DATES 2014 – FINAL VERSION
DATE
TIME
VENUE
Tuesday
28 January 2014
2pm – 4pm
Board Room, CRH
Tuesday
25 February 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
25 March 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
22 April 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
27 May 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
24 June 2014
1pm – 3pm
Discussion Room 1, HRI
Tuesday
22 July 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
26 August 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
23 September 2014
1pm – 3pm
Boardroom, HRI
Tuesday
28 October 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
25 November 2014
1pm – 3pm
Discussion Room 3, HRI
Tuesday
16 December 2014
1pm – 3pm
Discussion Room 3, HRI
SFJ/meeting dates QAB 2014 – FINAL version 1
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J
Cover Sheet
Meeting:
Report Author:
Board of Directors
Kathy Bray, Board Secretary
Date:
Thursday, 19th December 2013
Sponsoring Director:
Sabrina Armstrong,
Corporate Affairs
Assistant
Director
of
Title and brief summary:
DRAFT BOARD OF DIRECTORS-MEMBERSHIP COUNCIL ANNUAL GENERAL MEETING
MINUTES - 19.9.13 - To receive and approve the minutes from the joint BOD-MC Annual General
Meeting held on 19 September 2013.
Action required:
Approve
Strategic Direction area supported by this paper:
Keeping the Base Safe
Forums where this paper has previously been considered:
To be approved at Membership Council Meeting on Monday 20 January 2014
Governance Requirements:
Deliver the Regulations
Sustainability Implications:
None
15
Executive Summary
Summary:
As above
Main Body
Purpose:
As above
Background/Overview:
N/A
The Issue:
N/A
Next Steps:
N/A
Recommendations:
The Board is asked to approve the draft minutes from the BOD/MC Annual General Meeting held on 19
September 2013.
Appendix
Attachment:
DRAFT Minutes AGM - 19.9.13.pdf
16
Minutes of the Calderdale & Huddersfield NHS Trust Board of Directors and
Membership Council Members Annual General Meeting held on Thursday 19
September 2013 at 7.00 pm in the Lecture Theatre, Huddersfield Royal
Infirmary
PRESENT:Speakers present on the stage were:Mr Andrew Haigh, Chairman
Mr Owen Williams, Chief Executive
Mr Keith Griffiths, Director of Finance
Mrs Helen Thomson, Deputy Chief Executive/Director of Nursing
Mrs Janette Roberts, Publicly Elected Member-Deputy Chair/Lead MC
Others present were:Board of Directors
Dr David Anderson, Non Executive Director
Dr Barbara Crosse, Medical Director
Mrs Lesley Hill, Director of Planning, Performance, Estates & Facilities
Miss Julie Hull, Director of Personnel & Development
Mr Philip Oldfield, Non Executive Director
Mr Jeremy Pease, Non Executive Director
Prof. Peter Roberts, Non Executive Director
Mrs Jan Wilson, Non Executive Director
Membership Council
Mr Bernard Pierce
Mr Martin Urmston
Mrs Christine Breare
Mrs Liz Schofield
Mrs Marlene Chambers
Mr Andrew Sykes
Mrs Joan Taylor
Mrs Johanna Turner
Mrs Jennifer Beaumont
Mr Wayne Clarke
Mr Grenville Horsfall
Mrs Dianne Hughes
Mrs Christine Bentley
Miss Liz Farnell
Mrs Eileen Hamer
Mrs Dawn Stephenson
Prof J Playle
1.
CHAIR’S OPENING STATEMENT AND INTRODUCTIONS
The Chairman opened the meeting by thanking everyone for attending and
introduced the speakers. The change of venue from the John Smiths’ Stadium to the
Huddersfield Royal Infirmary was noted due to clashes with Super League rugby
games planned this year. Thanks were given to everyone who was involved in
reorganising the plans for the Healthfair and AGM at short notice.
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It was noted that other members of the Board of Directors and Membership
Councillors were also present in the audience.
The Chairman reported that this had been a year for the Trust and the whole NHS
when it had held the mirror up to itself especially in light of the Francis Report, Keogh
Review and Berwick Report. The CHFT had held the mirror up to itself in a number
of ways during the last year and two slides were given as examples – showing the 4
core objectives and 6 underpinning principles. He reported on the work being
undertaken in the Trust to address the recommendations made in each of the
reports.
The Chairman reported that this was the sixth year when the Board of Directors and
Membership Council had come together at a joint Annual General Meeting,
alternating sites between Huddersfield and Halifax each year. It was noted that the
Health Fair held from 5.30 to 7.00 pm that evening had been very successful and
thanks were given to all staff involved in arranging the marketplace and visits.
Particular thanks were also given to sponsors Henry Boot Developments for
providing sponsorship for the event and the hard work and dedication of staff,
volunteers and League of Friends.
It was noted that the packs which had been placed on seats contained:- Agenda
- Membership Council Register of Members at 19 September 2012
- Summary Annual Report and Accounts
- Evaluation Form
- Annual Audit Letter from the external auditors
- Medicine for Members Forthcoming Events
- Membership Forms
- Proposed changes to the Constitution
A number of paper copies of the full Annual Reports and Accounts were available at
the front of the room and this was also available electronically on the Trust website.
It was aimed to keep the formal meeting as brief as possible with opportunity for
questions at the end of the meeting.
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APOLOGIES
Apologies were received from:Board of Directors
Mrs Alison Fisher, Non Executive Director
Mrs Jane Hanson, Non Executive Director
Dr Linda Patterson, Non Executive Director
Membership Council Members
Mrs Sue Cannon
Mr Peter Middleton
Mrs Wendy Wood
Mrs Linda Wild
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Mrs Kate Wileman
Dr Mary Kiely
Mr Harjinder Singh Sandhu
Mrs Avril Henson
Mrs Jan Giles
Mrs Lisa Francis
Mrs Julie Mellor
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TRUST ANNUAL ACCOUNTS – APRIL 2012 TO MARCH 2013
Keith Griffiths presented the Annual Accounts, full details of which were available in
the Annual Report. It was noted that the details of these had been discussed at the
Board of Directors Meeting and these were approved as a correct record.
The key areas were noted:Financial Context
Turnover £351m
Patients
- 119,000 inpatients/day cases
- 414,000 outpatients
- 185,000 adult service community contacts
- 90,000 children service community contacts
5260 colleagues
2 main hospital sites that have a combined value of £201m
Our Performance in 2012/13
Our Results were:Income & Expenditure surplus of £3.8m, (1.1% of turnover £0.8m ahead of
plan
An investment of £10.6m in medical equipment, estates and IT
The cash balance at year end was £33m
Monitor risk rating of 4
Compared to 2011/12
3000 more patients were treated in our A&E department
5000 more patients received care in outpatients
Savings/efficiency gains worth £14m were delivered
Specific Facts
Income grew to £351m in 2012/13 – an increase of £10m from 2011/12
91% of our income continues to come from our 2 main health partners;
NHS Kirklees and NHS Calderdale
Total expenditure was £347m - £214m of our costs relate to pay, £119m
non-pay expenditure
Capital Financing charges £14m.
Summary
All key financial targets met or exceeded
Unqualified Audit opinion received
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ANNUAL REPORT 2012/13 and FORWARD PLAN
Owen Williams welcomed everyone to the meeting and gave a presentation
highlighting the achievements and challenges for 2012/13. He outlined the Trust’s
engagement work using the four pillars:We put the patient first
We ‘go see’
We work together to get results
We do the must-do’s
As briefly mentioned by the Chairman, Owen Williams drew the attention of those
present to the review into the quality of patient care and treatment brought to light by
the Keogh Review. Nationally it was noted that there had been an increase in
patients admitted to hospital over 65 years old, an increase in mortality of around
10% and 28% of consultant physicians rating their hospital’s ability to deliver
continuity of care for patients are very poor. Information regarding the partnerships
for patients and future care and results were received.
5
ELECTION RESULTS AND APPOINTMENTS
The Chair reported that the second half of the meeting would be concentrating on
the Membership Council AGM. There were a number of elections and appointments
over the last 12 months which required formal ratification.
a. Council Members
As members were aware, over the period 11 June to 23 August 2013, on behalf of
the Trust, the Electoral Reform Services had held elections. This had resulted in 5
public seats being filled.
All these appointments could be seen on the Register of Members which was
available within the packs. The ballot turnout rates this year were between 12.9%
and 20.3% which was comparable to other trusts.
The Chairman wished to thank the retiring members who included:- Harjinder Singh
Sandhu, Wendy Wood, Vic Siswick and Lisa Francis.
b. Board of Directors – Non Executive Directors (NEDs)
The Chair reported that the Nominations Sub Committee had considered the
forthcoming NED vacant positions this included Alison Fisher, Jane Hanson and
Michael Savage. Members of the Nominations Committee were thanked for making
the three appointments on the 31 July 2013, all of whom had been offered 3 year
tenures:Mr Philip Oldfield
Mr Jeremy Pease
Dr Linda Patterson
Thanks were given to Alison Fisher and Jane Hanson for their support as Vice Chair
and Senior Independent Non Executive Director respectively.
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Those present formally ratified the aforesaid appointments and introductions to new
members of the Membership Council and Board of Directors were made.
MEMBERSHIP COUNCIL UPDATE – OVERVIEW OF THE MEMBERSHIP
COUNCIL CONTRIBUTION DURING 2011/12
Janette Roberts, Deputy Chair gave an overview of the Membership Council
Contribution during 2012/13. This included:The work of the Remuneration and Terms of Service Sub Committee.
The role of the Membership Council and involvement via the Divisional
Reference Groups with Service Users to develop the plans for the Trust.
Training Programme for Membership Councillors continues
Joint workshops with the Membership Council and Board of Directors
Involvement in PEAT/PLACE visits to monitor the standards in both hospitals
Continuing to engage with members through Medicine for Members Events
and member engagement events.
Participation in the Health and Social Care Strategy Review.
Reviewing the role of the Membership Councillor in light of the new Health &
Social Care Act 2012.
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CONSTITUTIONAL CHANGES
Janette Roberts reported that two amendments to the Constitution had been
approved by the Board and Membership Council. This included the provisions within
the Health & Social Care Act 2012 for the Membership Council/Council of Governors
to approve amendments to the Foundation Trust Constitution without reference to
Monitor.
Secondly the Membership Council had agreed arrangements for a Constitutional
change to allow for the establishment of a Reserve Register for Membership
Councillors in the event of vacancies on the Membership Council. It was noted that
the a list had been established and two Reserve Membership Councillors had been
appointed to the Membership Council in accordance with the new clause and this
was highlighted on the Membership Council Register contained within the Pack.
The Chairman thanked Janette for the summary. It was noted that these
constitutional changes had been agreed at the Board of Directors and Membership
Council Meetings held on 27 June and 3 July 2013 respectively. All presented voted
via a show of hands in agreement of the proposed changes.
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STANDING IN THE PATIENT’S SHOES
Helen Thomson shared a clip from Youtube.
9
QUESTIONS AND ANSWERS
The Chairman gave opportunity for those present to raise any general questions of
the Board or Membership Council. The questions raised were:Tony Gorton – Huddersfield Epilepsy Action – wanted to thank Helen Thomson for
supporting his aims in getting a Neurological service up and running in the Trust.
Thanked Helen for the Group’s long relationship with the Trust.
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Long waiting list for Pain Clinic for follow-up appointment. Complimentary about
A&E services following a recent visit. Helen Thomson agreed to speak to the lady
outside of the meeting.
Thank you to the Trust for dealing with the cubicles in X-ray department for people
with a disability.
Black Ice Friday – had appointment to remove cataract at CRH. Dedicated staff in
department, ran out of coffee. Had good treatment. Doctors had difficulty getting
into work.
Q - Ophthalmology – saw GP last year, who could not guarantee they would be seen
quickly by the hospital so went privately for treatment (cataract removal). What is
the waiting list position? Is there a choice of where this can be done?
A – Helen Thomson said that if treatment is urgent you will be seen quickly. If GP
does not think it is urgent there is a choice of where to go.
Q - A&E – had a 4½ hour wait. Can’t GPs take on minor cases to relieve the
pressure on doctors.
A – Trust agrees but difficult to put in place.
Q - Andrew Sykes, Membership Councillor – rate of change and how is Trust
affected?
A – Owen Williams – this is part of the HSCR in partnership with SWYPFT, CCGs, 2
LAs and Locala. How do we move from care driven by an individual organisation’s
perspective to the patient’s perspective. Door to door experience is about meeting
patients’ needs and not organisations’ needs. We are working towards this in a
genuine partnership way. There is commitment to do the right thing and a quickly as
possible.
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DATE AND TIME OF NEXT MEETING
It was noted that details of the next Annual General Meeting had yet to be confirmed
but it was intended to be held on Thursday 18 September 2014. The time and venue
would be confirmed nearer the date.
There were no further matters of business. The Chairman closed the formal meeting
at approximately 8.30 pm.
/KB/AGM2013-MINS
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K
Cover Sheet
Meeting:
Report Author:
Board of Directors
Karen
Hemsworth,
Safeguarding
Associate
Date:
Sponsoring Director:
Thursday, 19th December 2013
Helen Thomson, Director of Nursing
Director
-
Title and brief summary:
Safeguarding Annual report 2012-13 - The Safeguarding Annual report provides and overview of the
work that has taken place over the past year with regard to safeguarding children and adults.
Action required:
Note
Strategic Direction area supported by this paper:
Keeping the Base Safe
Forums where this paper has previously been considered:
Trust Safeguarding Committee October 28th 2013
Governance Requirements:
Governance - In line with local and national guidance the annual safeguarding reports provides
assurances that the organisation is discharging its safeguarding responsibilities. .
Sustainability Implications:
Reduce social and health inequalities
23
Executive Summary
Summary:
The Safeguarding Annual Report Provides and overview of the safeguarding work that has been undertaken
over the past year in order to ensure our services are fit for purpose and meet the needs of the communities
we serve.
The Trust’s pledge to safeguarding remains a key priority and over the past year this has been evidenced
through staff’s dedication to ensuring that the quality of services we deliver are safe and meet the needs of
our services users. The Trust’s Safeguarding Team have continued to support and empower staff in working
with people who are experiencing or have experienced abuse and neglect, in order to ensure that they
continue to develop the necessary skills and competences to fulfil their safeguarding responsibilities,
whatever their role.
Work with the Safeguarding Boards and with our partners across the partnership has continued, in order to
protect children and vulnerable people from abuse and to collectively ensure that all organisations are
discharging their safeguarding responsibilities.
In particular, over the past year, the importance of ensuring that safeguarding is at the heart of everything
we do has been brought into spotlight with national reports published on Jimmy Saville “Giving Victims a
Voice” and Mid Staffordshire NHS Trust’s Public Inquiry.
Safeguarding truly is everyone’s business across the Trust and is integral to our work, whatever our role.
Whilst we embrace the changes and challenges that lay ahead, both within health and social care, it is
important that we remain focused on providing quality services that keeps children and vulnerable adults
safe.
Main Body
Purpose:
See attached report
Background/Overview:
See attached report
The Issue:
See attached report
Next Steps:
See attached report
Recommendations:
It is recommened that the Trust Board note this Annual Report
Appendix
Attachment:
CHFT SAFEGUARDING ANNUAL REPORT 2012 TO 2013.pdf
24
Annual Safeguarding Report 2012 – 2013
Author:
Karen Hemsworth, Associate Director Safeguarding Children
and Vulnerable Adults
10TH October 2013
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Foreword
I am pleased to introduce Calderdale and Huddersfield NHS Foundation Trust’s Annual
Safeguarding Report for 2012/13.
The Trust’s pledge to safeguarding remains a key priority and over the past year this has
been evidenced through staff’s dedication to ensuring that the quality of services that we
deliver are safe and meet the needs of our services users. The Trust’s Safeguarding Team
have continued to support and empower staff in working with people who are experiencing
or have experienced abuse and neglect, in order to ensure that they continue to develop the
necessary skills and competences to fulfil their safeguarding responsibilities, whatever their
role.
Work with our partners across the Calderdale and Kirklees footprint, has gained momentum
over the past year, in order to protect children and adults at risk from abuse and to
collectively ensure that all organisations are discharging their safeguarding responsibilities.
In particular, over the past year, the importance of ensuring that safeguarding is at the heart
of everything we all do has been brought into spotlight with national reports published on
Jimmy Saville “Giving Victims a Voice” and Mid Staffordshire NHS Trust’s Public Inquiry.
Safeguarding truly is everyone’s business across the Trust and is integral to our work,
whatever our role. Whilst we embrace the changes and challenges that lay ahead, both
within health and social care, it is important that we remain focused on providing quality
services that keep children and vulnerable adults safe.
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Introduction
The purpose of this report is to provide the Trust Board with an overview of safeguarding
activity within the organisation over the past year, outlining key achievements and
challenges. The report provides accurate and current information about the efficiency and
effectiveness of our internal systems and processes in order to demonstrate the status of
compliance with our statutory safeguarding obligations. It highlights ongoing work and
developments across the trust, as well as work across the health and social care footprint in
both Calderdale and Kirklees.
Since the Statutory safeguarding responsibilities transferred from Primary Care Trusts
(PCT’s) to the new Clinical Commissioning Groups in April 2013, the safeguarding team
have continued to work with the new commissioning bodies to ensure that critical functions
relating to safeguarding remain a priority during the period of great change within the NHS.
Changes, re-organisation, and uncertainty can create risks to Safeguarding arrangements.
It is therefore vital that Safeguarding standards are maintained and continue to improve,
and, accountability remains clear and unambiguous. With this is mind it is critical that
safeguarding remains a key priority and staff are fully supported in delivering safe and
quality services.
Safeguarding Children and Adults is an integral aspect of patient care, requiring services to
work effectively together to prevent harm and intervene only when harm, neglect, or abuse is
suspected.
Whilst historically safeguarding children policy and practice has been more established
within all organisations, during the past year there has been good progress in
implementing Safeguarding Adult Policy and Practice across the Trust, however, it must be
acknowledged that there is still much work to be done, both within the Trust and collectively
across the partnership.
Everyone who works with children, young people and their families in Calderdale and
Kirklees wants to do their best to make sure that all children are safe and happy, and are
supported as they grow up. Safeguarding not only means protecting children from physical,
emotional, and sexual abuse and from neglect, but helping them to grow up to be confident,
healthy and happy. Most children enjoy happy childhoods - but not all.
From an adult perspective, safeguarding is an integral aspect of patient care, requiring
services to work effectively together to prevent harm and intervene only when harm, neglect,
or abuse is suspected.
Calderdale and Huddersfield NHS Foundation Trust (CHFT) has continued to work hard over
the past year both as an organisation, and with partners, to ensure a clear focus remains on
those who are at risk of harm and are in need of support and protection.
It is crucial that safeguarding becomes embedded in practice and in everything we all do, as
opposed to there being a culture where ‘safeguarding’ is seen as being someone else’s
responsibility. If we are to learn lessons and ensure quality and safe services, staff across all
organisations have to be skilled, competent and supported in taking ownership and
responsibility for dealing with issues that arise.
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The Changing Face of Safeguarding: A National Context
(i) Children
Safeguarding activities in Health and Social Care organisations such as Calderdale and
Huddersfield NHS Foundation Trust NHS are regulated by the Care Quality Commission
(CQC). They make sure that the care people receive meets Essential Standards of Quality
and Safety whilst respecting their dignity and protecting their rights. Regulation 11 of the
Health & Social Care Act 2008 ensures that people who use services are safeguarded from
abuse. The Children Act 2004 and Working Together to Safeguard Children 2013 set out
how agencies work together to protect children.
In May 2011 Professor Eileen Munro concluded her review of the system in England for
safeguarding children. Her final report – A child centred system – made a number of
recommendations for reform, to create a shift from an overly bureaucratic system to one that
keeps the focus on the child. The Government’s response to the Munro review of child
protection (2011), accepted her analysis and as a result Working Together (2013) came into
force from the 15th April 2013. It clarifies the core legal requirements, making it much clearer
what individuals and organisations should do to keep children safe and promote their
welfare. It ensures that professionals focus on the needs of individual children and families
and take decisive and effective action to help those children.
Useful links
Working together to safeguard children 2013
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-indexnew/safeguarding-children
In addition a national panel of independent experts has been established to ensure that
lessons are learned from Serious Case Reviews (SCRs). The panel provides advice to Local
Safeguarding Children Boards (LSCBs) about the application of SCR criteria and the
requirement to publish reports. The Working Together guidance makes clear that LSCBs
should have regard to the panel’s advice when making decisions about SCRs and clarifies
the essential roles of local agencies – including health services and the police – in keeping
children safe and promoting the welfare of children in need.
(ii) Adults
This year the NHS Commissioning Board also published Safeguarding Vulnerable People in
the Reformed NHS (2013), an accountability and assurance framework for Safeguarding.
The framework complements the revised statutory guidance.
Useful links
Safeguarding vulnerable people in the reformed NHS
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-index-new/safeguardingadults
Changes to the Term Vulnerable Adult
The term ‘adult at risk’ has been used to replace the term ‘vulnerable adult’. This is because
‘vulnerable adult’ may wrongly imply that some of the fault for the abuse lies with the adult
being abused. Therefore ‘adult at risk’ is used as an exact replacement for ‘vulnerable adult’.
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An adult at risk is a person aged 18 years or over who is or may be in need of community
care services by reason of mental health, age or illness, and who may be unable to take
care of themselves, and who is or may be unable to take care of themselves, or protect
themselves against significant harm or exploitation (Law Commission, 2011).
(iii) Domestic Abuse
In March 2013 the Government extended the definition of domestic violence and abuse to
include young people aged 16 and 17 and includes wording to capture coercive control. The
new definition is:
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence
or abuse between those aged 16 or over who are or have been intimate partners or family
members regardless of gender or sexuality. This can encompass but is not limited to the
following types of abuse: psychological, physical, sexual, financial, and emotional.
Controlling behaviour
A range of acts designed to make a person subordinate and/or dependent by isolating them
from sources of support, exploiting their resources and capacities for personal gain,
depriving them of the means needed for independence, resistance and escape and
regulating their everyday behaviour.
Coercive behaviour
An act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that
is used to harm, punish, or frighten their victim. This definition includes ‘honour’ based
violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are
not confined to one gender or ethnic group.
(iv) Giving Victims a Voice & the Francis Inquiry Reports
In early 2013 the reports in to sexual allegations made against Jimmy Saville and the final
report of the Mid Staffordshire NHS Foundation Trust Public Inquiry were published. Whilst
both reports are different in their nature; one is of prolific sexual abuse of children and young
people over a significant time period by a high profile celebrity, and the other is first and
foremost of appalling suffering of many patients that was primarily caused by a serious
failure on the part of a provider NHS Trust Board; what both reports have in common is the
recording and description of unprecedented failings by agencies for early identification or
timely responses to reports of abuse (including neglect) and failure to act in a timely or
robust manner once such allegations had been made. Both reports include failings on behalf
of NHS organisations to ensure that the care people received met essential standards of
quality and safety whilst respecting their dignity and protecting their rights; thus ensuring that
people who use services are safeguarded from abuse.
From a safeguarding perspective both reports reiterate the continuing need for all NHS
health and social care employees to be professionally curious and directly ask patients
questions about abuse and neglect, to act upon suspected or reported abuse and to ensure
robust safety plans are in place escalating concerns with tenacity, whilst respecting patients’
human rights and demonstrating the candour expected of public organisations.
Work has taken place over the past year to ensure that the culture of learning and lessons
learned from Mid Staffordshire becomes shared and developed in all the Trust’s strategies.
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With regard to the Saville inquiries, the Trust has had the opportunity to review current
arrangements and a Visiting VIP and Visiting Media policy has now been developed and
highlighted across the organisation.
Useful links
Giving victims a voice. Joint report into sexual allegations made against Jimmy
Saville.
http://www.nspcc.org.uk/news-and-views/our-news/child-protection-news/13-01-11yewtree-report/yewtree-report-pdf_wdf93652.pdf
The Mid Staffordshire NHS Foundation Trust Public Inquiry
http://www.midstaffspublicinquiry.com
Policies for Visiting VIP’s and Visiting Media can be found at;
http://nww.cht.nhs.uk/index.php?id=4914#P
(v) Prevent Strategy
April saw the 2013/14 NHS contract being amended to include the ‘PREVENT’ strategy for
providers of services.
The Government’s counter-terrorism strategy is known as CONTEST. PREVENT is part of
CONTEST, and its aim is to stop people becoming terrorists or supporting terrorism. The
strategy promotes collaboration and co-operation among public organisations. The health
service is a key partner in PREVENT and encompasses all parts of the NHS, charitable
organisations and private sector bodies which deliver health services to NHS patients. The
aim of Prevent is to stop people from becoming terrorists or supporting terrorism. Three
national objectives have been identified for the Prevent strategy:
• Objective 1: respond to the ideological challenge of terrorism and the threat we face from
those who promote it.
• Objective 2: prevent people from being drawn into terrorism and ensure that they are
given appropriate advice and support.
• Objective 3: work with sectors and institutions where there are risks of radicalisation which
we need to address.
The health sector contribution to PREVENT; focuses primarily on Objectives 2 and 3 (DoH,
2011).
Useful links
Prevent strategy - Channel: Protecting vulnerable people from being drawn into
terrorism
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-indexnew/prevent-agenda
Safeguarding: Progress over 2012/13
Achievements
The Safeguarding Team, and staff across the Trust, have worked hard over the past year to
deliver the Trust’s 2012/13 objectives from a safeguarding perspective and to ensure that
the organisation fulfils its statutory safeguarding responsibilities including;
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• The development of a robust and reliable safeguarding framework that will monitor
compliance against both strategic and operational safeguarding functioning within CHFT,
whilst ensuring that strategic change does not impact negatively on safeguarding processes.
• Ensuring high levels of compliance and best practice
Changes, re-organisation, and uncertainty can create risks to safeguarding arrangements, it
is therefore vital that Safeguarding standards are maintained and continue to improve, and,
accountability remains clear and unambiguous. With this is mind it is critical that
safeguarding remains a key priority and staff are fully supported in delivering safe and
quality services. It is also crucial that all staff, whatever their role, engage with safeguarding
processes and understand their responsibilities
If we are improve outcomes for vulnerable groups and keep people safe from harm, it is
essential that safeguarding becomes everyone’s responsibility and part of everyone’s
practice, whatever their role. CHFT will therefore continue to support staff to embrace their
responsibilities so that safeguarding becomes embedded in practice.
Service users and their families at the
centre of Trust's safeguarding work
-Operational
and frontline staff
-Trust Safeguarding Team
-Trust Board
SAFEGUARDING AND PUBLIC
PROTECTION BOARDS
-Local Safeguarding Adukts Board
-Local Safeguarding Children Board
- DV partnerships
-Links with commissioners
-Links with Regulators
-Local and regional networks
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The Trust Safeguarding Team
The Trust has a dedicated Safeguarding Team who provides safeguarding advice and
support across the workforce. The team sits corporately within CHFT and is led by the
Associate Director for Safeguarding, who provides a strategic steer, in order to ensure that
the organisation is complaint with its safeguarding responsibilities. Regular reports and
updates to the Trust’s Safeguarding Committee, to the Trust Board, Quality Boards and
engagement with the Local Safeguarding Boards (LSCB’S), ensure that our approach is
open and transparent. The team provides the organisations linkage to the Local
Safeguarding Boards; namely Local Safeguarding Children Boards (LSCB), Local
Safeguarding Adult Boards (LSAB) as well as other strategic partnerships. The Team is
proactively engaged in multiagency working to enhance relationships, develop strategies
and strengthen processes to ensure that the people to whom the Trust provides services
and the communities in which it works are safeguarded from abuse and that early
intervention is available to assist vulnerable children and adults.
Lines of accountability
Director of Nursing
Associate Director for Safeguarding ( Safeguarding Team Administrator )
Looked After Children’s Team
Designated LAC Nurse )
Specialist LAC Nurse
LAC Administrator
Named Nurse
(Adults)
Named Nurse (acute)
Named Nurse(community)
Named Midwife
Paediatric Liaison
How have we developed and strengthened partnerships?
Collaborative work with partners continues to be at the heart of everything we do.
Child and adult safeguarding has continued to be a priority within CHFT over the last year,
with significant developments being made to strengthen and develop partnerships across the
health and social care economy. The Associate Director for safeguarding has continued to
provide a strategic steer within the organisation with regard to safeguarding and continues to
work closely with the Safeguarding children and adult Board’s and across the strategic
partnership. CHFT works with four safeguarding boards (across the Kirklees and Calderdale
footprint), the Associate Director for Safeguarding representing CHFT on all four boards and
holding the position of Vice chair of both safeguarding boards in Kirklees. Regular meetings
with lead safeguarding personnel within health and social care, both from an adult and
children’s perspective, as well as regular meetings with safeguarding leads within the
Clinical Commissioning Groups, have strengthened working relationships and ensured
effective communication and information sharing. Work continues to develop wider links
across the region.
How do we quality assure safeguarding work and work with partner agencies in
safeguarding and promoting the welfare of vulnerable adults and challenge any areas of
practice needing improvement?
We have worked hard to ensure strong and effective partnerships and working
arrangements both at an operational and strategic level.
Within the Trust, clear reporting mechanisms are in place for feedback from all board
meetings about safeguarding practice and developments. The Trust has continued to
engage and work with the safeguarding boards and all its current subgroups, ensuring
representation and effective contributions in order to take work forward, this has included
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contributions to the board’s development day and agreement of board priorities and the
2013/14 work plan.
How have we ensured effective communication and engagement with staff and the public in
respect of the work of the Trust and the wider safeguarding agenda?
Internal lines of accountability and internal structures within the Trust have been
strengthened to ensure the organisation has a clear process in place for communicating with
staff and ensuring they are engaged with the work of the board. Engagement with service
users is critical and involving them in the development of future services within local
communities is a priority. Learning from experience and from complaints and incidents is
crucial if we are to embrace a culture of openness and transparency. Within CHFT we
continue to move forward in relation to feedback following complaints, staff survey,
suggestion schemes etc and we have a strong and effective membership council made up of
local people, patients, carers, staff from partner organisations and staff employed by the
Trust.
The Trust’s vision is “Your Care, Our Concern”. This vision is at the heart of everything we
do and our success in achieving high quality care for all our patients.
How have we ensured continuous improvement in the efficiency and effectiveness of our
safeguarding work?
Over the past year governance arrangements around safeguarding within the Trust have
been reviewed. Lines of accountability and responsibility have been established and all
internal policies and procedures have been reviewed to reflect changes within health and
social care, as well as Local and National policy, and they can be accessed via
Safeguarding icon on the intranet.
The integrated Safeguarding Children and Adults Committee formed in 2012, continues
to take a strategic overview of the safeguarding arrangements within the Trust, and to
provide updates to the Trust’s Quality Assurance Board. It has continued to provide a forum
to bring together key senior safeguarding professionals and other senior managers across
Calderdale and Huddersfield Foundation Trust to ensure the organisation’s safeguarding
responsibilities’ are being discharged effectively. It provides a bridge between the
Safeguarding Boards, and all areas of service within the Trust, in order to be assured
safeguarding responsibilities are being fulfilled and risks identified and managed
appropriately. It also considers the implications of national policy on local practice and
oversees the safeguarding work programme and priority areas for action, as well as
providing regular updates to both commissioners and to the safeguarding board. Clear
links with the CCG’s have been established with the Designated Safeguarding Leads
within the CCG being formal members of the committee and as such having an
overview of the current position within the organisation. The two safeguarding
operational groups (children and adults), represented by divisions, continue to monitor
safeguarding practice at an operational level and provide a forum for monitoring and
progress and sharing information and specialist guidance and support, thus ensuring that
safeguarding becomes embedded throughout the entire breadth and depth of the
organisation.
Monitoring and Assurance
Section 11 Audits. The Section 11 audits and subsequent challenge events, as well as our
assurances to commissioners, have provided a vehicle for demonstrating CHFT’s level of
compliance and effectiveness with regard to our safeguarding responsibilities. Section 11 of
the Children Act 2004 places a statutory duty on organisations, and individuals, to ensure
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their functions are discharged with regard to the need to safeguard and promote the welfare
of children and all agencies are required to submit an annual self assessment to the
Safeguarding Children Board. The Safeguarding Team submitted the Section 11 self
assessment to Kirklees Safeguarding Children Board and in June 2013 and attended a
challenge event in July whereby the evidence submitted was challenged, not only by the
board but by a panel of young people. No issues with compliance were identified. Kirklees
Safeguarding Adults Board has planned a ‘challenge’ event at the end of August at which
CHFT’s safeguarding responsibilities will be challenged. In Calderdale, the Safeguarding
Boards have joined force to develop a joint child and adult self assessment which will assess
safeguarding arrangements across agencies and the Trust’s Safeguarding Team are
currently in the process of coordinating the response. Likewise, this will be followed up with a
‘challenge event’ in September.
Analytical reports for the purpose of Serious Case Reviews (SCR’s) are quality assured and
challenged, where necessary, by the safeguarding team and evidence that
recommendations from SCR’s have been implemented is closely monitored internally by the
Trusts Safeguarding Committee and externally by commissioners and the Safeguarding
Boards.
The Safeguarding Team’s annual work programme continues to be overseen by the Trust’s
Safeguarding Committee, which is chaired by the Associate Director for Safeguarding within
the Trust and has senior membership from across the divisions, as well as from
commissioning. The Committee provides quarterly reports to the Board of Directors for
assurance.
The Safeguarding Team provide frontline staff with additional advice and support in complex
and high risk situations, as well as being an escalation point for situations that require
resolution and intervention to improve outcomes for service users and their families.
CHFT has a clear learning from experience policy which outlines the procedure to follow
when something goes wrong or could potentially go wrong, and how we ensure that we learn
lessons from these events to improve the service we provide.
Risk management, or governance and safety, are integral to everything we do and the Trust
has an organisational framework which provides a robust, systematic approach through all
levels of the organisation.
How have we raised the profile of safeguarding policy and procedures and to ensure that
effective multi-agency and single agency training in relation to safeguarding is delivered, with
a measurement of outcomes on practice being embedded across agencies?
Policy - Significant work has taken place over the last year to review all our policies and
procedures to ensure they reflect local and national guidance.
Training - The last year has seen good uptake of safeguarding training with the series of
internal master classes and bespoke training also delivered. The training strategy has
been reviewed and updated and clear target groups have been set, outlining the levels of
training for specific staff groups. The Trust’s safeguarding training plan continues to be
under constant review and is accessible to staff in order to ensure they develop the
necessary skills and competencies to safeguard patients/ service users and their families.
This has included different learning opportunities continuing to be available from taught
courses, e learning, and access to multi agency training as well as specific training by
specific professional bodies.
Whilst the current training programme runs on a 3 yearly cycle, at the end of year one we
have seen a significant improvement in uptake which is in keeping with what would be
expected ( i.e. expectations would be 33% for year 1):
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Level 1 safeguarding – delivered via written updates and briefings across the
workforce in the form of the safeguarding newsletter which is circulated twice a year.
It not only gives relevant information to meet the criteria for level 1 training, but it also
supports levels 2 and 3 training - Currently at 100%. Work is underway on edition 4
which will be circulated in October 2013.
Level 2 training (Adults and Children) –Uptake at the end of quarter 1 was 38.6%.
The current position is 41.7%
Level 3 training (children) –Uptake at the end of quarter 1 was 41.9%. The current
position is 40.1%
More in depth safeguarding adults training sessions have been developed for
2013 aimed at those involved in the safeguarding adult’s process.
Master classes have been developed throughout 2013 covering a range of different
issues from learning from SCR’s to changes in policy and practice.
E learning Safeguarding Level 2 (children and adults) has been developed and is
now available.
All training programmes have been reviewed in order to meet the requirements
of the diverse workforce but at the same time in line with statutory requirements.
Prevent - Has now become part of the new NHS contract and all health providers are
required to provide assurances about how it is being implemented. Significant work has
taken place over the past year to support implementation of the PREVENT Strategy.
Progress to date includes;
an internal policy reflecting statutory requirements has been developed and ratified
an internal Prevent group has been established to oversee implementation
Prevent leads within divisions have been identified and have undertaken a 2 day
accredited Department of Health (DH) /Home Office (HO) train the trainers course
which will enable them to deliver a specific internal training package (this training is
stand alone and cannot be incorporated into existing risk, safeguarding or
mandatory training).
Training dates for the rest of the year have been circulated across the Trust
Monthly assurance to commissioners and NHS England about progress continues
Whilst all staff have to attend this training over time, key staff who have to be
prioritised are community staff, A&E staff, managers and chaplains.
Other work has included;
Development of Intranet pages to facilitate easier access to safeguarding
information. The safeguarding icon is now clearly visible on the Trust’s intranet
pages. . Work continues to develop the content of the safeguarding pages in order to
make it easier for staff to access up to date safeguarding information. A recent
screen saver has also been developed to remind the workforce that safeguarding is
‘everybody’s business’ and asks ‘do you know your responsibilities?’
Publication of fourth edition the safeguarding newsletter in October 2013. The next
publication is scheduled for Spring 2014
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A number of reflective learning sessions have been delivered to specific teams in
order to encourage reflection and learning from specific cases.
Further work has taken place to develop safeguarding links across the organisation,
with further work planned for 2014.
Safeguarding supervision continues to be delivered across the organisation in order
to support and empower staff in their roles
Safeguarding Team Development to ensure a more focused approach across the
Trust.
Significant work has taken place with the Risk Department. This has included work
to determine safeguarding adult thresholds; work continues in order to strengthen
this area further, in particular in relation to how this information is presented and
analysed so that it can inform practice.
Work has continued to develop the role of the safeguarding link/champion and
workshops have been delivered for staff both from an adult and child perspective.
Engagement is integral to taking the safeguarding agenda forward and raising
awareness. Further training is planned imminently for all band 6 and 7 nurses.
CHFT continues to engage with partners and contribute to the 4 Local safeguarding
Boards and their work streams, working closely with partners across the health and
social care footprint. Further work is required to ensure the workforce contributes
and engages more in the work of the safeguarding board sub groups.
See me and Care Campaign in Kirklees. The Trust has recently contributed to a
recent campaign led by Kirklees. See ME and care” is a campaign aimed primarily
at health and social care professionals, but is relevant to all partners. The campaign
is all about putting “yourself in others shoes” and thinking about the level of care
you give and see and whether this is how you would like yourself or those you care
for to be treated. The campaign encourages staff to notice and question bad
practice, either by reporting it to their managers, challenging their colleagues or by
using existing protocols in place. A message went out with payslips in July
highlighting the campaign and a series of screen savers will be posted, as well as
information being distributed across the divisions and departments.
OFSTED 2nd Unannounced Inspection of children’s social care in Calderdale took
place at the end of June 2013 and the council’s services continue to be judged as
inadequate, the main areas of improvement relating to social work practice and the
effective functioning of their first response team. CHFT continues to be a strong
partner in supporting children’s social care on their improvement journey.
April 2013 saw the Development of the new West Yorkshire Multi Agency
Safeguarding Adults Procedures which are now available on the intranet and staff
within CHFT have been briefed.
The newly revised publication of the Statutory Guidance, Working Together to
Safeguard Children was published in spring 2013 and can be accessed via the
intranet pages.
Outcome
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The Trust has worked jointly with other agencies to review safeguarding processes
including the development of a Multi-Agency Safeguarding Screening and tasking
team (MASSTT) in Calderdale.
The Trust continues to engage with partners with regard to Multi-Agency Risk
Assessment Conferences (MARACs) for high risk cases of domestic abuse
Supervision
From a children’s perspective, both individual and group supervision has been developed
further and uptake is closely monitored. Target groups have been established identifying the
type and frequency of supervision. The uptake for safeguarding supervision over the past
quarter is positive;
94% for Health Visitors and School, Nurses
100% for specialist midwives
59% for paediatric consultants
The uptake of overall safeguarding children’s supervision across the total workforce has
fallen slightly in the last quarter from 45%, to 38% but this may be due to the fact that some
teams are not recording or providing information with regard to peer group supervision that is
taking place. Whilst overall the uptake remains encouraging and engagement with
supervision from a community perspective remains good, further work is required to ensure
staff within the hospital setting becomes more engaged in the process. Work is underway to
address this with division leads.
Significant developments have also taken place in relation to safeguarding supervision for
adults over the last quarter, with 18 group sessions taking place over the latter half of the
year and 12 individuals accessing formal intensive supervision around specific cases. Work
is also now underway to develop reflective learning sessions, whereby groups of staff can
reflect on specific cases in order learn lessons and inform future practice.
Reviews and Lessons Learned
Over the last year the Trust has contributed to a Domestic Homicide Review (DHR). DHRs
were established on a statutory basis in 2011 under Section 9 of the Domestic Violence,
Crime and Victims Act (2004). This has highlighted for the Trust the importance of
embedding the full domestic abuse definition which includes family members, embedding
questions about abuse in all services and increasing the notion of professional curiosity
relating to suspected or potential abuse where full disclosure has not been made. Domestic
abuse has been incorporated into safeguarding training and significant work has taken place
to strengthen engagement with the MARAC process (Multi Agency Risk Assessment
Conference). In particular, much work has taken place to develop a Domestic abuse
pathway within Accident and Emergency.
Useful Links
Further information can be found on the safeguarding pages on the Trust’s intranet
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguardingindex/domestic-abuse
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Over the past year the Trust has contributed and worked with one of the Local Safeguarding
Children Board’s (LSCB) with regard to a serious case reviews. Local Safeguarding Children
Board’s are responsible for ensuring that services provided for children and families locally
are effective and well coordinated in order to keep children safe from harm. When a child
dies unexpectedly or there has been a serious incident of child abuse, the Safeguarding
Children Board is sometimes required to undertake a Serious Case Review. The purpose of
the review is to consider whether there are any lessons to be learned about the way
agencies have worked with the child and family. This case related to a case involving a baby
born to parents who were both known to a number of agencies including, health, the
substance misuse services and children’s Social, care both locally and cross boundary.
Although the findings of the review were that the child Child‘s death could not have be
predicted or prevented, a number of missed opportunities were identified in assessing and
engaging with the family. Work has taken place across the partnership to strengthen
information sharing, identifying risk and ‘SMART Planning’ in order to ensure services are
safe and fit for purpose and the needs of children and their families are met. A number of
recommendations were made for agencies to ensure that learning from this tragic event
becomes embedded into practice, including the review and development of the Multi Agency
Pregnancy and liaison Group (MAPLAG), which has now been strengthened. All actions
have been implemented. The findings have now been published
Useful links
Further information about MAPLAG protocol can be found by accessing the
safeguarding pages on the Trust Intranet
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-indexnew/safeguarding-children
The Trust is currently working with one of the LSCB’S in relation to another SCR, following a
child death but CHFT had no involvement with the case; there is a further case currently
being considered following the death by suicide, of a teenager, with a number of other cases
currently up for review.
The Trust contributed to and was involved in a Serious Case Review commissioned by the
Local Safeguarding Adults Board; this review has been considerably delayed in its
publication due to criminal proceeding. This case related to care being provided in a local
nursing home. However, the Trust has ensured that the resulting lessons become in practice
across the Trust and all actions have now been implemented. This has resulted in further
training and supervision in order to ensure the workforce is skilled and competent in
recognising and acting upon safeguarding concerns. A further adult’s serious case review is
currently underway but CHFT had minimal involvement.
The Trust carries out Root Cause Analysis investigations into serious incidents covering a
wide range of issues. All of these investigations include a review of safeguarding practice
relating to the case and thus safeguarding processes and practice are continually enhanced
to improve outcomes for patients / service users and their families
Local Picture
Calderdale and Kirklees Safeguarding Adults Boards
The increase of alerts from within Adult Health and Social Care across both Calderdale and
Kirklees reflects the work that has gone on to raise the profile of safeguarding. Neglect
continues to be the main category of abuse which is followed by physical abuse and financial
abuse. The alleged victims were predominantly white. Adult Social Care remains the highest
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referral source, with the highest percentage of alleged perpetrator’s coming from social care,
followed by family members.
Number of Alerts;
Calderdale
Kirklees
2011/12
2012/13
525
646
707
670
Useful Links
For Further information check out CSAB and KSAB Annual reports which can be
found at ;
http://www.calderdale.gov.uk/socialcare/safeguardingadults/
http://www.kirklees.gov.uk/community/careSupport/keepingSafe/safeguardingAdults.aspx
Calderdale and Kirklees Safeguarding Children Boards
The overall trend of recent years continues to show an increase in numbers of children
subject to child protection plans, with the emotional abuse and neglect continuing to be
predominantly the highest categories of abuse.
Number of children subject to a child
protection plan ;
Calderdale
Kirklees
2011/12
2012/13
281
382
335
391
Whilst the numbers of contacts to children’s social care remain high, the numbers of referrals
for early help remain relatively low, with the number of CAF’s being initiated continuing to be
relatively low across all agencies and work is currently underway to explore this further.
Useful Links
For further information check out the Calderdale and Kirklees Safeguarding Children
Board Annual reports which can be found at;
http://calderdale-scb.org.uk/
http://www.kirkleessafeguardingchildren.co.uk
Looked After Children
Looked after Child’ is a generic term introduced in the Children Act 1989 to describe children
and young people subject to care orders (placed into care of local authorities by order of a
court) and children accommodated under Section 20 (voluntary) of the Children Act 1989.
Looked after children may live within foster homes, residential placements or with family
members (connected carer’s)
Evidence from research shows that looked after children and young people share many of
the same health risks and problems of their peers, but often to a greater degree. They can
have greater challenges such as discord within their own families, frequent changes of home
or school, and lack of access to the support and advice of trusted adults. Children often enter
the care system with a worse level of health than their peers, in part due to the impact of
poverty, poor parenting, chaotic lifestyles and abuse or neglect. Longer term outcomes for
looked after children remain worse than their peers. ( Ref DH 2009.)
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Looked after children face greater challenges than their peers, and suffer long term health,
social and educational challenges and outcomes as compared to the general population.
These children are particularly vulnerable.
The health element of the looked After Children’s service in Calderdale sits with CHFT; the
service in Kirklees sits with LOCALA.
To date there is a national upward trend with regard to children who are looked after.
Currently there are 326 children who are looked after in Calderdale.
Useful links
Full statistical reports can be accessed via this link:
http://www.education.gov.uk/cgi-bin/rsgateway/search.pl?cat=3&subcat=3_1&q1=Search
Check out the LAC health annual report which can be accessed on the Truss’s intranet pages
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-index-new/safeguardingchildren
Conclusion
Safeguarding is everyone’s responsibility and should be part of everyone’s practice,
whatever their role. The roles are advisory and supportive and it is important that the
workforce take responsibility for safeguarding within their own area of work and know what
to do if they are concerned that someone is at risk of harm.
The landscape within health and social care is changing rapidly in relation to safeguarding
and development work will continue over the next months to ensure CHFT provides a
safeguarding service that is fit for purpose. It is essential that everyone within CHFT
continues to embrace their responsibilities so that safeguarding becomes embedded in
practice if we are improve outcomes for vulnerable groups and keep people safe from harm.
Karen Hemsworth
MA Child Protection, BSc(Hons) HV, RSCN, RM, RGN.
Associate Director for Safeguarding Adults and Children
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