Trust Board meeting - Halton and St Helens PCT

Agenda item 07/05/04 i
Halton and St Helens Primary Care Trust
Integrated Governance Committee
Notes of the meeting held on Tuesday, 27 February 2007 at 1.30 pm
in the Main Board Room, Cowley Hill
Minutes
Members:
Janina Morrison – Chair
Mrs Rebecca Burke-Sharples – Chief Executive
Mr Charles Storey – Risk Manager
Mr Peter Lloyd-Jones – Non-Executive
Mrs Christine Samosa – Director of Workforce Development
Ms Fiona Johnstone – Director of Public Health
Mr Kieran Colton – Snr Manager Information Governance & Records Management
Mrs Hayley Spindler – Clinical Governance Manager
Mrs Angela Green – Assistant Director
Mrs Margaret Geoghegan – Acting Head Medicines Management
Dr Steve Cox – Medical Director
Minute-taker:
Barbara Hitchen - PA
Action
27/02/1 Welcome and Introduction
Janina Morrison welcomed everyone to the meeting
27/02/2 Apologies
Mike Treharne, Debbie Fairclough, Janet McDonald, John Jones, Carl Powner,
Margaret Evans, John Bennett, Keeley Harrison
27/02/3 Minutes of the previous meeting
The minutes were approved as a true record – Chris Samosa pointed out it was
confusing having two people who share the same initials, i.e. Chris
Samosa/Charles Storey so where there are actions names to be put in full.
Terms of Reference - Agreed with the following changes
The ToR Membership to be updated to reflect quorate arrangements;
4 Board Directors, 1 Non-Executive Director and 1 Clinician
Workstream paper was agreed
Carl
Powner/
Debbie
Fairclough
Margaret Geoghegan suggested adding another Medicines Management
‘workstream’. However, it was suggested it could be a specific element of the
Finance and Resource Workstream.
1

Peter Lloyd-Jones to pick up with John Morris
Peter Lloyd-
Jones/John
Morris
27/02/4 Report back from Workstream leads;
Risk Management – Lead Charles Storey
Charles Storey reported that the Risk Management Workstream met on the 25
January and there were two main issues which arose from the meeting; under
reporting of incidents at Halton and SABS alerts outstanding in Halton. 66 alerts
outstanding picked up with Andy McMillan and this has been reduced to 31 other
plans to bring down to the end of March to meet the declaration.
Charles Storey gave assurance to the committee that we were on target for
March.
Local Risk Register will be issued to Directors on Friday.
Terms of Reference were agreed
Information Governance Workstream – Lead Kieran Colton
Kieran Colton reported that the main priorities were requirements for end of year
financial submission for Standards for Better Health. Looked at a number of
policies the majority of which were legacy documents for discussion. Looking
at TROVE document management system to progress with Information
Governance Workstream.
Organisation chart in Information Governance Workstream needs substituting
with the one Carl Powner has issued
Information governance training in place till the end of March.
Amalgamating old Freedom of Information, updating Records Management
Strategy and re-issuing Archiving and Retention guidelines. Also establishing
Records Management Workstream to feed directly to Information Governance
workstream.
Terms of Reference were agreed
Quality/Clinical Governance Workstream – Lead Margaret Evans
First meeting 31 January 2007. Margaret Evans will be the chair of the
Workstream, Dot Keates is chairing at the moment in Margaret’s absence and
Hayley Spindler representing.
Main risk identified issue of us not having robust processes around
implementation of the NICE guidance. Developing and firming up processes
round dissemination review and implementation of NICE guidance. Risk has
been mitigated since.
2

Chris Samosa noted that training was offered and was anxious that training
should be co-ordinated. Hayley confirmed the training was to be offered to
independent contractors.
Angela Green happy to use Trust Times as a single resource for dissemination
of information.
Terms of Reference were agreed
Workforce – Lead Chris Samosa
Chris Samosa stated she had not finalised any Terms of Reference for the
Workforce Workstream as yet but would try and pull them together for the next
meeting.
Key issues
ESR and the 2 parallel providers are currently on ‘green’ for readiness on the 1
April. Looking to provide a staff survey within the next month available online
Terms of Reference required for next meeting
Chris
Samosa
PPI – Lead John Jones
Angela Green commented the paper was a fresh approach built on the key
drivers within the commissioning framework and that it is a challenging agenda
but one we have to deliver. She was confident the issues have been covered by
Fit for Purpose and will be addressed by the organisation
Rebecca Burke-Sharples commented that it does not reflect the current
arrangements and it would be useful to have an updated paper for the next
meeting of what it looks like today.
Updated paper required for next meeting
Angela
Green
Finance and Resources – Lead Mike Treharne
A Draft Finance and Resources Workstream ToR paper was tabled in Mike
Treharne and John Morris’s absence.
The Committee felt the Terms of Reference do not meet with the Memorandum
of Accountability. Membership states that only one Executive Director needed to
be present the Committee stated there needs to be more than one Executive
Director on the Membership. There is no reference to Workstream
accountability to Integrated Governance Committee.
Management Executive to seek guidance from the Audit Committee and
bring back to the next meeting.
3

Health Protection & Emergency Planning Performance – Lead Fiona
Johnstone
Fiona Johnstone reported that the separate groups that existed within the 2
organisations are to be amalgamated and will be discussed at the next Infection
Control Committee meeting.
Emergency Planning - Fiona reported they have drafted the Terms of Reference
for the group with David Merrill taking the lead. Also started to bring some of the
legacy documents together. Fiona informed the group that a successful
Emergency Planning exercise, Halton 4, had taken place. Assurance for this
committee understanding how well our systems workings.
ToR will be available for next meeting
Fiona
Johnstone
27/02/5 Policy Verification
Standards for writing policies and procedures, guidelines, standard
operating procedures and approval process
Outlines the way in which we produce and ratify all the policies/procedures. All
policies must be subject to strict document control and contain reference
number, version number, and be logged with Policies Administrator and stored
on a document library system. Policy also details checklist that Workstreams to
use when they go through. Policy is based on various systems from the 2
legacy PCT’s.
Chris Samosa asked that people could be encouraged to have a one page with
a flow chart. Also, say who the policy administrator is.
Steve Cox commented that something quick that people can reference Also
when asked to write a policy enclose a couple of examples.
Angela Green urged using the Trust Times for disseminating any information
and to have a section saying which policies have been implemented.
Approved for implementation
Comments, Concerns & Complaints
Rebecca Burke-Sharples still felt there was some confusion in the system
of when is it a complaint or when is it whistleblowing.
Revisit Appendix B
1) At the beginning and in the introduction should state this is not
‘whistleblowing’ but comments concerns and complaints about service.
Needs to say for ‘whistleblowing’ visit policy ….
2) Rebecca asked if we could move away from the wording PCT patients;
PCT has users and staff and carers.
4

3) Some wording needs adding “Chief Executive will consider having
obtained reasonable advice and only then make a decision
Approved for implementation subject to the 3 alterations
Confidentiality code of practice
Kieran Colton confirmed this document was based on the most recent
guidance.
Agreed to test on a ‘live audience’ with a review in 6 months. Task someone to
check it.
Approved for implementation with 6 month review.
Subject Access Requests
This document pulling together previous legacy documents. It deals with record
data protection act previously known as Access to Records 1990. Streamlined
so that it goes through one central point through Kieran Colton and kept as far
as
possible from putting names in the document to make them robust as possible.
Access to records changed from 40 days to 21.
Steve Cox stated needs amending to state that providers can provide access
to records.
Rebecca Burke-Sharples wanted including ‘under certain circumstances
appropriate advice would be sought’.
Subject to alterations – approved
Information Governance Strategy and Policy
Approved
Freedom of Information Policy and Procedures
Rebecca Burke-Sharples had received requests for information
from Part II of the Board. Angela stated that if the data was of a
personal or sensitive nature then you have justification not to
release the information. Any requests under Freedom of
information must be in writing.
Ratified to go to the Board
Safe Haven
Falls out of the Code of Confidentiality practice. Currently working
with IT department to identify every safe haven fax we have. Listing
all internal safe haven faxes on the website.
5

It was agreed to put a note in to say good practice would be to
request a confirmation slip.
Approved with amendments
National Guidance Policy
Approved does not need to go to Board unless there are any problems.
Review in 6 months and test it out on Clinical Executive
Medicines Policy
Process should have considered by the Management Executive and
then have gone to the IGC. Ask ME to consider resource implications.
PCT Sponsorship Policy
Ratified to go to the board for approval
27/02/6 Standards for Better Health
Hygiene Code element to form pat of the 06/07 Health Care Commission
declaration position statement. Sue Wynn had attended the Quality and
Governance Workstream and has identified some gaps. Fiona Johntone to
progress through Health Protection Workstream
27/02/7 Assurance Framework
Charles Storey presented the refreshed Assurance Framework which is a working
document to be presented to the Board on the 20 March 2007 for assurance.
Dr Cox reported that his practice had piloted one part of Sirus administration
system and it was agreed if they were looking for a pilot PCT to nominate Halton &
St Helens.
27/02/8
Key Issues for reporting to Board
Charles Storey actioned to complete by 9 March.
Charles
Storey
27/02/9 Next meeting
24 April 2007 1.30 pm in the Main Board Room, Cowley Hill
6