PART A AGENDA ITEM 11 - The Princess Alexandra Hospital | NHS ...

Paper for Trust Board 28 th April 2011Report from Compliance Committee: 14 April 2011Key issues discussed• Risk register –now being strongly led by CEO at weekly ED meetings. Somemovement noted. Major review by ED team this month , Expectation RMprocess will become tighter and more dynamic• HSE action plan – Three issues outstanding – Small handling aids funding toremedy approved, Sharps – action plan in place and audit of retractableneedle use programmed, bariatric equipment – not funded and so actual riskto be defined and mitigation plans back to next meeting,• Information governance – compliant with tool kit except in two areas- stafftraining and corporate document management system – action in traincompliance by July• CQC – no major areas of concern• Stat/man training and PDRP – end year performance well in excess ofrequirement . Focus now on quality via PS+Q and also ensuring role specificstat man also tracked. Eg. COSH• RM strategy – further work to do• NPSA alert – one breach ( by one day ) . RCA underway to understand whyand report back• NHSLA- most department breach March milestone and capacity issues putachievement of programme to deliver at risk• Infection control – compliant with plan 2011/12 – issues for 2011/12 due toway target set and conflict between best practice increasing testingparameters some more people tested and meeting target . Work underway atregional/national level to clarify /resolveKey risks• NHSLA level 2 – patient care, reputational , financial ( £250K) and regulatory( authorisation) . further risk definition and mitigation plans to be brought back• HSE- Bariatric – patient care, financial , regulatory , safety - further definitionand mitigation to be brought back• Infection Control –to be defined in light of further information and broughtback with options / mitigationRefer / link to other board committees• PDRP – quality – to PS+Q• Sharps audit retractable needles – in audit plan – to Audit committeeJanet DalrympleNon-Executive Director and Chair of the Compliance Committee18 April 2011