Agenda item

University Hospitals Leicester, submits a general statement of compliance, draft declaration for 2008/09.  The Committee is invited to review the paper and provide any commentary as appropriate.

Malcolm Lowe-Lauri, Chief Executive of the University Hospitals Leicester NHS Trust (UHL) and Sharron Hotson, Acting Director of Clinical Governance presented the University Hospitals Leicester’s draft Annual Health Check Declaration for 2008/09.  Sharron Hotson noted that the final version of the declaration had yet to be approved by their Board and highlighted areas that had Insufficient Assurance.

Sharron Hotson noted that additional information had been obtained for Core Standard C7e, ‘challenge discrimination, promote equality and respect human rights within the organisation’, and it was hoped that the position would be altered to the compliant status for the final version.  In response to a question Malcolm Lowe-Lauri noted that a host of initiatives had taken place and that information could be sent to Members.  In addition it was agreed that the ethnic representation of the top five percent of directors would be supplied.

Further work had also taken place around C8b, ‘personal development plan (PDPs)’, however a  final decision was needed by the Board.  A Member of the Committee queried if the figures for the PDPs could be presented quarterly with separate information for consultancy, nursing and clinical staff.  Malcolm Lowe-Lauri agreed to provide this information, and noted that often problems arose when the completion of a PDP was not recorded, rather than not carried out.  A Member asked if the PDPs were linked to the Trusts business plan.  In response it was noted that the Trust was aiming to link the business plan with individual tasks.

Sharron Hotson reported that in relation to C20b, ‘supportive of patient privacy and confidentiality’, there had been a lapse within the year which had lowered the compliance level.  Members requested that more information be made available.  Malcolm Lowe-Lauri noted that in the three sections where there had been cases of mixed wards Urology was the hardest to separate, as staff needed a concentrated area of patients.  Some facilities had been implemented and it was hoped they would be compliant by the end of the year.

A Member of the Committee queried the compliance level of standard C4a, the reduction of acquired infections to patients.  He stated that a league table showed that the UHL hospital was rated 73^rd over the last 6 months with 21 cases of infection.  He acknowledged that this was in comparison with acute hospitals when compared to other teaching hospitals UHL was very good.  In response Malcolm Lowe-Lauri stated that as a teaching hospital UHL was  rated 2^nd for MRSA prevention.  The hospitals had a higher percentage of patents that had a low immune system, due to the type of care available.  Considerable work had been carried out since 2006 to reduce infection, as there had previously been a number of problems.  It was thought that the league table averaged out the information over a long period of time and included previous figures.  Malcolm Lowe-Lauri agreed to provide a written response for Members.

The Chair queried what percentage of information on patients was held by the Trust and how much was elsewhere.  Malcolm agreed to provide a written answer, as there were different areas of data.

It was noted that missing numbers within the report were due to those standards being measured though a different system, which was the same for all the Trusts.  It was agreed that these would be supplied to Members.

Members congratulated UHL on achieving 41 out of 44 core standards and presenting an easy to read report. 

RESOLVED:

1.     that the report be noted and the Committee agree to submit a commentary to the University Hospitals Leicester on their Annual Health Check Declaration.

2.     that a written response be provided to the Committee on the league table position of the hospitals in relation to reduction of acquired infections to patients       

3.     that information on staff personal development plans be provided to the Committee on a quarterly basis, and divided into consultant, nursing and clinical staff.

4.     that information on staff minority group initiatives and the ethnic representation of the top five percent of directors be provided to the Committee.

5.     that the outcomes of core standards measured under a different system be provided to the Committee.

6.     that the Committee be provided with a written response on the percentage of data held by the Trust.