WEST LONDON MENTAL HEALTH NHS TRUST
OPERATIONS BOARD (the board) MEETING
Minutes Tuesday 2nd February 2010 (draft)
Present:
Peter Cubbon, Chief Executive (Chair)
Mr Ian Kent, Deputy Chief Executive
Mrs Barbara Byrne, Director of Finance & Information
Dr Elizabeth Fellow-Smith, Medical Director
Mr Steve Trenchard, Director of Nursing and Patient Experience
Mr Andy Weir, West London Forensic SDU Director
Dr Nick Broughton, West London Forensic SDU Clinical Director
Ms Bridget Ledbury, Ealing SDU Director
Dr Jonathan Scott, Ealing SDU Clinical Director
Ms Helen Mangan, H&F (incl Gender Identity) SDU Director
Dr Michael Phelan, H&F (incl Gender Identity) SDU Clinical Director
Mrs Nicky Holdaway, Hounslow (incl Cassel Hospital) SDU Director
Dr Alice Parshall, Hounslow (incl Cassel Hospital) SDU Clinical Director
Mrs Kate Lyons, High Secure Services SDU Director
Also present:
Ms Gemma Stanion, Programme Director for the CQC Action Plan
Ms Lucey McGee, Director of Communications
Ms Nina Griffith, Head of Planning & Performance
Dr Clare Lucey, Named Doctor
Mr Trevor Farmer, Assistant Director
Dr Tim Bullock, Deputy Medical Director
Miss Abby Fadina, Board Secretary (minutes)
In attendance: Ms Heather Davies, PA Consulting – Programme Management Office
Mr John Lunn, PA Consulting – Programme Management Office
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1.1
APOLOGIES FOR ABSENCE
Ms Lesley Stephen, Director of Strategy & Performance
Mrs Ruth Lewis, Director of Workforce & Organisational Development
Miss Leeanne McGee, Director of High Secure Services
Dr Kevin Murray, High Secure Services SDU Clinical Director
Ms Linda Dyson, Acting Director of Workforce & Organisational Development
2
CORRECTIONS FROM THE DIRECTOR OF IM&T TO THE DECEMBER 09 MINUTES
(which had been approved at January 2010 Operations board meeting)
The Board Secretary explained that she had received further corrections to the minutes of
the December 2009 Operations board meeting after the January 10 meeting. The board
received the corrections to the minutes and agreed that they did not fundamentally change
the actions from the minutes but gave more clarification. The Operations board approved
the corrections; which can be found at the end of the minutes of this meeting.
2.1
3
3.1
MINUTES OF THE LAST MEETING
The minutes of the meeting held on the 5th January 2010 were agreed as a correct record.
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4
4.1
MATTERS ARISING
Complaints Tracker (as at 21st December 2009)
This item had been deferred from the previous meeting and Dr Fellow-Smith said that as
an update there were now 16 open complaints outside the timeframe as at 1st February
2010. SDU Directors as appropriate detailed why these were outstanding. The board
noted that in Ealing the MQ complaint was being dealt with by Ms Harrington.
The board noted that the signature trail pilot was working well in Hammersmith & Fulham
SDU and West London Forensic Service SDU.
Mr Trenchard and Anne Aiyegbusi, Head of Nursing – WLFS SDU, were asked by Mr
Cubbon to find out what neighbouring trusts do with regards to their corporate complaint
governance structure.
Action: Mr Trenchard
Mrs Byrne said that the complaints tracker was not currently on the Exchange but could be
if that was what was decided.
4.2
(para 3.2) Matters Arising - IM&T Strategy and presentation of the Exchange / Knowledge
Management of IT
Mrs Byrne said the issue regarding the number of 24 hour reports generated from the
incident reporting system on the Exchange to SDU leads was being discussed at a
meeting with Mr Weir, and the Exchange team.
4.3
(para 3.5) Matters Arising - Disciplinary Policy and Procedure Review
The board noted that the issues of the policy not reflecting the SDU structures had been
raised in a paper to the SMTs to review. Mr Cubbon said the policy was to be revised so
that it no longer required Non Executive Directors to chair the appeal hearings.
Action: Ms Dyson, Mrs Lewis
4.4
(para 5.2) Update on MORI
Mr Kent said he would be meeting with Lynne Read, Assistant Director Primary Care
Developments, to discuss progress with regards to the feedback and communication of the
3 SDU Primary Care Interface Improvement Plans to the GPs.
Action: Mr Kent
4.5
(6.2) Policy Review Group
Mr Trenchard said that the new Policy Review Group was in the process of being
established. The board agreed that the role of the new Policy Review Group would be to
review all policies, identify issues from incidents for the Trust to address and recommend
the new or revised policy to the Quality & Risk Committee for final sign off.
Action: Mr Trenchard
4.6
Integrated Governance Chart
Dr Fellow-Smith tabled the revised Integrated Governance Chart, approved at the Board in
January 10, and explained that the SDUs did not have to directly replicate the structure
chart within their SDUs but must have appropriate meetings in place to discharge their
duties. Mr Cubbon added that the report from Ursula Martin, title, must be considered by
the SDU Leads and embed its principles within their SDUs; Mr Weir and Mr Trenchard
agreed to take this work forward.
Action: Mr Weir, Mr Trenchard
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Mrs Byrne asked for clinical and managerial input into the Informatics Sub-Committee. Dr
Parshall said that the 3 local SDU Clinical Directors had agreed that they would represent
each other in a number of the Groups / Committees that they needed to be members of;
this would ensure representation and reduce the number of meetings they would each
have to attend.
4.7
(para 7.8) Follow-up from 5th Jan 10 CELF meeting – Mental Health Benchmarking Club
Mrs Byrne said she had met with other Finance Directors and they had agreed to share the
results of their respective organisations. Mrs Byrne said the results of the 7 major MH
Trusts would be circulated in due course.
Action: Mrs Byrne
4.8
(para 7.9) Follow-up from 5th Jan 10 CELF meeting – data analysis
The board noted that the SDUs had met with Dr Bullock to discuss and agree their data
analysis needs.
Dr Bullock, on his arrival at the meeting, informed the board that the data from RiO was still
being analysed and further data was being extracted. Once anomalies in the data are
understood this will be presented to the SDU's and forwarded to Mr Cubbon. SDU
Directors would consider how they could use the information presented by Dr Bullock to
support service improvement
Action: Dr Bullock, SDU Directors
4.9
(para 8.2) CQC Action Plan Update – hygiene and cleaning inspection
Mr Trenchard gave an update on the progress of works.
4.10
(para 12.1) CQC Registration
Mr Trenchard confirmed that Ms Harrington had circulated appropriate literature and that
the Trust had met the deadline for submission. He informed the board that the next steps
was that the Trust now had two months to review its submission and test it against the
CQC action plan. Mr Trenchard informed the board of the decisions made by the Board
and the Executive Directors with regards to the Trust’s compliance levels with the new
Regulations / Outcomes. The board noted that the CQC would be returning to the Trust
before the end of March 2010.
Mr Trenchard tabled the new leaflet titled “CQC Business as usual” which has been
developed to be used as part of the communication at Team Briefings in directorates, to
promote conversations in teams about what the CQC investigation means to all staff
members. The board discussed the new leaflet and some concerns were raised about the
clinical focus of the leaflet and concerns that it may not resonate with non-clinical staff in
the Trust. After discussion the board agreed that the content of the leaflet would stay as it
is and it was for non-clinical managers to adapt the leaflet to fit their service. The leaflets
would be printed and distributed.
Action: Mr Trenchard
Mr Kent said that he and Mr Trenchard had met with Ealing LinKs to talk to them about
commenting on the Trust’s submission.
4.11
(para 14, 15, 16, 17) Revised Policies D3, R5, R6 and S26
Miss Fadina confirmed that the revised policies had been cascaded to staff and placed on
the Exchange.
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4.11
(para 18.2) Admissions of under 18s
Mr Kent agreed to work with CAMHS consultants to develop an operational procedure for
the 2 wards that have been designated to admit under 18s.
Action: Mr Kent
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GROUP FEEDBACK FROM 5TH JANUARY 10 CLINICAL ENGAGEMENT &
LEADERSHIP FORUM (CELF)
The board received the raw transcripts responses from the six group tables at the CELF
meeting. The responses had been to the following questions:
 What are the quick wins to get this moving?
 What are the transformational changes that will deliver this and can we front load
these rather than back end load to ease the pressure?
5.1
5.1.1 It was noted that some of these ideas for service redesign had been conveyed to the
Programme Management Office to consider.
5.1.2
Mr Kent agreed to review the raw transcripts and group them into themes before they are
circulated to the wider CELF membership and the next 3 Way PCT meeting.
Action: Mr Kent
5.2
The board agreed that the next CELF, on the 2nd March 2010, would focus on dementia
and clinical care for individuals.
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6.1
BRANDING / PROMISE PROJECT
Item deferred to March 2010 meeting.
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7.1
PET UPDATE
Mr Trenchard informed the board that the first meeting of the PETS programme board had
taken place on the 13th January 2010; the programme board would report into the Time to
Care sub-group of the Clinical Standards sub-committee.
7.1.1
The board noted that the PETs were now in 7 wards and the project plan for the rollout and
the links to the Productive Wards had been agreed by the programme board. Mr
Trenchard agreed to provide a copy of this to the board.
Action: Mr Trenchard
7.1.2
Mr Trenchard informed the board that feedback from the PETs was received every Monday
and the Board had requested quarterly feedback.
7.1.3
The board debated the best way to ensure that daily feedback was received on the wards
so that each shift could see the service experience that the patients were receiving on their
individual wards. Mr Trenchard agreed to take forward Mr Cubbon’s suggestion of a white
board on each unit and ward showing what the patients have said, so that staff and
patients can immediately see what has been said and what has changed as a result of the
feedback.
Action: Mr Trenchard
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8.1
RESHAPING H&F SDU – SINGLE POINT OF ASSESSMENT
Ms Mangan’s report detailed a proposal to create a single Assessment Team and two
Recovery Teams, based at the Claybrook centre, from the existing intake and adult
CMHTs as part of the service redesign in H&F SDU.
8.1.1
Ms Mangan highlighted some of the benefits; which included clarity, assessment process
consistency and the potential to provide higher levels of expertise for all service users and
4
risks; which included loss of the links between smaller CMHTs an individual GPs, training
to improve assessment skills and the change / upheaval for some service users who would
not necessarily see the same specialist at each visit. The report also detailed the actions
to mitigate these risks – additional staff to the admission wards, reassurance that there
would be a Band 6 on duty to cover bed management issues, work with liaison service to
extend the current liaison service into Charing Cross Hospital.
8.1.2
Mr Kent confirmed there had been formal consultation in the form of a project board with
membership from PCTs and key stakeholders. Ms Mangan confirmed that the
commissioners supported the proposals. In response to Mr Cubbon’s question with
regards to PCT views on getting people back on standard CPA, Dr Phelan said that this
was not an issue so long as it was done well and there had been no negative feedback
from GPs and their main concerns related to clear pathways into the service.
8.1.3
The board discussed the proposed new establishment as detailed in the report, appendix
4, for the Assessment and two Recovery Teams and debated whether the same model
should be applied in the other SDUs. It was agreed that this debate / discussion would be
continued at the March CELF meeting.
8.2
The Operations board supported the proposal to create a single Assessment Team and
two Recovery Teams, based at the Claybrook centre, by 1st May 2010.
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10.1
THE NHS PERFORMANCE FRAMEWORK
In the absence of Ms Stephen, Nina Griffith presented the paper summarising the new
Department of Health Performance Framework that will be applied to all non-Foundation
Trusts from April 2010. Ms Griffith highlighted the 4 performance domains (financial
performance, operational standards, quality & safety and user experience) and explained
how the scores received would determine if a trust was categorised as:
 Performing
 Performance under review
 Underperforming
10.1.1 The board noted that Trust was predicted to be rated as ‘underperforming’ in the first
assessment at quarter 1, 2010/11. Ms Griffith stated that this would become a major risk
to the Trust if the position was not improved over 3 consecutive quarters, when the Trust
would automatically be classified as ‘challenged’.
A challenged trust which shows
insufficient improvement after a year may be moved into the ‘Regime for unsustainable
providers’, as defined by the Department of Health.
10.1.2 The board noted the importance of the patient experience as this would form the source of
the Trust’s assessment. Ms Griffith highlighted 2 additional service performance
indicators – proportion of patients in employment and in settled accommodation; the board
noted that the Trust must perform better against the outcome of the two targets. It was
noted that the Trust’s Quality Account also sets a target of 10% increase against these
indicators
10.2
The board noted that the Trust’s results would be reported to the Board on a monthly basis
in the Board Integrated Performance Report and monitored in detail via the Quality & Risk
Committee and the Finance & Performance Committee. Mrs Byrne said that work was
being done on the minimum data set and this would be reported via the latter committee.
Dr Lucey and Mr Farmer arrived
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9
POLICY C18B – VISITS TO PSYCHIATRIC INPATIENT SERVICES BY CHILDREN
POLICY C18C – CHILDREN WHO DO NOT ATTEND FOR OUTPATIENT
APPOINTMENTS
9.1
Dr Lucey confirmed that both policies had undergone consultation ending in December
2009 and had both been working document policies since 23rd October 2009. The
comments received during the consultation period had been included in the revised
policies and were presented to the board for approval.
9.1.1
In response to Dr Scott’s question regarding how feasible it was to audit DNAs, Dr Lucey
said that a methodology should be developed following local implementation of the policy;
she suggested the policy needs to become part of local practice, and three months later, a
local audit should be completed to test compliance.
Action: Dr Fellow-Smith, Dr Lucey, Mr Farmer
9.1.2
Dr Fellow-Smith and Mr Farmer gave an update to the board on the safeguarding training
targets; Level 3 training the Trust was on target (80%), Level 1 training was a lot closer to
target but more encouragement of staff to complete their e-learning training was still
needed, and Level 2 training the Trust was still below target and there was a proposal to
organise a training event in March to boost the numbers. The Operations board agreed
that a large training event day would be held in March for training on safeguarding Children
and Adults. This would take place either in the St Bernard’s site gym or at the Ramada
hotel in Ealing and staff would be paid extra to attend the training day. It was agreed that
separate training would be provided for the Cassel Hospital and the Broadmoor Hospital
staff.
Action: Dr Fellow-Smith, Dr Lucey, Mr Farmer
9.1.3
Mr Farmer clarified that domestic staff were only required to complete the Level 1 training
(e-learning) and that Level 2 training was a requirement for all staff who have regular
contact with children and parents. He informed the board that the Trust’s training matrix
and passports had been updated.
9.2
The board approved the revised policies to be cascaded to staff and placed on the
Exchange.
Action: Board Secretary
9.3
Mr Cubbon thanked Dr Lucey and Mr Farmer for presenting the revised policies to the
Committee; he informed the board that Mr Farmer was leaving the Trust and thanked him
for the work he had done for the Trust in the last 7 / 8 years.
Dr Lucey and Mr Farmer left the meeting
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11.1
DOORS IN INPATIENT SETTINGS
Mr Kent said that the NPSA had been involved in discussions with the Trust with regards to
the ligature risks that doors presented and it was important for people to understand that
doors can not be ligature free. Dr Fellow-Smith said that within the Suicide Reduction
Group there was a task group looking at the design of fixture and fitting in the Trust.
11.2
The board discussed the importance of ensuring that staff understand that the Trust would
never be in a position to eliminate all ligatures but that it was important to find ways to
manage risks. The board discussed the possibility of speaking to user forum groups about
preparing people who use the Trust’s services with advice on what they can or cannot
bring with them to the wards / units.
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11.3
The board agreed that Suzie Marriott (ex Nurse Consultant at Broadmoor Hospital) would
be asked to speak at an event to staff about service user suicides.
Action: Dr Fellow-Smith
Dr Bullock arrived
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12.1
POLICY C27 – CLINICAL RISK POLICY
Dr Bullock presented the new Clinical Risk Policy and said that it undergone a process of
focused consultation and revision, particularly by the CAMHS and Older Peoples Service.
12.2
The board approved the new policy to be cascaded to staff as a working document with a 4
week consultation period.
Action: Dr Bullock, Board Secretary
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13.1
POLICY C2 – CARE PROGRAMME APPROACH (CPA)
Dr Bullock said CPA policy had been revised to take into consideration the issues relating
to children and young people. He added that there would be a need for local protocols in
the CAMHS services / Tier 2 units for the Policy to be effective.
13.2
The board approved the revised policy to be cascaded to staff on the Exchange.
Action: Dr Bullock, Board Secretary
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14.1
EALING SDU SMT MEETING MINUTES – 16.11.09
Concerns relating to Tier 2 CAMHS workers not using RiO was highlighted and discussed.
The board suggested that that there was a need to develop a standard SLA. Mrs Byrne
agreed to raise with Mr Nelms the need for a technical solution.
Action: Mrs Ledbury, Dr Scott, Mrs Byrne
14.2
The board received and noted the minutes of the SDU’s SMT meeting.
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15.1
HIGH SECURE SERVICES SDU SMT MEETING MINUTES – 10.12.09
Mrs Lyon’s clarified that Broadmoor Hospital did have guidelines for handling patient /
patient bullying & harassment. She also highlighted the number of campaigns and
initiatives that the Hospital was engaged with the assistance of the Communications Team,
this included ‘a rat on a rat’ campaign, and effective communication training. With regards
to the re-licensing of Broadmoor Hospital the board noted that the necessary evidence was
submitted within deadline to NHS London.
15.2
The board received and noted the minutes of the SDU’s SMT meeting.
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16.1
WEST LONDON FORENSIC SERVICES SDU SMT MEETING MINUTES – 14.12.09
Mr Weir highlighted the discussion to remove CDs and DVDs in areas where they have in
the past been deliberately broken and used as weapons by service users and the decision
made to replace them with MP3 players in the Men’s Service. Mrs Lyon’s said that this
was also a problem at Broadmoor Hospital and she would share the WLFS SDU’s decision
and solution to reduce the violent incidents with the HSS SMT. Dr Fellow-Smith said that
the issue had been discussed at the Incident Review Group and whilst it was a solution for
WLFS and Broadmoor Hospital it was not a solution for low/medium secure units to adopt
where the risk of using broken CDs and DVDs as weapons was much lower.
16.2
The board received and noted the minutes of the SDU’s SMT meeting.
17
17.1
H&F SDU SMT meeting minutes
None received
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18
18.1
Hounslow SDU SMT meeting minutes
None received.
19
ANY OTHER BUSINESS
19.1 Sustainable Development Strategy
19.1.1 Mrs Byrne presented the paper prepared by the Trust’s Environmental Manager. The
board noted that the Trust is required to adopt a sustainable development strategy by
March 2010. Mrs Byrne said that the paper summarised the aims and objectives of the
Strategy, its governance structure and she drew particular attention to the focus on
Carbon reduction, reducing water wastage and preventing pollution.
19.1.2 The Operations board were asked to let her have any comments in time to incorporate as
appropriate before the Sustainable Development Strategy was presented to the Board.
The revised strategy would be presented to the Operation Board in March in addition to
the Strategy being presented to the Board in March for approval.
Action: Mrs Byrne
19.2 Pathology Services
19.2.1 The board agreed that arrangements would be the same across all three of the Trust sites.
19.3 Date of Next Meeting
19.1.1 The next meeting would be held on Tuesday 2nd March 2010 at 11a.m. following the
morning CELF meeting.
WEST LONDON MENTAL HEALTH NHS TRUST
OPERATIONS BOARD MEETING
Minutes (draft)
Thursday 17th December 2009 (draft)
1400hrs - 1630hrs Boardroom THQ
1
1.1
APOLOGIES FOR ABSENCE
Dr Elizabeth Fellow-Smith, Medical Director
Ms Lesley Stephen, Director of Strategy & Performance
Ms Carol Scott, Acting Director of Nursing
Ms Bridget Ledbury, Ealing SDU Director
Ms Angela Dolan, High Secure Services SDU Director (Acting)
Ms Helen Mangan, H&F (incl Gender Identity) SDU Director
2
2.1
MINUTES OF THE LAST MEETING
Discussed later in the meeting.
3
3.1
MATTERS ARISING
Discussed later in the meeting.
4
IM&T STRATEGY AND PRESENTATION OF THE EXCHANGE/KNOWLEDGE MANAGEMENT
OF IT
Mr Cubbon introduced the presentation which would explain where the Exchange was heading,
moving forward.
4.1
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4.2
Mr Nelms delivered a presentation on the proposed direction for knowledge management within the
Trust including the proposed future for the management of documents and e-mail. Mrs Byrne and
Mr Nelms underlined the un-sustainability of continually expanding the infrastructure to retain unindexed documents.
4.3
In response to Mr Cubbon’s question on the time required to deliver the proposed knowledge
management solution; Mr Nelms confirmed that it was a 2 year programme commencing next
financial year.
4.4
Mr Burton delivered a demonstration of the Exchange including incident management, HR one-stop
and performance monitoring. Regarding incidents, Mr Weir raised the issue of having received 90
incidents in the last 4 days from the Exchange, which Mr Nelms would review outside the meeting.
Action: Mrs Byrne / Mr Nelms
4.5
HR One Stop – it was noted that PDRs would be piloted on the Exchange from January 2010. Mr
Cubbon queried if alerts would be sent out if a member of staff was nearing out of time for training
deadlines to which Mr Burton replied that this had not been specified by the HR Team but was
technically possible.
(Dr Murray joined the meeting)
4.6
Performance/Corporate Objectives – Dr Murray requested access to the drill down levels and
statistics to which Mr Burton agreed.
Action: Mrs Byrne / Mr Burton
4.7
Ms Dhillon presented the Information Delivery Tool (IDT)
4.8
Mr Nelms asked for any questions regarding the IM&T Strategy 2009-14 document that had been
circulated previously. Mr Cubbon then asked for agreement that the strategy was approved, which it
was.
(Ms Watkeys and Ms Stanion joined the meeting)
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5.1
POLICY E6 - INTERNET AND E-MAIL POLICY
Mr Nelms presented an amendment to the E6 Internet and Email Policy and highlighted the change
to limit auto forwarding of email by rule (added section 5.13 following decision by IG manager and
SIRO).
5.2
Mrs Byrne raised concern that the current policy states that the e-mail system will auto-delete emails from inboxes after 120 days and that the policy needs to be either applied or amended.
5.3
It was agreed that this policy would be brought back to the January or February meeting in 2010.
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6.1
NEW POLICY I12 – PATIENT ACCESS TO IT
Mr Kent highlighted that this policy had been out for initial consultation but now needed wider
consultation.
6.2
Mr Weir raised concerns which needed to be translated into this policy, particularly with regards to
Appendix B.
6.3
It was agreed that Forensics and Broadmoor be removed to take this policy applicable to the 3 local
SDUs only, whilst a separate policy would be drafted for Forensics and Broadmoor.
6.4
It was agreed that, once amended, this policy would go out for a 4 week consultation.
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