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Agenda Item No:
Status of these minutes (check one box):
Paper No:
TB14/15/075
Trust Board Meeting
Draft for Approval:
☐
Report to:
Formally Approved:
☒
Meeting Date:
25 March 2015
MINUTES OF THE MEETING OF THE
Trust Board Meeting
Date:
Wednesday 28 January 2015
Venue:
Boardroom, 8 Princes Parade, Princes Dock. Liverpool L3 1DL
Name
Time: 10.30 a.m.
Job Title (Division/ Organisation*) *if not Mersey Care
Present:
Beatrice Fraenkel
Nick Williams
Neil Willcox
Matt Birch
Gerry O’Keeffe
Joe Rafferty
Neil Smith
David Fearnley
Ray Walker
Elaine Darbyshire
Amanda Oates
Chairman
Non Executive Director
Non Executive Director
Non Executive Director
Non Executive Director
Chief Executive
Executive Director of Resources (Deputy Chief Executive)
Medical Director
Executive Director of Nursing and Secure Services
Executive Director of Communications & Corporate Governance
Executive Director of Workforce
In Attendance:
Mandy Gregory
Louise Edwards
Andrea Chadwick
Jim Hughes
Mike Whelan
Alicia Whelan
Andy Meadows
Sarah Jennings
Staff Side
Director of Strategy
Corporate Director of Finance and Estates
Director of Informatics and Performance Improvement
Carer
Carer
Trust Secretary
Corporate Governance (Minute Secretary)
Apologies Received:
Brenda Roe
Chris Dowrick
Non Executive Director
Advisory Board Member
ISSUES CONSIDERED
2015
A1
1.
A2
2.
WELCOME
Mrs Fraenkel welcomed everyone to the Trust Board meeting and reminded Board
members that the meeting would be conducted on the basis that all members had read
the Board reports prior to the meeting.
CARER STORY
Mrs Fraenkel welcomed Mr and Mrs Whelan to the meeting and highlighted the
importance of providing opportunity for reflection on the experience of service users
and carers.
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Agenda Item No:
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3.
Mr Whelan provided a summary of his experience as a carer in respect of the trust’s
Asperger’s service and a series of areas for improvement including the better
signposting of support services and consistent provision of appropriate interventions.
4.
Mrs Fraenkel thanked Mr Whelan on behalf of the Board for sharing his experience
which set the context and focus for the remainder of the meeting and provided a vivid
account of the carer experience, the areas in need of improvement and the significant
impact of these areas on the service user and relatives / carers. Mrs Fraenkel
emphasised the importance of the Board considering the impact of mental health
service provision on carers and relatives in addition to those that use services.
5.
Mr Rafferty apologised, on behalf of the organisation, and welcomed the honest
summary of Mr Whelan’s experience. Mr Rafferty committed to undertake an in-depth
review of the Asperger’s service to further understand where issues needed to be
addressed.
6.
Mr Rafferty confirmed that service user and carer engagement was evident across the
majority of Mersey Care services to ensure services met the needs of both service
users and carers and that the lack of this engagement within the Asperger’s service
would be addressed. Mr Rafferty acknowledged Mr Whelan’s loss of trust in Mersey
Care and committed to re-establish this through improvement in the service. Whilst
some areas for improvement were not within the remint of the trust, Mr Rafferty
confirmed that the trust advocate improvement in these areas.
7.
Mr Rafferty advised Mr Whelan of on-going work to further understand the patient
perspective, which may then require the provision of alternative training for staff.
8.
Mr Rafferty agreed to remain in contact with Mr and Mrs Whelan as the trust
endeavoured to resolve the issues raised and proposed to negotiate associated
timescales with Mr and Mrs Whelan outside of the meeting. Mrs Fraenkel added that
Mr and Mrs Whelan would be invited to attend a future meeting of the Trust Board to
provide assurance that the concerns raised had been sufficiently resolved.
Action
Lead
Further actions required:

To review the Asperger’s service in light of the issues Mr Rafferty
raised by Mr Whelan
B1
9.
Timescale
June 2015
Status
On-going
APOLOGIES
The apologies for absence received for this meeting are detailed on page 1.
B2
DECLARATIONS OF INTEREST
10.
No declarations of interest were made.
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Agenda Item No:
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11.
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MINUTES OF THE MEETING HELD ON 17 DECEMBER 2014
The minutes of the previous meeting held on 17 December 2014 were approved as an
accurate record. No amendments were required.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

To approve the minutes of the previous meeting.
Further actions required:

None identified
B4
12.
B5
MATTERS ARISING
There were no matters arising to report.
CHIEF EXECUTIVE REPORT
13.
Mr Rafferty provided an update on key issues of interest and information arising since
the last Board meeting, particularly the recent publication of ‘The Forward View into
Action: Planning for 2015/16 by NHS England, and the Dalton Review, both of which
described opportunities for reviewing and re-shaping the way in which NHS services
were delivered through a structural solution.
14.
Mr Rafferty advised that whilst the Five Year Forward View set out a series of
structural options, it also placed focus on the need to prioritise prevention, patient
activation, and the role of communities.
15.
Mr Rafferty informed Board members of the publication of the Planning Guidance
2015/16 developed by Monitor in conjunction with the Trust Development Authority,
Care Quality Commission, Public Health England and Health Education England. Mr
Rafferty noted that English NHS trusts were currently £400m in deficit and this was
predicted to reach a deficit of £1billion by year end. The impact of this would be
significant and should be addressed through prevention, community services and
‘activated’ patients.
16.
Mr Rafferty confirmed that the trust was currently in the process of negotiating
contracts for 2015/16 to be signed-off in March 2015. He advised that where
agreement could not be reached, the arbitration process would apply where the total
full-year value of all the disputed amounts was over £1,000,000.
17.
In response to a question asked by Mr Birch, Mr Rafferty confirmed that the contracts
signed by March 2015 would be outline contracts only, but the trust anticipated no
involvement of arbitration.
18.
Mr Birch noted that the trusts sound financial position was reflective of the strong
executive team.
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Agenda Item No:
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19.
Mr Rafferty advised Board members that the forthcoming industrial action had been
cancelled. This would result in a pay award pressure and whilst the trust was aware of
this, this added to the on-going significant financial challenges.
20.
Mr Smith referred to the challenges faced by the NHS in respect of the need to deliver
improved services against a background of increases in demand, whilst ensuring the
delivery of cost savings. Mr Smith advised Board members of a 27% increase in
referrals from 2011/12 – 2014/15, reflected in over-performance reported against
contracted activity in local services, which was likely to impact on 2015/16 service
contracts. Mr Smith added that over performance against contracted activity within
Sefton services equated to £2.5m and thus required financial assistance. In this
context, the trust was keen to negotiate an alternative approach to contracting, i.e., on
a cost per case basis, given that the trust would not be able to deliver cost savings if
the case load continued to grow.
21.
In response to a question asked by Mrs Fraenkel concerning the financial implications
of government settlements, Mr Rafferty confirmed that the funding cuts to be made in
respect of social care would bring significant challenge and could only be delivered
through the provision of social care through an alternative approach. Whilst the
government was keen to retain social care, integration would enable efficiencies to be
made which were challenging through current Section 75 Agreements. Mr Smith
added that local authority funding pressures created risk for the Trust with regards the
sustainability of addiction services and the trust had already been notified on the
intention to tender these services due to financial pressures.
22.
In terms of local developments, Mr Rafferty advised that work of the Trust Boards of
both Mersey Care and Calderstones Partnerships NHS Foundation Trust continued to
explore the ways in which working together could provide more sustainable and high
quality learning disability services. In addition, following the Board’s approval of the
Outline Business Case in respect of the transformation of the Secure Care Pathway in
December 2014, consultation of the plans was underway and would close on 20
February 2015.
23.
In response to a question asked by Mr O’Keeffe concerning the decision made by the
Overview and Scrutiny Committees for St Helens and Sefton Councils to hold a joint
meeting to consider the trusts proposal, Mr Rafferty confirmed that this was usual
practice.
24.
Mr Rafferty advised that, following a request for assurance by Sefton Safeguarding
Adults Board, the trust had confirmed its intention to continue to contribute £12k in
2015/16 towards the Safeguarding Adult Board’s budget. The trust would continue to
work closely with Sefton Safeguarding Adults Board to ensure value for money.
25.
Mr Rafferty referred to the recent visit to the Trust by the Deputy Prime Minister, Nick
Clegg, on Thursday 15 January 2015 and a short video clip was played outlining the
media coverage of the event. Mrs Fraenkel gave thanks to Mrs Darbyshire and the
Communications Team for coordination of the visit and associated coverage.
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Agenda Item No:
26.
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Mr Rafferty referred to the proposed changes to Executive Director Portfolios, outlined
on page 8 of his report (and appendix A) and noted that Board was asked to agree the
changes, to come into effect from 1 February 2015.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Note the Chief Executives Report

Approve the changes to Directors portfolios
Further actions required:

None identified
C1
CARE AT A GLANCE
27.
Mr Smith provided a summary of Trust performance to 31 December 2014 [month 9]
and advised Board members that the report incorporated links to supplementary
information to provide further insight where required, in addition to key pieces of both
national and local intelligence.
28.
Mr Smith outlined the recommendations of the report, namely:
a) note the assessment of performance contained within this report and the
performance improvement actions detailed in the performance escalation sections
and supplementary reports;
b) note the content of the safer staffing report;
c) agree the performance reporting thresholds for the new additional staffing
measure detailed in the workforce report;
d) approve the increase in surplus to £5 million.
Quality Performance
29.
In respect of performance against quality indicators, Mr Smith reported that
improvement had been identified with regard to physical health indicators and, since
this report had been circulated, performance within high secure services had now met
the target. This improvement could be attributed in part to the on-going weekly
monitoring of performance against physical health indicators and the development of
improvement trajectories by Clinical Divisions.
30.
Mr Smith advised that concerning safer staffing levels, reporting indicated a number of
shifts for which there was understaffing against clinically required staffing levels and
this would be considered as part of the budget setting process and allocation of
resources.
External Performance
31.
Mr Smith advised Board members of over-performance against contracted activity
within local services which equated to in excess of £3m and underperformance within
secure services. Performance against contracted activity would be considered as part
of the contract negotiations for 2015/16.
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Agenda Item No:
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Financial Performance
32.
Mr Smith confirmed that the Trust continued to remain on target to achieve all statutory
financial duties but advised members of the request from the NHS Trust Development
Authority (TDA) that the trust consider increasing its planned surplus to support the
local health economy financial position. Mr Smith noted that in this context, the Board
was asked to agree an increase in surplus to £5m, which could be carried forward into
2015/16 for re-investment.
33.
Mr Smith advised Board members that the TDA had informed the trust that there were
central pressures on capital schemes and therefore had not yet confirmed the Capital
Resource Limit (CRL) increase requested by the trust in May 2014. The trust would be
notified of the revised CRL in February 2015.
Workforce Performance
34.
Mr Smith advised that in respect of workforce indicators, performance reflected
deterioration in staff attendance; however performance associated with the completion
of Personal Development Reviews had increased.
35.
Mr Willcox raised a concern with regard performance against workforce indicators,
particularly in the context of the carer experience outlined earlier in the meeting, which
emphasised the need for increased satisfaction. In response, Mrs Oates noted that
feedback from staff indicated that staffing levels were the cause of poor satisfaction.
Mrs Oates noted that feedback from staff indicated that staffing levels were the main
factor in terms of poor satisfaction.
36.
Mrs Oates advised Board members that the embedding of values would be a key
focus for 2015/16, in addition to the establishment of a development centre for leaders.
37.
Mr Willcox referred to the data quality kite mark and questioned the progress made in
ensuring the reliability of data, particularly in respect of workforce indicators. In
response, Mrs Oates advised that on the centralisation of staff sickness monitoring /
reporting, historical underperformance had been identified and this was now being
addressed. Mrs Oates added that long term sickness absence levels remained
significantly high and noted that whilst a number of staff returned to work in January
2015, there were currently 83 staff members on long term sickness absence with no
planned date for return to work. It was critical that staff were appropriately supported
by both the staff support services and occupational health service, both of which had
been recently reviewed and would be provided using an alternative approach.
38.
Mrs Gregory referred to safer staffing levels and advised that the impact of Staffing
levels had significant impact on the workforce and staff had raised concerns in respect
of this, along with Agenda for Change (AfC) changes, amendments to the provision of
lead payments and potential reduction in bank and agency workers. Mrs Fraenkel
acknowledged these concerns and noted that these would be explored by the Board in
a development session.
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Agenda Item No:
39.
B3
Mr Willcox highlighted the need to ensure clear articulation to staff with regard
underspend and increase in planned surplus, in the context of reinvestment.
Action
Lead
Recommendations approved by the Board, namely:

Note the assessment of performance contained
within the report and the performance improvement
actions detailed in the performance escalation
sections and supplementary reports.

Note the content of the safer staffing report

Agree the performance reporting thresholds for the
new additional staffing measure detailed in the
workforce report

Approve the increase in surplus to £5.0m
Further actions required:

To discuss the leadership development centre and
consider the impact of lead payments at a future
Board development session
C2
Mrs Oates
Timescale
Feb 2015
Status
Completed
INDEPENDENT INVESTIGATION REPORT
40.
Mr Walker provided the Trust Board with the executive summary of the independent
review report completed by HASCAS into the care and treatment of Mr Y and the
associated action plan recently published on the NHS England website.
41.
Mr Walker confirmed that the incident had occurred some five years previously and
delay in the closure of the incident could be largely attributed to a request for inquest.
Mr Walker added that the incident had been subject to both a 72 hour review and
external (independent) investigation. The outcomes of the independent investigation
had been considered by the Trust Board and the associated action plan had been
monitored regularly by the Quality Assurance Committee to ensure delivery.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Note the content of the report and action plan.

Identify any further assurances required.
Further actions required:

None identified
C3
QUALITY SURVEILLANCE REPORT
42.
Dr Fearnley provided Trust Board members with a high level summary of views
expressed by service users, carers and staff on the services provided by the trust,
through visits undertaken by Executive / Non Executive Directors and via concerns
and compliments received. Dr Fearnley advised that the report would be further
developed in due course.
43.
Mrs Fraenkel requested that the term ‘formal’ was to be removed from references to
whistleblowing cases.
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Agenda Item No:
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Action
Lead
Recommendations approved by the Board, namely:

note the contents of the report;

comment on the content of this new report;

Identify any further assurance required / actions to be
taken.
Further actions required:
S Jennings

term ‘formal’ to be removed from references to
whistleblowing cases within reports
C4
Timescale
Status
March 2015
completed
SERIOUS INCIDENTS AND COMPLAINTS REPORT
44.
Dr Fearnley provided the Board with high level information relating to Serious Incidents
(SUIs) and complaints for November and December 2014, in addition to data from
previous months to enable comparison.
45.
Dr Fearnley advised Board members of a suicide incident reported in the Broadoak
Unit currently under investigation, the outcomes of which would be reported to the
Board once concluded.
46.
Dr Fearnley confirmed that Locktons had been commissioned to review the trusts
reporting of safety and risk, which was due to conclude imminently. In the interim, the
SUI report had been amended to reflect further detail of actions taken following
incidents and complaints.
47.
In response to a question asked by Mrs Fraenkel, Dr Fearnley confirmed that the
financial cost of a suicide incident was taken from a report developed by London
Economics and was based upon a series of factors including, but not limited to,
immediate response and staff involvement. Mrs Fraenkel advised that London
Economics were currently exploring the cost of mental health on the whole economy
for which the trust may request involvement.
48.
Mr Rafferty referred to the broader social economic burden and noted that if the trust
successfully reduced the cost of a suicide incident by 20%, this would bring significant
benefits to services.
Action
Lead
Recommendations approved by the Board, namely:

note the contents of the report;
Further actions required:

Report to Board on the outcomes of the investigation
into the serous untoward incident at Broadoak Unit.
C5
STAFFING – SIX MONTHLY REVIEW
Page 8 of 16
Dr Fearnley
Timescale
May 2015
Status
On-going
Agenda Item No:
B3
49.
Mr Walker outlined the process undertaken to review the budgeted staffing
establishment for inpatient areas and the requirements to support the variances for
both planned and unplanned care. Mr Walker advised that a new method of data
collection had been utilised in conjunction with the finance and workforce function to
identify the cost for provision of unplanned care linked to, for example, special
observations. Mr Walker confirmed that the review had identified an overall cost of
£3m to support unplanned care and this would be further explored.
50.
Mrs Oates added that concerns had been raised by Staff Side in respect of the
potential increase in the in-patient staffing establishment which would subsequently
reduce bank and agency usage but acknowledged the need for consistency of staff to
ensure better care.
51.
Mr Walker advised that whilst staffing levels were below those required, an
improvement in the patient experience was demonstrable, however there was a need
to review the allocation of funding, reduce the use of bank / agency staff and increase
the proportion of permanent staff.
52.
In response to Mr Smith, Mr Walker confirmed that services were not filling shifts on a
reoccurring basis which impacted negatively on the continuity of care, staff experience
and cost of service provision. In addition, managers were being required to provide
clinical cover which impacted on the capacity to undertake supervision and appraisals.
Mr Walker advised that by increasing the staffing establishment, there would be an
expectation that all staff were able to evidence regular supervision, personal
development reviews and compliance with mandatory training requirements.
53.
Mr Smith noted that some wards had reported over-staffing, to which Mr Walker
confirmed that 10% of wards had higher staffing levels than required in terms of clinical
need and it was intended that this would be reduced to 5%.
54.
Mrs Edwards queried the process to be used to review staffing levels in the community
in light of the significant number of community services across the Trust. Mr Walker
advised that external expertise had been commissioned to undertake a baseline of
staffing in community teams, however it was acknowledged that this was challenging
in the context of on-going changes to the models of care.
55.
In response to a question asked by Mr O’Keeffe, Mr Walker confirmed that the review
had identified that £3million had been spent on unplanned activity, therefore the Board
was asked to agree that this be considered as part of budget setting. This would result
in the recruitment of a substantial number of permanent clinical staff (approximately
100 whole time equivalent). Mr Smith noted that this would present some financial
pressure, as services had held vacant posts to assist in the delivery of Cost
Improvement Plans.
56.
Mr O’Keeffe raised a concern that reduction in the use of bank staff would impact
negatively upon those staff that relied on this additional income. In response, Mr Smith
advised that 80% of the trusts costs were pay-related and thus there was a need to
Page 9 of 16
Agenda Item No:
B3
make such efficiencies. Mr Rafferty added that additional funding was being invested
in services to increase patient safety through better continuity of care.
57.
Mrs Fraenkel proposed that a Board development session was held to further explore
safer staffing levels.
Action
Lead
Recommendations approved by the Board, namely:

Each Division to ensure that the staff identified in the
review to support planned care are allocated to the
clinical areas.

The additional investment of £3,009,721 million for
unplanned care is identified as a priority in the cost
pressures exercise as part of budget setting for
2015/16.

The current 22% head room is reviewed prior to
budgets being approved.

Any in-year proposed decreases to in-patient budgets
will require the support and agreement of the
Executive Director of Nursing and Secure Services.
Further actions required:
A Meadows

Board Development Session in respect of Safer
Staffing Levels to be scheduled.
D1
Timescale
Status
February 15
Completed
CAPITAL PROGRAMME 2015/16
58.
Mr Smith referred to the Trust Board’s approval of the Estates Framework in May
2014, which provided high level details of planned capital schemes, and confirmed that
the Capital Programme sought to move the plans forward through investment of
£35.88m. This total investment was broken down in operation capital investment
equating to £8.40m and strategic capital investment of £27.48m.
59.
Mr Smith advised that the Capital Programme for 2015/16 had been considered and
recommended by the both the Performance and Investment Committee and Executive
Committee for Trust Board approval. Mr Birch added that following a request for
additional assurance, further detail had been provided in respect of those schemes
that had been rejected (following a prioritisation exercise) and thus were not reflected
in the Capital Programme for 2015/16.
60.
Dr Fearnley, referring to the trust’s strategic priority in respect of zero suicide incidents,
emphasised the need to be assured that service assessments of ligature opportunities
were consistent through a more robust strategic approach. Dr Fearnley questioned
whether there was provision to eliminate ligatures through capital investment during
2015/16. In response Mrs Chadwick, at the request of Mr Smith, confirmed that
concerns had been raised within the Capital Investment Group with regard to the need
to escalate work to remove ligatures across services and proposed that Mr Walker and
Dr Fearnley define the anti-ligature standard to then be implemented. This would result
in clear, quantifiable requirements for capital investment, for which there was flexibility
in the Programme to fund through contingency monies and slippage.
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Agenda Item No:
61.
B3
Mr Birch advised that whilst the level of investment required to remove ligatures was
not yet quantifiable, there was a need to progress this quickly to ensure delivery of the
Capital Programme was not delayed.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Approve the proposed Capital Programme for
2015/16.
Further actions required:

None identified
D2
RATHBONE LEASE BUY OUT
62.
Mr Smith referred to previous discussion with Board members concerning the potential
opportunity to buy out the Rathbone Rehabilitation Unit lease with Contour Housing
Association (CHA).
63.
Mr Smith advised that the trust had a lease with CHA for the 24 bed Rehabilitation Unit
on the Rathbone site under a 25 year agreement, which had 17 years remaining. Mr
Smith confirmed that the trust had paid £0.56m to CHA in 2014/15 and the lease was
subject to retail price indexing (RPI), thus by 2032 this cost was anticipated to rise to
£0.85m (based on 2.5% inflation per annum). The non-discounted total cost of the
remaining lease was £11.95m assuming 2.5% inflation per annum.
64.
Mr Smith informed Board members that the trust had recently negotiated the surrender
of the lease with CHA for a payment of £4.50m (ex VAT), plus legal and accountancy
fees and subject to the transaction being completed by 31st March 2015. Mr Smith
proposed that the trust’s cash resources were utilised to buy out the lease and
confirmed that this purchase would contribute long-term to cost improvement plan
delivery.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Approve the proposed buy out of the Rathbone
Rehabilitation Unit lease with CHA.
Further actions required:

None identified
E1
65.
ANNUAL UPDATE OF THE STRATEGIC FRAMEWORK
Mrs Edwards outlined the 2015/16 strategic aims and objectives for approval which
had been previously subject to the consideration of the Performance and Investment
Committee and Board (through a development session). Mrs Edwards confirmed that it
was intended that the revised aims and objectives built upon the relative success of
the work undertaken over the previous 2 years, whilst simplifying objectives to ensure
staff were clear as to how their work contributed to delivery.
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Agenda Item No:
B3
66.
Mrs Edwards confirmed that in the development of the strategic aims and objectives
for 2015/16, the trust had clearly articulated the intention to ensure programmes of
work were very focussed on the challenge of improving quality whilst reducing cost;
with increased focus on the point of care.
67.
Mrs Edwards added that, subject to Board approval, programmes of work
underpinning each strategic objective would be developed and prioritised with the
engagement of divisions. The work programmes and associated financial impact would
be reported to the Trust Board in March 2015.
68.
In response to a question from Mr Walker, Mrs Edwards advised that timeframes for
the development of metrics for strategic objectives would be confirmed in due course
and the reporting against delivery would be simplified.
69.
Mr Willcox acknowledged the significant work undertaken in the development of the
Strategic Framework and provided support of the revised aims and objectives for
2015/16.
70.
In response to Mrs Fraenkel, Mrs Oates confirmed that staff would be alerted to the
revised Strategic Framework and awareness of this would be supported through the
provision of road shows. Mr Walker added that each team across the organisation
would be required to produce a set of shared objectives, which were aligned to the
strategic objectives.
71.
Mrs Edwards proposed that the revised Strategic Framework was to be utilised with
effect from 1 February 2015 and would be cascaded quickly to allow staff to consider
the revised aims and objectives prior to the Performance Development Review
process to commence from 1 April 2015. Mr Rafferty requested that the date and
version control were added to the document to ensure staff referred to the correct
document.
Action
Lead
Recommendations approved by the Board, namely:

Note the planning process and milestones for 201516

Formally sign-off the strategic aims and objectives for
2015-16

Note that the strategic programmes and planned
investment will be signed off in March.
Further actions required:

Version control and date to be added to the Strategic L Edwards
Wheel prior to cascade

Strategic Framework Work Programmes and costings L Edwards
to be reported to the Trust Board
Page 12 of 16
Timescale
Status
1 Feb 2015
Completed.
25 Mar 2015
On-going
Agenda Item No:
E2
72.
B3
FOUNDATION TRUST APPLICATION UPDATE
Mr Smith provided Board members with an update on the trust’s application for NHS
foundation trust (FT) status.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

note the content of this report.

note the trust continues to progress with its
application for NHS FT status.
Further actions required:

None identified
E3
BOARD ASSURANCE AND ESCALATION FRAMEWORK
73.
Dr Fearnley presented the Board Assurance & Escalation Framework to Board
members, noting it reflected the high level risks that may be significant enough to
impact upon delivery of the organisation’s strategic objectives.
74.
Dr Fearnley advised that following concerns raised within the Audit Committee
regarding the capacity of the senior management team in the context of the on-going
transformational changes, a risk had been added the to Strategic Risk Register
accordingly. Dr Fearnley confirmed that this risk had been scored (8) but did not meet
the threshold for escalation to the Board through the Board Assurance and Escalation
Framework. The Audit Committee would be in receipt of the full Strategic Risk
Register in February 2015.
75.
Dr Fearnley confirmed that an independent review of the trusts risk management
systems and processes had been commissioned to ensure best practice was being
utilised.
Action
Lead
Recommendations approved by the Board, namely:

Note the contents of the Strategic Risk Register

Agree any amendments or further assurances
required.
Further actions required:

None identified
Page 13 of 16
Timescale
Status
Agenda Item No:
E4
76.
B3
BOARD GOVERNANCE
Mr Meadows outlined a series of proposed changes to the trust’s corporate
governance framework (Standing Orders, Standing Financial Instruction and Scheme
of Reservation & Delegation) in addition to minor amendments to the Raising
Concerns at Work Policy, for approval.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Consider and approve the changes to the following
documents with effect from 1 February 2015
o
Standing Orders
o
Standing Financial Instructions
o
Scheme of Reservation and Delegation
o
Raising Concerns at Work Policy
Further actions required:

None identified
E5
FIT AND PROPER PERSONS TEST PROCESS FOR DIRECTORS
77.
Mrs Oates outlined to the Trust Board the process to be adopted by the trust to ensure
that directors were subject to the fit and proper person test introduced as a statutory
requirement through the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014.
78.
Mrs Oates advised that in respect of the Disclosure and Barring Service checks,
Executive Directors and advisory Directors would be required to register with the DBS
Update Services. In addition, all Non Executive Directors, Executive Directors and
Advisory Directors would be required to complete a self declaration form (appendix B)
on an annual basis.
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

comment on and approve the process to be adopted
by the trust to undertake a fit and proper persons test
for directors
Further actions required:

None identified
E6
MEMBERS’ COUNCIL: LESSONS LEARNT REPORT
79.
Mrs Fraenkel outlined the lessons learnt through the Members’ Council, which would
be taken into consideration by the trust when establishing a Council of Governors,
subject to foundation trust authorisation.
80.
Mrs Fraenkel confirmed that the Members’ Council had accepted the report and had
agreed to act as a reference group to assist in the preparation for establishing a
Council of Governors in due course.
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Agenda Item No:
B3
Action
Lead
Timescale
Status
Recommendations approved by the Board, namely:

Note the contents of the report

Note that Council members agreed to act as a
reference group for the trust.
Further actions required:

None identified
E7
BOARD COMMITTEE MINUTES:
A) AUDIT COMMITTEE
81.
The Board noted the minutes and chair’s report of the Audit Committee.
B) EXECUTIVE COMMITTEE
82.
Mr Walker referred to the benchmarking report recently considered by the Quality
Assurance Committee and proposed that this was reported to the Board.
83.
The Board noted the minutes and chair’s report of the Executive Committee.
C) PERFORMANCE AND INVESTMENT COMMITTEE
84.
Mr Birch confirmed that the Committee continued to divide its capacity effectively
between scrutiny of performance and the monitoring of strategic programmes.
85.
The Board noted the minutes and chair’s report of the Performance and Investment
Committee.
D) QUALITY ASSURANCE COMMITTEE
86.
The Board noted the minutes and chair’s report of the Quality Assurance Committee.
E) MEMBERS’ COUNCIL
87.
The Board noted the minutes and chair’s report of the final Members’ Council.
F) REMUNERATION AND TERMS OF SERVICE COMMITTEE
88.
The Board noted the outcomes of the Remuneration and Terms of Service Committee.
Page 15 of 16
Agenda Item No:
F1
B3
CHAIRMANS REPORT
89.
Mrs Fraenkel referred to the recent Ministerial Visit which provided opportunity for the
trust to outline its ambitions in respect of suicide prevention and perfect care. Mrs
Fraenkel acknowledged the contribution made by Mr Robert Greenburg in providing a
description of his experience as a service user during the visit.
90.
Mrs Fraenkel advised that preparations for the opening of Clock View continued to
progress well and referred to the forthcoming over-night stay for Board members at the
new facility to take place in February 2015.
91.
Finally, Mrs Fraenkel referred to a meeting held on 27 January 2015 with Mr Morgan
and the family of a service user, in respect of a series of complaints regarding the
trusts provision of care and treatment. Mrs Fraenkel highlighted the importance that
the trust was open and transparent with regards areas that required improvement to
ensure these areas could be addressed and progress tracked.
F2
ANY OTHER BUSINESS
92.
No other items of business were discussed.
93.
The meeting closed.
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