MINUTES OF THE TRUST BOARD MEETING (PART 1)
Held on Wednesday 31st July 2013
In Room 1, Lampton Park Conference Centre
Civic Centre, Lampton Road, Hounslow TW3 4DN
Present:
Mr Nigel McCorkell
Mr Steve Shrubb
Dr Anne Aiyegbusi
Mrs Barbara Byrne
Ms Jean George
Ms Carolyn Gray
Ms Christine Higgins
Miss Leeanne McGee
Mrs Rachael Moench
Ms Elizabeth Rantzen
Chairman
Chief Executive
Interim Director of Nursing & Patient Experience
Director of Finance / Deputy Chief Executive
Director of Local Services CSU
Non Executive Director
Non Executive Director
Director of High Secure Services
Director of Organisation Development & Workforce
Non Executive Director
In
attendance
Ms Sarah Rushton
Dr Kevin Murray
Mr Mike Gill
Ms Ann Utley
Mr Bryan Joseph
Mrs Barbara Wörts
& 1 member of the public
Acting Director of Specialist & Forensic Services
Clinical Director, High Secure Services
(observer)
(observer)
Head of Risk, Health & Safety (item 14)
Board Secretary (minutes)
Items were discussed in the sequence they are recorded in the minutes
290/13
Item 1
OPENING & WELCOME
The Chairman welcomed all those present at the meeting, including Dr Kevin
Murray who was representing Dr Broughton.
291/13
Item 2
APOLOGIES FOR ABSENCE
Apologies for absence were received from
Mrs Barbara Kerin
Non Executive Director
Mr Neville Manuel
Deputy Chair / Non Executive Director
Mr Geoff Rose
Non Executive Director
Prof Lefkos Middleton
Non Executive Director
Dr Nick Broughton
Medical Director
Mr Andy Weir
Director of Specialist & Forensic Services
292/13
Item 3
DECLARATIONS OF INTEREST
No Board member had interests to declare in any of the agenda items.
293/13
Item 4
MINUTES OF THE LAST MEETING
The minutes of the Board meeting held on Wednesday 26th June 2013 were
agreed to be a correct record.
294/13
Item 5
BOARD ACTION SCHEDULE & MATTERS ARISING
a) Action Schedule
The Board reviewed the action schedule, noting the completed actions and
receiving the following update:
b) 26/06/13 – 250/13(a) – Cassel protocol for patients being escorted to
hospital by other patients: Ms Rushton provided the Board with an outline of
the protocol followed, saying this process was based on a clear clinical rationale,
care planned and carefully risk assessed on the day. The care team were very
clear that the patient could decline to act as escort and Ms Rushton said she had
been reassured with the approach taken. Mr Shrubb said that he was assured
by the information provided and Board members agreed.
c) 26/06/13 – 250/13(a) – Tony Hillis Wing grille: Ms Rushton advised the Board
that a grille had been made and tested by the security department and clinical
teams. It was found to meet service requirements. Planning permission to install
it is being sought. The Board agreed that this item no longer required their
oversight and Ms Rushton would only bring an update in the event of unexpected
difficulties.
d) 26/06/13 – 250/13(b) – review of smoking policy: Progress is being made with
setting up the policy review group, which will be chaired by Mr Jimmy Noak.
e) 26/06/2013 - 259/13(c) - TDA assurance framework: Mr Stacey has
circulated the summary as requested.
f) 29/05/13 – 195/13(g) – Review of service user & carer involvement in Local
Services: Dr Aiyegbusi reported that planning meetings were scheduled for
August and, therefore, the draft action plan would not be completed until
September.
Matters Arising
g) 266/13(c) - procurement of a new patient information system: The
Chairman confirmed that he had been provided with the financial information
requested.
295/13
BOARD MEMBER VISITS
Item 6.1
Cherington House – 19th June 2013
a) Miss McGee reported that as there had been no clinics running at the time of the
visit, she and Ms Higgins had been unable to speak with service users, however,
the staff they met were organised, motivated and enthusiastic. Ms Higgins drew
attention to comments made regarding referral and re referral rates and Ms
George outlined how this would be reviewed through contract monitoring
meetings. Ms Higgins emphasised the staff’s stated willingness to embrace
change but said they felt they had not had the opportunity to be involved in the
service redesign. Ms George explained that some change had been mandated
through the contracting process. However, Ms Maggie Gairdner was in the
process with speaking to staff across all community services regarding the
impact and implementation of change.
Item 6.2
Wolsey Wing – 19th June 2013
a) Dr Aiyegbusi fed back on the visit she and Mr Rose had made to Wolsey Wing.
She commented positively on the work being undertaken by the pharmacist,
meeting with service users regarding medication issues but had noted, with
concern, the reported issues with CPA where input from the community based
care co-ordinators had been described as insufficient. Mr Shrubb asked Dr
Aiyegbusi to meet with Ms Maggie Gairdner and Ms Bernadette Hennigan to find
solutions to this issue.
ACTION: Dr Aiyegbusi
b) Ms George reported that the Local Services CSU team were aware of the issue
and had developed a new key performance indicator to measure the scope of the
problem and to permit focus on areas of particular concern. Mrs Byrne
commented that access to Skype had been raised as a possible solution but Mr
Shrubb said this would not be appropriate as staff needed to be physically
present to enable effective discussion to take place. Ms Rantzen felt strongly
that the suggestion should have received further consideration.
c) The Board noted staff’s expressed concern regarding the short notice they had
been given of the forthcoming closure of Starlight Ward. Ms George outlined the
requirement and rationale for choosing this area for closure, in consultation with
commissioners and said that lessons had been learned by the CSU management
team and, in future, there would be greater involvement of staff below the senior
nursing team.
d) The Board noted the agreed action to address concerns regarding patients’
privacy and dignity and security caused by issues relating to the fencing and gate
outside of the building.
Item 6.3
Wolsey Wing & Jubilee Ward – 19th June 2013
a) It was noted that the Estates & Facilities team had been working with Jubilee
ward staff to address the areas of concern raised following the ward’s
refurbishment. In addition partitioning was being installed in Wolsey Wing, to
divide the large room where two home treatment teams were based. Mrs Byrne
said she, Mrs Kerin and Professor Middleton who had undertaken the visit felt
the key issue was to understand how clinical service input into ward design could
be improved and what the process for design change sign-off is for capital
projects. Ms George said the CSU was holding a lessons learned session on 2nd
September 2013 at which such issues would be considered. The Chairman
asked that feedback from this event, a progress report on addressing the Jubilee
ward issues and the quality impact assessment of the Starlight Ward closure be
brought to the Board in the autumn.
ACTION: Ms George
Item 6.4
Tagore Ward – 11th July 2013
a) The Board noted the report of the visit made by Miss McGee and Mr Rose to
Tagore ward. Ms Rushton said Mr Meechan was addressing the apparent damp
patches with Estates & Facilities. Miss McGee highlighted the staff’s concern at
the length of time patients were waiting to transfer to a rehabilitation ward and
also at the impact on staffing of patients leaving the ward to smoke.
Item 6.5
Wells Unit – 11th July 2013
a) Miss McGee fed back on the positive visit she and Mr Rose had made to the
Wells Unit. The patients had been very positive about their care and treatment
and good access to activities was noted. Miss McGee said there were specific
issues some patients presented with, related to their ethnic background but said
the ward manager had an excellent command of these matters.
296/13
Item 7
ANNUAL PLAN – QUARTER 1 UPDATE
a) Mrs Byrne presented this report, advising Board members that the milestones
had been updated, following discussion in May 2013 and were now measurable.
The summary of progress contained both qualitative and quantitative
assessment and the exception report highlighted areas requiring particular focus.
b) Board members agreed that this revised version represented a significant
improvement on previous formats, however, it was noted that some milestones,
where there were still some qualitative issues to be addressed (e.g. developing
strategic partnerships and outsourcing HR services) were rated as ‘green’ but,
intuitively, this did not feel right as there were still issues to be addressed. Mr
Shrubb thought it would be difficult to find a better way of reporting progress but
said he would ask Mr Stacey to develop a way of reflecting outstanding issues in
the report’s narrative.
ACTION: Mr Shrubb / Mr Stacey
c) Non executive directors raised some points of clarification which the executives
were able to explain and the Board noted that the next update report was
scheduled for October 2013.
297/13
Item 8
CHAIRMAN’S REPORT
a) The Chairman presented his report to the Board. He fed back on a recent
conference he had attended regarding chairing governors’ meetings,
emphasising the effort and challenge setting up a Council of Governors and
developing positive working relationships would entail. He advised members that
a number of briefing sessions had been planned for the coming months, aimed at
people who were interested in becoming governors. Dates will be circulated for
members’ information.
ACTION: Mrs Wörts
b) Mr Shrubb reported that a Company Secretary role was to be created and this
role would be key in providing newly appointed governors with a single point of
contact for assistance and information. It was noted that both the King’s Fund
and FT Network run events on working with governors that it would be helpful to
participate in.
298/13
Item 9
CHIEF EXECUTIVE’S REPORT
The Board received and noted Mr Shrubb’s report. He commented positively on
his recent experience of speaking at the Hounslow & Richmond Community
Trust’s Annual General Meeting which, he said, had provided a useful platform to
discuss future partnership working.
299/13
EXECUTIVE DIRECTORS’ REPORTS
Item 10.1
Director of Nursing & Patient Experience’s Report
a) The Board was pleased to note the Trust’s 6th Annual Nursing Conference, held
on 3rd July 2013 had been very well attended and resulted in positive feedback.
Dr Aiyegbusi said that next year’s event would be held in May, to fall in line with
International Nurses’ Week.
b) Dr Aiyegbusi then provided a verbal report on the legionella that had been found
last week in taps in the Tony Hillis Wing. She told the Board there was no
evidence of Legionnaires’ Disease. A review of how this could have occurred
revealed that the legionella had built up in a number of taps that were not being
used regularly. However, these were taps that had previously had high use.
When their useage level changed, they were not subject to an updated risk
assessment and revised management plan. Dr Aiyegbusi said that as there was
the potential for this to be a Trust wide issue, she had requested the flushing of
all taps twice a week, issued messages and posters to educate staff and
instructed Estates & Facilities to undertake random testing. An appropriate entry
will be made on the Trust’s level 1 risk register.
c) All taps in the currently affected area had been subject to daily flushing since the
legionella had been discovered and have now been re-tested. Results were
expected within 2 weeks.
d) Mr Shrubb thanked Dr Aiyegbusi for her decisive action and the good education
programme she had swiftly implemented across the organisation. He suggested
there would be merit in sharing the learning with other organisations.
ACTION: Dr Aiyegbusi
Item 10.2
Medical Director’s Report
a) Dr Murray drew Board members’ attention to the Medical Director’s report on
revalidation, highlighting the requirement for Trust Boards to be aware of the
associated handbook and emphasising that the Quality Assurance Committee
will be responsible for overseeing the evaluation of the Trust’s governance
systems in relation to this process. Ms Higgins asked how the revalidation was
progressing and whether any doctors had not been revalidated. Dr Murray said
medical managers were going through it first and, to date, there had been no
issues of concern.
b) The Board noted that Ms Higgins had accompanied Dr Broughton to a recent
meeting of the Board of Imperial College Health Partners and that Mr Robert
Bolas had recently taken up his appointment as the Trust’s Interim Director of
Governance.
Item 10.3
Director of High Secure Services’ Report
a) The Board received Miss McGee’s report, noting the positive outcome of the
unannounced CQC inspection of Broadmoor Hospital on 25th and 26th June.
Recent celebrations connected with the Hospital’s 150th Anniversary had been a
success as had the visit of the Danish delegation on 3rd July.
Item 10.4
Director of Local Services’ Report
a) Ms George presented her report to the Board, highlighting the successful bid for
CAMHS IAPT funding, the receipt of further funding from Hammersmith &
Fulham CCG for perinatal services and the well attended “learning lessons” day
held on 25th June 2013.
b) She advised the Board that the signing of heads of terms, contracts and
schedules with Ealing CCG was still delayed and the matter had been escalated.
Other areas of concern included the operation of Avonmore Ward, for which an
improvement action plan had been developed and the slippage on the CSUs
CIPs. Ms George told the Board she would be taking a detailed financial
recovery plan to the Finance & Investment Committee meeting in August.
300/13
Item 11
INTEGRATED PERFORMANCE REPORT
a) The Board received and discussed the integrated performance report for June
2013.
b) Ms Higgins drew attention to KPI019 (CPA 7 day follow up) which, at 96% was
RAG rated green, commenting that underlying this was Hammersmith & Fulham
services at 88% compliance. Ms George said the 3 cases that this poor score
reflected were being reviewed on an individual basis by the CSU through the
performance review process.
c) Ms Gray asked why compliance with KPI024 had reduced from 81% in quarter 4
2012/13 to 47% in quarter 1 2013/14 and Mrs Moench explained that this was
due to the cyclical nature of the process. However, she agreed that compliance
should be higher and assured the Board that this issues was being picked up
with all three CSUs in their quarterly performance review meetings, although the
non compliant outlier was Local Services CSU. She undertook to provide a
weekly progress report to the executive directors.
d) Ms Rantzen asked if the deterioration in KPI013 (% inpatient readmission rates)
could be attributable to any pressure on services to discharge patients and Ms
George said that, given recent bed reductions, this was something that the
services were looking at closely. Each case of readmission, noted to be in small
numbers, was reviewed clinically and independently.
e) The Board discussed the thematic reporting of complaints, noting that “all
aspects of care” was a national measure. Dr Aiyegbusi said that qualitative
sampling was being undertaken on a regular basis to improve understanding of
what was being categorised this way.
f) The Local Services CSU was commended for the sustained improvement
against KPI063 (delayed transfers of care for health reasons).
g) The Board agreed that, at its next meeting, it would receive expanded
information from the Director of OD & Workforce on PDR compliance and from
the Director of Local Services on CPA 7 day follow up and readmission rates.
ACTION: Mrs Moench / Ms George
301/13
Item 12
GOVERNANCE OF ANNUAL ACCOUNTS APPROVAL
a) The Board noted the proposed process for meeting to approve the Trust’s annual
accounts for 2013/14. The Chairman advised members that this had been
developed by Mrs Byrne following a discussion that they had held with Ms
Higgins as Chair of the Audit Committee.
b) The Board agreed that the proposals were sensible and constituted good
governance. The report’s recommendations were approved.
302/13
Item 13
SUBMISSION DOCUMENTS SCHEDULE
a) The Board received a schedule of documents that were required as part of the
final submission to the NHS Trust Development Authority (NTDA) in September
2013 and would also form part of the formal submission to Monitor in due course.
The Chairman drew attention to the potential size of the agenda for the Board
meeting on 18th September 2013.
b) The schedule was formally noted and approved.
c) The Chairman also confirmed that the Board to Board Meeting with the NTDA
would take place on 12th November 2013. Further information will be provided to
members as it becomes available.
ACTION: Mr McCorkell
303/13
Item 14
BOARD ASSURANCE FRAMEWORK
a) Mr Bryan Joseph was welcomed to the meeting. He advised the Board that
since the last report they received in May 2013, the level 1 risk register had been
largely static. There were no new risks to report, no changes to risk ratings and
no archived risks.
b) Ms Rantzen drew attention to the key control for risk reference 5802 (failure to
ensure Trust Local Services meets the requirements for future funding
arrangements) relating to close working with Central & North West London NHS
Foundation Trust (CNWL), noting there were no examples internal or external
assurance provided by this control. Ms George said Local Services were
working with CNWL on packages of care and reports were being submitted to the
Programme Board. She undertook to see this BAF entry was updated and
properly populated.
ACTION: Ms George
c) The Board reviewed the risk summary information, noting an improvement in the
frequency with which risk entries were being scrutinised by the responsible
committee and the inclusion of their assurance opinion.
d) Mr Joseph was thanked for his report.
304/13
Item 15
305/13
Item 16
QUARTERLY REPORT OF DOCUMENTS SEALED
The Board received and noted the report of documents sealed during quarter 1
2013/14, which also contained information on legally binding documents formally
signed.
FOUNDATION TRUST PROGRAMME BOARD
a) The Chair’s report of the FT Programme Board meeting held on 25th June 2013
and the approved minutes of its meeting of 28th April 2013 were received and
noted.
b) Mrs Byrne reported that a further meeting had been held yesterday. Further
information regarding the quality review process had now been received and a
date for the Board to Board meeting (12th November 2013) had been agreed.
306/13
Item 17
SERVICE USERS’ & CARERS’ FORUM
a) The Chair’s report of the Service Users’ & Carers’ Forum (SU&CF) held on 2nd
July was received and noted.
b) There was some discussion regarding the composition of the SU&CF, which did
not include representation from the Specialist & Forensic or High Secure
Services CSUs. Ms Rushton suggested efforts should be made to ensure there
was a Trust-wide, overarching forum. The Board discussed reorganising
arrangements in the context of the recommendations arising from Mr Hough’s
report (presented to Trust Board on 29th May 2013). Dr Aiyegbusi said she
would endeavour to seek inclusive solutions in her currently ongoing work to
implement the report’s findings.
ACTION: Dr Aiyegbusi
307/13
Item 18
QUALITY ASSURANCE COMMITTEE
a) The Board received and noted the Chair’s report of the Quality Assurance
Committee meeting held on 17th July 2013 and the approved minutes of its
meeting of 9th May 2013.
b) There was some discussion regarding the Board visits’ programme. Mrs Wörts
confirmed there was a schedule in place to run to end March 2014 and that the
Quality Assurance Committee fed its recommendations into this programme,
which had designated slots to accommodate them. Ms Rantzen suggested there
would be merit in making unannounced visits and also to inviting CCG
representatives to join Board members in this activity.
c) Mrs Byrne reminded the Board that the Leadership & Vision sub-group she
chaired was currently engaged in reviewing the arrangements for Board visits
and she would feed these suggestions into it. Mr Shrubb proposed that the first
phase of work should include the recommendations arising from the reporters’
feedback and consider the proposal for unannounced visits. Thereafter, once
the new programme of visits was agreed, a second phase of work, to involve
CCGs and Wellbeing Boards, should be undertaken.
ACTION: Mrs Byrne
d) The Board formally received and approved the Mental Health Act Managers’
Annual Report and the Infection Control Annual Report 2012/13, noting that both
these documents had undergone detailed discussion and scrutiny at the recent
Quality Assurance Committee meeting.
e) Ms Higgins asked how the Trust compared with other organisations, in terms of
the resources invested in the Mental Health Act Managers. Mr Shrubb said it
was very similar. He also advised the Board that the Trust was going to reinstigate some of the unannounced visits that the Managers made to in-patient
areas.
f) Miss McGee noted there was no reference to legionalla in the annual report and
Dr Aiyegbusi confirmed this would be picked up in the forward plan.
ACTION: Dr Aiyegbusi
308/13
Item 19
TRUST MANAGEMENT TEAM
The Board received and noted the Chair’s report of the Trust Management Team
meeting held on 17th July 2013 and the approved minutes of its meeting of 12th
May 2013.
309/13
Item 20
ANY NEW RISKS OR REVISIONS TO RISKS PROPOSED
A new entry is to be made on the level 1 risk register concerning the discovery of
legionella.
310/13
Item 21
ACTIONS REMITTED TO OTHER COMMITTEES
To the Quality Assurance Committee
 monitoring progress with implementation of the Francis report action plan
To the Finance & Investment Committee
 review of the financial recovery plans from Specialist & Forensic Services
CSU and from Local Services CSU
To the Leadership & Vision sub-group
 recommendation for unannounced Board member visits and the inclusion, in
due course of representatives from CCGs and Wellbeing Boards.
311/13
Item 22
ANY OTHER BUSINESS
There were no other items for discussion.
312/13
Item 23
313/13
QUESTIONS FROM MEMBERS OF THE PUBLIC
a) There were no questions from members of the public on this occasion.
DATE OF NEXT MEETING
Wednesday 18th September 2013
Board Room, Trust Headquarters
1 Armstrong Way
Southall UB2 4SA
Signed:
314/13
________________________________
Date: ________________________
REVIEW OF BOARD MEETING
After the conclusion of all Board business, members reflected in confidence on
the operation and content of the day’s meeting.