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th
Board of Directors
Dave Mellish
Archie Herron
Anne Taylor
Paul Ward
James Kellock
Seyi Clement
Steve James
Stephen Firn
Helen Smith
Ify Okocha
Wilf Bardsley
Ben Travis
Simon Hart
In attendance
Trevor Eldridge
Ann Rozier
Susan Owen
Chair
Vice Chair and Non-Executive Director
Non-Executive Director
Non Executive Director
Non Executive Director
Non-Executive Director
Non-Executive Director
Chief Executive
Deputy Chief Executive and Director of Service Delivery
Medical Director
Director of Nursing and Governance
Director of Finance
Director of HR and Organisational Development
Director Acute Adult Mental Health Services
Trust Secretary and Head of Governance
Risk Manager (Minutes)
Apologies for Absence
None received
Minutes of the Board of Directors Meeting held on 10 January 2013
Item 3 – This should read “Occupancy in Atlas House is low.”
Item 4 – The action relating to the SUSD report should be attributed to IO and WB.
Subject to these amendments, the minutes were agreed as an accurate record.
Matters arising
Item 3 – The workforce EDS grading meeting has been held and results have improved.
These will be reported to the Board meeting on 2 May 2013.
Key Performance Indicators Report – January 2013
The target for Care Programme Approach clients having a formal review within 12 months has been breached in Forensic and Prison Services, but this is due to a data quality issue which is being investigated.
Waiting times in A&E are within target. The Urgent Care Centre is getting busier and waiting times are being closely monitored to ensure that they are manageable.
The referral to treatment 18 week waiting times for psychological therapies has been included in the KPI Report from this month.
DM – Do we need to reduce waiting times to less than 18 weeks by investing in this area?
HS – There are many services where waiting times are not as high as 18 weeks and teams have waiting list management processes to check that people are not going into crisis.
PW – Do we need one short burst of investment to bring down the waiting times?
HS – We are not an outlier compared to other trusts.
In terms of in-patient activity, all UEA placements have been eliminated.
JK – These are exceptional results.
Action
Noted
Noted and
Approved
SH
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Director of Service Delivery Report
Green Parks House
The task force has now completed its work and has signed off the action plan. The triage ward on Betts has been closed and this is now a generic ward. Values based recruitment is about to go live and medical leadership has been reviewed. Unannounced visits are being held. ResearchNET are producing a DVD on patient experience. Staffside have held a focus group with staff to improve morale. The HR disciplinary processes are complete. Essential skills training is green a across all areas. There have been no further serious incidents and no further complaints between September and December 2012. Three complaints have been received this year; one was not upheld and two are in progress. The Band 6 development programme is out for consultation. No concerns were raised from the recent
CQC visit to Green Parks House.
Adult mental health services reconfiguration
The two Assistant Director posts have been advertised and interview dates have been set.
Community Dental Services
The Community Dental Services transferred to Kings Hospital NHS Trust on 7 March 2013.
Winter pressures
The Trust continues to work with commissioners to support nursing homes and provide subacute care.
SC – What action is being taken to manage pressure on Bexley and Greenwich CAMHS?
HS – We will look at how ‘front door’ services are managed across all three boroughs.
PW – Following on from the ‘Right Care, Right Time, Right Place’ event, what scale of change should be envisaged?
HS – Our services will coalesce around GP localities and commissioners are involved in the work programme. Initially the Project Board will focus on community health and older person’s services.
JK – Will the smoking cessation programme be implemented in other directorates?
WB – This only being implemented in Forensic services at present. As patient stays are longer, there is more time to work with people.
DM – Will the review of student nurse training include the recommendations of the Francis
Report?
SC – Has the University of Greenwich improved?
WB – There is new leadership in place. A recent student survey showed that the University of Greenwich is rated the second best in London.
Francis Report
The report has been discussed at the MAC and the Executive Team. The three priorities for the Board are 1) how we will identify poor standards; 2) how we can be assured that there are processes for raising concerns; 3) how the Board can nurture or strengthen clinicians.
We will meet with clinical directors at the away day to address those issues.
DM - The Board and the organisation must respond to the Francis Report.
SC – What is the current process for raising concerns?
SH – We have a ‘Raising a Matter of Concern’ policy. Staff can approach myself, Chrissie
Strickland or Anne Taylor. The policy will be reviewed with Staffside.
BT – There will be a quarterly meeting with Service Directors, Clinical Directors, the Medical
Director and the Director of Nursing to formally sign off that CRE plans do not impact on clinical care.
JK – Do we have any statistics on how comfortable staff are with reporting concerns?
SH – This is a specific question in the Staff Survey. We achieved a high score.
AR – We issued a risk survey last year, inviting staff to raise any kind of risk issue. We had three responses, but we could run this more regularly.
Step-up, Step-down and Chislehurst Ward report
Step-up, Step-down
A task force has been established to oversee the action plan and the input of Angus
Gartshore and Mary Titchener has been helpful in progressing this. There have been no new complaints and no further serious incidents.
DM – Will the findings of the last year’s complaint be brought to the Board given the nature of the concerns raised?
WB – There are clear areas of learning and these can be shared.
Action
Noted
Noted
Noted
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Chislehurst Ward
Oxleas took over management of Chislehurst Ward on 1 March 2013 to support winter pressures. The adequacy of medical and nursing cover has been agreed. Staffing levels are stable and patients have been complimentary.
SJ – How will we check that improvements are sustained?
IO – There are set of indicators that will be used on a daily basis.
HS – Janna Maxfield and her team are to be commended for their support in ensuring appropriate staff are in post.
Serious incident – DA report and action plan
This Level 5 incident occurred on 29 June 2012 and relates to the serious assault of a male not known to DA. DA had a complex presentation with a range of substance misuse problems, a forensic history and a reluctance to engage. The panel concluded that there were no root causes but there were lessons to be learned from the incident. The main findings were:
 The risk assessment was not comprehensive and had not been reviewed.
 An HCR-20 risk assessment had not been completed.
 There was no joint care plan between Edgehill and the AOT.
 There was an over reliance on the Edgehill Manager.
 The home manager and Forensic CPN were not invited to the CPA review.
 Due to his belief system, DA would use mutism to avoid engaging with particular staff.
 There was no drug screening in place.
 There was no clear structure for medical advice when the consultant was on leave.
 There was a gap in allocating a new care co-ordinator.
 The deterioration in his mental state did not impact on how DA was zoned as the focus was on medication adherence.
HS – A directorate wide zoning protocol has been developed in response to this and we will also look at a Trustwide response. Systems are in place to ensure that protocols for reviewing long tem AOT cases are fully implemented. The joint monthly meeting between
Forensics and AOT has been re-instated. Training on HCR-20 is being delivered and a high risk panel has been established in Greenwich which will be used to decide how we respond to people presenting as high risk. Mutual sharing guidelines are to be developed by
Greenwich Residential Panel. Specific risks that might arise around service users belief systems will be considered when allocating care co-ordinators and training on these issues will be delivered. There will be additional middle grade medical input and the consultant will ensure that cover arrangements are in place when they are on leave.
Serious incident – ME report and action plan
ME was a 49 year old male who committed suicide on 13 September 2012 following discharge from Betts Ward. He suffered from depression and anxiety and had a number of life stressors. The main findings were:
 There was a lack of engagement and recognition of risks as ME presented as coping well.
 The planned seven day post discharge follow up did not take place.
 There was a was a lack of referral to the Bromley Drugs and Alcohol Service.
 There was an issue around zoning – the default position appeared to be green.
 The discharge team did not communicate guidance on Benzodiazepine detoxification.
 All inpatient units should have at least two nurses with level 3 dual diagnosis training.
TE – Zoning processes have been reviewed and an alert feature for suicide risk has been included in the specification for the RIO replacement. Processes for seven day follow up have been reviewed. Medical staff have been made aware of the guidance on
Benzodiazepine detoxification. The recommendation relating to dual diagnosis training for nursing staff has been implemented in all three acute units.
PW – Do we need to capitalise on the Local Authorities taking over the responsibility for commissioning Dual Diagnosis services and seek to engage all three boroughs in this?
WB – We have a Dual Diagnosis Strategy but this focuses on staff skills. We have the opportunity to influence changes in commissioning arrangements.
DM – The inquiries are well conducted but the process must be reviewed so that we can better link the recommendations to the events. The results of this review to be reported to the Board in four months.
Action
SF/HS
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Audit Committee update
The Audit Committee met on 26 February 2013.
Tenders
The Strategic Procurement Group has reviewed the organisations that provide services to
Oxleas and many tenders are no better than the amount the Trust are currently paying. At the selection stage, more attention is being given the political and financial issues and the
Strategic Procurement Group will review these risks in relation to the organisations being hosted on the Queen Mary’s site.
Internal Audit Programme
The Audit Committee received a number of internal audit reports. The audits on budgetary processes, records management and patient monies received substantial assurance. Nonpay expenditure, clinical governance and IT support received limited assurance. There were three audits earlier this year which also received limited assurance. These six put the Annual
Governance Statement at risk. Deloitte have been asked to revisit the areas to make sure the recommendations have been put into place.
Non-pay expenditure should achieve substantial assurance by year end. There were two recommendations, one of which was high priority. Much work has been done in this area, including a review of authorisation limits and processes for documenting how changes to supplier bank accounts are validated. The auditors have undertaken a further review of patient monies and gave an opinion of substantial assurance. Much work has been done to strengthen arrangements.
Bank investment limits
The Audit Committee recommended that the investment limit should be increased to £25M per bank but changes have been announced that will mean the Trust will be required to invest in the Government Bank. The Board agreed the increase to the investment limit in the meantime.
Annual bribery statement
The auditors have recommended that we include a bribery statement in the Annual Report and Accounts.
Appointment of internal and external auditors
KPMG have been appointed to undertake internal audit and counter fraud on a three year contract. The Audit Committee will make a recommendation to the Council of Governors that Deloitte be appointed as external auditors. This is a change from the current position, which is PwC.
JK – What action was taken following the theft of money at Erith Health Centre?
BT – The recommendations relating to staff conduct have been implemented. We are providing training on cash handing and security. We are also undertaking spot checks.
DM – Are the local authorities supporting this?
BT – We have agreed protocols for how cash is transferred and we are working to reduce the amount of local authority cash that we handle.
JK – The Audit Committee received a paper about the Treasury Review Tax arrangements.
Do we employ anyone in such a way that it could be interpreted as trying to reduce the amount of income tax and national insurance we pay?
BT – We received a report on this in November and we are compliant in this area.
SC – Is there any update on the Memorial fraud case?
BT – The alleged perpetrator has been dismissed. She is currently on bail and we are awaiting feedback from the CPS as to whether a charge will be brought.
DM – On a temporary basis, the increase of the investment limit from £20M to £25M is agreed.
Governance Board update
The January meeting of the Governance Board reviewed the Corporate Risk Register. The following changes were made.
This has been reduced on the strength of the CPA audit. There has been an improvement in all directorates. Consequence to remain at 4, likelihood reduced from 3 to
2; rating reduced from HIGH (12) to MODERATE (8).
Action
Noted and agreed
Approved
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. This risk was reduced as the target has been met for seven months. The loss of dental services will mean that the overall number of cases will be very low so the Trust cannot afford slippage. This will be monitored closely. Consequence to remain at 4, likelihood reduced from 3 to 2, rating reduced from HIGH (12) to MODERATE (8).
AH – Is there more theatre space available?
HS – This is still a challenge.
SJ – Does the risk rating reflect the true picture?
SF – Yes. There has been clear oversight.
One new risk has been identified for inclusion on the Corporate Risk Register.
Consequence = 3, likelihood = 3, risk rating = MODERATE (9).
Quality Report
There have been no red indicators in the Mental Health QSIP for six consecutive months.
There are two Amber indicators; registering carers details on RiO and s132 explanation of rights. In the Community Health QSIP, pressure ulcers remains a red area as there has been a BBG wide increase in grade 2 and 3 pressure ulcers. Commissioners have now put in place a BBG-wide pressure ulcer panel to review cases and share good practice.
SF – Reducing pressure ulcers is one of the areas we should invest in. This does cause harm to patients and is linked to our CQUIN.
AR – It will also be a Monitor target next year.
Recording care plans on RiO for Long Term Condition Teams is also red and teams have been asked to check data accuracy.
The Trust is on track to achieve the HPV immunisation target. An audit on ensuring that young people who attend CASH services are offered Chlamydia screening kits has taken place and data is being analysed. Root Cause Analysis of Grade 3 and 4 pressure ulcers is taking place, but there is a timing issue so the process is being reviewed.
We have received confirmation that all mental health CQUINs were achieved in quarter 3 but commissioners expressed some concerns about the differences in performance across the three boroughs. We are on track to achieve all CQUINS in quarter 4 with the exception of recording care plans on RiO for Long Term Condition Teams.
CQUINS for 2013/14 have yet to be finalised.
Compliance Report
There have been no breaches of regulatory standards. No significant concerns have been raised from MHA Commissioner visits, CQC compliance visits or Ofsted inspections. As at the end of January 2013, all Monitor targets were met. The highest rated item on the QRP is
‘high yellow’ for Outcome 7. The CQC visits to HMP Rochester and Green Parks House, and the Ofsted inspection of Wensley Close went well. Three serious incidents were reported in
January 2012. One occurred at the PRUH so will be investigated by SLHT and one took place at HMP Elmley, so will be investigated by HMPI. For complaints, care planning, relationships with staff and information remain the most frequently raised issues in both mental health and community health services. To date this year, 15 complaints have been referred to the Ombudsman; seven are in review and for the other eight, the Ombudsman are taking no further action.
JK – Does the data provided on page 16 “Safety and Suitability of Premises” mean that patients are more at risk in ALD services?
WB – A response will be included in the next report.
DM – omplaints relating to care planning needs to be broken down for future reports.
Action
Noted
Noted
WB
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Business Committee update
Corporate imagery
The Trust corporate imagery has been updated to better reflect that we are a combined mental health and community health care Trust. The images have been chosen to represent
“all round care” to improve lives and to represent our values.
SARD
There have been much more interest since doctors’ revalidation has become mandatory.
SARD JV have secured the sale of the software to Guys and St Thomas’.
Bids
The Trust was not successful in the bid for the Bexley IAPT service. We will ask for feedback.
Health and Social Care Act
The Board were asked to note the key implications of the Health and Social Care Act. The changes take place from 1 April 2013.
Board meetings held in public
All Formal Board meetings must be held in public, so our first public meeting will be on 2
May 2013. Members of the public will attend as observers. Informal meetings with Service
Directors and Clinical Directors will continue.
Significant transactions
Transactions of over £20M must be notified to the Council of Governors. A form of words for the Constitution will be developed.
Holding Non Executive Directors to Account
We have agreed that Governors will be supplied with background information about NEDs including their interests and involvement of committees in Oxleas.
JK – Are we intending to have Part II meetings?
DM – That will depend on the agenda.
JK – Will the governors receive a full set of papers?
DM – They will receive the agenda and the approved minutes.
AR – I will circulate the rules for what should be included in the Part II meeting.
Council of Governors update
Elections for the Council of Governors will be held in April and May 2013. AT’s current term as NED ends on 30 April 2013. The Nominations Committee will meet on 11 March to approve the process for DM to re-appoint AT for a final term of three years. This will be reported to the Council of Governors to note.
Sealing of Documents
The following documents require the affixing of the Trust Seal:
 Contracts relating to alterations to 1 st
Ltd (£33,190.07)
 Contracts and Specification of Works relating to Somerset Villa en-suite refurbishment

Floor Reception Area, Stepping Stones – Proforce and associated works – Adams Contracts Ltd (£85,950.00)
Contracts relating to lift modernisation at Bostall House – Elite Elevators Installations Ltd
(£51,830.00)
 Contracts and tender documents on disc relating to Goldie Leigh drainage – UKDN
Waterflow (£138,000.00)
 Contracts and Specifications of Works relating to Bracken House extension and heating –

Cosmur Construction (£206,221.00)
Contracts, document register, drawings and tender documents relating to the major refurbishment of 137-139 Lodge Hill (Project 106 relocation) – DCB (Kent)
(£1,410,762.15)
 Licence for alterations between Affinity Sutton Homes Ltd and Oxleas NHS FT relating to the refurbishment of Bridgeways Day Centre
 Licence to share premises between Mayor and Burgesses of the London Borough of
Bromley and Oxleas NHS FT relating to Yeoman House
 Contracts relating to undercroft ventilation works at Memorial – Pembury FM Services Ltd
(£23,243.98)
 National Variation Deed 2012/13 in relation to the (multilateral) NHS Standard Mental
Health and Learning Disability Services Contract dated April 2010 between Medway PCT
(as co-ordinating commissioner for itself and as agent for and on behalf of the associates) and Oxleas NHS FT as provider
Action
Noted
AR
Noted
Noted
Approved
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Finance report – February 2013
The Trust has delivered a surplus of £5.0M, which is £2.4M higher than plan. We are currently forecasting a surplus of £5.4M, which is £2.2m higher than plan. CREs for 2012/13 have been delivered and next year’s target has been reduced by £600K. Overall, the Trust has cash and short term investments of just under £82M at the end of January. The Trust’s financial risk rating is 3, in line with the plan.
The Executive Team have agreed the budgeting framework for 2013/14. The target for
CREs is just under £8M and this reflects the contracting round and cost inflation issues.
Changes at the Government Banking Service mean that it will no longer be beneficial to invest cash in commercial banks. Every NHS Foundation Trust has to pay an annual public dividend to the Treasury and the Government Bank will now calculate this based on the daily cash balance instead of the annual cash balance. We would expect to earn £1.2M interest from commercial banks, but this not be possible.
SF – The surplus is below average for foundation trusts. There are SLHT cost pressures of
£0.5M and £1.2M loss of interest. We have not been able to plan for this.
BT – We do have strong cash balances. Services are feeling under pressure. Adult Mental
Health will struggle to meet CREs.
SF – Over the next two years, the Trust is planning to invest £30M in quality improvement and £10M in new technology.
It was agreed that the Board would consider an option paper at the April Informal Meeting with the Service Directors and Clincial Directors,
SLHT rent dispute
Following extensive negotiations, the disputed amount has been reduced to £0.5M. The proposal is that we pay this amount and that all historic debt up to March 2011 is written off.
SF – We will need to meet with the successor organisation.
AH – This should be arranged before the dissolution of SLHT but with a break clause.
Private Practice Policy
This has been developed to be consistent with the Private Patients Policy and provide guidance on how to manage a conflict of interest. Clinicians are free to engage in private practice but this must be entirely separate from NHS work and must not adversely impact on
NHS services. All clinicians engaging in private practice will be required to complete a declaration of interests form.
SC – At BMI, NHS employers would sometimes ask how many hours of private practice a clinician had undertaken but we did not have the consent of clinicians to disclose this. Do we need to have a process whereby the employee consents to us approaching private practice organisations so they can disclose this information to us?
AR – This could be added to section 3 of the declaration of interests form.
SH – This could also be added to contracts of employment.
Workforce report
Sickness absence for January was 5.45%. Anxiety and stress account for the majority of days lost. Vacancy rates are static at 10.59%. There are 197 recruitment campaigns in progress including staffing of the extra beds in Step-up, Step-down and on-going campaigns to attract health visitors.
PDR compliance has dropped below 80%; there are some areas causing particular concern including district nursing teams, IAPT and crisis teams and health visitors. The Executive
Team will need to ensure that compliance increases. All areas of mandatory training are above 80%. Four directorates are above 80% in all areas. For essential skills training, four out of seven areas are above 80%. There are currently 19 live disciplinary cases and four staff are suspended from duty.
The new Employee Assistance Programme (EAP) contract will take effect from 1 April 2013.
The contract has been awarded to CareFirst who will provide a 24/7 service.
SC – PDR for corporate teams seems to be lagging.
DM – If there has been no improvement by May, we will look at this as a Board. Can we withold pay if PDRs have not taken place?
SH – This is in discussion.
Action
Noted
BT
Noted
Approved
AR
Noted
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National Staff Survey 2012
The NHS Staff survey 2012 surveyed 850 Oxleas staff of whom 51% responded; this is a lower response than last year. The report groups the responses of all the questions into 28 key findings. Oxleas comparative scores are
 18 key findings were in the 20% of mental health trusts
 7 key findings were above average for mental health trusts
 0 key findings were average for mental health trusts
 2 key findings were below average
 1 key finding was in the worst 20%
We are below average for staff working extra hours and staff experiencing physical violence from staff in last 12 months. We are in the worst 20% for staff experiencing discrimination in the last 12 months. We have done some further work and it is clear that this is discrimination from patients and the public.
Nine scores were the top scores nationally for any mental health or learning disability trust
 Feeling satisfied with quality of work and patient care delivered
 Effective team working
 Receiving well-structured appraisals
 Support from immediate line manager
 Fairness and Effectiveness of incident reporting
 Being able to contribute to improvements at work
 Job Satisfaction
 Recommending the trust as a place to work and receive treatment
 Equal opportunities for career progression
Seven scores have experienced a statistically significant change between the 2011 and 2012 surveys
 Having an appraisal in the last 12 months - Improved
 Receiving a well-structured appraisal in the last 12 months - Improved
 Receiving equality & diversity training in the last 12 months - Improved
 Staff feel that incident reporting procedures are fair and effective - Improved
 Staff job satisfaction - Improved
 Staff recommending the trust as a place to work and receive care – Improved
 Staff suffering work place stress – Worsened
The significant shift in staff suffering from workplace stress should be looked at in view of the amount of organisational change that has taken place.
In relation to violence towards staff from other staff, we have no evidence that this is an issue. We must not be complacent and assume staff have misread the question. People need to be able to come forward and raise issues.
SF – For the staff experiencing violence from staff, we scored 4% and the average is 4% so why are we in the worst category?
SH – This could be a rounding issue. I will ask for clarification. Seventeen staff responded to this question. We are not aware of concerns through incident data.
Chief Executive update
NE has been convicted of murder and attempted murder and was sentenced to 37 years.
We have responded to the media coverage and have been as open as possible. We received a Freedom of Information request from a charity called “100 Families” on the number of people in contact with Oxleas services who have been convicted of homicide. We responded with a figure of 11. We have compared this with the data in the National Confidential
Enquiry Report. Homicides as a whole in London have risen by 21% in ten years but homicides by people with a history of mental illness have not risen in London. The report states that nationally there are 57 homicides per year committed by people with a mental illness, an average of one per trust. As a London trust with forensic services, we could expect to be at least average or higher but our figures show there have been seven in the past nine years that met the criteria. Of the eleven cases included in the FOI response, four had been in contact with services but did not meet the National Confidential Enquiry Report
SH
Action
Noted
Noted
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26 criteria. We can only compare the ones that meet the criteria. There is the possibility of a
Coroner’s inquest and there will also be an independent review.
Unsustainable Provider Regime
There has been a pre-action notice on TSA Recommendation 5, the downgrading of the A&E department at Lewisham Hospital. A request for a Judicial Review has since been submitted by Lewisham Council on the basis that the TSA went beyond his legal scope in including
Recommendation 5. This is likely to delay progress. The aim was to dissolve the Trust on 1
July 2013, but this will now be later. We should expect an announcement soon about the appointment of a new TSA and Programme Director.
Meetings about transitional revenue and capital funding have been held. Capital funding should be forthcoming from the centre. In terms of revenue funding, we will need to make a case to the Board for the maximum and minimum needed in conjunction with other providers.
Based on the current timescales, the Department of Health will need our decision by 1 June.
This means we will need to submit an approved Business Case to Monitor by the beginning of June. We will aim to approve the Business Case at the Board of Directors in May.
Service Development Strategy
The SDS has been developed over the last nine months with input from the Board, the
Council of Governors and our members. The final report includes the analysis and the final set of priorities and will form the basis of the 2013/14 Annual Plan. This will be submitted to
Monitor in May.
DM – This will be submitted to the Council of Governors.
HS – Feedback from the focus groups has been included. The main direction is improving quality and the 4 must-do’s.
DM – This will be the key focus of all we do.
Any other business
None raised.
Next meeting of the Board of Directors
2 May 2013, Holiday Inn, Bexley
Action
Noted
Approved
9