rd
Board of Directors
Dave Mellish
Archie Herron
Anne Taylor
Paul Ward
James Kellock
Seyi Clement
Stephen Firn
Helen Smith
Ify Okocha
Chair
Vice Chair and 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
Wilf Bardsley
Ben Travis
Simon Hart
In attendance
Rachel Evans
Ann Rozier
Susan Owen
Director of Estates and Facilities
Trust Secretary and Head of Governance
Risk Manager (Minutes)
Members of the Council of Governors in attendance
Richard Diment
John Woolgrove
Public Governor, Bexley
Public Governor, Bromley
1
2
3
4
Apologies for absence
Steve James, Non-executive Director
Minutes of the Board of Directors meeting 9 January 2014
 Page 3 – Intermediate Care Task Group: Amend SF’s comment to read that there is a stable group of HCAs at the Step-up, Step-down Unit.
 Page 6 – Staff Survey: Amend SF’s comment to read that the Trust is performing well, but there are some areas were staff are not as satisfied as they were last year.
Pending these amendments, the minutes of the Board of Directors meeting on 9 January
2014 were approved as an accurate record.
Matters arising
Page 7 – Queen Mary’s Hospital: The public events on the QMH site were well attended.
People gave feedback that they are pleased with progress and supportive of our plans for the site.
Key Performance Indicators
All Monitor targets are comfortably met. There has been an increase in UCC attendance in
January 2014, but we remain well within the waiting times target. Bed occupancy in acute adult in-patient units remains high. The Trust has an escalation plan which is used effectively. This remains more challenging for the Children and Young Peoples directorate as there is a large volume of legacy records. New cases are being captured. Multi-disciplinary meetings are being held at the Step-up, Step-down Unit to ensure that discharge planning targets are met.
AT – Older Persons bed occupancy is now at 100% - does this reflect the reduced bed base?
HS – There have been challenges in managing occupancy in the dementia wards.
SF – There is also pressure on the functional wards. We need to monitor that this does not become a trend.
AH – Can we draw a line under ethnicity recording for the legacy records in C&YP?
HS – We will look into this.
Action
Noted
Approved
Noted
Noted
Page 1 of 8

5
6
JK – What is the progress on the 18-week referral to treatment target for Psychological
Therapies?
SF – This is currently 83%. Plans are in place to increase this, including data cleansing.
Michael Witney will be present at the April meeting to report further.
DM – At the next informal meeting, we will have a focused discussion on how we will manage the increase in bed occupancy and detentions.
Service delivery report
The Greenwich Integrated Care Team have won an award for their work in delivering integrated care. Norman Lamb and Frank Bruno visited Oxleas House for the launch of the
Mental Health Crisis Care Concordat.
JK – I am impressed with the initiative to include young people on recruitment panels in the
Children’s Services – will this be implemented Trust wide?
SH – Plans are in place to do this.
DM – Are service users are involved in AAC panels?
SH – This is being discussed.
AT – Are the trainee health visitor posts funded?
WB – Yes. 500 new posts are projected across London.
SF – The Coalition Government made an election pledge to increase the number of health visitors so we are under pressure to fill these posts.
AH – Do the outcome measures for Atlas House include the financial situation?
BT – We are making sure that it is financially viable.
SC – Do we have the capacity to meet the extra demand on Atlas House in light of the closure of the SLaM service?
BT – We are undertaking market analysis.
HS – We are developing a close care suite within Atlas House.
SC – Why are the number of pressure ulcers increasing?
IO – The increase in Grade 2 pressure ulcer reporting is a positive indicator of better detection and prevention. Grade 4 pressure ulcers are decreasing. We need to look at
Grade 3 pressure ulcers more closely. An Embedding Learning Nurse is in post to focus on this.
DM – Are there plans to implement text reminders across the Trust so that we can further reduce DNAs?
IO – This is being considered. We have data that shows that this as contributed to our DNA rate and we have had a query from the BMJ about how we achieved this.
JK – The reduction in Bracton patients describing themselves as smokers is an excellent achievement.
SF – This is an indicator that we should consider whether it would be appropriate to implement the smoke free policy across the Trust.
SC – It is disappointing that the bid to run the Family Nurse Partnership service in Bexley and
Bromley was lost to Bromley Healthcare. Can we look at the impact that this partnership will have on us?
BT – The next 18 months will be important. The Board will need to have a focus on this.
Quality Report
Of the 27 QSIP indicators, 18 have been achieved, 4 are amber and 3 are red. The target of
95% for new birth visits undertaken within 14 days of birth has been achieved for the first time in 2013/14. The red indicators are:
 CE3.2MH – Consent to treatment for patients detained under the Mental Health Act (S58):
Evidence could not be found for 2 out of 6 patients.
PS1.3CH – Number of grade 2 pressure ulcers 
 PS1.4CH – Number of grade 3 pressure ulcers
A wide scope of work to reduce and learn from pressure ulcers is taking place. Other areas of focus are recording carer details on RiO, smoking cessation and discharge processes.
JK – Does smoking cessation apply to children’s services?
IO – This is not included in the data at present. This is a more challenging group to work with.
DM – Is the increase in pressure ulcers related to nursing practice?
IO – This is due to the vulnerability of the patients. Of the 62 cases audited, 40% were over
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Action
HS
Noted
Noted

7
8
9 the age of 80. A number were in nursing homes or on an end of life care pathway. These groups are more at risk. Implementing preventative measures is paramount.
Patient Safety
The suicide prevention action plan includes suicide prevention training and communicating assessments and management plans to primary care. A review of Level 4 serious incidents identified key themes around documentation, standards of risk assessment, substance misuse, family involvement, transfer of care and implementation of CPA. Training on the completion of the falls assessments is underway across all inpatient teams and an Embedding the Learning Event focused specifically on falls prevention and management. Following two
Level 4 incidents in Children’s Services, there has been a standardisation of all protocols for services that undertake vaccinations. Since 2012 there have been four Serious Case Reviews conducted under pan-London Safeguarding Children Procedures which have touched on
Oxleas services. Key themes from these cases relate to communication between teams,
DNAs, failure to engage and disengagement. These SCR’s will be reviewed by the Patient
Safety Group to ensure that actions have been implemented and lessons learned Trustwide.
PW – Do we need to do more work on providing access to in house substance misuse services?
WB – We do need to do more to adhere to NICE guidance on detoxification and developing our relationship with specialist services.
Compliance Report
Ivy Willis House has been cited as an example of good practice in the CQC MHA 2012/13
Annual Report for its work in involving patients in the development of their care plans. No serious concerns have been raised from night visits. Much work has been undertaken in relation to the intermediate care units. Key posts have been recruited to. The Level 4 incidents on Step-up, Step-down have been downgraded. Three new serious incidents were reported in January 2014, all of which are being investigated at directorate level. Completing investigations within 45 days remains a challenge, but we have strengthened directorate oversight, so these delays should be reduced.
JK – Are we managing risks in relation to health and safety, if risks assessments are not being completed?
WB – This has been raised with service directorates and plans have been made to ensure these are completed by the end of the month.
SF – The CQC raised concerns about the timeliness of equipment repairs at Oxleas House.
We are often waiting for the PFI providers to act on requests for repairs. We need to be able to ensure that we can respond if they do not.
Governance Board update
Two new workforce risks have been accepted onto the Corporate Risk Register.
Consequence = 4, likelihood = 3, risk rating = HIGH (12).
. Consequence = 3, likelihood = 3, risk rating = MODERATE (9).
AH – Are we considering overseas recruitment as a long term option?
SH – We will assess the impact of the current campaign first.
PW – Do we need further assurance that we can meet mobilisation targets?
SH – This tends to be specific to contracts.
JK – There are no low or significant risks. Is this the right balance?
SF – Low risks will have met the target rating, so would not appear on the risk register.
AH – Significant risks are exceptional as they would have the most serious impact.
AR – We do not include inherent risks. These would be escalated if concerns are identified.
NED Report – Board visits
DM –
good signage of ‘you said, we did’ feedback. Positive feedback from staff, but some concerns raised about the length of time taken to be accepted onto the Bank.
Feedback from patients was also positive. Carers were complimentary but said that support tended to be on a collective rather than individual basis. that there should be more integration between teams.
Staff suggested
good signage of ‘you said, we did’ feedback. Staff discussed the Francis Report in the ward meeting and each had
Page 3 of 8
Action
Noted
Noted

individual action plans. Concerns about recruitment were raised.
AT –
AH –
merited as a range of options are offered. staff felt under pressure and that there were not enough staff. Bank shifts were paid on a lower rate. Care for the patients shone through.
Staff felt strongly that the CQC concerns about choice of food were not
Due to the reduction in beds,
There were some challenges in organising co-ordinated care. Relocation to the QMH site is being considered which would improve this.
Nonambulant service users are unable to access this as the team are based on the 4 th floor of
Yeoman House. Alternative accommodation is being sourced. LA staff indicated that they would be happy to be seconded to Oxleas, which would support leadership at the service.
SC –
There were some concerns about the isolation from the
Bracton Centre. Senior management changes have unsettled staff, this will be kept under review. There were also concerns about drugs being brought into the unit. There are proposals to install CCTV so this can be better monitored. One patient on Greenwood has made significant progress with his recovery and is happy for his story to be published.
Staff were proud of what they do, but felt that they could do more.
This is an excellent service, but some staffing is provided by an external provider which creates some challenges for Oxleas clinicians. John Enser and Jackie Craissati have been asked to review this with the provider.
A supportive and cohesive team. There were good examples JK – of reflective practice. Concerns with liaising with the Bank Office were raised.
PW –
There was a clear depth of need which put additional pressure on the service. There is some scope to re-design services. Technology is being used to support self-management and self-care.
need is low compared to inner London.
This is a good service. The level of
This would benefit from redecoration. This is planned within the next few months.
10 Business Committee update
A private sector company has expressed an interest in the SARD JV, but this is not being pursued.
11 Council of Governors update
Members of the Council of Governors were involved in the focus groups to agree the SDS and
Annual Plan priorities. The Nominations Committee is meeting on Tuesday 11 March 2013.
The next meeting of the Council of Governors is on 20 March 2014. The pre-meeting before this will focus on the implementation of the Health and Social Care Act.
12 Sealing of Documents
The following documents require the affixing of the Trust Seal:
 Contracts and Specifications of Works relating to ensuite refurbishments at Barefoot
Lodge – Adams Contracts Ltd. (£61,283.67) - Approved
 Contracts and Contract documents relating to the development of PICU at the Bracton
Centre – Cosmur Construction Ltd. (£669,036.79) - Approved
Land Registry Transfer of part of Queen Mary’s Hospital, Sidcup (Site A) from Oxleas NHS 

FT to Anchor Trust (£3,800,000) - Approved
Lease of part of Block A and Block B Queen Mary’s Hospital, Sidcup to Lewisham and
Greenwich NHS Trust - Approved
13 Estates Programme
Much work is planned in relation to QMH and this will be broken down into a number of schemes. The remainder of the programme is based on the known developments planned by service directorates and estates, but further schemes may be identified to respond to both service redesign and future tenders.
JK – How much of the programme will be financed by sales?
RE – This is being considered. We can sell properties or terminate leases.
AH – Is there are market for a PICU at the Bracton Centre?
SF – Four beds are planned increase our ability to admit people quickly. We are at a market disadvantage by not having a Forensic PICU.
DM – We currently have over 125 properties. At the June meeting, the Board should receive a strategy on how we can rationalise this taking into account CREs, procurement and non-
Action
Approved
Approved
RE
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staffing costs.
RE – Expanding the use of new technology can help us to reduce our properties.
RE – The cost of the Market Street refurbishment is higher than expected as the building will need to reconfigured and the service will need to be decanted whilst the work takes place.
The Estates Programme was approved.
14 Finance Report
Year to date, the Trust has delivered a surplus of £3.4m / 2.0%, which is £0.8m higher than plan (£2.7m / 1.5%). The year-end position will need to be resolved, including a revaluation of the estate. Overall, the Trust had cash and short term investments of £79.3m at the end of January 2014; this is £6.0m ahead of plan. The Monitor Financial Risk Rating remains at
4. We are on target to deliver all CREs. The CRE target for 2014/15 is the most challenging to date and much work is taking place to plan for this.
SC – Are there any concerns about the recovery of debts?
BT – These will be recovered. New guidance has been issued on paying for UCC attendance. There will be a block contract for Bexley residents and for non-Bexley residents, the appropriate CCG will be charged.
SC – Why are we not meeting the target on payment terms?
BT – This is a challenging target. We are not an outlier.
Contracting position
The Greenwich contract has been signed. The Bexley contract includes proposals for a new falls service. For mental health, we have identified areas where savings can be made.
Bromley are proposing to reduce the contract value by £2m over two years. This is in addition to a 4% efficiency target and bed base reduction. Negotiations are on-going.
AT – In the past, we have had discussions about paying for out of area beds.
BT – Risk share arrangements are part of the discussions.
JK – We should consider if this risk is at an appropriate level on the Risk Register.
Procurement
The Procurement Group will meet for the first time next week. We have been communicating changes Trustwide.
15 Staff Satisfaction Survey 2013
The NHS Staff survey 2013 surveyed 850 Oxleas staff of whom 481 (57%) responded. We are in the top 20%, which is a good indicator of staff morale. There were 28 key findings.
Oxleas comparative scores are
 15 key findings were in the top 20% of mental health trusts
 6 key findings were above average for mental health trusts
 4 key findings were average for mental health trusts
 1 key findings were below average
 2 key finding were in the worst 20%
We achieved high scores for staff recommending the Trust as a place to work and receive treatment. This should be treated as a positive marker for the staff ‘friends and family’ test.
Scores in the bottom two categories were staff saying that they have experienced harassment or abuse from patients, relatives or the public, staff experiencing discrimination in the last 12 months and staff experiencing physical violence from staff. For violence from other staff, we know that there the number of incidents is very low, but we do need to have clear communication on zero tolerance. The Acute Care Forum has established a work stream on supporting staff affected by abuse from patients. We will talk to trusts with a similar proportion of BME staff to ourselves to learn from how they approach this.
16 Workforce Equality Report
The Trust is required to publish equality data annually. The report sets out the action we have taken to make improvements. There are some staff groups where particular ethnic groups are clustered, such as Band 5 nursing staff. As they are patient facing roles, they are more likely to experience harassment and abuse. We will be clear in our advertising that we are actively seeking candidates from underrepresented groups. The Equality, Diversity and
Human Rights Group will be asked to set targets.
17 Workforce Report
Sickness absence in January was 4.63%. There has been a downward trend in sickness
Action
Noted
Noted
Noted
Page 5 of 8

absence since December 2013. Vacancy rates are 10.16%. This level of vacancy is within the normal range but masks some areas of recruitment difficulty. An overseas recruitment campaign has been successful and a wider marketing campaign highlighting the Trust’s requirements for a range of staff across community services will be launched in March using a variety of media. PDR compliance is at 80% across the Trust. All mandatory and essential skills, including patient handling, is above 80% compliance. There are six disciplinary cases under investigation and two grievance cases. Four members of staff are suspended from duty. There are three outstanding tribunal claims against the Trust; two are new claims and one is a long standing case that is awaiting a hearing date. The Trust made its annual submission to the Stonewall Equality index last September. Oxleas was rated 52nd which is a considerable improvement on the previous year (118th). The Trust was the 4th highest placed NHS organisation.
DM – Is the process for suspended staff taken forward as quickly as possible?
SH – I personally review these.
18 Revised SDS priorities 2014/15 to 2015/16 and Annual Plan priorities
These have been discussed extensively with the Board, Council of Governors and Members.
The priorities reflect national and local requirements and the key areas we need to focus on such as activity levels, crisis care and bed reduction. The priorities will be presented to the
Council of Governors in March for their agreement and then to the Board of Directors in April for formal approval.
19 Mental Health Crisis Care Concordat
This will be reviewed in detail by the Executive Team. DM asked that the Trust’s position in relation to places of safety, partnership working and crisis lines is brought to the June meeting of the Board of Directors. WB was asked to review the data we will need to consider in relation to this.
20 Chief Executive update
A Board level inquiry will be convened to investigate the homicide committed by a service user who has been known to the Trust for 10 years. The Police and the Local Authority will also be conducting their own investigations.
21 Written questions from the public
None received.
Next meeting of the Board of Directors
Thursday 3 rd April 2014 at 2.30 pm
Room 4, Memorial Hospital
I confirm that the minutes of Board of Directors meeting of 6 th March 2014 are a true record
Signed
Date:
Action
Noted
Noted
WB
Noted
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This jargon buster is a glossary of acronyms and abbreviations.
It is intended that we will update this on a regular basis but we will also agree standards to reduce jargon usage.
If you feel there are more that should be included on the list please email anne.rozier@oxleas.nhs.uk
ACS – Adult Community
Services
ADHD – Attention Deficit
Hyperactivity Disorder
ADL – Assessments of
Daily Living or Activities of
Daily Living
AfC – Agenda for Change
AHP – Allied Health
Professional
ALBs – Arms Lengths
Bodies
ALD – Adult Learning
Disabilities
AMH – Adult Mental Health
AMHP – Approved Mental
Health Professional
ASBO – Anti-Social
Behaviour Order
ASD – Autistic Spectrum
Disorder
ASW – Approved Social
Worker
BMs – Business Managers
CAMHS – Child and
Adolescent Mental Health
Services
CAPA – Choice and
Partnership approach (a new way of managing referrals into CAMHS)
CAS – Central Alerts
System
CBT – Cognitive
Behavioural Therapy
CCG – Clinical
Commissioning Group
CDM – Chronic Disease
Management
CEG – Clinical Effectiveness
Group
CIP – Cost Improvement
Programme
CLDT – Community
Learning Disability Team
CNST – Clinical Negligence
Scheme Trust
CPA – Care Programme
Approach
CPC – Cost Per Case
CPN – Community
Psychiatric Nurse
CRB – Criminal Records
Bureau
CRE – Cash Releasing
Efficiency
CRHTT – Crisis and Home
Treatment Team
C&YPS – Children and
Young People’s Service
CQC – Care Quality
Commission
CQUIN – Commissioning for quality and innovation
DADL – Domestic Activities of Daily Living
DESMOND – Diabetes education and self management programme for on-going and newly diagnosed
DH – Department of Health
DN – District Nurse
DNA – Did Not Attend
ECR – Electronic Care
Records
ECT – Electro Convulsive
Therapy
EI – Early Implementer
ESR – Electronic Staff
Records
ETP – Electronic Transfer of Prescriptions
FCPN – Forensic
Community Psychiatric
Nurse
FOI – Freedom of
Information
HCA – Health Care
Assistant
HEE – Health Education
England
HID – Hospital Integrated
Discharge Team
HIMP – Her Majesty’s
Inspectorate of Prisons
HR – Human Resources
HTT – Home Treatment
Team
HV – Health Visitor
ICP – Integrated Care
Pathway
ICT – Information
Communication
Technology iFox – Trust Business
Information System
IGG – Information
Governance Group
IGT – Information
Governance Toolkit
IMHER – Integrated Mental
Health Electronic Record
IM&T – Information
Management and
Technology
ISA – Information Sharing
Agreement
KPI – Key Performance
Indicators
KSF – Knowledge and Skills
Framework
LAS – London Ambulance
Service
LD – Learning Disability
LGBT – Lesbian, Gay,
Bisexual, and Transgender
LHC – Local Health
Community
LSP – Local Service
Provider
LTC – Long Term Condition
MAPP – Multi Agency
Protection Panel
MCA – Mental Capacity Act
MDA – Multi-disciplinary
Assessment
MDO – Mentally disordered offender
MDT – Multidisciplinary team
MEWS – Modified Early
Warning Score Tool
MH – Mental Health
MHA – Mental Health Act
MH MDS – Mental Health
Minimum Dataset
MHRA – Medicines
Healthcare and products
Regulatory Agency
MHRN – Mental Health
Research Network
MSK – Musculo-skeletal
Services
NAC – Nursing Advisory
Committee
NCC – National Consortium of Colleges
NEDs – Non Executive
Directors
NHSLA – NHS Litigation
Authority
NICHE – National Institute for Health and Care
Excellence
NIHR - National Institute for Health Research
NPSA – National Patient
Safety Agency
NSF – National Service
Framework
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OOHs – Out of Hours
OPD – Outpatients
Department
OPM – Office for Public
Management
OPMH – Older Peoples’
Mental Health
PEEP – Personal
Emergency Evacuation
Plan
PQQ - Pre Qualification
Questionnaire
PADL – Personal Activities of Daily Living
PALS - Patient Advice and
Liaison Service
PEG – Patient Experience
Group
PD – Personality Disorder
PDP – Personal
Development Plan
PDR– Personal
Development Review
PDS – Patient
Demographic Service
(national repository holding demographic information)
PEAT – Patient
Environment Action Team
PFI – Private Finance
Initiative
PICU – Psychiatric
Intensive Care Unit
POMH – Prescribing
Observatory for Mental
Health
PRUH – Princess Royal
University Hospital
PSA – Personal Safety
Awareness
QEH – Queen Elizabeth
Hospital
QMS – Queen Mary’s
Hospital Sidcup
QRP – CQC Quality and
Risk Profile
QSIP – Quality and Safety
Improvement Plan
RAG – Red/Amber/Green
RC – Responsible Clinician
RCA – Root Cause Analysis
RGN – Registered General
Nurse
RM – Risk Management
RMN – Registered Mental
Nurse
RMO – Responsible Medical
Officer
RPST – Risk Pooling
Scheme Trust
SAP – Single Assessment
Process
SCG – Specialist
Commissioning group
SDS – Service
Development Strategy
SLaM – South London &
Maudsley NHS Trust
SLR – Service Line
Reporting
SMs – Service Managers
SN – School Nurse
SPD – Safety, Privacy and
Dignity
SUI – Serious Untoward
Incidents
TDA – NHS Trust
Development Authority
TSA – Trust Special
Administrator
TUPED – Transfer Under
Present Employment
UEAs – Uncontracted
Emergency Admissions
VTE – Venous thromboembolis
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