MEETING OF THE TRUST BOARD OF STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST

Transcription

1 Enc 00 MEETING OF THE TRUST BOARD OF STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST Town Hall, King Edward Place, Burton upon Trent, Staffordshire DE14 2EB Wednesday 24 July hrs AGENDA Item Enclosure Description Time Number 1. Welcome and Apologies Prof Nigel Ratcliffe Verbal Questions from members of the public Prof Nigel Ratcliffe Verbal Declarations of interest Prof Nigel Ratcliffe Verbal Patient story Enc 01 Minutes of the last Staffordshire and Stoke on Trent Partnership NHS Trust Board meeting and matters arising Prof Nigel Ratcliffe Enc 02 Chief Executive Officer Report Stuart Poynor Enc 03 Minutes of the Audit, Finance, Investment & Performance and Quality Governance Committees Chairs Reports Jennifer Ledgar, Jeni Jobson, David Pearson Assurance Enc 04 Corporate Risk Register Melanie Print Enc 05 Quality Report Siobhan Heafield Break Enc 06 Quality Governance Reporting Arrangements Siobhan Heafield Enc 07 Finance Report - Month 3 Jonathan Tringham Enc 08 Performance Report Month 3 Jonathan Tringham Enc 09 Security Management Annual Report Siobhan Heafield Enc 10 Transforming Welfare Benefits and Financial Assessment Services in Staffordshire Geraint Griffiths Page 1 of 2

2 Enc Enc Enc 12 Public Inquiry into Mid Staffordshire NHS Foundation Trust Update Kieron Murphy Strategy Better Together Programme Management Office Update Geraint Griffiths Verbal Any Other Business Prof Nigel Ratcliffe Close Date of Next Meeting Wednesday 25 September 2013 Page 2 of 2

3 Enc 01 REPORT TO: STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST BOARD TO BE HELD ON: WEDNESDAY 24 JULY 2013 Enclosure: 01 Subject: Lead: Minutes of the Staffordshire and Stoke on Trent Partnership NHS Trust Board Meeting on Wednesday 26 June 2013 Melanie Print Recommendation: For Approval & Assurance x For Discussion For Information PURPOSE OF THE REPORT: The unapproved draft minutes of the Staffordshire and Stoke on Trent Partnership NHS Trust Board meeting held on 26 June 2013 are enclosed for review and approval. KEY POINTS: An action tracker is attached that shows the status of each action. INTER DEPENDENCIES: Legal and/or Risk - Clinical - Financial - HR - Social Care - Patient & Public Involvement - Equality Impact - Requirement for further review - RECOMMENDATIONS / ACTION REQUIRED: The Trust Board is requested to appraise and approve the minutes of the Trust Board Meeting on Wednesday 26 June 2013 Page 1 of 26

4 Enc 01 Page 2 of 26

5 Enc 01 Key: Overdue On Target Action Complete Meeting of the Trust Board of Directors of Staffordshire and Stoke on Trent Partnership NHS Trust Wednesday 26 June 2013 Main Hall, Rising Brook Church, Burton Square, Stafford ST17 9LT ACTION TRACKER Action No. Date of Meeting Agenda Item No. Action Status/ Due Date Comments (incl. interface with/reference to another Committee/Sub Committee/Working Group) Responsible Officer RAG Rating Non-Executive Director Designate, Andrew Talbot, to meet with the Director of Nursing & Quality and any other Executive Directors to discuss how the Trust currently collates feedback from patients and service users to be debated at the Trust Board meeting in May or June Non-Executive Director Designate, Andrew Talbot, and the Director of Nursing & Quality to meet to discuss the presentation for the Trust Board meeting to be held on 25 September Non-Executive Director Designate - Andrew Talbot/ Director of Nursing & Quality Director of Nursing & Quality to provide an update of arrangements that are put in place to address issues when services are experiencing difficulties, to the Quality Governance Committee A paper regarding the Quality Governance Reporting Arrangements is included on the agenda for the Trust Board meeting on 24 July Director of Nursing & Quality Page 3 of 26

6 Enc Deputy Chief Executive Officer to arrange for Kay Fradley, Trust Development Authority Relationship Manager, to meet with the Chairman Corporate Business Manager is awaiting confirmation from the Trust Development Authority office of a suitable date for such a meeting to take place. Deputy Chief Executive Officer Finance report to provide details of the Cost Improvement Programme (CIP) plans Revised CIP plan presented to the Finance, Investment and Performance Committee on 17 July 2013 Finance Report to the Trust Board meeting on 24 July 2013 includes progress against CIP and profile of delivery. Director of Finance & Resources Report to Members a summary of CIP schemes that have gone through the CIP Quality Impact Assessment and Scrutiny Panels An update of progress of Quality Impact Assessment and Scrutiny panels for all 2013/14 CIP schemes presented at the Quality Governance Committee meeting held on 16 July Deputy Chief Executive Officer A RAG rated spread sheet with the detail as to any quality impact reported to be presented to the Quality Governance Committee on a quarterly basis to enable the Committee to provide assurance to the Trust Board Members were provided with an update as part of agenda item 7 on the agenda of the Trust Board meeting of 26 June Director of Finance & Resources Ascertain if the target rate of against a target of 150 for permanent admissions to residential/nursing care is based on peopled aged 65+years Director of Finance & Resources confirmed that the target rate of against a target of 150 for permanent admissions to residential/nursing care is based on people aged 65+ years of age. Director of Finance & Resources Page 4 of 26

7 Enc Work with the Associate Director of Organisational Development about how the Trust encourages staff to reflect on their changes of behaviour and delivery of care within the Trust organisational development strategy Director of Workforce & Development confirmed that she has met with the Associate Director of Organisational Development and confirmed that details of how the Trust encourages staff to reflect on their changes of behaviours and delivery of care within the Trust has been included in the organisational development strategy. Director of Workforce & Development Minute of the Finance, Investment and Performance Committee meeting of 15 May 2013 to be changed to reflect that the Health Assure system is not fully up and running and is not yet embedded in the Trust (page 8) Minutes reviewed at the Finance, Investment and Performance Committee meeting on 17 July Minute changed to reflect the action. Director of Finance & Resources The collation of evidence as part of the management of the Health Assure system to be discussed at the next Finance, Investment and Performance Committee meeting Discussed at the meeting of the Finance, Investment and Performance Committee meeting on 17 July Director of Finance & Resources Director of Nursing & Quality to draft personal letters to staff from the Chief Executive Officer providing feedback of action taken following adult safeguarding incidents and to communicate other examples to frontline staff Verbal update to be given by the Director of Nursing & Quality at the Trust Board meeting on 24 July Director of Nursing & Quality Director of Nursing & Quality to provide feedback to the Trust Board from the work that the Associate Director of Nursing and the Professional Lead for Social Work are undertaking with the Multi-Agency Safeguarding Hub Verbal update to be given by the Director of Nursing & Quality at the Trust Board meeting on 24 July Director of Nursing & Quality Page 5 of 26

8 Enc Director of Nursing & Quality to consider how incidents can be identified in the future at the point of transfer for patients moving from the community hospitals to their homes and if transfer at the time is appropriate Verbal update to be given by the Director of Nursing & Quality at the Trust Board meeting on 24 July Director of Nursing & Quality Director of Nursing & Quality to produce a short summary of the Quality Account for staff Director of Nursing & Quality The number of complaints escalated to the Ombudsman and not upheld to be included in future Performance Reports to the Trust Board in the performance indicators annex Information will be included in future Performance Reports. Director of Finance & Resources Director of Children s Services to provide regular updates relating to the integration of Children s Services to be provided at future Trust Board meetings Director of Finance & Resources to provide an update of the Information Technology Strategy to the next Trust Board Verbal update to be provided at the Trust Board meeting on 24 July 2013 and a written report to be presented at the meeting to be held on 25 September Agenda item for Trust Board meeting on 24 July Director of Children s Services Director of Finance & Resources Page 6 of 26

9 Enc 01 MEETING OF THE TRUST BOARD OF STAFFORDSHIRE AND STOKE ON TRENT PARTNERSHIP NHS TRUST Wednesday 26 June 2013 Main Hall, Rising Brook Church, Burton Square, Stafford ST17 9LT MINUTES Present: Prof Roger Evans Non-Executive Director Siobhan Heafield Director of Nursing and Quality Jennifer Ledgar Vice Chairman and Non-Executive Director Kieron Murphy Director of Children s Services David Pearson Non-Executive Director Stuart Poynor Chief Executive Officer Prof Nigel Ratcliffe Chairman Andrew Talbot Non-Executive Director Designate Julie Tanner Director of Workforce & Development Jonathan Tringham Director of Finance & Resources Dr John Scarpello Non-Executive Director Dr Doug Wulff Medical Director In attendance: Wendy Dale Corporate Business Manager Melanie Print Company Secretary Apologies: Geraint Griffiths Deputy Chief Executive Director Jeni Jobson Non-Executive Director Welcome and Apologies The Chairman welcomed Trust Board Members to the meeting and noted apologies from Non-Executive Director, Jeni Jobson, and Deputy Chief Executive Officer, Geraint Griffiths. He welcomed Kay Fradley, Trust Development Agency Senior Delivery and Development Manager, attending as an observer; and Jessie Dickson, Trust Communication Manager. The Chairman explained that time at the end of the meeting would be available for questions and he invited questions at the start of the meeting to enable immediate points in the agenda to be addressed Declarations of Interest The Chairman asked if Members had any declarations of interest to declare at the meeting. No declarations of interest were made Patient Story The Chairman explained that a patient, carer or representative is invited to attend every meeting to talk about their experience of receiving Community Health and Adult Social Care services. He welcomed Mr Thamer Abed Majboor to the meeting, along with Sarah Wilshaw, Specialist Mental Health Nurse, Asylum Seeker and Refugee Health Team, Shelton Primary Care Centre based in Stoke-on-Trent. Sarah Wilshaw informed Members that the service she represented had been Page 7 of 26

10 Enc 01 established eleven years ago a unique service that has not been available in the area previously. She reported that the Home Office notifies the service of individuals who will be entering the City of Stoke-on-Trent and who require the support of the service i.e. health issues treated upon arrival and continued support. Sarah Wilshaw informed Members that she had met Mr Majboor following a T.B. screening he had received with her colleague. Mr Majboor informed Members of his life as an investigating judge in Baghdad that involved investigating mass graves that were found, attending the scheme of murders and submitting reports to the court on his findings. He told of how he was held in high esteem by those who knew him and that his life was busy. He described the time when he began working with the coalition forces resulting in him and his family becoming the target of violence from those who were opposed to change. Mr Majboor informed Members that he moved his family from Baghdad to the Green Zone a safe area designated to the Red Cross. He told of how his house was fire bombed and that soldiers had attempted to kidnap his son and an assassination attempt made on his life. Mr Majboor explained that upon his arrival to Stoke-on-Trent he was placed in accommodation with three Kurdish men and was immediately ostracised and spent all of his time in isolation. With nothing else to do, Mr Majboor explained that his thoughts were constantly on his family. He became depressed and told of his feelings of not wanting to live. Sarah Wilshaw explained that due to Mr Majboor s rapidly deteriorating mental health he was referred to The Crisis Home Treatment Team and then into the Mental Health Service at North Staffordshire Combined NHS Healthcare. Sarah Wilshaw explained that four years have now passed and that Mr Majboor is receiving treatment and support from secondary Mental Health Services via a Care Programme approach by a Multi-Disciplinary Team Approach. Sarah Wilshaw informed Members of a voluntary community social group the Burslem Jubilee Group for Asylum Seekers and Refugees that provides support, friendship and English classes. She explained that this is where Mr Majboor met the Trust Chief Executive Officer and that Mr Majboor s mental health has greatly improved since he has joined the group. The Chairman thanked Mr Majboor for sharing his personal experience and that of the service provided to Members. The Director of Workforce & Development asked Sarah Wilshaw if the service accesses the Trust s interpretation service. Sarah Wilshaw informed Members that the service uses Language Line and confirmed that this is one of the best services for additional support and guidance. She informed Members that staff struggle more due to a lack of training and confidence. The Chairman thanked Mr Majboor and Sarah Wilshaw for their time and invited them to stay for the remainder of the meeting. Mr Majboor and Sarah Wilshaw thanked the Chairman and informed him that they would not remain at the meeting. Mr Majboor and Sarah Wilshaw left the meeting. Page 8 of 26

11 Enc Minutes of the meeting and matters arising The Chairman referred Members of the Trust Board to the minutes of the meeting held on 29 May Members of the Trust Board agreed that the minutes were a true record and raised the following changes: Page five - Chief Executive Officer was not present at the meeting and therefore should be recorded under apologies in the list of attendees and under point The Chairman referred Members to the final paragraph on page fifteen under point Annual Report on Workforce Activity; and asked the Director of Workforce & Development how the Trust ensures that members of staff have individual training plans in place The Director of Workforce & Development informed Members that individual training plans are discussed with members of staff as part of the appraisal process. The Chairman referred Members to the action tracker on pages three and four and asked for an update on the overdue and on target actions as follows: Non-Executive Director Designate, Andrew Talbot, informed Members that the action had not been progressed as quickly as he would have wanted; a modified update was included in the quality report. He confirmed that the debate with regard to the collation of feedback from patients and service users will take place at the Trust Board meeting to be held on 24 July The Director of Nursing & Quality informed Members that a number of changes have been made to the overall quality governance arrangements and that a high level plan will be presented to the Quality Governance Committee (QGC) in July She confirmed that a detailed plan will be presented to the Trust Board meeting on 24 July The Chairman asked for a date to be scheduled for him to meet with Kay Fradley, Trust Development Agency Senior Delivery and Development Manager The Director of Finance & Resources confirmed that the Cost Improvement Programme is part of the Transformation Programme and is led by the Deputy Chief Executive Officer. The Chief Executive Officer informed Members that a detailed CIP report has been produced and there is currently a shortfall of 4m. He confirmed that all but 4m have been subject to the Quality Impact Assurance (QIA) reviews and that colleagues are currently reviewing the gaps in the programme. He reported that a meeting will take place on 1 July 2013 to discuss corporate directorate savings and that plans are being drawn up for the Children s Services directorate and in the Operations directorate. He informed Members that prudent assumptions had been made as to the efficiencies that will be derived from transformation and the implementation of the Integrated Locality Teams and that further work will be presented to the Finance, Investment & Performance (FIP) Committee The Director of Finance & Resources informed Members that he would provide an update for the action at agenda item seven when feeding back from the Finance, Investment & Performance Committee meeting The Director of Finance & Resources confirmed that the target rate of against a target of 150 for permanent admissions to residential/nursing Page 9 of 26

12 Enc 01 care is based on people aged 65+ years of age The Director of Workforce & Development confirmed that she has met with the Associate Director of Organisational Development and confirmed that details of how the Trust encourages staff to reflect on their changes of behaviours and delivery of care within the Trust has been included in the organisational development strategy. Members of the Trust Board accepted the minutes of the meeting held on 29 May 2013 as a true and accurate record subject to the changes noted and received assurance from the Executive Directors from the updates provided from the action tracker Chief Executive Officer Report The Chief Executive Officer referred Members to his report and confirmed that the report provides not only notes of national information but also a rolling progress to Members on the Trust s journey to Foundation Trust (FT) status. He gave feedback from a recent meeting that he and the FT Project Manager had had with colleagues from the Trust Development Agency to discuss the Trust s progress to date. The Chief Executive Officer gave positive feedback to Members from a recent meeting he had been invited to attend with Monitor and a subsequent telephone conversation with a Director at Monitor with regard to the Trust s health and social care integration. The Chief Executive Officer reported progress with the arrangements around the administration of Mid Staffordshire NHS Foundation Trust (MSFT). He reported that the Partnership Trust s continues to engage with the TSA within the confines of the Confidentiality Agreement to which all prospective bidders are subject to; and that the terms of any bid by the Partnership Trust is predicated on what is right for the people of Stafford and Cannock areas; which can deliver long term benefits for the population and which is clinically and financially sustainable. The Chief Executive Officer gave feedback from a recent unannounced frontline visit to Bradwell Hospital in Newcastle-under-Lyme with the Ambassador of Cultural Change, Helene Donnelly. He reported that the environment was clean and orderly and that any staffing issues raised on the evening have been investigated. He reported that a number of organisations are interested in the work of the Trust around Helene Donnelly s role and the openness of the Trust Board. The Chief Executive Officer referred Members to the Cross Economy Leaders Group (CELG) report on page seven from its meeting on 23 May 2013 and reported that a further meeting had been held of the Group on 20 June 2013 that the Deputy Chief Executive Officer had attended (as the Chief Executive Officer attended the launch of a joint Trust and Staffordshire County Council Children s Integration event) along with the Chairman. The Chief Executive Officer confirmed that he and Helene Donnelly presented to the CELG group on 23 May 2013 and the Group agreed that a consolidated approach is required. The Chief Executive Officer reported that he and Helene Donnelly will also be presenting the Trust s work at a joint Staffordshire and Shropshire Local Area Team meeting to Chief Executive Officers, Accountable Officers and Local Area Team Directors. Page 10 of 26

13 Enc 01 The Chief Executive Officer reported that the Trust has received recognition with two features recently in the Nursing Times about Helene Donnelly s role and the direction of the Trust in developing an open and responsive culture. The Chairman thanked the Chief Executive Officer for the report. He emphasised that with regard to the Trust working towards FT status that the principal driver for the Partnership Trust is the delivery of effective and efficient services to patients and services users. The Chairman informed Members that he, the Chief Executive Officer and the Director of Children s Services recently visited the Multi-Agency Safeguarding Hub (MASH) he encouraged others to attend to look at the partnership work in place. Non-Executive Director, Dr John Scarpello, asked with the promotion of an open culture whether the Chief Executive Officer had detected changes to the behaviours of middle management and that of members of staff in being more open. The Chief Executive Officer gave Members and example of a recent received from a member of staff (who was working a night shift) in the early hours of one morning raising concerns about the team s workload and with particular reference to members of staff s conduct whilst on duty that night. The communication informed the Chief Executive Officer that the member of staff had attended a focus group with Helene Donnelly who had informed him/her that the Chief Executive Officer would be interested to hear about any concerns. The Chief Executive Officer informed Members that relevant colleagues were notified the next day and a sixteen point action plan put in place within a matter of days. The Chief Executive Officer confirmed to Members that there are other examples of staff that have raised concerns and action has been taken. Members noted the contents of the report Minutes of the Finance, Investment & Performance and Quality Governance Committees Chairs Reports Finance, Investment & Performance (FIP) Committee The Director of Finance & Resources presented the approved minutes of the meeting of the FIP Committee of 15 May He confirmed that the report incorporates a summary report from the Chairman of the Committee, Non- Executive Director, Jeni Jobson, on the key issues and business of the Committee raised at its recent meeting held on 19 June He reported that this is made by way of assurance to Members that the Committee is effectively discharging its terms of reference and current cycle of business for the 2013/14 year. Non-Executive Director, David Pearson, noted that the Cycle of Business for the Quality Governance Committee incorporated a quarterly review of the quality impact of relevant CIP schemes, with assurance to the Board that any quality impact had been removed or mitigated. He reported that he is keen to receive further details at the next QGC meeting and feedback from each of the Chief Operating Officers. He asked for assurance that the CIP bridging gap for 2013/14 CIP of 5.1m is receiving the high level of scrutiny. The Chief Executive Officer confirmed that the QIA process will not be rushed however assured David Pearson that there is pace around the schemes. The Company Secretary confirmed that the Deputy Chief Executive Officer is due to l present a report at the next QGC meeting. Page 11 of 26

14 Enc 01 Non-Executive Director, David Pearson, asked for sufficient time to be allocated to the agenda item to ensure full discussion of the quality impact of any CIP schemes and the steps taken to mitigate any risks to the quality of care or services. The Director of Nursing & Quality reported that she and the Medical Director have approved a summary of the schemes; noting that the current round of QIA panels can demonstrate where schemes have been referred back with the reasons for the rejection of the scheme clearly stated. The Chief Executive Officer thanked the Director of Nursing & Quality for the assurance that a robust system is in place; and for the input of the Director of Nursing & Quality and Medical Director in providing appropriate challenge during the QIA panels. The Director of Nursing & Quality asked for further clarification in the minutes. She referred Members to page eight of the minutes of the FIP Committee meeting held on 15 May 2013, paragraph three under the heading Data Quality Scores when the Associate Director of Performance is reported to have said that Health Assure was working well. She informed Members that it the system is not fully implemented and embedded in the Trust and asked for the minute to be changed to reflect this. The Director of Nursing & Quality referred Members to page nine of the minutes of the FIP Committee meeting held on 15 May 2013, eighth paragraph under the heading of Service Line Management and the Associate Director of Performance s statement that there is a team in place within the structure to manage the Health Assure system. The Director of Nursing & Quality reported that the collection of evidence is an operational function and that this should be collated by staff in the Operations directorate. The Chief Executive Officer endorsed this and asked for the matter to be discussed further at the next FIP Committee meeting. JT JT Vice Chairman and Non-Executive Director, Jennifer Ledgar, referred Members to page five of the minutes of the FIP Committee meeting held on 15 May 2013, paragraph seven under the heading Business Development Update and asked for information in future with regard to the tenders that have been awarded, pending or unsuccessful. The Chief Executive Officer confirmed that the details of tenders submitted by the Trust will be included in future Chief Executive Officer reports. The Chairman thanked the Director of Finance & Resources for the report. Members of the Trust Board: Noted the approved minutes of the FIP Committee meeting held on 15 May 2013; Noted the business covered at the recent meeting of the FIP Committee held on 19 June 2013; Gained assurance from the FIP Chair s summary report as to the on-going business of the Committee and its effectiveness in discharging its terms of reference and cycle of business. Quality Governance Committee (QGC) Non-Executive Director, David Pearson, provided an update and over view of the actions and business of the recent meeting of the QGC held on 12 June He gave apologies that his report referred to the minutes of the meeting held on 14 Page 12 of 26

15 Enc 01 May 2013, however that the minutes of the meeting held on 10 April 2013 had been included with the report in error. Non-Executive Director, David Pearson, presented the key points of the report including a service review deep dive into the Safeguarding Adults adult protection process. He informed Members that the deep dive was carried out as a result of concerns raised by both the Audit Committee and the QCG into the increased number of referrals to the MASH and Safeguarding Adult Protection Investigation Team (SAPIT); and the impact on the operational teams undertaking investigations. Non-Executive Director, David Pearson, reported that the Commissioner for Safety, County Commissioner Adult Safeguarding, and the MASH Development Officer presented an overview to the QGC of the development of the MASH; it was established to enable the sharing of information amongst agencies in a safe, secure and proportionate manner with the intent of mitigating risks to vulnerable adults and children; to develop and implement a whole family approach to adult safeguarding, with enhanced and early risk assessments of vulnerable persons and families which triggered action by the relevant agency. Non-Executive Director, David Pearson, gave feedback to Members on the consensus of the service review and confirmed that a full report of the review will be presented to the next meeting of the QGC meeting. Non-Executive Director, David Pearson, referred Members to the Quality Account at enclosure eight and reported that the document is the second draft and was being presented to the Trust Board for approval for publication. Non-Executive Director, David Pearson, informed Members that he is encouraged with the first draft of the quality dashboard and that members of the QGC are working with the Associate Director of Quality and her team to refine the same; it will provide a snapshot of quality and areas requiring improvement. The Chief Executive Officer confirmed that the identification of risk, principally, the increase in adult safeguarding incidents and referrals to the MASH and SAPIT; and the follow up by way of the Service Review at the Quality Governance Committee; together with the actions taken to address the risk were a positive example of good governance within the Partnership Trust. He informed Members that it is important to communicate this and other similar examples to front line staff. He asked the Director of Nursing & Quality to draft personal letters to staff from him. SH The Chairman referred Members to the actions from the service review as listed at the top of page two of the report and asked what the next steps are to ensure that actions are completed. The Director of Nursing & Quality informed Members that the Associate Director of Nursing and the Professional Lead for Social Work are working with the MASH and will report back progress, initially to the next meeting of the Quality Governance Committee and then to the Trust Board. SH Non-Executive Director, David Pearson, informed Members that plans are in place for the sub groups and committees of the QGC to report back on a quarterly basis instead of monthly. The Chairman thanked David Pearson for the report. Page 13 of 26

16 Enc 01 Members of the Trust Board: Noted the Chair s report on the current business of the Committee and as raised at its meeting on 12 June 2013; and Noted that minutes of the meeting of the Committee of 14 May 2013 would be presented at the next meeting of the Board Corporate Risk Register The Company Secretary presented the Corporate Risk Register for review and note of the updated risks incorporated on to the Register, following the meeting of the Executive Risk Management Committee held on 10 June The Company Secretary requested that Members take assurance that the reported risks are the subject of risk controls and actions to mitigate the residual risk reported on the Register. The Company Secretary reported that all Executive Directors undertook a review of the corporate risks where they are identified as the lead Director, providing assurance that all actions are in place, with supporting evidence of completion, and that timelines for the implementation of actions to mitigate and/or minimise risks had been reviewed and revised (where appropriate). The Company Secretary informed Members that the legacy risks from the preceding year (2012/13) have been de-escalated from then Corporate Risk Register and a full refresh of the remaining legacy risks has been undertaken. She reported that three new risks have been escalated on to the Corporate Risk Register and one risk de-escalated. The Chairman thanked the Company Secretary for the report. Members of the Trust Board: Noted the updated version of the Corporate Risk Register in the form appended to the report; Noted the actions that are being taken to manage the reported risks; Received assurance that risk is a standing item for each Committee and Sub-Committee of the Trust Board Assurance Report Annual Governance Statement The Company Secretary presented the Annual Governance Statement for 2012/13, as reported to the Audit Committee on 17 April 2013, for approval before referral to the National Trust Development Agency. The Company Secretary informed members that a review of the significant issues reported in the Statement has been undertaken and the report gives assurance to the Trust Board that all actions have been implemented or that implementation is in progress. She informed Members the relevant actions have been assigned to a Director lead and principal Committee of the Trust board so that there is both executive and non-executive oversight and scrutiny of the completed actions and evidence in support of completion. The Company Secretary informed Members that the Statement gives overall assurance that there are sound systems of internal control and that individual responsibilities of the Chief Executive Officer, as the Accountable Officer for the Trust, have been discharged. The Company Secretary referred Members to the issues of significance listed under Key Points on page one of the report; and informed Members that the control weaknesses, reported in the Statement, have been incorporated into the Board Page 14 of 26

17 Enc 01 Assurance Framework 2013/14, that will be reported to the Audit Committee on 12 July The Chairman thanked the Company Secretary for the report. Members of the Trust Board: Noted the assurance report which provided assurance that all significant issues reported in the Annual Governance Statement for 2012/13 had been addressed; and Noted that the Quarter 1 review of the Board Assurance Statement 2013/14 will review the actions taken to address the control weaknesses reported in the Annual Governance Statement for 2012/ Annual Risk Management Report The Director of Nursing & Quality presented the Risk Management Annual Report the mechanism for measuring the progress that has been made towards achieving the strategic goals and objectives within the Risk Management Strategy. The Director of Nursing & Quality informed Members that the report presented the achievements and progress of the Risk Management Strategy and Policy over the 2012/13 financial year. The Director of Nursing & Quality presented the following key points of the report: Board Assurance Framework process presented to the Audit Committee three times a year. Audit Committee members were satisfied that the current process secures an audit overview and scrutiny of the controls and assurances described in the Board Assurance Framework; aligned to the work plan of the internal auditors and Audit Committee cycle of business. Internal Audit carried out a review of the Assurance Framework and Risk Register processes during 2012/13. The subsequent report identified that there has been a significant amount of work undertaken building on the governance arrangements in place, to provide more of a consistent approach. Executive Risk Management Committee fully established and reviews the Corporate Risk Register on a monthly basis. Committee ensures that monitoring of the Register is robustly documented and ensures that the Trust Risk Register is updated accordingly. NHS Litigation Authority (NHSLA) Risk Management Strategy and Policy (and a suite of further policies) were submitted as part of the NHSLA Risk management Standards assessment in May The policies achieved level 1 of the NHSLA Risk Management Standards. The Chairman thanked the Director of Nursing & Quality for the report. Members of the Trust Board: Discussed and noted the contents of the report; Noted the actions being taken for 2013/ Quality Report The Director of Nursing & Quality presented the report to Members to give an update on the experience, safety and clinical effectiveness of users and carers during May 2013; to provide assurance of experience, safety and effectiveness outcomes, which have been analysed; and actions taken to improve or mitigate the outcomes. Page 15 of 26

18 Enc 01 The Director of Nursing & Quality informed Members of the key points of the report around patient safety, patient experience and effectiveness. The Director of Nursing & Quality informed Members that the total number of incidents reported has decreased and the total number of incidents with harm has increased. She informed Members that this relates to the number of patients that have returned to the University Hospital of North Staffordshire (UHNS) after a short period of time in a community hospital. The Chairman asked how long patients have been in the care of the community hospitals before they return to UHNS. The Director of Nursing & Quality informed Members that on occasion patients have been sent to community services too early and can be in a community hospital for only forty eight hours. In these cases, she confirmed that patients would not have been ready to leave acute care. She informed Members that she meets regularly with the Director of Nursing and Medical Director at UHNS to discuss the reasons for this and confirmed a spectrum of issues including: the acuity of the patient resulting in the need for that patient to remain in an acute care setting; differences of clinical opinion; the capacity of the out of hours service; and medical staff not always on duty during the night. She informed Members that medical issues are raised with the Partnership Trust s Medical Director and fed back to colleagues at UHNS. The Medical Director agreed and informed Members that some of the clinical decisions made at the acute setting result in inappropriate discharges of patients into a community setting. He also informed Members that some patients do have to return to an acute hospital for tests. Non-Executive Director, Prof Roger Evans, asked who identifies patients to be discharged from the acute settings. The Director of Nursing & Quality reported that in the North Division a Partnership Trust Nurse works at UHNS to identify sub-acute patients to be discharged. The Medical Director confirmed that patients are not always step down patients but sometimes step across patients. Non-Executive Director, Dr John Scarpello, confirmed that the figures relating to the number of incidents are useful and should be used when working with partner organisations to reduce the number of inappropriate discharges from an acute setting to community services. The Chief Executive Officer reported that the number of patients turned down by community hospitals is very small; the reasons for refusing to admit a patient into our care are principally clinical i.e. the patient needs to remain in an acute setting until they are fit for discharge into our care. He confirmed that community hospitals do need support to manage the effective discharge of patients from acute hospitals during the evenings; that the agreed discharge processes should be adhered to consistently by community hospitals; and that the problem can lie with late discharges with a discharge being agreed from an acute setting in the afternoon, resulting in an evening discharge for the patient. He reiterated that the Board had agreed that evening discharges were inappropriate and that we must be seen to be supporting staff to make the right decisions. Non-Executive Director, David Pearson, welcomed the 76% increase in the number Page 16 of 26

19 Enc 01 of compliments received in May The Chief Executive Officer informed Members that compliments received to the Trust are publicised in the Trust s weekly newsletter. Non-Executive Director, David Pearson, referred Members to point 4.0 Mortality Review Group on page twenty of the report and raised concern of the lack of engagement of medical staff working in the community hospitals as members of the Mortality Review Group. The Medical Director assured Non-Executive Director, David Pearson that medical staff are being encouraged to join the Group and have been contacted to request attendance. Non-Executive Director, David Pearson, further asked that in relation to Inquests whether active review of the outcomes of an Inquest and feedback is taking place. The Director of Nursing & Quality confirmed that prior to inquests she and the Company Secretary meets with the team involved, so as to provide support and to develop an action plan and evidence pack to demonstrate what has been put in place to-date. The Chairman asked for assurance that issues relating to the Central Booking System in the South Division have been resolved. The Director of Nursing & Quality confirmed that there have been a number of issues including the introduction of a telephone system; it did not have the capacity to take the number of calls received. She confirmed that a new system will be in place w/c 24 June The Chief Executive Officer informed Members that the implementation of change for the service was not handled well. He confirmed that he has spoken to a number of staff working in the service and that a review will be undertaken once issues have been resolved. The Chairman expressed concern about the time it has taken to resolve the issues and asked for an early resolution. The Chairman sought an assurance that the Partnership Trust is participating in National Audits and whether our participation is proportionate to the benefits to be derived from such audits. The Director of Nursing & Quality confirmed that there has been a period of reflection in relation to which audits the Trust participates in. The Chairman referred Members to page two of the report, sixth paragraph under the heading of Effectiveness and asked what the Commissioning Delivery Hub (CDH) is. The Director of Nursing & Quality confirmed that the CDH was previously the Joint Commissioning Unit at Staffordshire County Council. The Chairman referred Members to point 1.1 NHS Safety Thermometer Harms first paragraph, and asked if the four key themes: pressure ulcers; falls with injury; catheter acquired UTIs; and Venous Thromboembolism; within community hospitals and community nursing services; will be reviewed and changed. Page 17 of 26

20 Enc 01 The Director of Nursing & Quality confirmed that the themes are now set nationally and will not be changed. The Chairman referred Members to page seven of the report, point 1.2 Incidents identified at the point of transfer to Partnership Trust care and asked how the Trust ensures that discharge from acute or community hospitals to patients homes is appropriate. The Director of Nursing & Quality confirmed that if patients continue to receive care in their homes that this would be identified by the nursing services; some individuals will also have a domiciliary care package and a care plan in place, any issues in relation to their care in a Care Home setting would be picked up through the adult safeguarding route. Non-Executive Director, Dr John Scarpello, confirmed that local data will inform such monitoring. The Director of Nursing & Quality confirmed that a Practice Audit Programme will be presented to the QGC meeting to be held on 16 July The Chairman asked the Director of Nursing & Quality to consider his point and how this can be captured in the future. SH Non-Executive Director Designate, Andrew Talbot, asked for assurance that action plans are in place for podiatry surgery patients. The Director of Nursing & Quality reported that arrangements have been made for the service to be delivered at another setting and that patients are being dealt with by the Patient, Advice and Liaison and Complaints teams. The Director of Nursing & Quality closed by confirming to Members that the net promoter score for May 2013 is an increase from the previous month. The Chairman thanked the Director of Nursing & Quality for the report. Members of the Trust Board: Noted the contents of the report; Gained assurance that systems and processes are in place to identify patient safety, service user/carer experience and clinical effectiveness for the Trust; and that all areas are being managed appropriately along with implementation and improvement plans to address lessons learnt Quality Account 2012/3 The Director of Nursing & Quality presented the Quality Account for 2012/13 and informed Members that it has been produced in line with statutory requirements and national guidance. She reported that the draft text was shared with local partners including Healthwatch, the local overview and scrutiny committees and with commissioners; and furthermore that the Trust has consulted with other stakeholders on the content. She confirmed that the formal consultation period ended on 30 May The Director of Nursing & Quality informed Members that the final Quality Account will be published on the Trust website, on the NHS Choices website and presented to the Secretary of State by 30 June The Chairman thanked the Director of Nursing & Quality for the report and asked if the Quality Account will be available for attendees at the Trust s Annual General Meeting (AGM) to be held in September Page 18 of 26

21 Enc 01 The Director of Nursing & Quality confirmed that it will be available at the AGM. She confirmed that all relevant Executive Directors have signed the Statement of Directors Responsibilities within the document. Non-Executive Director, David Pearson, confirmed that draft versions of the Quality Account have been presented to the QGC and asked if a short summary of the document can be produced for staff. SH The Chairman agreed that a summary for staff would be useful. Non-Executive Director Designate, Andrew Talbot, asked if the piece relating to the Trust Staff Excellence Awards can be moved towards the front of the document. The Director of Nursing & Quality informed Andrew Talbot that the areas at the front of the report were prescriptive and the order cannot be changed. The Chairman thanked the Director of Nursing & Quality for the report. Members of the Trust Board approved the Quality Account for 2012/ Mid Staffordshire NHS Foundation Trust Public Inquiry Response Update The Director of Children s Service presented a report to Members to appraise them of the progress of the coordination of the Trust s response to the Mid Staffordshire NHS Foundation Trust (MSFT) public inquiry report published on 6 February The Director of Children s Service confirmed to Members their endorsement at the Trust Board meeting on 24 April 2013 to the proposed methodology for the staff listening events as an essential component of the Trust s response. The Director of Children s Service reported that he has met with colleagues and members of the Organisational Development Team to explore how the listening events may support and reinforce existing and planned staff and public engagement events; and how the results of the staff listening events will be fed back and acted upon across the organisation. The Director of Children s Service reported that further discussion has taken place with the Leadership Team to promote awareness and gain leadership support for the listening events. He informed Members that feedback from the events will be fed into a series of fourteen focus groups that will be led by Members of the Trust Board. The Director of Children s Service informed Members that key themes will be identified from the listening events and will be provided to Members to assist in the delivery of the focus group sessions. The Chairman thanked the Director of Children s Services for the report. Members of the Trust Board: Noted the report; Received an update on progress on the staff listening events and focus groups and the next steps in implementing the recommendations of the Public Inquiry into Mid-Staffordshire NHS Foundation Trust. Page 19 of 26

22 Enc Finance Report The Director of Finance & Resources presented the Finance report for May 2013 of the 2013/14 year. He reported that the Trust is reporting an actual deficit of 876k; this is higher than planned due to the delays in implementing the CIP schemes for the year and that these must gather pace, failing which the Trust was at risk of not achieving its CIP target; and that the Trust s financial position fell short of planned performance by 0.369m. The Director of Finance & Resources confirmed that the Cost Improvement Programme (CIP) targets (with the exception of Adult Social Care) have not yet been devolved to divisional budgets with a number of schemes scheduled to go through Quality Impact Assessment panels in June and July The Director of Finance & Resources reported the year to date performance includes an underachievement against the original CIP of 547k. The Director of Finance & Resources reported cash balances of 31.4m - 0.4m ahead of plan and a financial risk rating of 1 against a plan of 3. The Director of Finance & Resources reported the following financial risk: Year to date score of 2.75 against plan of 3.60, this was due to achievement of 13.2% of EBITDA target and I&E surplus margin of -1.4%. The Director of Finance & Resources noted the additional risk factors reported to the Board by way of exception with compliance against 8 out of 11 with planned compliance with debtors by quarter one; creditors quarter two; and capital expenditure by year end. The Director of Finance & Resources presented the following statement of comprehensive income: Total planned income for the year 367.0m: Forecast surplus of 3.795m in line with plan; Achievement of 3.795m is challenging in light of performance against CIP to date; Included in the year to date position is 0.547m shortfall on CIP which is expected to be identified and a report will be made to the Trust at the earliest opportunity when this shortfall is identified. The Director of Finance & Resources informed Members of the current risks and opportunities: growing demand and prices; delivery of the 20.4m CIP this year and the need to bring additional schemes on line to bridge the current CIP gap of 5M and reported the following operational performance: North division overspend 0.026m; South division overspend 0.221m; Adult Social Care overspend 0.133m; Corporate Functions underspend 0.186m CIP under achievement 0.547m; Service Level Agreement Income over recovery 0.372m. The Chairman asked the Director of Finance & Resources the reason why the Trust does not pay its creditors in a timely manner. Page 20 of 26