MAIDSTONE & TUNBRIDGE WELLS NHS TRUST TRUST BOARD. Minutes of the Meeting held on Wednesday 27 August 2008, Room 105/106, Maidstone Hospital

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1 MAIDSTONE & TUNBRIDGE WELLS NHS TRUST TRUST BOARD Minutes of the Meeting held on Wednesday 27 August 2008, Room 105/106, Maidstone Hospital PRESENT: IN ATTENDANCE: Mr G Jenkins (Chair) Mrs S Denton, Non-executive Director Mr K Tallett, Non-executive Director Mr P Wynn-Owen, Non-executive Director Mr T Jones, Non-executive Director Mr G Douglas, Chief Executive Mr P Turner, Finance Director Ms F Panel-Coates, Director of Nursing Ms N Luffingham, Chief Operating Officer Mr J Lewis, Medical Director Mrs C Edwards, Chief Nurse Mr G Goddard, Estates Development Director Mr T Coode, Human Resources Director Dr S Mumford, Director of Infection Prevention and Control Mrs C Moysey, Staff Side Chair Ms J Chadwick-Bell, Service Improvement Director Ms W Glazier, Matron, Surgery (Agenda Item 076/08 only) Ms H Thomas, Matron, Women s & Children s (Agenda Item 076/08 only) Ms J Butler, Matron, Medicine (Agenda Item 076/08 only) Ms J Pullen, Matron, Infection Control (Agenda Item 076/08 only) Ms C Roberts, Head of Quality and Governance Mr P Kenmore, Hayes Group (Observing) Mrs G Spinks, Corporate Business Manager (Minutes) A quorum being present, the Chairman declared the meeting open. It was noted that the meeting had been validly convened in accordance with the Trust s Standing Orders. The Board declared their interests in the items for discussion and confirmed that they had no pecuniary interest, direct or indirect, in the items for discussion, but acknowledged that they were to be regarded as interested generally in the matters to be discussed in the meeting. 070/08 WELCOME MEMBERS OF THE PUBLIC The Chair welcomed the members of the public who were present at the meeting. 071/08 APOLOGIES Ms D Harker, Non-executive Director Mr F Sims, Corporate Development Director The Chairman took the opportunity to welcome Ms Flo Panel-Coates who has been appointed to the substantive post of Director of Nursing. George Jenkins thanked Christina Edwards for the work done during her time at the Trust as Interim Chief Nurse. 1

2 George stated that the Trust was entering a new era and that it should do so with Heads held high recognising that there are still issues and problems to be addressed and resolved. 072/08 MINUTES OF THE LAST MEETING The Minutes of the 28 May 2008 were reviewed. Page 6, agenda item 059/08, third last paragraph: for clarity penultimate paragraph to read The Board were advised that the Trust currently has 72 vacancies out of 472 theatre staff. The minutes were then accepted as a true and accurate record of the meeting. The Minutes of 16 June 2008 were reviewed and accepted as a true and accurate record of the meeting. MATTERS ARISING and SUB-COMMITTEE REPORTS The Board were advised that the Trust is in receipt of an unqualified audit opinion. Terry Coode advised that appraisal data, broken down by Directorate, had not yet been circulated to members. T Coode George Jenkins advised that the date of his departure from the Trust has been deferred. Terry Coode advised that length of service of staff departing the Trust is not yet available. In relation to readmission data the Board requested at 14 day data be presented in future reports. Sylvia Denton advised that she had not yet met with Jim Lewis and Christina Edwards in order to gain an understanding of ongoing claims and potential claims against the Trust. T Coode N Luffingham S Denton The Board were advised that the Trust will hold stocks Personal Protective Equipment. These stocks will be in place by November. The Board were asked to note that there will be a table top exercise on 28 September in relation to Influenza. This will be an all day event attended by the Chief Executive, Chief Operating Officer, Director of Infection Prevention and Control. Kevin Tallett offered to meet with Nikki Luffingham, Chief Operating Officer and Julie Elphick, Emergency Planning Officer, ahead of the day. Audit Committee In the absence of Denise Harker, Chair, Audit Committee, the Board received and noted a written report of the meeting held on 5 August. 2

3 There was nothing to report from either the Quality & Safety Committee Chair or the Remuneration Committee Chair. 073/08 CHAIRMAN AND NON-EXECUTIVE DIRECTORS REPORT The Chairman stated that it is almost one year since he started work in the organisation, and that it has been a very challenging time, which has challenged all of his personal experience. George stated that he believed that significant strides have been made to change how patients are treated but that there is still a long way to go. George reminded those present that for the first time since he joined the organisation the Board and Executive team was now complete and was taking full ownership of the patient experience, journey and care. George stated that it was important that the Trust remember to communicate its successes. The Chairman advised that Tony Jones, Non-executive Director, has agreed to hold the post of Deputy Chair. Tony will be spending more time in the organisation. The Non-executive Directors advised that there was nothing to report. The Board noted this report. STANDING ITEMS 074/08 Chief Executive s Report Glenn Douglas reiterated the Chairman s thanks to Christina Edwards and formally recorded the Trust s thanks to Morfydd Williams for her hard work as ICT Programme Director. Glenn stated that Morfydd had laid in place the foundations for a better IT infrastructure upon which the Trust can build. Saving Lives/Hygiene Code Glenn reminded those present of the Trust position of zero tolerance of avoidable Hospital Acquired Infections and that in order to achieve this infection control has to be at the top of everyone s agenda. Glenn reminded the Board that everyone should comply with the Trust dress code that requires staff to be bare below the elbows, no wrist watch, no rings other than a plain wedding band. New Hospital Development, Pembury Glenn stated that the outline shape of the new hospital should be complete by the end of the year. Four tower cranes are now on site. The Trust now needs to focus on everything else the organisation needs to be in preparation for Clinical Strategy Day Glenn advised the Board that he had been impressed by the commitment of clinical staff who gave up their time to attend the half day seminar at the East Malling Research Centre. The Board were 3

4 reminded that the new hospital forms only part of the Trust strategy and that the Trust must decide what business we are actually in, e.g., the ologies, what is appropriate for the Trust to deliver? Glenn advised that there will be a further day held to discuss what sort of organisation do we need to be to deliver the proposed strategy. Governance Structure Glenn advised that the Trust is now almost 1 year on from when he was first approached to join the organisation, and that during that year the Trust has been focused on fire-fighting. Glenn stated that the time is now appropriate to move the organisation forward to a more sustainable governance structure, with a clear focus on Patient Experience. Performance 18 Weeks Glenn advised that the organisation has made great strides towards improving performance, particularly in relation to the 18 week referral to treatment target and that this is having a very real impact on improvement in patient care. The Board noted this report. 075/08 Integrated Performance Report including Patient Safety and Experience Report Nikki Luffingham advised the Board that the Trust had had a positive month and that the report presented was for the month of July. Nikki stated that in respect to the 18 Week Referral to Treatment target the operations team had taken some time to create a new mindset but that this work was proving effective with the waiting list backlog reducing from 1,000s of cases to around 700. Nikki advised that Trauma & Orthopaedics remains an outlier, predominantly as a result of capacity issues and that there is a large amount of outsourcing occurring in this speciality. The Board were advised that operationally the Trust is currently subject to a weekly performance meeting with the Strategic Health Authority and Primary Care Trust, that there is a weekly performance monitoring telephone call with the Department of Health and that a Department of Health support team are visiting the Trust on a monthly basis. July saw the first rolling month attainment of the Emergency Access 4 hour target although this performance has slipped again as a result of having to close a ward at Kent & Sussex Hospital in order to comply with the Healthcare Commission cleaning plan. The revised trajectory has revealed that the Trust is unable to achieve the 98% performance target with a ward closed. The Board were advised that the Trust currently has 40 beds being utilised at the Kent & Sussex Hospital by non-acute patients, e.g., neuro-rehabilitation patients. The Trust is working with Primary Care Trust colleagues to move these patients into a more appropriate setting and release the beds back into the system for acute patients. 4

5 The Board were specifically asked to note the year to date increase in GP referrals of 3.4% compared to April to June 2007/08. Referrals to Trauma & Orthopaedics are currently up 12.8% on the same period. The Trust 14 day readmission rate to the same speciality is 3% against a target of 4.3%. There has been further improvement in relation to cancelled operations. July saw a 1.4% cancellation rate for non-clinical reasons. However, the Trust will be unable to achieve the Healthcare Commission target of 0.8%. The Board were advised that the Trust is an outlier in respect to DNA rates. The Operations team are investigating methods of improving this position such as telephone calls the day before admission. The Board were advised that the Trust theatre utilisation rate fell in July to 71.4%. The Board requested that the subject of Theatre Utilisation be brought back to Board for fuller discussion and debate in September. N Luffingham Paul Turner presented the financial position and asked Board members to provide him with feedback in relation to the new format of appendices to the report. Paul advised the Board that the Trust is not yet in a position where it is able to provide service line reporting. In relation to the current financial position Paul advised that as at Month 4 the Trust is reporting a deficit of 1.4m. Paul stated that, in his opinion, it is highly unlikely that the Trust will achieve a year end position of breakeven, that the likely position would be 3.8m deficit and that this is dependent upon the Trust being in receipt of 11.5m additional funding from the local health economy Strategic Investment Fund. Paul advised the Board the Trust was working in conjunction with the Primary Care Trust to develop an action plan to achieve year end breakeven. Once the Trust and Primary Care Trust evidence that everything possible has been done to facilitate a year end breakeven position and this proves to be not possible only then will the Strategic Health Authority accept a revised deficit forecast position. In relation to the issue of accelerated depreciation of the Kent & Sussex site the Board were advised that this is totally outwith the Trust control and could impact the bottom line position. The Board were asked to be aware of the issue and be advised that the Trust is working with external auditors to agree a position. In relation to activity/income levels Paul Turner advised that there appear to be shortfalls in relation to elective services, this is based on the assumptions made in relation to the required activity to delivery the 18 week referral to treatment target. In reality the 18 week target is being delivered through lower levels of activity than anticipated. Paul further advised that there is a shortfall of non-elective activity potentially as a result of GP fund holder influence. Sara Mumford advised the Board that in relation to MRSA June and July had not been good months with 6 cases reported against a trajectory of 4. This puts the Trust 2 cases above trajectory for the year 5

6 to date. However in relation to Clostridium Difficile the Trust is performing at below the 2010/2011 trajectory target and below national average. There have been no infection outbreaks or ward closures for 3 months. Sara advised the Board that new infection control policies are currently being completed and will be implemented within the organisation after approval. The Board were advised that improved signage would soon be in place a door and ward entrances in relation to hand hygiene. Sara reminded those present that hand hygiene is important to everyone, staff, patients and visitors and that the alcohol gel is more efficient than soap and water unless in an outbreak situation. Patients and visitors should be encouraged to challenge those treating them to ensure that they have washed/gelled their hands. In relation to patient safety Jim Lewis advised that it is currently very difficult to identify trends. However, the CLIP group has just been reestablished and will identify trends and make recommendations for action. Over 3,500 trust staff have attended the mandatory Saving Lives/Hand Hygiene training sessions. There will be more session run in October. In respect to complaints the Board were advised that a new process came into effect in June. Communication appears to be a major issue. The Board were advised that the Customer Service department is under pressure. The department is being reviewed. An update will be provided to the next meeting. F Panel- Coates The Board noted this report and the actions being undertaken. 076/08 Nursing Standards Update Christina Edwards delivered a presentation to Board (copy attached). Christina stressed the importance of nurse leadership at the top of each of the Divisions and advised that the Trust now has 24 matrons, including 2 elderly care matrons and a vulnerable adult matron. New uniforms will soon be issued to matrons in order they are clearly identifiable to patients, visitors and other staff members. Christina reminded those present that quality of patient care and experience is now high on the Board agenda. Christina advised that the nursing establishment was being rebased into ward and non-ward based establishment. Christina stated that it is important that the Trust continue to recruit to substantive posts. The Board were advised that the recently approved self-rostering system will enable ward managers to ensure that wards are staffed with those who have the right skills mix to provide the appropriate level of care to the patients on the ward. 6

7 Christina advised that she has had a good experience whilst working on wards, that talking to patients first had has been extremely helpful, and that during the time spent on wards a number of audits have been carried out the results of which were used to inform the nursing standards key performance indictors. Christina identified three barriers/risk to change: Balance of new/experienced skilled staff on wards; Environmental issues e.g., old wards, layout, space; Development of whole Team approach to patient care. Christina stated that although there have been improvements in patients care and experience there is still further work to do. The development of ward managers is pivotal to ensuring that nurses receive support and training and are happy at work. The Board were asked to note that accommodation costs for nursing staff is an issue, the South East is expensive and nurses are attracted to working in London where London weighting payments are made. The Non-executive Directors advised that they were very impressed with the enthusiasm of ward staff, that morale appears to be improving, and that there is evidence that things are getting better. It was stated that there is a positivity from the nurses and a real will to change things for the better. A sense of pride is returning to the workforce. The Non-executive Directors stated that it is important that they get out onto wards, talk to staff and patients in order that they gain assurance that the improvements reported at Board are actually evidenced at ward level. The Non-executive Directors stated that they welcomed honest two way dialogue and encouraged the Matrons present to advise their colleagues of this. The Board thanked Christina for the presentation and her work in the Trust and noted that there is still more work to do in order to get it right as far as possible all of the time. 077/08 Healthcare Commission Action Plan Update Christina Edwards advised that the Trust has completed the Hygiene Code self assessment evidence for which has been cross referenced to the Healthcare Commission Action Plan and the Annual Healthcheck Core Standards. The Strategic Health Authority and West Kent Primary Care Trust will be revisiting the Trust on Friday 29 August to review the evidence and identify any gaps. The Board were assured that all evidence will be in place by end September. A stocktake against the action plan will be completed in October. The Board noted the report. F Panel- Coates 7

8 078/08 Annual Health Check Update The Board were advised that the Trust has taken a better, systematic approach to the Annual Health Check Self Assessment and will only declare compliant against a standard when evidence is in place and not before. A stocktake of the position will be undertaken in October. The Board noted the report. F Panel- Coates 079/08 Governance Structure The Board were presented with details of the new system of governance proposed for the organisation. After discussion the proposal was agreed. All Committee Chairs were requested to review and agree Terms of Reference at the first meeting and to formally agree a Deputy Chair of each Committee. The Chair and Chief Executive agreed to meet and review the requirement for Non-executive Director Champions. All Committee Chairs G Jenkins/ G Douglas With regard to the Joint Strategic Programme Board those present were assured that the Trust retains sovereignty, that the Trust Chief Executive remain the Accountable Officer. The Joint Strategic Programme Board is an advisory body for the Trust Chief Executive. Board members requested that a schedule of Committee meetings be published for 2009 as soon as practicable. G Spinks The Board approved the new system of governance and noted the report. 080/08 Service Reconfiguration Surgery and Trauma & Orthopaedics The Board were reminded of the full discussions held around the issue of the proposed Surgery and Trauma & Orthopaedics service reconfiguration at the last meeting and the fact there at the time there were a number of issues still outstanding. The Board were reminded that the West Kent Primary Care Trust is the decision making body and that the proposals have now been presented to that Board and approved. The Trust proposed a go-live date of May Paul Skinner reminded the Board that there is nationally a difficulty in recruiting junior grade doctors and that in relation to Trauma and Orthopaedics if the Trust failed to proceed with the reconfiguration between 8 to 12 additional junior doctors would be required on each site in order for the Trust to be compliant with the European Working Time Director and New Deal. Philip Bentley advised that there will be problems in General Surgery and that the Trust is looking abroad to recruit suitable doctors. Philip reminded the Board that the clinicians believe that reconfiguration will lead to better quality experience and outcomes for patients and that if the reconfiguration is not approved the Trust will fall behind 8

9 neighbouring Trusts who have already reconfigured. The Board concurred that the reconfiguration was required. The Board considered two options in relation to the provision of middle grade cover. The Board approved the option presented as Option 2, agreed the proposed go-live date, May 2009, and check-date of January /08 Darzi Review In the absence of Frank Sims Glenn Douglas presented the paper. Glenn advised that the Darzi next stage review provides a focus on quality of care and a recognition that management and priorities were previously too focused on targets. Patient choice needs to be at the forefront of what we do. Glenn stated that as a Trust we need to get the Planned Care Office and Appointments systems right, we need to recognise who the Trust customers are, e.g., Patients, GPs., we need to provide good quality, accurate and timely information. Glenn advised the Board that the newly constituted Patient Experience Forum will be a key source of assurance for the Board and will enable the Trust to get patient and public involved in redesign at an early stage. The Board noted the report, the potential actions outlined and agreed the priorities of service quality and patient experience. 082/08 Kent Health Watch The Board were advised that Kent County Council will be launching Kent Health Watch in September 2008 and that the Trust will have representation on the policy Board. It is the Trust intention to make the Kent Health Watch seamless with our own processes and systems. Kent County Council will use data gather to inform the Health Overview and Scrutiny Committee. The Kent Health Watch will gather statistical data only, not patient specific data. The Board noted the report. 083/08 Assurance Framework and Risk Register The Board were asked to review the Assurance Framework for 2008/09 and were advised that a number of the Amber risks will not be able to be regraded until after the final Healthcare Commission inspection visit and report. The Board were assured that risk is taken seriously by the organisation and that the number of Board level risks has been reduced as action plans have been worked through, delivered, completed and risks closed. The Board were advised that red risks would be brought to Board for F Panel- 9

10 discussion and debate as to the appropriate course of action to be taken. The Board approved the assurance framework and risk register and requested that a summary be provided of risk review dates missed and the reasons behind such failing. The Board also requested that risks older then 1 year be highlighted and that a process chart be circulated. Coates F Panel- Coates 084/08 Health & Safety Policy The Board were advised that the Health & Safety Policy was presented for approval. The policy has been reviewed and updated to reflect the revised management and governance structures of the Trust. The Board requested that page 7 section 2.6 be amended to read: Each Divisional Director will have Associate Directors of Operations and Associate Directors of Nursing Services. These will also have responsibility for health and safety and risk within their Division. F Panel- Coates The Board requested that the Trust environmental policy be integrated into the Health & Safety Policy at the next review. Subject to the amendment cited above the Policy was approved. 085/08 Health & Safety Executive Visit The Chairman advised that the Health & Safety Executive have advised the Trust that there is insufficient evidence to carry out a full criminal investigation into the Clostridium Difficile deaths at the Trust. The Health & Safety Executive will be undertaking a three day inspection visit and audit on 2, 3 and 4 September focusing on how the Trust protects people and patients with particular emphasis on infection control. 086/08 Questions from the Public Mr Grant presented four questions to the Board: Q1. Proposed changes to orthopaedic and general surgical services Once details have been clarified, could it be made clear to the public exactly what effect the reconfiguration and later the opening of the new Pembury Hospital will have on the Maidstone A&E Department? The Board s papers and those of the Primary Care Trust make many reference to the European Working Time Directives, as do Lord Darzi s proposals. These directives seem to be a major driver of the reconfiguration changes yet the public have been given virtually no information about them. Could the Board produce a short paper clarifying this issue? Is the New Deal, whatever that means, part of this? A1. A timeline of effect, if any, the reconfiguration of orthopaedic and general surgical services will have on the Maidstone A&E Department will be presented at a future meeting. F Sims 10

11 Terry Coode will prepare and present a paper in relation to the European Working Time Directive and its impact on the patient environment. T Coode Q2. Hospital Infections To what extent are patients screened preadmission and on admission for MRSA, Clostridium Difficile and other infections? The Assurance Framework paper, at 1.4 on page 4 of 8 suggests cohorting all Clostridium Difficile patients at Maidstone. From a patients point of view, would it not be advisable also to have a facility at the Kent & Sussex, so that relatives from that part of the area can visit more easily? Is the Board satisfied that users, particularly visitors are fully aware of the different circumstances to use soap and water or alcohol gel? Also is it advisable to cleanse hands on leaving wards and the hospital? A2. Currently the Trust screens for MRSA at pre-admission clinics. However this is not routinely done for elective procedure day cases. By the end of September all patients bar Ophthalmology day cases will be screened. In relation to cohorting of patients the facility at Maidstone was established when the ward previously used at Kent & Sussex was closed for refurbishment. The staff on the ward at Maidstone (Whitehead) have specialist skills in relation to treatment of infection control. Patient and visitor feedback has been very positive. The Trust provides assistance with transport for visitors where there is a need. With regard to hand cleaning the Trust encourages everyone to clean their hands on leaving as well as entering the hospital and clinical areas. On the cohort ward hand should be gelled on the way in, hand should be washed with soap and water before gloves, aprons, etc., are donned and again on removal. Signage is being improved, particularly at the rear hospital entrance. Q3. Lung Function Tests I understand that the necessary equipment is available at Maidstone Hospital. Would it be possible to offer this service at the hospital? A3. While the equipment is at Maidstone Hospital negotiations are currently on going with the Primary Care Trust in relation to funding of such a service. The Primary Care Trust currently commissions this service to be carried out in two locations, Ashford and East Grinstead. The Trust wishes to provide this service at Maidstone. Q4. Patient Feeding What progress has been made on the consideration and introduction of a Red Tray service, to clearly identify patients who need special assistance with eating? A4. Discussions are ongoing with the Head Dietician in relation to patient feeding. 300 volunteers are being trained to assist with feeding and monitoring of patients. It is proposed to commence roll out via the productive ward programme. Mr Grant concluded by requesting that fewer acronyms be used in the 11

12 production of Board and other papers to be made available to the public. All Mr Denis Fowle, Downs Mail, asked if all members of the Board were aware of the resistance amongst Maidstone residents in relation to the proposed service moves to Pembury and Tunbridge wells and if members were aware of the Maidstone Action to Save the Hospital group. Denis stated that Maidstone residents would not view Pembury and Tunbridge Wells as local in relation to patient choice. Denis challenged members of the Board to undertake the journey from Maidstone to Kent & Sussex by public transport. George Jenkins responded stating that the members of the Board were fully aware of the difficulties of travel between the Trust sites and advised that the Trust is engaging with public transport suppliers. George reminded Denis that the reconfiguration decision had been based on clinical argument of better services for patients. George assured Denis that the Trust had listened to the concerns of stakeholders and change the original proposals to ensure that 24 hour medical cover would be available to the Maidstone A&E. Glenn stated that it was incumbent upon the Trust to sell the reconfiguration to the public over the next six months. Glenn advised that he a Frank Sims, Corporate Development Director, would be meeting shortly with members of the Maidstone Action to Save the Hospital group. Ms Mary Graham, Kent Messenger, stated that Board had heard from Clinical Directors, the difficulties being experienced in the recruitment of junior doctors and asked that the Trust be open and honest in relation to the impact of the inability to recruit on the Trust ability to deliver the service set out in the approved Option 2 of the service reconfiguration paper. Glenn Douglas advised that consultant staff would be available and non-resident opinion would be available and therefore the Trust do not believe this difficulty would impact the service delivery. 087/08 Items Distributed Earlier for Information 088/08 Any Other Business There being no other business the meeting concluded. DATE OF NEXT MEETING: 24 September 2008 Time: 15:30 Venue: Jarvis Ramada Hotel, Tonbridge Road, Pembury Signed:. Chair Date:. 12