ROYAL UNITED HOSPITALS BATH NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS HELD IN PUBLIC ON WEDNESDAY

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1 Present: ROYAL UNITED HOSPITALS BATH NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS HELD IN PUBLIC ON WEDNESDAY 29 th JULY 2015 OASIS CONFERENCE CENTRE, BATH Voting Directors Brian Stables, Chairman James Scott, Chief Executive Francesca Thompson, Chief Operating Officer Tim Craft, Medical Director Michael Earp, Non-Executive Director Moira Brennan, Non-Executive Director Nick Hood, Non-Executive Director Nigel Sullivan, Non-Executive Director Non-Voting Directors Claire Buchanan, Director of Human Resources Joss Foster, Commercial Director Howard Jones, Director of Estates and Facilities In attendance Julie Hill, Trust Board Secretary Mary Lewis, Deputy Director of Nursing Quality and Patient Safety (deputising for Helen Blanchard, Director of Nursing and Midwifery) Lisa Thomas, Deputy Director of Finance (deputising for Sarah Truelove, Deputy Chief Executive and Director of Finance) Sharon Manhi, Lead for Patient and Carer Experience (present for item 15/07/06) Jenny Lewis, Senior Clinical Research Occupational Therapist (present for item 15/07/06) Claire Scott, Senior Occupational Therapist, Complex Regional Pain Syndrome and Breast Radiation Injury Rehabilitation Service (present for item 15/07/06) Bernie Marden, Head, Women and Children s Division (present for item 15/07/07) Kelly Jupp, Acting Divisional Manager, Women and Children s Division (present for item 15/07/07) Anne Plaskitt, Senior Nurse Quality Improvement (present for item 15/07/09) BD/15/07/01 Chairman s Welcome and Apologies The Chairman welcomed everyone to the meeting. Apologies were received from: Joanna Hole, Non-Executive Director, Helen Blanchard, Director of Nursing and Midwifery and Sarah Truelove, Director of Finance and Deputy Chief Executive. BD/15/07/02 Written Questions from the Public There were no written questions from the public. Agenda Item: 4 Page 1 of 13

2 BD/15/07/03 Declarations of Interest Each Director present confirmed that they had no direct or indirect interest in any way in the proposed transactions to be considered at the meeting. BD/15/07/04 Minutes of the Board of Directors meeting held in public on 24 TH June 2015 The minutes of the meeting held on 24 th June 2015 were approved as a true and correct record of the meeting. BD/15/07/05 Action List and Matters Arising The Action List updates were discussed and those indicated as closed were approved. BD/15/07/06 Patient Story: A Complex Regional Pain Syndrome Story The Chairman welcomed Sharon Manhi in her new role as Lead for Patient and Carer Experience. The Chairman also welcomed Jenny Lewis, Senior Clinical Research Occupational Therapist and Claire Scott, Senior Occupational Therapist, Complex Regional Pain Syndrome and Breast Radiation Injury Rehabilitation Service. The Senior Clinical Research Occupational Therapist said that the Complex Regional Pain Syndrome (CRPS) service was a specialist service commissioned by NHS England. It was noted that CRPS was usually triggered by an injury and could result in excruciating pain in the affected limb. Around 220 patients a year were referred to the CRPS service. The Senior Clinical Research Occupational Therapist said that there was no cure for CRPS, patients but could be taught how to self-manage the condition by attending CRPS two week residential programme. The Senior Clinical Research Occupational Therapist said that the patient s story concerned a 50 year old man who had recently attended the two week CRPS programme. The Senior Occupational Therapist, Complex Regional Pain Syndrome gave an overview of the content of the two week CRPS programme. The Lead for Patient and Carer Experience played an audio clip in which the patient explained that one of the key benefits of attending the CRPS programme was to meet other sufferers. The patient spoke very highly about the staff who ran the programme. The patient suggested that carers should be invited to the final day of the programme as it was important that they gained a better understanding of CRPS and said that more help with cardiovascular exercises would also be beneficial. The Lead for Patient and Carer Experience said that she had spoken to the patient yesterday and he had said that since attending the programme, he had continued with the exercises and had gained more movement in his affected arm and in addition, his mental outlook had significantly improved. Agenda Item: 4 Page 2 of 13

3 A Non-Executive Director (Moira Brennan) asked whether social media was used to help patients with CRPS to connect with other sufferers. The Senior Clinical Research Occupational Therapist said that patients were signposted to a range of online support including a patient support group for people with CRPS. The Chairman asked whether the CRPS programme offered support to carers. The Senior Clinical Research Occupational Therapist said that the service was currently developing a programme for a Carers day as part of the CRPS programme. The Medical Director said the CRPS programme was a good example of personalised care which aimed at helping patients to self-manage a long term condition and to achieve what was important to them. The Chairman thanked the Lead for Patient and Carer Experience, the Senior Clinical Research Occupational Therapist and the Senior Occupational Therapist, Complex Regional Pain Syndrome for sharing the patient s story and for raising awareness of CRPS. BD/15/07/07 Divisional Team Presentation on Patient Safety Priorities Women and Children s Division The Chairman welcomed the Head and Acting Divisional Manager of the Women and Children s Division and invited them to give a presentation on the Women and Children s Division s patient safety priorities. The Head, Women and Children s Division highlighted the following points: The Women and Children s Division s five key patient safety priorities were: o Increasing consultant presence on the Labour Ward; o Developing the Gynaecology Emergency Pathway; o Improving acute paediatric flow; o Reducing neonatal re-admissions to the Maternity service; and o Reducing the number of full term admissions to the Neonatal Intensive Care Unit. The transfer of maternity services and the creation of the new Women and Children s Division had resulted in closer working between Gynaecology, Obstetrics, Midwifery, Neonatal and Paediatric staff. The Chairman thanked the Head and the Acting Divisional Manager, Women and Children s Division for their presentation. BD/15/07/08 Quality Report The Deputy Director of Nursing Quality and Patient Safety presented the report and highlighted the following points: Agenda Item: 4 Page 3 of 13

4 The number of patients completing Meridian Surveys had increased this month. This month s report included a Meridian Inpatient Survey Performance map in order to provide more information in relation to patient experience, including a list of the issues which patients had identified as being important to them. William Budd Ward had been flagged on the ward triangulation chart for the first time this month, predominantly due to staffing issues. Active recruitment was in place. Midford Ward had improved its performance this month and was not flagged on the triangulation chart and had achieved ward accreditation. Dementia training was now part of the Trust s mandatory training. The Trust s VTE performance had improved by 62.5% compared with the previous quarter. The Divisions were improving both the timeliness and the quality of root cause analyses into serious incidents. The Chief Executive commented that the list of issues which were important to the patients who had completed the Meridian Surveys was interesting because it was about staff being kind and friendly and having someone to talk to if they were worried rather than about the quality of care. The Medical Director said that the Trust s Patient Empowerment Programme was considering how best to engage with Governors and Members in a debate about developing a more active role for patients and carers in healthcare. A Non-Executive Director (Michael Earp) congratulated everyone involved in improving the Trust s VTE performance. The Board of Directors noted the report. BD/15/07/09 Ward Accreditation Update Report The Senior Nurse Quality Improvement presented the report and gave a presentation and highlighted the following points: The ward accreditation programme had been developed to recognise and incentivise high standards of care and to reduce variation in practice at ward level. The ward accreditation programme also provided assurance that regulatory requirements, including the Care Quality Commission fundamental standards were being met, and to identify where any improvements in practice were required. Agenda Item: 4 Page 4 of 13

5 Wards were initially assessed over a six month period between May and October wards achieved the target percentage of 75% or more for all four Care Quality Commission domains assessed. There were 11 wards that had not achieved the target percentage for all four Care Quality Commission domains assessed with two wards also not achieving the overall target percentage. In May 2015, the 11 wards were re-assessed for the period of November 2014 to April wards had achieved the target percentage of 75% or more for all four Care Quality Commission domains. There were four wards which did not meet the requirements for Foundation Level. These wards would be re-assessed in December. The Senior Nurse Quality Improvement and Quality Assurance and Clinical Audit Lead will meet with the matrons and senior sisters for each ward that has not met the criteria for Foundation Level re-assessment. Wards that have achieved Foundation Level will be assessed at bronze level. The assessment will include observations of care and unannounced visits. A Non-Executive Director (Nick Hood) asked about the importance of wards achieving the well-led standards. The Senior Nurse Quality Improvement said that the Trust was currently developing the bronze standards and these would include more qualitative information, for example, what does well-led feel like for staff. The Director of Human Resources asked whether waiting until December to re-assess the wards which did not meet the foundation level standards was too long. The Senior Nurse Quality Improvement said that it was important to give wards sufficient time to improve before starting the re-assessment process. A Non-Executive Director (Michael Earp) congratulated everyone involved in developing the Ward Accreditation Framework and asked whether there were enough resources in the Trust to complete the next stage of the programme which would involve visits and observational sessions. The Senior Nurse Quality Improvement said that until the bronze assessment process was underway it was difficult to get a sense of what was involved in terms of staff time. A Non-Executive Director (Nigel Sullivan) said that the development of the Ward Accreditation Framework was a very impressive piece of work and provided assurance to the Board of Directors on patient safety and quality. The Chairman asked what more the Board of Directors could do to support the Ward Accreditation work. The Deputy Director of Nursing Quality and Patient Safety said that it would be helpful if members of the Board could engage ward staff in a discussion about the ward accreditation framework as part of their patient safety visits. The Board of Directors noted the report and thanked the Senior Nurse Quality Improvement for her presentation. Agenda Item: 4 Page 5 of 13

6 BD/15/07/10 Complaints Annual Report 2014/15 The Deputy Director Nursing of Quality and Patient Safety presented the report and highlighted the following points: The number of formal complaints received during 2014/15 was 310 compared with 385 received during 2013/14. There had been a significant reduction in the number of re-opened complaints. The Trust had received 301 formal compliments in 2014/15 (this excluded thank you cards sent directly to areas and departments). The Trust s Unique Voice event had been very successful in helping staff to understand complaints from the patient s perspective. A Non-Executive Director (Michael Earp) said that communication was a key complaint theme and asked what more could be done to address this issue. The Deputy Director of Nursing of Quality and Patient Safety said that patient communication was one of the areas of focus of the Patient Empowerment Programme. The Chief Operating Officer referred to the graph on page 6 of the report which illustrated the surgical division complaints by speciality and asked the Deputy Director of Nursing Quality and Patient Safety to provide some context about the activity level in relation to general surgery and orthopaedics. Action: Deputy Director of Nursing Quality and Patient Safety A Non-Executive Director (Moira Brennan) asked the Deputy Director of Nursing Quality and Patient Safety to correct the statistical information set out in the Executive Summary of the report (bullet point number 4). Action: Deputy Director of Nursing Quality and Patient Safety The Board of Directors approved the Annual Complaints Report 2014/15 subject to the amendments above. BD/15/07/11 Complaints, PALS, Inquests and Claims Quarterly Report The Deputy Director of Nursing Quality and Patient Safety presented the report and said that the Trust was now recording inquests and clinical claims onto the Datix system which would provide a mechanism for disseminating any learning. The Chief Executive referred to a maternity clinical claim which dated back to 1992 and asked whether there was any learning from the case. The Deputy Director of Nursing Quality and Patient Safety said that one of the areas of learning was in relation to documenting any actions taken and said that since 1992 there had been a number of significant changes in practice. Agenda Item: 4 Page 6 of 13

7 The Chief Executive said that the cost of the Trust s Clinical Negligence Scheme for Trusts (CNST) was 165,000 less than in the previous year because of the Trust s low claims history compared with other similar sized Trusts. The Board of Directors noted the report. BD/15/07/12 Tissue Viability Annual Report 2014/15 The Deputy Director of Nursing Quality and Patient Safety presented the Tissue Viability Annual Report 2014/15 report said that the Trust s pressure ulcer rapid spread programme had been successful in significantly reducing the number of hospital acquired pressure ulcers (82% reduction) and had received national recognition. The Deputy Director of Nursing Quality and Patient Safety reported that the Trust was planning to hold a showcasing event in the autumn to share the learning of the pressure ulcer rapid spread programme to other Trusts. The Medical Director suggested a number of amendments to make the report easier for the public to understand. The Medical Director agreed to forward his comments to the Deputy Director of Nursing Quality and Patient Safety. Action: Medical Director On behalf of the Board of Directors, the Chairman congratulated all those involved in significantly reducing the number of hospital acquired pressure ulcers. The Board of Directors noted the report. BD/15/07/09 Operational Performance Report The Chief Operating Officer presented the report and highlighted the following points: The Trust was rated red against the Monitor Risk Assessment Framework access measures for June and for the first quarter. The Trust s four hour performance for June was 92.3%. The Trust had failed to meet the two week wait for cancer target and the 62 day referral to treatment from screening target. The Trust s C.difficile performance was rated red for June because there had been five C.difficile cases. There had been four 52 week breaches in June. There had also been a case of MRSA in June. The admitted and non-admitted referral to treatment targets were due to be abolished for the purposes of external reporting. The open pathway referral to treatment target was now the sole measure of the patients NHS constitutional right to start treatment within 18 weeks of referral. The Trust had consistently achieved the open pathways at Trust level since March The number of individual specialties consistently failing the open pathway target had reduced to general surgery, trauma and orthopaedics, oral surgery and gastroenterology. Agenda Item: 4 Page 7 of 13

8 Enhanced engagement with the Commissioners was providing an opportunity for constructive dialogue within which to discuss pressures and identify robust strategies and operational solutions. There had been a decrease in the overall size of the waiting list from 4,211 at the end of February 2015 to 3,994 in July The overall size of the backlog remained an area of concern. The Deputy Director of Nursing Quality and Patient Safety reported that the Trust undertook a root cause analysis in relation to every case of hospital acquired C.difficile. The Deputy Director of Nursing Quality and Patient Safety said that antibiotic prescribing was one of the key issues identified in relation to the recent C.difficile cases. The Medical Director said that the failure of the flu vaccination last winter may have resulted in an increase in the use of antibiotics and this may have led to the national increase in the number of C.difficle cases. The Chief Executive said that June was the Trust s worst operational performance for many years and asked the Chief Operating Officer for assurance that robust plans were in place to get performance back on track, particularly in relation to meeting the breast cancer wait targets. The Chief Operating Officer said that there had been an increase in the number of referrals for older women with breast symptoms in response to a national awareness campaign. It was noted that some of the breaches were due to patient choice. The Chief Operating Officer referred to page 11 of the report which set out the actions which had been put in place to ensure that the Trust met the cancer targets. The Board of Directors expressed concern about the Trust s operational performance in June. On behalf of the Board of Directors, the Chairman asked Management Board to review the five individual Emergency Department performance indicators and to report performance against these indicators as part of the Operational Performance report. Action: Chief Executive/Chief Operating Officer BD/15/07/14 Four Hour Performance The Chief Operating Officer presented the report and highlighted the following points: The Trust s four hour performance for June was 92.3%. From September, the Four Hour Performance report would focus on progress made to deliver the four hour recovery plan. The diagnostic had indicated that the reduced performance was due to the impact of red escalation throughout June attributable to a number of reasons, including Ambulatory Care activity compromised due to escalation and poor patient flow; high monthly average length of stay; and a high number of DTOC patients. Agenda Item: 4 Page 8 of 13

9 The Trust was considering whether consultant job plans, nursing and porter rotas needed to be reviewed to meet the increased number of ambulance conveyances throughout the night. Using RNHRD beds as part of the mitigation plan for the closure of Waterhouse Ward for refurbishment was working well. A member of the Emergency Care Intensive Support Team (ECIST) had attended the Urgent Care Away Day on 23 June ECIST had been invited to re-visit the Trust to find out if there were any further actions required in order to improve four hour performance. The Medical Director asked the Chief Operating Officer to provide assurance to the Board of Directors that during busy periods in the Emergency Department, patient safety had not been put at risk. The Chief Operating Officer confirmed that although there had been 520 four hour breaches in the month of June, there had been zero breaches in relation to the length of time a patient had waited to be initially seen and assessed by a clinician and in respect of the length of time to treatment. The Chief Operating Officer agreed to include the Trust s Emergency Department performance against five individual Emergency Department indicators in the Operational Performance report from September. Action: Chief Operating Officer The Chief Executive said that feedback from patients had identified that what mattered most to them was not the time they spent waiting for a hospital bed, but being seen quickly and having a plan in place for their treatment. A Non-Executive Director (Moira Brennan) asked how Wiltshire had managed to reduce the number of hospital admissions. The Chief Operating Officer said that Wiltshire CCG was using the Better Care Fund to reduce admissions. The Chief Operating Officer reported that B&NES CCG was planning to introduce a similar scheme. A Non-Executive Director (Nick Hood) asked whether increasing the number of beds would help to improve performance. The Chief Executive said that increasing the hospital s capacity without addressing the underlying issues would only help in the short term and that once the additional beds were used, the Trust would be in the same position. The Chief Executive said that improving patient flow through the hospital was the only sustainable way of improving performance. The Chief Executive said that he and the Medical Director had recently met with a group of Wiltshire GPs to discuss what more could be done collectively to reduce admissions and to speed up discharges. The Board of Directors noted the report and the continuing pressures on four hour performance. Agenda Item: 4 Page 9 of 13

10 BD/15/07/15 Finance Report The Deputy Director of Finance presented the report and highlighted the following points: The Trust s year to date financial position (excluding donated asset income) was a 1.9m deficit which was 0.4m adverse to plan. The Trust was still on-track to deliver its financial plan at year end but there were three key risks to delivery: o Medicine Division performance; o Reduction in Elective work due to Non-Elective pressure; o The Trust had so far failed to reach agreement with NHS England in relation to the specialist commissioning contract. QIPP performance was 77% delivery to date. The main area of non-delivery was within the Medicine Division. The Trust s cash balance at month end was 17.9m which was above plan. The Trust s Monitor financial risk rating for liquidity was 4. Monitor s continuity of service rating at the end of quarter one was 3 which was lower than the planned level of 4. The Continuity of Service rating was planned to increase to 4 at the end of the financial year. The Chief Executive said that if the Trust failed to reach an agreement with NHS England in relation to the Speciality Commissioning Contract, the Trust would probably have to use the mediation process. A Non-Executive Director (Nick Hood) asked whether in view of the financial situation, the Trust needed to refocus its plans for the year. The Deputy Director of Finance reported that there would be an opportunity to discuss the Trust s plans to improve financial performance in more detail at the Private Board of Directors meeting in the afternoon. The Board of Directors noted the report and the deterioration in the Trust s financial position. The Board of Directors agreed to consider the detailed financial plans to get performance back on track at the Private Board of Directors meeting this afternoon. BD/15/07/16 West of England Genomics Medical Partnership Briefing Paper The Medical Director presented the report and highlighted the following point: The national Genomes Project was officially launched in 2013 and aimed to sequence about 75,000 people by the end of The West of England Genomics Partnership was established to bid for a Wave 2 designated Genome Medical Centre. The local delivery partners were: the RUH, North Bristol Hospital, University Hospitals Bristol and Gloucester and Cheltenham Hospital. Agenda Item: 4 Page 10 of 13

11 The Board of Directors: a) Noted the good engagement that the Trust had with the West of England Genome Medical Centre and that RUH representation was visible and embedded within all seven working groups and the Trust was also represented on the West of England Partnership Board; b) Noted the potential timescales for submission of a Wave 2 bid; c) Endorsed the aims of the West of England Partnership to: (a) secure a successful bid as a wave 2 Genome Medical Centre and (b) to establish a long-term sustainable partnership through which the transformation of health services could be achieved and (c) to approve the ongoing partnership of the RUH. d) Noted that the potential risks relevant to the Trust (and other partners) related to this project were being scoped by the RUH (and other) representatives in each of the working groups and a risk register was being complied for the partnership board. BD/15/07/17 Clinical Led Services the Next Steps for Service Line Management The Deputy Director of Finance presented the report and highlighted the following points: The Service Line Management programme had been successfully introduced into the Trust. The Clinical Teams had identified the clinical priorities for the next stage of Service Line Management development and had agreed that the tier assessment process and increasing the numbers of specialties progressing though the tiers was not currently a priority. The current focus was on getting the infrastructure right to support clinical teams, addressing their priorities for action before re-introducing the tier framework. The Trust had been invited to be part of a pilot programme with Monitor for a year as part of Monitor s Change Agent Programme. The programme focussed on supporting trusts to improve clinical accountability in the management of resources and delivery of services. A Non-Executive Director (Michael Earp) commented that the continued development of Service Line Management used to be a key feature of the Trust s QIPP programme and asked whether this was still the case. A Non-Executive Director (Moira Brennan) said that the QIPP schemes were now described in terms of being clinically led rather than as being part of the development of Service Line Management. The Chairman said that the Board had previously discussed the issue and requested that the Trust Board Secretary forward Mr Earp a copy of the relevant minute. Action: Trust Board Secretary Agenda Item: 4 Page 11 of 13

12 The Board of Directors approved: a) The Service Line Management Programme Governance structure and aims; b) The priorities for action in 2015/16; c) The review of Service Line Management development training and the proposed next steps; d) Plans for a Service Line Management Support Team linked to funding from Monitor s Change Agent Pilot; and e) Changes to the timetable for tier progression which was on hold until 2016/17. BD/15/07/18 Item withdrawn BD/15/07/19 Estates and Facilities Sustainability Update Report The Director of Estates and Facilities presented the report and highlighted the following points: Construction of the new Pharmacy Building and a temporary car park was scheduled to commence on 1 September The Trust s new combined heat and power engine and the work to replace the Trust s lighting units with LED units had resulted in around 700k energy savings per annum. A Non-Executive Director (Moira Brennan) asked for assurance that the Trust s Salix funded Energy Conservation scheme had not been dropped. The Director of Estates and Facilities reported that Salix would not currently fund the scheme because the drop in fuel costs had made the scheme uneconomic. The Director of Estates and Facilities reported that the Trust was currently reviewing whether there was scope to amend the original scheme and was considering whether it would be possible to fund the scheme out of the Trust s maintenance fund. Action: Director of Estates and Facilities The Board of Directors noted the report. BD/15/07/20 Management Board Update Report The Management Board Update Report for June 2015 had been circulated for information. The Board of Directors noted the report. BD/15/07/21 West of England Academic Health Science Network Update Report The West of England Academic Health Science Network Update report had been circulated for information. The Board of Directors noted the report Agenda Item: 4 Page 12 of 13

13 BD/15/07/22 Chief Executive s Report The Chief Executive s report had been circulated. The Chief Executive reported that he was delighted that the RNHRD had won an award in the Health Journal Nursing Times best places to work 2015 in the specialist hospital category. It was noted that the RUH had also been shortlisted. The Chief Executive reported that the Staff Governor election had closed and that Phil Lunt, Network Analyst had won the election. The Board of Directors noted that the Trust s seal had been affixed to a minor works contract on 1 July 2015 for an asbestos survey, asbestos removal and demolition of block 29 (former Pathology Laboratory Building) ad Block 28 (former Mortuary/Cellular Pathology Building). The Board of Directors noted the report. BD/15/07/23 Chairman s Report The Chairman s report had been circulated. The Chairman reported that the Lord Lieutenant and Deputy Lord Lieutenant for Wiltshire had visited the Trust. The Chairman also reported that he had attended a Caring for You Event on Mental Health Services. The Vice Chairman asked the Medical Director to report back on the Trust s meeting with representatives from the Department of Health. The Medical Director reported that the Department of Health had requested an opportunity to visit the Trust to discuss seven day working and had returned to visit the Trust last Sunday afternoon to see seven day working on the ground. The Board of Directors noted that report. BD/15/07/24 Resolution to exclude members of the public and press pursuant to the Public Bodies (Admission to Meeting) Act 1960 The Board of Directors approved the resolution. The next Trust Board meeting was due to be held on Wednesday 30 th September 2015 in the RUH Boardroom, Oasis Centre, RUH, Bath. The meeting was closed by the Chairman at Signed Date... Agenda Item: 4 Page 13 of 13