75thMeeting of the Board of Directors
Thursday 7 March 2013
2.30pm Boardroom, Pinewood House
Board of Directors
Dave MellishChair
Archie HerronVice Chair andNon-Executive Director
Anne TaylorNon-Executive Director
Paul Ward Non Executive Director
James KellockNon Executive Director
Seyi ClementNon-Executive Director
Steve JamesNon-Executive Director
Stephen FirnChief Executive
Helen SmithDeputy Chief Executive and Director of Service Delivery
Ify OkochaMedical Director
Wilf BardsleyDirector of Nursing and Governance
Ben TravisDirector of Finance
Simon HartDirector of HR and Organisational Development
In attendance
Trevor EldridgeDirector Acute Adult Mental Health Services
Ann RozierTrust Secretary and Head of Governance
Susan OwenRisk Manager (Minutes)
Action
1 / Apologies for AbsenceNone received / Noted
2 / Minutes of the Board of Directors Meeting held on 10 January 2013
Item 3 – This should read “Occupancy in Atlas House is low.”
Item 4 – The action relating to the SUSD report should be attributed to IO and WB.
Subject to these amendments, the minutes were agreed as an accurate record. / Noted and Approved
3 / Matters arising
Item 3 – The workforce EDS grading meeting has been held and results have improved. These will be reported to the Board meeting on 2 May 2013. / SH
4 / Key Performance Indicators Report – January 2013
The target for Care Programme Approach clients having a formal review within 12 months has been breached in Forensic and Prison Services, but this is due to a data quality issue which is being investigated.
Waiting times in A&E are within target. The Urgent Care Centre is getting busier and waiting times are being closely monitored to ensure that they are manageable.
The referral to treatment 18 week waiting times for psychological therapies has been included in the KPI Report from this month.
DM – Do we need to reduce waiting times to less than 18 weeks by investing in this area?
HS –There are many services where waiting times are not as high as 18 weeks and teams have waiting list management processes to check that people are not going into crisis.
PW –Do we need one short burst of investment to bring down the waiting times?
HS – We are not an outlier compared to other trusts.
In terms of in-patient activity, all UEA placements have been eliminated.
JK – These are exceptional results.
5 / Director of Service Delivery Report
Green Parks House
The task force has now completed its work and has signed off the action plan. The triage ward on Betts has been closed and this is now a generic ward. Values based recruitment is about to go live and medical leadership has been reviewed. Unannounced visits are being held. ResearchNET are producing aDVD on patient experience. Staffside have held a focus group with staff to improve morale. The HR disciplinary processes are complete. Essential skills training is green a across all areas. There have been no further serious incidents and no further complaints between September and December 2012. Three complaints have been received this year; one was not upheld and two are in progress. The Band 6 development programme is out for consultation. No concerns were raised from the recent CQC visit to Green Parks House.
Adult mental health services reconfiguration
The two Assistant Director posts have been advertised and interview dates have been set.
Community Dental Services
The Community Dental Services transferred to Kings Hospital NHS Trust on 7 March 2013.
Winter pressures
The Trust continues to work with commissioners to support nursing homes and provide sub-acute care.
SC – What action is being taken to manage pressure on Bexley and Greenwich CAMHS?
HS –We will look at how ‘front door’ services are managed across all three boroughs.
PW – Following on from the ‘Right Care, Right Time, Right Place’ event, what scale of change should be envisaged?
HS – Our services will coalesce around GP localities and commissioners are involved in the work programme. Initially the Project Board will focus on community health and older person’s services.
JK – Will the smoking cessation programme be implemented in other directorates?
WB – This only being implemented in Forensic services at present. As patient stays are longer, there ismore time to work with people.
DM –Will the review of student nurse training include the recommendations of the Francis Report?
SC – Has the University of Greenwich improved?
WB – There is new leadership in place. A recent student survey showed that the University of Greenwich is rated the second best in London. / Noted
6 / Francis Report
The report has been discussed at the MAC and the Executive Team. The three priorities for the Board are 1) how we will identify poor standards; 2) how we can be assured that there are processes for raising concerns; 3) how the Board can nurture or strengthen clinicians. We will meet with clinical directors at the away day to address those issues.
DM - The Board and the organisation must respond to the Francis Report.
SC – What is the current process for raising concerns?
SH – We have a ‘Raising a Matter of Concern’ policy. Staff can approach myself, Chrissie Strickland or Anne Taylor. The policy will be reviewed with Staffside.
BT –There will be a quarterly meeting with Service Directors, Clinical Directors, the Medical Director and the Director of Nursing to formally sign off that CRE plans do not impact on clinical care.
JK – Do we have any statistics on how comfortable staff are with reporting concerns?
SH – This is a specific question in the Staff Survey. We achieved a high score.
AR – We issued a risk survey last year, inviting staff to raise any kind of risk issue. We had three responses, but we could run this more regularly. / Noted
7 / Step-up, Step-down and Chislehurst Ward report
Step-up, Step-down
A task force has been established to oversee the action plan and the input of Angus Gartshore and Mary Titchener has been helpful in progressing this. There have been no new complaints and no further serious incidents.
DM – Will the findings of the last year’s complaint be brought to the Board given the nature of the concerns raised?
WB –There are clear areas of learning and these can be shared.
Chislehurst Ward
Oxleas took over management of Chislehurst Ward on 1 March 2013 to support winter pressures. The adequacy of medical and nursing cover has been agreed. Staffing levels are stable and patients have been complimentary.
SJ – How will we check that improvements are sustained?
IO – There are set of indicators that will be used on a daily basis.
HS –Janna Maxfield and her team are to be commended for their support in ensuring appropriate staffare in post. / Noted
8 / Serious incident – DA report and action plan
This Level 5 incident occurred on 29 June 2012 and relates to the serious assault of a male not known to DA. DA had a complex presentation with a range of substance misuse problems, a forensic history and a reluctance to engage. The panel concluded that there were no root causes but there were lessons to be learned from the incident. The main findings were:
- The risk assessment was not comprehensive and had not been reviewed.
- An HCR-20 risk assessment had not been completed.
- There was no joint care plan between Edgehill and the AOT.
- There was an over reliance on the Edgehill Manager.
- The home manager and Forensic CPN were not invited to the CPA review.
- Due to his belief system, DA would use mutism to avoid engaging with particular staff.
- There was no drug screening in place.
- There was no clear structure for medical advice when the consultant was on leave.
- There was a gap in allocating a new care co-ordinator.
- The deterioration in his mental state did not impact on how DA was zoned as the focus was on medication adherence.
9 / Serious incident – ME report and action plan
ME was a 49 year old male who committed suicide on 13 September 2012 following discharge from Betts Ward. He suffered from depression and anxiety and had a number of life stressors. The main findings were:
- There was a lack of engagement and recognition of risks as ME presented as coping well.
- The planned seven day post discharge follow up did not take place.
- There was a was a lack of referral to the Bromley Drugs and Alcohol Service.
- There was an issue around zoning – the default position appeared to be green.
- The discharge team did not communicate guidance on Benzodiazepine detoxification.
- All inpatient units should have at least two nurses with level 3 dual diagnosis training.
PW – Do we need to capitalise on the Local Authorities taking over the responsibility for commissioning Dual Diagnosis services and seek to engage all three boroughs in this?
WB – We have a Dual Diagnosis Strategy but this focuses on staff skills. We have the opportunity to influence changes in commissioning arrangements.
DM – The inquiries are well conducted but the process must be reviewed so that we can better link the recommendations to the events. The results of this review to be reported to the Board in four months. / SF/HS
10 / Audit Committee update
The Audit Committee met on 26 February 2013.
Tenders
The Strategic Procurement Group has reviewed the organisations that provide services to Oxleas and many tenders are no better than the amount the Trust are currently paying. At the selection stage, more attention is being given the political and financial issues and the Strategic Procurement Group will review these risks in relation to the organisations being hosted on the Queen Mary’s site.
Internal Audit Programme
The Audit Committee received a number of internal audit reports. The audits on budgetary processes, records management and patient monies received substantial assurance. Non-pay expenditure, clinical governance and IT support received limited assurance. There were three audits earlier this year which also received limited assurance. These six put the Annual Governance Statement at risk. Deloitte have been asked to revisit the areas to make sure the recommendations have been put into place.
Non-pay expenditure should achieve substantial assurance by year end. There were two recommendations, one of which was high priority. Much work has been done in this area, including a review of authorisation limits and processes for documenting how changes to supplier bank accounts are validated. The auditors have undertaken a further review of patient monies and gave an opinion of substantial assurance. Much work has been done to strengthen arrangements.
Bank investment limits
The Audit Committee recommended that the investment limit should be increased to £25M per bank but changes have been announced that will mean the Trust will be required to invest in the Government Bank. The Board agreed the increase to the investment limit in the meantime.
Annual bribery statement
The auditors have recommended that we include a bribery statement in the Annual Report and Accounts.
Appointment of internal and external auditors
KPMG have been appointed to undertake internal audit and counter fraud on a three year contract. The Audit Committee will make a recommendation to the Council of Governors that Deloitte be appointed as external auditors. This is a change from the current position, which is PwC.
JK – What action was taken following the theft of money at Erith Health Centre?
BT – The recommendations relating to staff conduct have been implemented. We are providing training on cash handing and security. We are also undertaking spot checks.
DM – Are the local authorities supporting this?
BT – We have agreed protocols for how cash is transferred and we are working to reduce the amount of local authority cash that we handle.
JK – The Audit Committee received a paper about the Treasury Review Tax arrangements. Do we employ anyone in such a way that it could be interpreted as trying to reduce the amount of income tax and national insurance we pay?
BT – We received a report on this in November and we are compliant in this area.
SC – Is there any update on the Memorial fraud case?
BT – The alleged perpetrator has been dismissed. She is currently on bail and we are awaiting feedback from the CPS as to whether a charge will be brought.
DM – On a temporary basis, the increase of the investment limit from £20M to £25M is agreed. / Noted and agreed
11 / Governance Board update
The January meeting of the Governance Board reviewed the Corporate Risk Register. The following changes were made.
KP1.3.5: Care plan interventions for clients with identified risks are not always evident. This means that clinical risks may not always be managed, impacting on patient outcomes and safety. This has been reduced on the strength of the CPA audit. There has been an improvement in all directorates. Consequence to remain at 4, likelihood reduced from 3 to 2; rating reduced from HIGH (12) to MODERATE (8).
MT2.1: There is a risk that the 18-week target for admitted cases may not be achieved due to: a) it is not always possible to treat complex cases within timescale; and b) limited theatre space. This means that patients may not be getting timely treatment. There is also a reputational impact as failure to achieve the target will results in an Amber/Red Governance Risk Rating. This risk was reduced as the target has been met for seven months. The loss of dental services will mean that the overall number of cases will be very low so the Trust cannot afford slippage. This will be monitored closely. Consequence to remain at 4, likelihood reduced from 3 to 2, rating reduced from HIGH (12) to MODERATE (8).
AH – Is there more theatre space available?
HS – This is still a challenge.
SJ – Does the risk rating reflect the true picture?
SF – Yes. There has been clear oversight.
One new risk has been identified for inclusion on the Corporate Risk Register. KP3.3.1: Trust systems do not currently support the collection and analysis ofdata by all nine of the protected characteristics of the Equality Delivery System (EDS). Until the data collection issue is addressed, the Trust will not be able to put in place the more detailed actions needed to progress to the higher levels of the EDS grading scheme. Consequence = 3, likelihood = 3, risk rating = MODERATE (9). / Approved
12 / Quality Report
There have been no red indicators in the Mental Health QSIP for six consecutive months. There are two Amber indicators; registering carers details on RiO and s132 explanation of rights. In the Community Health QSIP, pressure ulcers remains a red area as there has been a BBG wide increase in grade 2 and 3 pressure ulcers. Commissioners have now put in place a BBG-wide pressure ulcer panel to review cases and share good practice.
SF – Reducing pressure ulcers is one of the areas we should invest in. This does cause harm to patients and is linked to our CQUIN.
AR – It will also be a Monitor target next year.
Recording care plans on RiO for Long Term Condition Teams is also red and teams have been asked to check data accuracy.
The Trust is on track to achieve the HPV immunisation target. An audit on ensuring that young people who attend CASH services are offered Chlamydia screening kits has taken place and data is being analysed. Root Cause Analysis of Grade 3 and 4 pressure ulcers is taking place, but there is a timing issue so the process is being reviewed.
We have received confirmation that all mental health CQUINs were achieved in quarter 3 but commissioners expressed some concerns about the differences in performance across the three boroughs. We are on track to achieve all CQUINS in quarter 4 with the exception of recording care plans on RiO for Long Term Condition Teams.