SEPT
SEPT
MINUTES OF CLOSED BOARD OF DIRECTORS
PART 1
held on 26 May 2010
in Hawthorn Centre, Rochford
Members Present:
Lorraine Cabel Chair
Janet Wood Non-Executive Director
Gary Scott Non-Executive Director
Dawn Hillier Non-Executive Director
Steve Currell Non-Executive Director
Leslie Cuthbert Non-Executive Director
Dr Patrick Geoghegan OBE Chief Executive/Executive Nurse
Philip Howe Director of Partnerships
Dr Pauline Roberts Medical Director – Essex
Dr Hameen Markar Medical Director – Bedfordshire & Luton
Nikki Richardson Director of People Management & Business
Development
Sally Morris Director of Operations
Ray Jennings Chief Finance Officer
Andy Brogan Interim Director of Clinical
Governance & Quality
Also Present:
Peter Wadum-Buhl Director of Strategy &
Business Development
Debbie Dunning Trust Secretary
Julie Collins Board Secretary
Members were reminded of the Trust’s vision statement.
147/10 APOLOGIES FOR ABSENCE
Apologies were received from George Sutherland Non-Executive Director.
148/10 DECLARATIONS OF INTEREST
There were no Declarations of Interest.
Presentation of Mental Health Act Annual Statement by Surrinder Kaur, Care Quality Commission
Surrinder introduced George Nazer, Named Commissioner and Richard Khoo, Commissioner to the Board.
Surrinder presented the South Essex Mental Health Trust, Annual Statement for 2009/10.
Board members were invited to provide feedback and comments on the presentation as the content was intended to inform the Annual statement.
Surrinder explained the areas that the Care Quality Commission is responsible for within the Mental Health act which include:
· To keep under review the exercise of powers & discharge of duties of the Act in relation to the detention of patients;
· To visit and interview detained patients in private and review as necessary documentation regarding patients detained under the Act
· The Second Opinion Appointed Doctor service
· To publish to the Secretary of State and Parliament an Annual Report of their work and findings.
· To review appeals against the decisions of High Secure Hospitals to withhold letters
· Complaints
Surrinder advised that from the data provided within the report, there appear to
be no trends within the complaints data.
She also emphasised that overall there were no major concerns about the performance of the Trust in discharging its responsibilities in relation to the Mental Health Act.
Surrinder then highlighted to the Board of Directors the recommendations of good practice identified within SEPT:
§ Patients spoke highly of their care
§ Patients praised the staff caring for them
§ Good access to activities
§ Named social workers attached to wards
§ Good access to advocacy & IMHA
§ Access to Section 17 leave
§ Good staff training arrangements in place
§ Good staff morale
§ Ward areas were clean & of a high standard
One area Surrinder advised the Board that needs to be addressed is the storage of electronic information.
The filing of electronic information was not consistent across the Trust. Some staff found it difficult to retrieve information which was stored in the system.
Surrinder commented that staff should ensure that staff record the fact that patients are in agreement and had consented to treatment as there were some areas where this was not evident from their reviews.
A discussion took place on future visits. The Board were made aware that future visits would require evidence of patient participation and involvement with care plans and physical health assessments. More precise numerical data would be included, with the data being passed to compliance managers and used in the quality risk profiles.
Leslie Cuthbert stressed the importance of recording and storing information and data appropriately. Leslie commented that it was interesting that the CQC appeared to have highlighted a common issue regarding the finding of information.
Leslie asked if the CQC had found any good practice ideas or suggestions to improve this within other Trusts. Surrinder commented that many NHS organisations now use the Rio system.
Patrick Geoghegan was very pleased with the findings which supported all of the good practices currently taking place within the Trust in safeguarding the needs of patients and ensuring that their rights are being met.
Board members recognised that good practice was important and agreed to take on board recommendations. Sally Morris will be taking these forward with Medical Directors and other key staff.
It was also agreed that Sally Morris will provide the Board with full update and roll out of the action plans at the November Board meeting.
Eunan Mcintyre commented that he had recently taken over the responsibility of computerised records and gave assurance to the Board of continued work on the electronic records.
Janet Wood commented that the presentation had been most useful in seeing an independent assurance of how the trust undertakes its duty.
The Chair thanked Surrinder for the excellent presentation.
ACTION
1 THE BOARD NOTED the contents of the presentation.
2 Sally Morris to provide an update to the November 2010 Board meeting.
149/10 MINUTES OF THE MEETING of SEPT held on 28th April 2010
Amendments were made to:-
Page 1- Peter Wadum Buhl was also present.
Page 3 – staff serving a population of £1.5m was amended to 1.5m people.
With the above amendments the minutes of the meeting held on 28th April 2010 were agreed and were signed by Lorraine Cabel, as an accurate record of the meeting.
Patrick Geoghegan gave feedback following the SHA infection control visit earlier in the week.
The SHA were extremely pleased with the high quality of cleanliness within the Trust.
Patrick thanked Dawn Hillier for her time spent visiting wards with Teresa Kearney and asked for these visits to continue.
Dawn Hillier commented that she had raised concerns at the cleanliness of a small number of areas and she congratulated staff on the energy and commitment they had taken to address the issues quickly.
The Chair commented that it was excellent for the NED’s to be involved with Infection Control but stressed that all Board members had a responsibility to maintain and ensure compliance with infection control standards.
Patrick Geoghegan suggested that a report on Infection Control be presented at a future Audit Committee meeting and that as part of the monitoring of quality this happens on a regular basis.
Peter Wadum-Buhl suggested that this would be a good idea and would look into pulling together a system by which this information could go to the Audit Committee at least twice a year.
Lorraine Cabel was happy with this as this would give added assurance to the Board that infection control is well managed within the organisation.
ACTION
1 Peter Wadum-Buhl to provide the Board in June with a workable document to capture all infection control data.
2 Andy Brogan to liaise with Janet Wood and arrange for the action plan supporting paper to be presented to a future Audit Committee.
150/10 MATTERS ARISING
1. Mental Health Minimum Dataset Update (Pg 4)
Patrick Geoghegan advised members that we have received information from CQC who are now considering requests made by the Trust to reconsider the construction of some information required. Once further information is available Patrick Geoghegan will update the Board.
ACTION
Patrick Geoghegan to update the Board when further information is received from CQC.
2. Appraisal Compliance (Pg 8)
Nikki Richardson advised the Board that the new Appraisal Policy for SEPT is scheduled with tight timescales for the end of July. Nikki Richardson assured the Board that this is being monitored closely with regular updates to the Executive Committee.
Hameem Markar asked for confirmation that appraisals for medical staff are not included in this Policy, Nikki Richardson confirmed that they are not included.
3. Executive Summary of Risk Management Framework (Pg 14)
Peter Wadum-Buhl advised the Board that a number of items had been reviewed and will be distributed in the public version of the document which will be circulated to staff.
151/10 Integrated Performance Report including Financial Report
Finance:
Ray Jennings presented the Finance report in a new format which included the performance of both divisions of the South Essex Partnership University NHS Foundation Trust and the Bedfordshire & Luton Mental Health and Social Care Partnerships Trust. Ray requested feedback and comments on the new format and stressed that the report would further develop over the next month or two.
The report shows a high level Dash Board summary which is then split by division for the combined Trust. Ray provided assurance that the Trust is on target and at month one cash flow was healthy and that risk rating was 5.
Ray reported that Corporate Services continue in the right direction, with finance being slightly stretched, he gave assurances that this will improve as the months progress.
Ray also assured the Board that CIP plans are being closely monitored and
advised members that notes had been missed off appendix 6 of the report, the updated version would be circulated to Board members.
Janet Wood fed back that the format on the new report was good, but that she found the detail to be slightly repetitive. Janet asked for an updated position of contract targets. Sally Morris advised the Board that there had been slight timing issues with bank payments, but both divisions delivered on contract.
Patrick Geoghegan commented that he wanted to provide the Board with assurance that budget management would tighten over the next couple of months as much as possible.
The Chair stressed the importance of making savings and asked for assurance that the potential for slippage had been built into the plan. Ray Jennings confirmed at the current stage the plan was on target and that slippage had been built into the plan.
Patrick Geoghegan reminded the Board that the next Transformation Committee meeting is scheduled for 7th June 2010 where Ray Jennings will provide a further update.
ACTION
Ray Jennings to update Board members at the next meeting in June.
Lorraine Cabel asked for assurance regarding the debtors over 30 days for BLPT and Ray Jennings assured the Board that this presented no problems as payments were expected.
Dr Patrick Geoghegan updated on the following hotspots:
CPA Review in 12 months:
The threshold has been set at 95% and current performance is at 91%.
Both Beds & Luton and South Essex are below the 95% target. Denise Cook and Declan Jacob are working to address this issue to ensure that we will achieve full compliance in this year’s performance.
Mandatory Training
Mandatory training is currently at a level of 97% of staff who are up to date with training against an internally set target of 100%. Patrick Geoghegan advised the Board that the Trust will be ensuring that we meet the target.
ACTION
THE BOARD NOTED and DISCUSSED the report / update on the Trust’s:
1. Key Performance Indicators and Overview as at Month 1
2. Overall Financial Position
3. Performance on Delegated Expenditure Budgets
4. Performance on Income Generation Budgets
5. Performance on Main Income Budgets
6. Performance on CIP and Income Generation Plans
7. Capital Plans for 2010/11
8. Performance on Cash Plans
9. Performance on Statement of Financial Position (including Debtors and
Creditors)
10. Performance on Monitor Risk Rating
THE BOARD NOTED and DISCUSSED the performance hotspots identified and reported for the current period.
THE BOARD NOTED and APPROVED the actions identified to address performance hotspots
152/10 Draft Annual Report & Accounts BLPT
Ray Jennings presented the Board with the Draft Annual Report and Accounts for the former BLPT for the year end 31 March 2010
The Trust is required to submit separate Annual accounts and reports for the two former Trusts, which were separate entities until 31 March 2010.
The Annual accounts were submitted to the Department of Health and the Audit Commission (the Trust external auditor) by the 23rd April 2010.
The accounts, together with a letter of Representation will be presented at the Audit Committee on 2nd June 2010 followed by the presenting of the accounts to the Board of Directors for approval at an Extra Ordinary Board meeting on 2nd June 2010.
Ray Jennings thanked Trish Donovan, Cynthia Fernandez and the team for all the work they have done on finalising the accounts.
Ray Jennings advised Board members of a minor issue regarding repayments, but gave assurance that overall the position was good.
Patrick Geoghegan echoed his thanks to the team for their extremely hard work on the accounts.
The Board of Directors:
DISCUSSED AND NOTED the draft Annual Accounts for 2009/10
AGREED that the accounts are prepared on the going concern basis
NOTED the draft annual report had been submitted to the external
Auditors
153/10 Draft Annual Report & Accounts SEPT
The Draft Annual Report and Accounts in respect of Essex for the period ending 31 March 2010 were presented to Board members.
The Trust has a requirement to submit separate Annual accounts and reports for the two former Trusts, which were separate entities until 31 March 2010.
This report has previously been reviewed by the Trusts Executive Operational Committee.
The Board were advised that there is a requirement under the Code of Governance, to include a statement within the annual report and accounts as to whether or not the financial statements have been prepared on a “going concern” basis and the reasons for this decision. Ray Jennings recommended that this be included in the report.
The Annual accounts were submitted to the Department of Health and the Trust external auditor (the Audit Commission) by the 22nd April 2010.
The Accounts with a letter of Representation will be presented at the Audit Committee on 2nd June 2010 followed by the presenting of the accounts to the Board of Directors for approval at an Extra Ordinary Board meeting taking place on 2nd June 2010.
Based on the draft accounts the Trust has achieved an overall financial risk rating of 4.
The final Annual report is due to be submitted to Monitor on the 8th June 2010 and approved by Parliament by the 20th July after which they will be presented to the Board of Governors.
The Board of Directors:
DISCUSSED and NOTED the draft Annual Report and Accounts for 2009/10
APPROVED the proposed disclosure statement in relation to ‘going concern’ for inclusion within the Foundation Trust’s Annual Report and Accounts for 2009/10.