72ndMeeting of the Board of Directors
Thursday 1st November2012
3.00pm Boardroom, Pinewood House
Board of Directors
Dave MellishChair
Archie HerronVice Chair & Non-Executive Director
Anne TaylorNon-Executive Director
Sally JacobsonNon Executive Director
Paul Ward Non Executive Director
James KellockNon Executive Director
Seyi ClementNon-Executive Director
Steve JamesBoard Advisor
Helen SmithDeputy Chief Executive & Director of Service Delivery
Ify OkochaMedical Director
Wilf BardsleyDirector of Nursing & Governance
Ben TravisDirector of Finance
Simon HartDirector of HR & Organisational Development
In attendance
Trevor Eldridge (Items 5 & 6) Service Director, Acute Adult Mental Health Services
Ann RozierTrust Secretary & Head of Governance
Keith SoperHead of Compliance
Action
1. / Apologies for AbsenceStephen Firn. / Noted
2. / Minutes of the Board of Directors Meeting held on the 6thSeptember2012
Under item 4 on page 2 it was agreed to amend the last sentence attributed to HS to read ‘The Director of Finance is exploring options regarding the application of CRE targets for the Acute Adult Mental Health Directorate.’ Under item 7 on page 3 an error was noted on the fourth line - the word ‘to’ should be replaced with ‘the’. Noting the corrections the Minutes were approvedas an accurate record.
Matters Arising
Item 11 Compliance Report - SUSD incident
WB advised that the report following the Level 4 incident on Step Up Step Down has been drafted. The initial delay was due to safeguarding arrangements outside of the trust and the ability to convene panel meetings at times convenient to all members. Lessons to be learnt relate to wound management, escalation and record keeping. The full report and action plan will be brought to the next meeting of the Board of Directors.
SC - Is this incident similar to previous concerns raised regarding pressure ulcers?
WB - Some of the required actions are similar, namely record keeping standards and prompt referrals to tissue viability. The rapid decline in the patient, however, was as a result of an invasive Strep A infection. This is not common to pressure ulcers.
Item 21 Workforce Report - Staff survey
SH stated that the surveys have been sent to staff with initial feedback from Picker due in January and the full report from the CQC expected in March 2013. The current response rate is at 25%.
Minutes of the Board of Directors Meeting held on the 4th October 2012
The Minutes were approved as an accurate record. There were no matters arising. / Noted and Approved
3. / Key Performance Indicator Report- September 2012
Performance against all Monitor targets remains on track. September saw a slight deterioration in compliance with recording the community dataset but performance remains well above target. The median arrival to treatment time at the Urgent Care Centre continues to be lowat 27 minutes despite high levels of activity. New birth visits are marginally under the new target of 14 days in Bexley. Occupancy in Acute Adult Mental Health inpatient services continues to be high with admissions remaining above expected levels. Occupancy at the Tarn has reduced, which is evidence of good practice in respect of shorter lengths of stay but does have a resultant impact on income. Occupancy at Atlas House was also lower than planned although is now at full capacity.
DM - Demand for acute mental health services has risen across London, with a 7% increase in section 136 assessments.
HS - There is no obvious explanation for the increase although it is reassuring that the local picture is consistent with that seen across London.
SJam - Is it felt that the model of provision at Atlas House is one with a long term future in light of recent national concerns?
HS - Atlas House is considered to be a very good service. The CQC Inspection report in 2011 confirmed that the service was fully compliant with Essential Standards of Quality and Safety.
BT - Prices at Atlas House are competitive. Extra Contractual Referral (ECR) sales increased in the past year.
SJac - Although below target, performance against new birth visits has improved significantly since the transfer of community services to the trust. / Noted
4. / Director of Service Delivery Report
As planned Oakwood Drive closed at the end of September 2012. All nine service users either moved to other trust facilities or into supported housing. Staff either relocated to other services or took retirement. The trust is currently considering whether to lease the building or purchase and then look to sell the property.
Good progress has been made against the Green Parks House action plan. Only one complaint has been received regarding Betts Ward since the change in use of the ward from a triage ward. There have been no serious incidents. The disciplinary action relating to four members of staff will be completed by 22nd November 2012.
The Board of Directors was alerted to a serious incident that occurred on 23rd October 2012. A recovery patient stabbed a member of the public and their dog. The patient is a known drug user who has shown no attempts to reduce his drug use. The patient was last reviewed by his consultant in July 2012 and was seen in October 2012, albeit not as part of a formal review, and appeared well.
WB - The incident has initially been graded as a Level 4. An early review of the records indicates exemplary documentation. The sudden change in behaviour was possibly linked to a sudden increase in drug use.
Following an annual visit from the Deanery the trust was issued with an immediate action notice in respect of the assessment area at the Woodlands Unit. . There were three key issues the first is about the suitability of the premise as it now does not meet recent recommendations by the College of Psychiatry in terms of dimensions of the room; the second is that the room is also used as an office with tables and filing cabinets and the third is that trainees did not always have another qualified staff member with whom to carry out assessments. As a result the trust immediately stopped using the area for emergency assessments and section 136 assessments. The Chief Executive responded to the Deanery’s concerns in writing, a copy of which was shared with members. A response has been received from the Deanery thanking the trust for the prompt response and highlighting positive findings from their visit especially the Trainees’ positive feedback of the Trust as a place to work and receive care.
IO - This issue has been brought to the attention of the Board of Directors as the London Deanery are obliged to inform the General Medical Council who may inform the Care Quality Commission (CQC), which would then feature in the trust’s Quality and Risk Profile and may influence the CQC’s inspection programme. The actions taken have mitigated any risks. / Noted
5. / MO Action Plan
The recommendations contained in the action plan relate to two broad areas; management of physical health and management of illicit drug use. An update was provided to the Board of Directors on progress made against the identified actions.
AH - Did the security review consider the creation of air-locks on the unit?
TE - This was considered as part of the review but not felt necessary. The unit is not, by definition, a secure unit and many patients are informal and not detained.
WB - Consideration is being given to the introduction of CCTV to support services to challenge any inappropriate behaviour in respect of elicit substances.
PW - Is there an access issue for clients requiring specialist drug services?
TE - Provision is in place in each of the three boroughs, although successful treatment is reliant on a commitment from the client to want to reduce or stop drug use. This is not always the case.
DM - It would be naïve to think that drug use could ever be completely eradicated in non-secure units. Are staff aware of their powers in respect of searching clients?
TE - The powers that staff are able to use have been made very clear to all staff and this has been communicated in a safety alert. If drug use is suspected staff should search clients.
SC - Thought the facility to scan documents was already in place?
WB - The facility to scan documents has been in place for sometime but improvements to network capacity and better integration with the electronic health record are required to ensure this can be done effectively.
The Board of Directors approved the action plan. It was agreed that TE would revisit the outcome of the security review and reconsider the possibility of introducing an airlock. / Noted and Approved
TE
6. / Update on Implementation of NE Action Plan
The review of the implementation of actions took place throughout September 2012. The Bracton Centre, Oxleas House and Green Parks House were visited and in-depth discussions held both with senior managers and clinicians and with frontline staff working in relevant teams. From the visits, it was noted that all staff, including frontline staff, had a high level of awareness of the incident and the corresponding recommendations. To provide additional assurance, audits of RiO records of patients admitted directly to the ward at Oxleas House and those discharged from the Bracton were undertaken. They showed that, in most cases, doctors saw patients within 2 hours of transfer to Oxleas House and consultants were involved in discharge planning meetings at the Bracton. Following completion of the review it is recommended to the Board of Directors that:
- The operation of the crisis line be reviewed again, with consideration of putting a trust wide response in place.
- Representation continues to be made to SLHT regarding RiO access and offices.
- Consideration is given to how staff safely can contact their unit if in pursuit of an absconding patient.
TE - The court case is scheduled for January 2013. The Inquest will be after the court case has been concluded.
PW - Are we confident that the small number of outstanding actions can be completed before the Inquest?
HS - There is now adequate assessment space in QEH A&E although there remains no dedicated office space for Oxleas staff. Access to RiO, whilst not available via the SLHT network, can be accessed by staff using trust laptops and there is an Oxleas computer in the mental health assessment room.
TE - There has been a real safety improvement following the change to clerk patients directly on to the ward so as not to delay admission to the unit.
The Board of Directors approved the recommendations. / Noted and Approved
7. / Review of Monitor compliance actions
In July 2012 Monitor published its annual report and review, in which it sets out the regulatory action taken to support foundation trusts. Three foundation trusts are referred to specifically as examples of where there has been regulatory concern:
- University Hospitals of MorecambeBay NHS FT
- Peterborough and Stamford Hospitals NHS FT
- Mid Staffordshire NHS FT
- Financial planning processes not robust
- Inadequate oversight/ challenge from Board
- Failure to deliver CREs recurrently
- Inadequate reporting to the Board
AR - There is less evidence of challenge in the minutes of the Board of Directors of the routine financial report compared to other agenda items, where there is good evidence.
AH - The detailed discussion in respect of financial performance is reflected in the Business Committee minutes. In addition, the routine finance report presented to the Board of Directors includes an analysis of income and expenditure across all service lines.
SJam - It is natural for boards to focus on areas of concern and therefore one would not expect significant challenge of an area performing consistently well.
SJac - The stability of the Board of Directors should not be underestimated as a key ingredient for success. / Noted
8. / Governance Board Update
The Annual Risk Management Report for 2011/12 was noted by the Governance Board. A number of risks have been reduced. Risk KP1.2.3 relating to policy integration in community services has been closed. Work is in progress to update the corporate risk register with trust priorities for 2013 and beyond.
SJam - How does the risk regarding medical devices relate to the low risk position described in the trust’s Compliance Report?
AR - The Compliance Report seeks to present a range of pieces of information to provide the Board of Directors with a broader view. Data held by the CQC does not suggest that the relevant outcome is one that is high risk.
WB - The risk relating to medical devices is one regarding insufficient assurance and a lack of evident controls rather than as a result of patient safety concerns. It should be noted that there have been no patient safety incidents or complaints regarding medical devices.
AT - Should a risk be added regarding the implications of the Trust Specialist Administrator’s draft report?
DM - These risks will be discussed at the next meeting of the Governance Board in November.
The Board of Directors approved the changes to the corporate risk register. / Noted and Approved
AR
9. / Quality Report- September 2012
An update was provided detailing key exceptions (red and amber areas):
QSIP
Red
- Increased number of grade 2 pressure ulcers reported for a second consecutive month (community health)
- Carer details recorded on RiO (mental health)
- Carers offered an assessment (mental health)
- Section 132 compliance (mental health)
- CPA review within last 6 months (mental health)
The trust is on target for delivery of all CQUINS. Two new CQUINS have been inherited following the transfer of integrated children’s services. These are in the process of being discussed with commissioners.
The responsibilities of the NHS to deliver Outcomes is articulated in the Outcomes Framework for 2012/13 which has 5 domains, namely:
- Domain 1 - Preventing people from dying prematurely
- Domain 2 - Enhancing quality of life for people with long-term conditions
- Domain 3 - Helping people to recover from episodes of ill health or following injury
- Domain 4 - Ensuring that people have a positive experience of care
- Domain 5 - Treating and caring for people in a safe environment; and protecting them from avoidable harm
PW - Once local authorities have selected their public health outcomes can these be reflected in our work against the Outcomes Framework?
IO - Yes, the local authority priorities will be integrated as far as possible.
SC - Do we know the reason for the decline in six monthly CPA reviews?
IO - This has been raised with every directorate as a priority. There are some legitimate reasons for non-compliance, such as patients not attending, but all teams have sight of forthcoming CPA reviews and a focus needs to be given to this within directorates. / Noted
10. / Compliance Report - September 2012
As a result of sustained improved performance against the referral to treatment targets the trust’s governance risk rating with Monitor has reverted to green. The highest risks in the CQC’s Quality & Risk Profile relate to safeguarding and staffing. Two serious incidents were reported in September relating to thesuicide of a patient who had recently been discharged from Green Parks House and a serious assault by a service user on a neighbour. A third incident of an unexpected death of a community recovery mental health patient was also reported, although this is currently being investigated before assigning an incident level.
The Board of Directors was advised that changes to registered locations with the CQC have been made and approved, reducing the overall number from 36 to 23. The CQC has reiterated its intention to visit all trust services before the end of the financial year.
An analysis of complaints data was presented. This showed a split in complaints received between mental health and community services of approximately 60/40. Key areas of complaint across both mental health and community services were care planning, relationships with staff, access and information. 82 complaints have been received year to date. A spike in complaints was seen in June 2012, when 24 were received, otherwise levels have been broadly consistent through the year.
DM - Can the next report include information on complaints at team level, along with trends?
WB - The next report will also include further analysis on upheld complaints.
JK - Are there any barriers to complain?
WB - There are no apparent barriers. The Patient Advice and Liaison Service is available to patients and surgeries are held in inpatient areas to ensure patients have access. It should be noted the trust received 147 compliments in the same period. / Noted