Board of Directors - Heart of England NHS Foundation …€¦ · (inc. Progress Report on Monitor Action Plan, ... training and bespoke public ... Director of HECL 2) Pfizer Virtual

AgendaPart Two

Declarationof

InterestApologies Minutes

Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

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Board of Directors 10 September 2013

9.30am

St John's Hotel, Warwick RdSolihull

HELD IN PUBLIC

AgendaSeptember 2013

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AGENDAfor a meeting of the Board of Directors of Heart of England NHS Foundation Trust

to be held in the St John’s Hotel, Warwick Road, Solihullon 10 September 2013 at 9.30am

PART ONE:1. APOLOGIES

2. DECLARATIONS OF INTEREST (Enclosure)

3. MINUTES:28 May 20132 July 2013

(Enclosure)(Enclosure)

4. MATTERS ARISING (Enclosure)

5. CHAIRMAN’S REPORT (Enclosure)

6. COUNCIL OF GOVERNORS REPORT (Chair) (Oral)

7. CHIEF EXECUTIVE’S REPORT (Enclosure)

8. SAFETY, GOVERNANCE AND ORGANISATIONAL DEVELOPMENT8.1 Governance and Risk Committee Report (Chair/ AK)8.2 Francis Report Review (AK)8.3 National Staff Survey (AK)8.4 Safety Sitrep Update (AK)8.5 Governance and Risk Committee ToR (Chair/ AK)8.6 Nurse Staffing (SF)

(Enclosure)(Enclosure)(Enclosure)(Enclosure)(Enclosure)(Enclosure)

9. FINANCE AND PERFORMANCE 9.1 Finance and Performance Committee Report (LL, AS)

(inc. Progress Report on Monitor Action Plan, Winter Planning, Committee Report & Minutes)(Enclosure)

10. EXTERNAL AND STRATEGIC REVIEW10.1 External and Strategic Review (SH) (Enclosure)

11. PATIENT AND PUBLIC FEEDBACK REPORT (LT) (Enclosure)

12 CORPORATE GOVERNANCE12.1 Review of Board Committees (Chair)12.2 Donated Funds Structure - (Chair)12.3 Board Assurance Framework – Quarterly Review (LT)

(Enclosure)(Enclosure)(Enclosure)

13. BOARD COMMITTEE REPORTS13.1 Audit Committee (AL)13.2 Donated Funds Committee (Chair)13.3 Monitor Standing Committee (Chair)

(Enclosure)(Enclosure)(Enclosure)

14. ANY OTHER BUSINESS

PART TWO:15. SOLIHULL HOSPITAL AND COMMUNITY SERVICES REPORT (LT) (Enclosure)

16. GOOD HOPE HOSPITAL REPORT (SM) (Enclosure)

17. HEARTLANDS HOSPITAL REPORT (MN) (Enclosure)

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EXCLUSION OF THE PRESS AND PUBLICThe Board will be asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”.

PART THREE (PRIVATE):

18.

19.

SAFEGUARDING CHILDREN – SERIOUS CASE FINDINGS (SF)

IP REVIEW:19.1 Launch Plan (LT)19.2 Proposed Indemnity (LT)

(Enclosure)

(Enclosure)(Enclosure)

DATE AND VENUE OF NEXT MEETING – 5 November 2013, St John’s Hotel, Warwick Road, Solihull

PRESS AND PUBLIC ARE WELCOME TO ATTEND THIS MEETING AS OBSERVERS ONLY

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Welcome

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ApologiesApologies

September 2013

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Declaration of Interests

Board of Directors September 2013

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REGISTER OF DIRECTORS and REGISTER OF DIRECTORS’ INTERESTS

VOTING TRUST BOARD MEMBERS

NAMEDATE OF

APPOINTMENT

INTEREST (if any) DATE OF NOTIFICATION

DATE OF TERMINATION OF INTEREST

Dr Aresh Anwar 01.03.11 1. South Asian Health Foundation : Member of Diabetes Working Group

01.03.11

Dr Patrick Cadigan 01.07.13 1. Consultant cardiologist at Sandwell and West Birmingham Hospital Trust.

2. Registrar of the Royal College of Physicians of London.

3. Member of the clinical advisory group advising the Trust Special Administrators re the future of Mid Staffs NHS Trust

25.06.13

Mr Simon Hackwell

01.03.07 1) Board Director for a 1 year term of office at MidTECH - one of a network of nine regional NHS innovation hubs, established by the Department of Health to identify, protect and commercialise innovative ideas from within the NHS.

2) Director on the interim board of the West Midlands Academic Health Science Network until April 2014.

3) Governor at CTC Kingshurst Academy for term of 4 years.

09.10.09

10.10.12

12.03.13

26.06.2012

Rt Hon Lord Philip Hunt PC OBE

01.10.10 1) Member and Deputy Leader of the Opposition, House of Lords

2) Self-Employed Consultant on NHS and wider health issues, t/a Phillip Hunt Consultancy

3) Trainer and Policy Analyst, Cumberlege Connections Ltd. (NHS leadership / awareness programmes)

4) Philip Hunt Consultancy consultant and trainer,

5) President, British Fluoridation Society6) Trustee, Terrence Higgins Trust7) President, Royal Society of Public

Health8) President, Health Care Supply

Association9) Chair, Birmingham University Policy

Commission on Nuclear Energy10) Member of the National Advisory

Council of the Easy Care Foundation11) Chamberlain Sixth Form College

(where Lady Hunt is Vice Principal)has occasionally since 1993 utilised the services of HEFT OH Dept. There is no formal contact, neither Lord nor Lady Hunt are involved in the arrangement and the value is approx £1,500pa

12) Patron/Ambassador of Saving Lives 13) Lord Hunt’s wife, Selina Stewart, Vice

Principle at Chamberlain Sixth Form College, is working with HEFT on a volunteer programme.

14) Son, Benjamin Hunt Stewart is a volunteer at HEFT.

15) President of GS1 UK to take effect on. This is subject to ratification at the annual meeting of GS1 on 12

11.10.10

11.10.1011.10.10

26.04.11

June 2011

June 2011

01.10.2011

17 Oct 2011

Nov 2011

03.01.2012

17.08.11

03.07.2012

03.07.2012


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November. It is a remunerated office for a not for profit organisation dedicated to standardised processes in the procurement global bar coding standards for supply chains.

From 12 November, 2013

Mr Les Lawrence 01.04.12 1. Trustee for the National Institute for Conductive Education

2. Governor of City of Birmingham SchoolMarch 2013

March 2013

Mr David Lock 01.07.13 1. Practising barrister and a member of No5 chambers. Providing legal advice and representation to a wide range of individuals, NHS organisations, local authorities, charities and commercial organisations mainly on public law issues. These frequently involve issues concerning the rights of patients to NHS treatment as well as structural and management issues involving NHS bodies.

2. Director of No5 Chambers Limited (management company running No5 chambers)

3. Member of Amnesty International4. Trustee of Brook, the Sexual Health

Charity for young people (unremunerated)

5. Member of the BMA Ethics Committee (unremunerated)

6. Member of the Labour Party and occasional legal advice to Labour Party and elected Members of Parliament on NHS policy issues

7. Chair of the West Midlands Labour Finance and Industry Group

8. Mr Lock’s wife Dr Bernadette Gregory, is a medical doctor employed by Redditch and Bromsgrove Clinical Commissioning Group and is Clinical Lead for the Worcestershire Integrated Care Project.

Mrs Alison Lord 01 May 13 1. CEO and Shareholder of Allegra Ltd.

2. Voluntary role as a business mentor for the Prince's Trust.

Dr Mark Newbold 01.08.10

01.08.12

Oct 2012

Nov 2012

Nov 2012

1) Member of Multidisciplinary Professional Advisory Panel of BabyLifeline (Charity)

2) Governor on the Council of Aston University

3) Chair of the NHS Confederation Hospital Forum

4) Member of the BMA Medical Manager Committee

5) Governor of Waverley School (November 2012

01.01.2012

01.08.2012

Prof Edward Peck 01.04.12

Nov 2012

1) Pro-Vice Chancellor, Head of College of Social Science at the University of Birmingham

2) Wife is the chair designate of the proposed organisation to deliver community health services in Gloucestershire

3) Councillor for Birmingham Chambers of Commerce

Nov 2012


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Dr Jammi Rao 01.07.13 1. Sole director of Gorway Global Ltd. a private company owning 50% of the share capital. it is a consulting company offering management support, training and bespoke public health analytical support to public sector organisations involved in health, well-being and health care.

2. Board Director of Welcome CIC - aCommunity Interest Company supporting minority and disadvantaged communities by working with statutory and other agencies.

3. Shareholder in GSK .4. Trustee of the Faculty of Public Health

as an elected General Board Member. Term of office from 2010 to July 2013.

5. Visiting Professorship in Public Health in the School of Health, Staffordshire University.

Ms Lisa Thomson23.10.08 1) Non Executive Director of Multistory

2) Trustee of a charity ... Redditch United Football In the Community

22.12.08

07.11.11

Prof Laura Serrant-Green

01.04.12 1) Director of Research & Enterprise at University of Wolverhampton

2) Board member of MOSAIC – aregistered charity

Mr Adrian Stokes 01.07.08 (as voting board

member)

1) Director of HECL2) Pfizer Virtual Customer programme

1) On app’t2) 20/6/2011

Ms Mandie Sunderland

01.12.08 Nothing to declare

Dr Sarah Woolley 07.05.07 Energy & Home Condition Surveys Ltd –Company Secretary

16.03.07 July 08

REGISTER OF INTERESTSNON VOTING TRUST BOARD MEMBERS

NAME DATE OFAPPOINTMENT

INTEREST (if any) DATE OFNOTIFICATION

DATE OF TERMINATION OF INTEREST

Mrs Hazel Gunter 01.01.13 Nothing to declare 15.01.13

Mr Andy Laverick Nothing to declare 18.12.08

Ms Susan Moore 01.09.2011 Nothing to declare 01.09.11

Mr John Sellars 08.01.07 Nothing to declare 16.04.08

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Minutes


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Minutes of a meeting of theBOARD OF DIRECTORS

of Heart of England NHS Foundation Trustheld in the Board Room, Devon House, Birmingham Heartlands Hospital

on 28 May 2013

PRESENT: Lord P Hunt (Chairman)Dr A Anwar Mrs A EastMr S HackwellMr P HenselMr L LawrenceDr M NewboldMr A Stokes Ms M SunderlandMrs L Thomson Dr S Woolley

IN ATTENDANCE: Ms R Blackburn

Mrs A Hudson (Minutes)

13.051 APOLOGIES

Apologies were received from Mrs N Hafeez, Ms C Jinks, Prof E Peck, Prof L Serrant-Green

The Chairman thanked everyone for attending and apologised for the time delay experienced between that day’s meeting of the Audit Committee and the Board meeting.

The Chairman suggested that it would be helpful going forward if a sub-committee was formed with Board authority to sign off the final Annual Report and Annual Accounts. The group should include the Chair, Finance Director, Chief Executive and Chair of Audit.

Mrs East advised that the Audit Committee had reviewed all final amendments and had approved the report. She advised that much work had been undertaken in its preparation and over the past few weeks it had been subject to audit including figures, content and statutory wording. The reports had also been presented through the relevant Board Committees as well as to the Council of Governors.

The Chairman suggested that the final review process should be reconsidered for next year to ensure that final scrutiny was completed in a timely manner.

Mr Stokes advised that as part of the report and accounts process, the Board present the final accounts to the PWC, the External Auditors, to undertake their audit; if this meeting were to make changes to any figures, the reports would then need to be re-audited.

Mrs East advised that the Audit Committee had written out to the Board for

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comments to be submitted by a specified deadline stating that comments after that deadline would cause issues with accounts and reporting deadlines.

Mr Stokes added that changes to the annual report narrative were easier so long as it did not change the tone of the document; however, any factual errors needed to be raised with the auditors.

The Chairman asked if it was possible to see the individual documents combined in order that the Board could give the final document more attention and focus to ensure it is correct.

Mrs Thomson recognised that in preparing the new style Annual Report thereneeded to be some further work to provide greater clarity on the review process in readiness for next year’s Report. This would be built into the auditing/review timetable to ensure sufficient time was allowed for appropriate engagement and scrutiny of the final report. In addition, she would also ensure delegated authorityto an approved committee was arranged.

Mr Hensel noted that in the past, all NEDs had been members of Audit Committee and therefore there had been a collective study of the whole document.

13.052 ANNUAL REPORT & ACCOUNTS and Associated Documents

Mrs Anna East (Chair of the Audit Committee) advised the Board that the Audit Committee had seen previous drafts of the documents that the Board were being asked to approve today. The Committee had met for a substantive meeting with both PWC (External Auditors) and KPMG (Internal Auditors) immediately prior to the Board meeting and had received opportunities to comment on the various documents. PWC commented that the Report & Accounts had been produced to a tight timescale but that the process has been well conducted throughout.

They confirmed that the main items of note were: • Revaluation of Trust’s Estate. PWC had worked closely with the Trust and

their appointed valuers and were satisfied with the assumptions made. • Provisions.

o Redundancy/Restructure: The accounts included provision for redundancy/restructure and, in accordance with standard accounting protocol, PWC had challenged the Trust’s future plans and likely requirement of the provision.

o Asbestos. An estimated provision of £1.5m had been made for removal of asbestos. PWC agreed that this was a realistic estimate for the work planned but noted that until the work was undertaken and the scale of the removal required would not be known and therefore the final cost could not be quantified.

o Debtors. A provision of £4.2m for the outstanding debt owed by Birmingham City Council had been provided for. This had been based on recent settlement negotiations. The financial difficulties being experienced by Birmingham City Council and the ability for them tosettle the outstanding debt were noted.

• Quality Account. It was noted that there was one item outstanding in relation to the 62 day cancer target. PWC were reviewing the documentation in more detail in this regard to obtain clarity and satisfaction on this issue. Upon

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completion it would be circulated for approval. Mrs Thomson provided further clarity around this issue and advised that the Trust had advised that it had not breached this target but it needed to supply evidence to support this. Due to this outstanding item, the auditors comments were yet to be published.However, it was expected they would be standard wording with the exception of the 62 day cancer target.

• The Management Representation letter was considered and approved.

In addition to the draft documents presented for consideration, the Audit Committee also considered and reviewed a number of other detailed documents presented by PWC. Specifically there was the ISA 260 Report which highlighted a number of financial related features and the Quality Report.

Mrs East and Mr Hensel expressed thanks to all staff and professional advisors involved in the preparation of the Report & Accounts and related documents.

The Chairman noted the following items:

Page 12, first paragraph to be moved to elsewhere in section.

Page 26 questioned the heading Declaration of Interest - he was unsure this was the right heading to use.

Page 30 Palliative Care. It was noted that the Board had not discussed reference to performance and this ought to come back to a future meeting. It was noted that the business case had been approved by EMB once the finance and underpinning information had been given. The Executive team had fully supported the business case; however no funding had been available at that time.

Page 35 Hyper-Acute services. There was a query around wording. Chairman asked if there was a commitment to 24/7 opening as it said it was still in discussion. Mr Hackwell was confident that the service would be opening 24/7.

Page 48 Solihull Breast Care Review. Query around the wording. Dr Woolley advised that the Trust was unable to pre-empt Sir Ian Kennedy’s report and therefore it needed to be mindful of any apologies published. Mrs Thomson agreed to look at the wording and add some information around why the Trust took action and include recognition of the profound impact this review was having on patient, families and staff.

Page 104 National Quality Indicators are required to be reported in the Quality Account. Could we identify where we are below national average? Dr Woolley advised that the Department of Health required us include much informationincluding national data and we have to respond to it. Sue Moore had been working with teams to go through the data.

Page 107 Staff Recommender Index. More information was required on the position of the organisation was in relation to other similar Trusts. Mrs Thomson believed that the data was available but that we needed to ensure that it was validas appropriate benchmarks.

Page 130 Inpatient Survey. Change the word ‘average’ in the 3rd sentence in order

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that we do not look complacent.

Page 142 Solihull Healthier Communities Scrutiny Board – check title.

Page 148 Corporate Governance. 2nd paragraph Anna East has held the post for at least 2 years.

Page 154 there was a discussion on the criteria for an Executive Director serving as a NED or Govenor of another institution. The criteria state that it is only relevant where they are serving in a senior position of influence.

Page 158 Query around wording of 3rd paragraph. Agreed to remove.

It was agreed that the Annual Report & Accounts 2012/13 be approved and that the Chairman was authorised to give final approval to any further or consequential changes that might be required.

The meeting then went on to consider the draft Letter of Representation which specifically identified various topics discussed during the meeting. The letter was approved and either Lord Hunt or Dr Newbold were authorised to sign it on behalf of the Board.

The Board asked that its thanks be conveyed to all staff and professional advisors involved in the preparation of the Report & Accounts and related documents.Particular thanks were extended to Angeline Jones, Rachael Blackburn and Surraya Richards.

13.053 CHARITABLE FUNDS ANNUAL REPORT AND ACCOUNTS

Mr Hensel advised that the Donated Funds Committee had approved the Charitable Funds Annual Report and Accounts, Charitable Funds ISA 260 Report and Charitable Funds Management Representation Letter for submission to Audit Committee for recommendation to the Board.

13.054 MONITOR ANNUAL PLAN

Monitor Annual Plan Summary

The Chairman reminded the meeting that Directors had seen the detail of the Monitor Annual Plan in various guises over preceding months and it was now drawn together in finalised form.

The Plan had received general approval from the Council of Governors at itsmeeting on 22 May 2013.

Mr Stokes advised that;• The financial plan showed a surplus of £6m per year across the plan period

of 2013/14 to 2015/16.• The proposed Capital Spend indicated approximately £36m- £40m in each

of the next three years.• The Plan indicated a cash balance of £50m by the end of the plan period

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which would result in a Financial Risk Rating of 3.• The narrative in the Plan was quite prescriptive in format and designed to

support the Financial Plan.• The Planned CIP target is £23m for each of the three years.• The Board were required to state ‘confirmed’ or ‘not confirmed’ against 19

statements. Where it is ‘not confirmed’ a commentary is required to explain the reasons for this and the action being taken to address the matter. There were 4 key statements requiring consideration. • (7) All current key risks to compliance with the Trust’s licence had been

identified (raised either internally or by external audit and assessment bodies) and addressed – or there are appropriate action plans in place to address the issues – in a timely manner

• (8) The Board had considered all likely future risks to compliance with its licence and had reviewed appropriate evidence regarding the level of severity, likelihood of a breach occurring and the plans for mitigation of these risks to ensure continued compliance.

• (9) The necessary planning, performance management and corporate and clinical risk management processes and mitigation plans were in place to deliver the annual plan, including that all audit committee recommendations accepted by the board were implemented satisfactorily.

• (11) The Board was satisfied that plans in place were sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix B; and a commitment to comply with all known targets going forwards.

The Board discussed the above statements in detail and it was noted that statement (11) was the most significant risk of being ‘not confirmed’ and which the Board would be less comfortable in signing.

The Trust was expecting to miss the A&E 4 hour 95% target for May but was planning to achieve the target from June onwards and the run rate would be positive.

It was noted that the CDiff target for 2013/14 was very small. The Trust had in place strong processes for infection prevention and it was expected to achieve the year end target but there may be a risk to achieving the target due to the very low threshold year on year.

Following further detailed consideration, subject to changes in the wording around A&E and CDiff adjustments, the Monitor Annual Plan 2013/2014 was approved and the Chairman or Chief Executive were authorised to sign it on behalf of the Board.

13.055 ANY OTHER BUSINESS

Internal Review - Maternity Services Report

Mrs East advised that the Audit Committee had received an update on the recent Internal Review of Maternity Services. Dr Clive Ryder, Associate Medical Director, Dr Hilary Thomas, and KPMG had attended the meeting to give feedback on the report. The review had consisted of a high level review of women’s and children’s

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Minutes 28 May 2013

division including staffing levels, CIPs, Governance and options related to service reconfiguration. The review was carried out between 2 and 22 October 2012. There had been differing opinions following the issue of the original draft report butfollowing significant changes to the draft, Dr Ryder and KPMG had now agreed a way forward. The Audit Committee had requested that the final report and action plan and progress update were brought to the next meeting. The Chairman asked if Audit Committee would continue to oversee the action plan? Mr Stokes advised that once Audit Committee had been assured that actions had been undertaken they would discharge their interest. The meeting discussed the background that had triggered the review and were assured that quality, staffing numbers, CIP and governance, and service redesign issues had been explored and there was reassurance that an agreed way forward was in place. Dr Newbold agreed to bring back assurance to the next meeting on progress.

....................................... Chairman


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Minutes 2 July 2013

Minutes of a meeting of theBOARD OF DIRECTORS

of Heart of England NHS Foundation Trustheld in the Thomas Guy Lecture Theatre, Good Hope Hospital, Sutton Coldfield

on 2 July 2013

PRESENT: Lord P HuntMr S HackwellMr HenselMr L LawrenceMrs A Lord Dr M NewboldProf E PeckDr J RaoMr A Stokes Ms M SunderlandMrs L ThomsonDr S Woolley

IN ATTENDANCE: Ms C JinksMrs A Hudson (Minutes)Ms S Moore for Part Two

Members of the Public

13.056 APOLOGIES and WELCOME

Apologies were received from Dr A Anwar, Dr P Cadigan, Ms N Hafeez, Mr D Lock and Prof L Serrant-Green.

The Chairman welcomed Jammi Rao, Non Executive Director, to his first meetingfollowing his commencement of position on 1 July 2013.

Lord Hunt noted with regret that today was the last formal Board Meeting for Paul Hensel and thanked him for the excellent contribution he had made to the Board and organisation during his two terms of office. The Board endorsed the Chairman’s remarks and wished him all the best for the future.

Lord Hunt also advised the Board of the resignation of Najma Hafeez and thanked her for her contribution.

13.057 DECLARATION OF INTEREST

The Declaration of Interests were received and the following items noted:

The new NEDs Patrick Cadigan, David Lock, Alison Lord and Jammi Rao had all submitted their Declarations of Interest and these were recorded on the Register enclosed in the pack.


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13.058 MINUTES OF PREVIOUS MEETINGS

7 May 2013

13.042 Mr Stokes advised that the reference to the revaluation of office accommodation was an example rather than the actual subject of the revaluation.

Following the above amendment, the minutes of the meeting held on 7 May 2013 were approved by the Board and signed by the Chairman.

13.059 MATTERS ARISING

The Schedule of Matters Arising was discussed and the following actions noted:

12.075 Medical Revalidation Progress. Dr Newbold advised that this project was being led by Dr Adedeji Okubadejo and the revalidation of doctors in HEFT began on 11 May and was continuing in line with GMC allocated revalidation submission dates. 29 doctors had so far received a positive revalidation recommendation by the Responsible Officer and all of these had been approved by the GMC. There had been no deferrals or formal notifications of non-engagement. 2 doctors who were not fully engaging with the local systems and processes that support revalidation had been discussed with the GMC and hadsubsequently had their revalidation submission dates brought forward to 3rd

October 2013. These doctors had agreed to have their appraisal by the end of July. A Medical Appraisal & Revalidation Support Group has been set up as part the quality assurance and management of the revalidation system. It was agreed to keep the Board up to date with progress.

13.042 Monitor Action Plan. Progress Update. The Trust was still waiting to hear what action was being planned for extra capacity for winter from the Urgent Care Board. If no response was forthcoming the Trust would approach CCGs directly.

13.031.01 Pathology Tender. Mr Hackwell advised that more details on the tender were due to be circulated by the end of July. The delay was due to information on staffing and TUPE not being released which providers needed in order to submit their tenders. Mr Hackwell believed that the tender process would proceed and he would be able to update the Board further in September.

13.059.01 CQC New Rating System. The Chairman noted that CQC are now developing a new rating system similar to that used by OFSTED. The Trust hadoffered to be a pilot for the new rating scheme.

All other outstanding items would be addressed within the agenda.

13.060 CHAIRMAN’S REPORT

Lord Hunt presented his Chairman’s report which was taken as read although he drew the Board’s attention to the following items;

Sir Bruce Keogh was to deliver the next Chairman’s Lecture on 16 August which

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was very timely given the quality issues which were affecting trusts across the NHS.

Following a number of comments received from the new NEDs regarding the size of the board pack, it was felt that a review of the board papers was appropriate.This would take place over the summer and would include a review of what information should come to the Board.

The Board had agreed the following actions at the recent Board Strategy Away Day in June:1) There was a need for a document to be produced that captured our strategic

work in one place. It was accepted that this document would not have all the answers but it should contain a strong narrative around our future direction.

2) The Trust will look to secure a transformation partner to assist with making medium to long-term change. Of particular importance was the need to improve our capability around managing the ‘people’ aspects of change and winning hearts and minds.

3) It was important to explore some new approaches to managing patients with long-term conditions. This would be achieved through three programmes:(i) examining whether the Trust could position itself as ‘chief integrator’ along a particular pathway (diabetes was considered most likely);(ii) whether different arrangements around managing population health could be achieved by working in partnership with a number of GP practices;(iii) active support and participation in the integration of Solihull’s health and social care system.

Work had already commences on items 1 and 2 and updates would be presented to the September meeting.

Mr Hackwell would present an update on item 3 at the November meeting.

The report was received.

13.061 COUNCIL OF GOVERNORS REPORT

Lord Hunt presented a summary of his pre-circulated written report that was taken as read subject to raising the following points of note:

• A&E pressures - Governors continued to express their concerns on this subject and there was a further lengthy discussion. It had been agreed that Adrian Stokes would bring a specific presentation to the next meeting whichwould address the concerns that they raised. This would be in addition to theWinter Planning Review which was scheduled to be brought to the Council of Governors in September.

• Birmingham City Debt –The Governors were updated on the current situation with the recovery of the debt owed by Birmingham City Council. They were advised that BCC had made another offer which was being considered; however, there were some issues still to be settled around delayed transfer of care which needed to be agreed before a decision could be made. Governors were reassured that there was the focus on the resolution of this issue by the Board but did push for a deadline to be given for resolution. This was estimated as July.

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• Governor Elections At the CoG on 21 March 2013 the Governors approved a revised Constitution which required all elected governors’ positions (both public and staff) to be subject to fresh elections and which would enable the Trust to elect all Governors at one time. It was a requirement of the Constitution that an external Returning Officer was appointed to conduct the election process and together with colleagues from the Trust’s Procurement Directorate, a tender process was completed with UK Engage appointed as the Preferred Supplier. A series of Governor Information Sessions had beenheld at each site and proved popular with potential new Governor nominations. Today, 2 July was the final date for receipt of nominations; thePoll would close on 9 August with results declared on 12 August.

The Chairman formally thanked the current Governors for the contribution they had made during their terms of office. This was also endorsed by the Board.

Appointment of Senior Independent Director & Deputy Chair. The Chairman had advised the Governors that Monitor’s Code of Governance proposed that all Foundation Trusts have both a Deputy Chair and SID both of which should subject to the consultation and approval of the Council of Governors. As Anna East was standing down from her NED role at the end of June 2013 it was necessary to appoint a new Deputy Chair of the Trust. At the same time. it was also appropriate that a Senior Independent Director (SID) was appointed. The Chairman had recommended that Les Lawrence, who was appointed as a NED in March 2012 and also chaired the Board’s Finance and Performance Committee and was previously chair of The Royal Orthopaedic Hospital NHS Foundation Trust, be considered for both rolesand the motion approving the appointment with effect from 1 July 2013 was carried.


13.062 CHIEF EXECUTIVE’S REPORT

Dr Newbold presented a summary of his pre-circulated written report. The report was taken as read subject to the following points:

Dr Newbold had been invited to speak at the Royal College of Surgeons (RCS) of England Regional Representatives Conference in June. The RCS England hold a conference twice a year that aims to bring together Directors of Professional Affairs and Regional Specialty Professional Advisers plus Heads of School, Training Programme Directors and Surgical Tutors from around England, Wales & NI, to discuss the latest healthcare issues and also share the work RCS England was currently undertaking. The conference had been heavily influenced by the Francis Report with the overarching theme for June’s conference beingprofessionalism. Dr Newbold spoke on the topic of ‘raising concerns regarding professionalism’ at Trust level.

Vascular Surgery had been the subject of the first outcome data released and results had shown that there were no true outliers nationally. This was the first in a tranche of specialties where outcomes would be released over the next few months. The Chairman asked what this meant for HEFT. Dr Woolley advised

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that Dr Anwar was working with Clinical Directors to identify surgical outcomes across the organisation; this would also compliment the work being undertaken on mapping national audits. A paper had been received at the April meeting of the Governance & Risk Committee and was to be discussed with the clinical audit leads.

Dr Newbold had been invited to speak at the Patient Safety Congress Chief Executives Summit which was in its sixth year. The Summit offered a protected environment to explore the areas around patient safety that provide the greatest challenges. He had taken part in a stimulating session on using clinical insight to inform strategic change. Many organisations struggle with implementing processes and practice that can have a major impact on improved performance and patient safety outcomes.


13.063 SAFETY, GOVERNANCE AND RISK

13.063.01 Governance and Risk Committee Report

Mr Hensel reported on behalf of Mrs East who had completed her Term of Office as a Non Executive Director. The Committee had met on 10 June 2013 and it was noted that:

• It was Mrs East last meeting and thanks were duly noted. • An updated on the Francis Report had been presented including the

workstreams going forwards from this• Never Events had been the subject of a detailed discussion (see report

below)• The National Staff Survey had been discussed in detail (see report

below).

The report together with the minutes contained in the Board Pack were received.

13.063.02 Safety Sit Rep Update

Dr Woolley presented the Safety Sit Rep Report. There were no changes on the Strategic Risk Register and no new red operational risks to report. There had been a significant discussion at the last Governance & Risk Committee on the two Never Events and concerns raised about the learnings and how embedded these were. A further discussion would be held at the next Governance & Risk Committee meeting including actions agreed as a result of the report. The Board discussed the process for conducting investigations and timescales for reporting.

Dr Woolley advised that the CQC had revisited Good Hope Hospital and were satisfied with their follow up visit. The Chairman noted that the CQC had changed the way in which it would undertake spot checks with 3-4 weekly inspections taking place and that in the future Executive Directors would be required to take part in CQC inspections. Dr Woolley advised that the Trust were also developing new guidelines.

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Dr Woolley advised that a summary of learning and good practice from safety are now being distributed with payslips to all staff three times per year each with different messages.

The Board went on to discuss at length risk scoring and how this was calculated and reviewed in detail. It was agreed that a balance was required on the level of detail bought for review by the Board including the need to ensure that boardcommittees such as Finance and Performance and Governance and Risk worked in a complementary way.

Dr Woolley advised that the Trust had seen a spike in mortality in February 2013 when the organisation had been under significant winter pressures. The Board discussed the spike in mortality in detail in order to understand what this meant and the causes. Dr Newbold advised that the Trust monitors mortality continuously and there was always a trend for this to increase over the winter period. However, the Trust had seen potentially more deaths over and above theexpected figure. A case note review was underway to understand the increase in numbers and a report on the finding would be bought to the next meeting of the Governance & Risk Committee and following this a report would be presented to the Board. The spike was not expected to have an impact on our financial risk rating. Prof Peck, Ms Lord and Dr Rao all noted that the report back to Board needed to be written in lay terms and ensure that the language used was clear and concise.


13.063.03 Infection Control Annual Report

Ms Sunderland introduced Dr Keith Struthers, Director of Infection Prevention and Control to present an overview of the report which included the following key points:

• The report summarised the activities of the Infection Prevention and Control Team (IPCT) at the Heart of England NHS Foundation Trust (HEFT) during 2012-2013.

• It also demonstrated the systems the Trust had in place for compliance with the Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections and related guidance.

• Infection Control was a key marker of patient safety within HEFT, as it encompassed a broad range of factors, from the state of the environment through to the effect of antibiotic use on the selection of organisms such as C.Difficile and MRSA. This required the involvement of all grades of staff, on an ongoing basis, and the Infection Prevention and Control Team were central to this.

• In order to improve the overall process various initiatives have been progressed. These included the development of the catheter passport, the introduction of Octenesan shampoo and body wash for all patients, and the involvement of the Information Technology department to develop systems that can streamline the monitoring of Infection Control practices. The systems introduced to monitor MRSA screening compliance, and prescriptionof MRSA decolonisation agents were examples of this

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• On MRSA, the Trust had ended the year at one over target at seven. At the end of the financial year the days to the last MRSA bacteraemia were: Heartlands (BHH) 56; Good Hope (GHH) 84; and Solihull (SH) 377 days. It was noted that GHH went 529 days without an MRSA bacteraemia up to the case that occurred in December 2012.

• All new MRSA patients positive laboratory results were cross-checked with Electronic Prescribing to confirm that the patient had been prescribed mupirocin nasal cream and chlorhexidine body wash.

• A monthly email from the DIPC/Deputy DIPC was now circulated to all consultants and lead nurses, highlighting the current HEFT status of MRSA bacteraemia and C diff toxin numbers. These included key educational messages to be discussed with medical and nursing teams.

• CDiff infection cases in 2012/13 were 30% less in comparison to 2011/12, 86 cases versus 123. A range of actions were in place to control CDI. In addition to the usual standards of cleanliness, comode audits, antibiotic review, all post-48 hour CDI cases had an audit done on 6 key practice issues. The collated information was then fed back to the nursing and clinical teams. Where there are periods of increased incidence (PII), with 2 or more CDI in a 28 day period, a PII Infection Control and Antibiotic Audit was also undertaken. This information is also fed back to nursing and medical staff.

• Infection control was key in looking at the infection outbreak issues within neo natal, actions were identified and in conjunction with the operations team improvement had been seen within the neonatal unit.

• Norovirus continued to have a significant effect of the activities of the Trust, and in terms of the numbers of patients and staff affected. Overall there was a total of 1300 bed days lost over the year across the Trust. In order to restrict the spread of Norovirus the Trust was introducing doors onto the bays in the wards in the Tower Block at Heartlands Hospital.

• Underlying the whole process was the involvement of consultant-led clinical teams in Infection Control, where leading by good example would continuallyhave a positive influence on patient care. An Infection Control Summit was held in April 2013, chaired by the Chief Nurse and Medical Director, with the site medical and nursing leads and the DIPC/Lead Nurse IPCT present. A plan to reinvigorate infection control practices was drawn up, including the re-emphasis of Bare Below the Elbow, and the “five moments” of hand hygiene at the point of patient care.

Ms Sunderland added that the Trust had been very disappointed to go over the MRSA by one but was delighted with the C.Diff target performance. The improvements seen over the past year was a credit to the IPC team and staff at the Trust.

Mr Hensel advised that IM&T Committee had received an insight into electronic alerts and asked when this system would be in implemented. Dr Struthers advised that it was already in place and was really making a difference.

Prof Peck asked how the targets were set and what changes would be made in the treatment of Cdiff in order meet the target. Dr Struthers advised that the target was set by the DoH and that there was no exact science behind this. Ms Sunderland added that in the future there would be financial penalties when not achieving targets. In terms of how the Trust can improve it was felt that there were always improvements to be made including root cause analysis (RCA) for

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all cases. The Trust also has in place ‘confirm and challenge’ meetings for all MRSA bacteria.

Prof Peck asked how HEFT compared to other Trusts. Dr Newbold advised that we were good in terms of C.Diff and about average for MRSA. MRSA was a difficult target as there was a very small for the number of allowable cases per annum. The Chairman noted that it would be useful to have comparative information available in future reports. It was agreed to include this in the Quarter 1 Progress Report.

The Chairman thanked Dr Struthers for attending and noted the huge improvements seen in infection prevention over the last year and that the Board’sthanks were given to all staff involved.


13.063.04 Organisational Development – Staff Survey Findings & Response

Dr Woolley presented the report on the overall key findings from the 2012 National Survey Report, comparing, where appropriate, to 2011 scores. It was noted that;• The report highlighted key areas of internal improvement since last year, and

areas of concern where improvement was required.• With the publication of the Francis Report in February, it was inevitable that

the outcomes from the survey would be subject to closer scrutiny, and assuch, important that the Board thoroughly reviewed the survey outcomes and acted as champions for recommendations put forward.

• The National Staff Survey 2012 was run between September and December 2012. The Trust chose to run a census survey this year, and therefore every member of staff was issued with the survey. This was to enable the organisation to add in its own local engagement questions for benchmarking purpose. There was an overall response rated of 31%.

• The CQC compared the Trust against all other Acute Trusts and show where we are ranked i.e. in the lowest 20%, below average, average, or top 20%.The differences between HEFT and the national average were minimal TheCQC key findings data were based on a sample of 850 staff, of which just over 43% responded; this was a slight decline on last year’s 45% response rate.

• Individual directorate reports setting out the results would be produced during March.

• The results identified some key areas where the Trust should focusincluding: o Increasing staffs’ positive views of the Trust as a place for treatment and

to work was paramount. A clear strategy and robust leadership would berequired to ensure this is successful.

o Bullying and harassment of staff was a key priority for further assessmentand scrutiny. This topic would be discussed with the Live Well Work Well Steering Group for recommendations to be made

o Equality and Diversity training had been low for the last 4 years. The Trust does provide training but it is woven in to other programmes, rather thanbeing an overt E&D session. This may need to be reviewed by the Faculty

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in order to propose a different approach. o The incident reporting procedures may need to be reviewed to ensure

fairness and equity, including scoping work to understand the issues.o A review of communication between senior management and staff was

recommended in order to aid engagement and motivation level. o Work-related stress had increased and it was agreed that a stress audit

should be undertaken as a priority by leaders and managers to reduce work-related stress, which in turn will help to reduce absence levels. Workhad been undertaken over the last few weeks to produce a report in more detail and had looked at key areas around engagement and stress in order to focus intervention on key areas. The top performers are corporate areas with front line A&E and elderly being poorer performers. Specific improvement plans are being drawn up.

The Board discussed and debated the results of the survey and the subsequent actions that the Trust needed to implement to improve future staff survey outcomes. The following comments reflected the lengthy discussion:

The Chairman asked whether the issues discussed would be embraced as part of a management improvement programme. Dr Woolley confirmed that they would and would set out the focus and action plan for improvement.

Mr Lawrence noted that staff sickness absence was a concern and asked how this linked in to the CQC inspection. Dr Woolly confirmed that Governance & Risk Committee (G&R) and F&PC would jointly lead the work in this regard.

Mr Hackwell asked if there was a sense of priorities. Dr Woolley believed that whilst the Trust needed to address the issue of equality and diversity training, the number one priority was engaging, involving and supporting staff in clinical frontline areas such as acute medicine and A&E where they experienced the impact of winter pressures etc

The Chairman summed up the discussion by noting that the National Staff Survey was a very important report and in order to move the organisation forward an action plan was required. He asked for this to be bought back to a future meeting.


13.064 FINANCE AND PERFORMANCE

13.064.01 Finance and Performance Committee Report

Mr Lawrence, Chair of Finance and Performance Committee, and Mr Stokes presented the pre-circulated report for the 2 months to the end of May 2013. Mr Stokes advised that following a difficult April position, the divisions withoverspends greater than 2% had been asked to submit rectification plans in line with the escalation process. Facilities, Clinical Support Services and Good Hope had submitted acceptable rectification plans and these will be monitored monthly. The rectification plans of Heartland’s, Solihull and Women’s & Children’s were not sufficiently ambitious in cost reduction terms to be acceptable and would, if combined, leave the Trust in a potential deficit position at year end. The F&P

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Committee had therefore declined the rectification plans of BHH, SOL and Women & Children’s. Revised plans were to be represented to the next meeting with improved positions including confirmation of governance processes. The Trust’s income and expenditure position in May was a £0.2m deficit, £1.3m year to date. Against operational budget the Trust is over spent by £3.9m year to date. Key areas of concern are around the BHH and SOL business units with loss of control around pay and failure to deliver CIP. Both areas have new managementarrangements in place and meetings are planned to discuss the areas in need of improvement. Mr Stokes was not unduly concerned around the overspend given the difficult winter experienced and the knock on effects that this had and heexpected to see improvements over the next month.

Performance

A&E 95% target. The Trust met the 95% A&E target in May for the first time since October 2012, with overall performance at 95.4%, which represented a 5% improvement on April’s outturn. BHH achieved the target for the first time in 11 months and GHH showed a 6% improvement in performance. Whilst this was a significant improvement in performance, sustainable delivery of this target still remained a cause for concern.

Infection Control. There was one case of MRSA in May. Whilst Monitor still apply a ‘de minimis’ target of 6, the national contract indicator is zero tolerance of MRSA.

Pressure Ulcers. There was a zero tolerance indicator for avoidable Grade 2-4pressure ulcers in the contract this year. In May there were 25 avoidablepressure ulcers; assurance had been sought from the Nursing and Midwifery Performance Committee that they have plans in place to address this.

Ambulance Handover. Performance against the ambulance handover 15 minute target was 55.26% in May; an improvement of almost 10% against the April performance of 45.85%. Solihull achieved the best performance at 69.1% closely followed by Good Hope at 65.3%.

The Chairman noted that at its meeting in April with Monitor, the Trust advised Monitor that A&E would be running at 95% from the end of May onwards and asked if the Trust was still confident that this would be achievable. Mr Stokeswas confident that the Trust would deliver on its plans. He advised that the supervisory ward sister posts would take effect properly from September onwards. The Trust had recruited 80 new nurses to fill the vacancies created by the new supervisory ward sister roles. He was also confident that the plans in place around escalation were also on track although there was still some room for improvement.

The Chairman noted that the Board were aware from past performance that the first two months of the financial year were not as good as expected and if there was anything that should give the Board cause for concern. Mr Stokes responded that the position was as expected. There was £4m additional income due from HPA, as well as some bad debt income due.


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13.064.02 Car Parking Strategy

Mr Stokes presented the report on behalf of Mr Sellars who was on annual leave. The report was taken as read with the following items noted:

• There was an acute shortage of spaces on the Heartlands and Good Hope Sites which needed to be addressed.

• An additional 1300 spaces across the two sites were required to resolve the current and future parking issues at a cost of approximately £17m.

• The Board had previously discussed and agreed ‘in principle’ that the investment required for these additional car parking spaces should be self funding.

• The Board was asked to agree an increase in the cost of both visitor and staff parking to fund this investment as follows:

• Staff @ £2.50 per month (new total £25.00 per month)• Visitors @ 70p per band• Retaining the existing charge of £22.50 per month for staff who park off site at

Yardley Green Road for the Heartlands Hospital site. • The introduction of salary sacrifice for staff paying car parking charges to

reduce cost to staff• Future car parking charges to be linked to CPI (RPI no concern measured).• Cessation of the free visitor car parking during the evenings at GHH. The pilot

scheme had not had any impact in alleviating parking difficulties during the day.

The Board felt that a modest increase in parking charges annually was more beneficial than one larger increase after several years gap. Dr Rao asked if staff had been consulted on the increase in parking charges and how they felt about this to fund the investment. Dr Newbold responded that the Trust had spent a lotof time discussing this with staff and there had been a concensus of opinion that investment in parking should be funded in this way.

Dr Rao asked if the Trust had given consideration to encouraging staff cycling and use of public transport and what were the strategic plans around this. The Chairman advised that the Trust already offered subsidised rates to staff who used public transport as well as offering a bike-to-work scheme. Dr Newbold advised that the Trust were also working on a cycle scheme around Good Hope. Ms Lord asked if offsite parking been considered in the past and the Chairman confirmed it had.

The report was received and the proposals approved.

13.064.03 Energy Sustainability Project Business Case

Mr Stokes presented the report on behalf of Mr Sellars and it was noted that: • The paper set out the plans for carbon reduction which were being presented

to the Board before it had been agreed at Cross Site Strategy Committee andEMB.

• Due to the time imperatives to comply with DoH funding criteria, the Business Case needed to be brought to the Board immediately for approval.

• The business case set out two options:

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Option 1 The base scheme would contribute 10% towards the Trust’s target for CO2 reduction, of 25% by 2015. There was a guaranteed payback withnet annual savings of £505k per annum and overall savings of £6.9m (max £9.8m with funding) after 15 years.

• Option 2 This scheme would contribute 12% towards the Trust’s target for CO2 reduction, of 25% by 2015. There was a guaranteed payback with netannual savings of £632k per annum and overall savings of £7.9m (max £10.7m with funding) after 15 years. The Trust would have an improved infrastructure and a dedicated HEFT Energy Manager. This Scheme would be recommended if the Trust was not successful in getting a full grant from the DoH.

The Board unanimously approved Option One and agreed to delegate authority to Mr Lawrence and Mr Stokes to consider Option 2 once all the carbon reduction benefits realisations had been considered in further detail and the outcome of the bid to the DoH was known.

13.065 EXTERNAL AND STRATEGIC REVIEW

13.065.01 Mr Hackwell presented a summary of his pre-circulated report which was taken as read with the following key items noted:

• The Trust was continuing to work with the CCG in Solihull on Urgent Carewith the first in a series of meetings looking at the case for change. It was hoped that these meetings would be facilitated by Nigel Edwards from the Kings Fund. Although there was no suggestion of services being withdrawn, it was felt that a formal public consultation would be undertaken in the autumn. A key question would clearly be how widely the future of the hospital, including the A&E department, featured in these discussions. The work was being sponsored by the Health and Well Being Board of Solihull Council and their support would be important in moving forward.

• Monitor Consultation on Choice and Competition - draft guidance for providers of NHS funded services. As a general rule, HEFT used the Foundation Trust Network to respond to these consultations. The FTN wasbroadly supportive of the proposed changes outlined below, although has requested clarification on a number of points. Under the health reforms, local commissioners would decide when patients should be able to choose between different services (competition in the market). Monitor’s regulatory regime is designed to underpin these patient rights, as well as to ensure that neither providers or commissioners behave in an anticompetitive manner and uses the provider licence as its route to enforcing its powers in respect of competition. In identifying possible licence breaches in this area, anyone can lodge a complaint about anticompetitive behaviour. Where a provider is deemed to have breached its licence, Monitor may require the licensee to ensure the breach does not continue or recur; require the licensee to take action to restore the situation to what it would have been, had the breach not taken place or require the licensee to pay a financial penalty. Monitor may also revoke a provider’s licence.

• Consultation on guidance concerning merger benefits. Monitor was required to provide advice to the OFT on the benefits for patients of mergers involving foundation trusts. It would also conduct a risk assessment of the merger from

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the perspective of governance and continuity of services. The OFT may refer a merger to the Competition Commission (CC) if it thinks the merger will or may result in a substantial lessening of competition. If the OFT decides to investigate a merger, it would inform Monitor as soon as reasonably practicable. Monitor was urging providers to engage with it informally at the earliest possible opportunity where they think a merger will give rise to relevant customer benefits and that a case for merger has to focus more on the benefits around care for patients rather than business. The Chairman asked how this would fit with Trusts who do not have FT status. Mr Hackwell believed that the measures for patients were often qualitative and therefore difficult to quantify. Mr Stokes added that some trusts who do not achieve FT status may not be able to merge. Ms Lord believed that it was about how things are positioned eg better to have one clinically safe service rather than two clinically unsafe services.

• The Board discussed examples of trusts that had experience of merger benefits and the difficulties that this created with services and changes offered by those trusts. Dr Newbold advised that this has been a big discussion topic at a recent hospital forum given that hospital groups wouldbe subject to same constraints. Mr Lawrence raised his concerns around the effects this will have on the Solihull Integrated Care Pioneer bid where service redesign is paramount.

• Ms Lord believed that service positioning and terminology was crucial.


13.065.02 Academic Health Science Network [AHSN]

Mr Hackwell presented an overview of the role of AHSN and the next steps now that the bid from the West Midlands AHSN had been successful. It was noted that:

• The AHSN were developed in the belief that the UK is (arguably) the largestresearch laboratory in the world and the NHS was recognised as a worldleader in innovation. However, the spread of innovation within the NHS wasslow and fragmented and this therefore presents a problem with adoption and diffusion of new ideas.

• The AHSNs would present a unique opportunity to align education, clinical research, informatics, innovation, training & education and healthcare delivery. Their goal would be to improve patient and population health outcomes by translating research into practice and developing and implementing integrated health care services.

• The three key priorities of the AHSN were;o Drug safety and medicines optimisationo Chronic diseaseo Mental health

• The West Midlands AHSNs bid had been approved and the draft licence issued.

The Board discussed the role of AHSN and the following comments were noted:

• Dr Rao noted that there was an absence of social care organisations in the network and asked if the Trust should not be adding value through caring for

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the elderly population with the use of technology. Mr Hackwell believed that this would happen although the current structure of the AHSN did not cover local authorities.

• Prof Peck believed it crucial HEFT positioned itself in order to gain as much as possible from the collaboration, and that clinicians needed to be fully engaged otherwise there would be no change in practice seen.

• Mr Hensel asked about Intellectual Property (IP) and if any consideration hadbeen given to the pooling of IP. Mr Hackwell advised that the NHS had areasonable way of protecting IP but this had not been explored in detail.

The Chairman was very encouraged by the progress made and asked for regularreports.

13.065.03 Better Care Through Research Strategy

Prof Milligan joined the meeting for this agenda item. Professors Peck and Milligan presented an overview of the report that was taken as read subject to the following key points of note:

• There had been two formal and two informal meetings held in order to map out the Research Strategy for the Trust in order to create an infrastructure and environment to: • Ensure that research supports the on-going development of beacon

clinical services. • Underpin the priority areas of safety and quality. • Further support the development of fundamental nursing care. • Inform new care models (service integration and reconfiguration) through

population. based medicine in long term conditions/chronic disease management

• Prof Milligan had been in post as Director of Research and Development (R&D) for approximately 12 months.

• The new Research Committee was working well with lots of input enabling the development of the strategy.

• The number of patients involved in clinical trials had increased by 50% in the last 12 months.

• The Trust needed to recruit clinicians with academic and research capacity. As an example, the Nursing directorate were currently working with the Florence Nightingale Foundation on the appointment of a nursing Chair.

• The Trust appointment of a Chair in Public Health was very unusual for anacute trust and would be considered ground-breaking in ensuring our integration with primary care and developing care services within the local community

• Further academic work to develop ‘Beacon’ departments such as Diabeteswould be welcome.

• The Trust was currently out to advert to fill the Infection Control Chair appointment.

• In order to continue to support the delivery of the research strategy a financial investment of £2.2m over 3 years was required. A further recurrent £350k per annum of existing research funding was requested from the Trust to support frontline clinical posts to deliver increased research activity in improvingpatient outcomes. The Research Committee would monitor the return on

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investment to ensure that clear outcomes were achieved for the Trust.

Mr Stokes advised that is was not the usual route for a business case to be bought to Board although recognised that this was a unique situation. He was also of the view that the investment requested was relative modest and that the Board had already agreed a strong strategic position in respect of R&D.

Prof Peck advised that prioritisation would be undertaken for those areas where investment would have most impact which would include reputational investments around appointments and retainment.

Mr Hackwell noted that a key strength would be the position HEFT held in research areas such as nursing and public health.

Mr Lawrence noted that the financial investment was relatively modest and queried to what extent colleagues in health and well being in the city had been included. He felt that it was important that the Trust had a joined up approach to research. Prof Peck advised that a discussion about the public health post had been held with the City Council.

Ms Lord suggested that the paper did not set out a convincing case as to why the Trust needed to spend an additional £1m on research rather than staff. Prof Milligan responded that the Trust needed to ensure it had identifiable competences to take research forward.

The Chairman reiterated that the Trust wanted to enhance its reputation and be known for its research excellence. Dr Newbold further supported that by saying that we would attract better staff to the Trust.

Dr Rao noted that there was evidence that those patients in clinical trials do better than those not. He added that reputation follows a ‘clinical trial-driven environment which gives better patient care.

The Chairman noted the comments and consensus of the Board. The Board approved the Strategy and Business Case.

13.066 PATIENT AND PUBLIC FEEDBACK REPORT

Mrs Thomson presented the pre-circulated report drawing the Board’s attention to the following:

• Overall, complaint numbers remained stable with a greater number of concerns being managed outside the NHS Complaints Regulations (2009) where complainants have agreed to this. Many complaints are now being handled at ward level as/when they occur.

• The Friends & Family Test continued to gain acceptance through the organisation with 69% of responders Trust-wide viewed as ‘promoters’ who responded ‘extremely likely’ when asked whether they would recommend the service to friends or family. The proportion of ‘promoters’ rises further to 84% of all responders in Community Services. Initial indications show the text/phone system being trialled in A&E has achieved the target 15% response rate;

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• The PLACE inspections have been completed for 2013 with 68 wards inspected. Focusing on the environment (from a patient perspective), the national comparison tables were expected later this Autumn;

• The KO41 written complaints submission to the Department of Health showeda further fall in the number of written complaints received over the last 12 months (904 in 2011- 2012 compared with 804 in 2012-2013) with indications showing that early intervention prevents written complaints being received.Cases were reviewed by the CDs and medical team.

• The rankings of both Good Hope Hospital and Solihull Hospital had both slipped on NHS Choices recommended from 2nd and 4th with Good Hope now listed as 10th and Solihull listed as 5th in terms of overall satisfaction levels with the service received;

• A Notice of Elections had been issued to fill the positions of 22 public and 5 staff governors;

• A wide-reaching youth engagement programme continues to gain momentum in Solihull and Heartlands Hospitals

The Board discussed the complaints system in detail and it was noted that:• The number of complaints referred to the Parliamentary Health Service

Ombudsman [PHSO] in 2012/13 was less than half than was referred in 2011/12. Since 2010/2011, the amount of compensation the Trust had been told to pay out had decreased and the findings of service failure and mal-administration have halved each financial year. There was now a zero tolerance with mal-administration which is seen very much as an improvement. The Chairman observed that two years ago the Trust had come under criticism for the number of cases which went to the ombudsman and this therefore was an important improvement. He advised the meeting he had recently met with Dr Woolley and Mrs Thomson to discuss how the Board could be more involved in complaints.

• Mrs Thomson and Ms Sunderland had met with the Patient Association to understand how complainants felt we handled their complaints in order to improve our systems going forward. The feedback had been very positive.

• Dr Woolley advised that there was a national review of the complaints system underway. Dr Newbold suggested that the Trust needed to wait to see the results of the outcome before changes to its current systems were undertaken.

• It was believed that more work was required to gain better staff engagement in the complaints process.


13.067 REPORTS FROM BOARD COMMITTEES

13.067.01 Audit Committee Report

Mr Hensel presented an update of the items discussed at the meeting held on 28 May 2013;

• Lisa Thomson had presented the new style Annual report which was well received and it was acknowledged that it was prepared with a target audience in mind which included Monitor and Commissioners etc. It was confirmed that the new report contained the required disclosures and assurance

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statements and that the report had been circulated on a number of occasions to ensure accuracy of information. Dr Mark Newbold, as Accounting Officer, provided assurance to the Committee that this was the case.

• Adrian Stokes had presented the Annual Accounts. He highlighted that the revaluation of the Trust’s estate was the single biggest item to note which had resulted in the asset base of the Trust being reduced by £73m. The Trust had ended the year with a deficit of £30m (having taken a c£40m charge relating to the revaluation). It had been forecasting a £6m surplus (before any changes associated with the revaluation) and a breakeven run rate at year end.

• Specific provisions had been made for the cost of asbestos removal, Sir Ian Kennedy internal review, the debt owed by Birmingham City Council and restructuring costs.

• The External Auditors, PwC had presented the ISO 260 Report and were able to provide an unqualified Opinion on the financial statements. They confirmed that the accounts had been prepared on a prudent basis and were consistent with last years. They highlighted four key areas of judgment; the focus revaluation of the Trust’s estate, accelerated depreciation charge, provision for redundancy and provision for the removal of asbestos. Each item was reviewed in turn and Committee was satisfied that appropriate judgments hadbeen made.

• It was noted that there was an outstanding query in relation to the 62 day cancer target. Further information was awaited in order to complete this work.

• The Auditors advised that the quality and reporting of accounts was of a good standard.

• The Quality Account was presented by Rachael Blackburn. This had been previously circulated for comment and feedback. The Council of Governors had also been involved in the scrutiny of the report. Feedback from external stakeholders had been overall supportive with some minor additional points included.

• The Charitable Funds Annual Report and Account report was presented. It had been presented to the Donated Funds Committee on 24 May prior to coming to Audit Committee for ratification. It was noted that there had beenan increase in donations received. Acknowledgement and thanks were extended to Alison Evans and Angeline Jones for their efforts in bringing the accounts forward to tie in with year-end reporting in readiness for consolidating with the Trust Report and Accounts next year. The External Auditors had noted a couple of minor internal control issues but these were considered low risk.

• A report on Maternity Services had been presented following completion of a high level review by our Internal Auditors, which included review of CIPs, staffing levels, Governance, options related to service reconfiguration, Dr Clive Ryder reported that;

• Historical CIP had been written off and that CIP plans now had to be submitted for approval and delivery and were subject to scrutiny of Operations Management board.

• Role and responsibilities – there was now a better working ethos and clearer divisional structure following a change in the senior team structure

• Staffing – the Trust had agreed to invest £1m to increase staffing on labour ward

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• Project Pelican which included the re-design of the maternity unit, services and patient pathways was underway and the business and workforce plan had been presented to Finance & Performance Committee

It was confirmed that an action plan was in place to monitor progress of actions which would be scrutinised by the F&P Committee as well as the Governors Finance & Strategy Committee. The Chair of Audit Committee had advised that the report needed to be finalised and a progress update brought back to the committee.

The Chairman asked if the committee was satisfied with the report. Mr Stokes advised that now the report was finalised he was confident that theCommittee was satisfied with it. Progress reports would come to Trust Board formally by way of the Audit Committee report.

• Private Patient Income generation had been discussed around the potential of growing this income. The Board meeting discussed this and it was agreed that it needed to given further thought and consideration. It was agreed to bring this topic back to a future meeting for a more dedicated discussion.

13.067.02 Donated Funds Committee

Mr Hensel advised that the Committee had met on 24 May 2013 to approve the HEFT Charity Annual Report and Financial Statements for 2012/13 and the main items of discussion were:• The Trust had to produce separate accounts and narrative of its fundraising

activities as part of its statutory duty for the 2012/13 financial year. From next year the Charity Annual Accounts would be consolidated with the Trust’sAnnual Report and Accounts process. It was recognised that the new process would be a challenge. However, Ms Bissell from the External Auditors (PwC)believed that the Trust was very well prepared for this having brought the reporting of the Trust’s Charitable Accounts forward to tie in with the Trust’s Annual Accounts.

• The document gave a good narrative and overall picture of the fundraising during the 2012/13 financial year and the Committee approved the Annual Report and Financial Statement 2012/13.

• Ms Bissell presented the ISA 260 report on the General Charitable Fund 2012/13. They issued an unqualified audit opinion on the accounts with no adjustments and the ISA 260 Report was approved.

• The draft Letter of Representation addressed to PwC was presented by Mrs Thomson on behalf of Mr Stokes for approval. The letter had been approved with no amendments for submission to the Audit Committee.

The Chairman noted that over the last few months there had been lots of debate around how trust funds should be organised with emerging views that funds should be operated by an independent trustee on behalf of the trust. Mr Hensel confirmed that the Donated Funds Committee had discussed this and a paper would be presented to the Board setting out a view on how this would operate.

Prof Peck asked what the target was for generating income and spending donations and whether the Trust had a strategy for fundraising. Mrs Thomson

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confirmed that it did have a strategy in place and would circulate it for information.

13.067.03 I M&T Committee

Mr Hensel advised that the Committee had met on 19 April 2013 and the 28 June. The main items of discussion at the meeting on the 19 April being:• The challenge of the NHS being paperless by 2018 where although there

had been a great deal already achieved there were still considerable culture issues to be overcome.

• The Clinical IT Committee would support the drive towards the paperless office and a presentation was to be made at the next Board Strategy Meeting.

• Dr Anwar noted that work was underway on the scanning of the Trust’s medical records archive .

• The Chairman commended the work being undertaken towards a paperless NHS and the work of the Clinical IT Committee.

At the meeting held on the 28 June it was noted that:• Progress was ongoing with Concerto and e-JONAH. • A bid had been put in for funding for e-resources, however it was unknown

whether this was to be a matched bid or not. If it was a matched bid then a discussion on finances would need to be held with finance around potential funding.

The draft minutes of the meeting held on 19 April 2013 were received.

13.067.04 Research Committee

Prof Peck advised that the Committee had met on 14 June 2013 with the main items of discussion being:

• Dr Anwar had suggested that a statement should be put into recruitment material about contribution to research as a core activity. Further information on this and how the Trust can manage recruitment, reward, monitoring and appraisals for consultants was to be undertaken.

• Chair and Senior Lecturer/Senior Fellow in Public Health Primary Care and Chronic Disease Management posts are due to go out to advert shortly.

The draft minutes of the meeting held on 14 June 2013 were received.

13.067.05 Organ Donation Committee The Chairman advised that the Committee had met on 17 June 2013. The main items of discussion were:

• The requirement by the Committee to have a Non Executive Director as Chair. This post was formerly held by Richard Harris who had recently left the Trust. Lord Hunt had agreed to take on this role for the next 12 monthsuntil a new chair could be appointed.

• It was a requirement of the Organ Donation Committee to report to the Board on an annual basis. Dr Julian Hull currently presents the Annual Report data

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at the Trust Board meeting in January. It was suggested synchronising this with the completion of the Annual Report to NHSBT in September of each year and the Board Business Plan had been amended to this effect.

• The Terms of Reference for the Committee had been updated with the inclusion that a Governor should be a member of the Committee. The Chairman asked the Board to approve the amendments.

The Board approved the Terms of Reference. The draft minutes of the meeting held on 17 June 2013 were received.


No items were raised.

13.069 DATE OF FUTURE MEETING

10th September 2013 at St John’s Hotel, Warwick Road, Solihull

13.070 PART TWO13.070.01 Solihull Hospital and Community Services Report

Mrs Thomson presented the report and it was noted that:

• The priorities to improve stroke and dementia pathways working across the hospital sites were ongoing with the Stroke pathway being the first to move over to the Heartlands site.

• There were significant financial challenges in both non-pay and pay for the Solihull site. Rectification plans were in place and a report would be given to the next F&P Committee on actions taken.

• Improvement in ambulance handover times were required The three key priorities for the Solihull site are:• Review of the staffing model across all staff including clinical and non-clinical

to deliver efficiencies and reduce bank spend• Solihull Integrated Care Project – Solihull Hospital had submitted an

expression of interest to become an integration pioneer, which, if successful, would provide access and expertise in overcoming some of the challenges to providing integrated care.

• Urgent Care Review. There was focus on supporting the review of this pathway which was being led by the CCG. There were currently a number of ways that patients could access urgent care in Solihull and the review wouldhighlight duplication in care plus indicate where efficiencies can be made whilst ensuring that a more equitable service for patients was provided. Apublic consultation is planned for later in the year around A&E services.

The Chairman asked if the residents of Solihull were aware of the discussions being held around the designation of its A&E department. Mrs Thomson believed that there was some confusion at the present time. The Chairman raised his concerns over the timing of the public consultation given that it was not taking place until the autumn and wondered if the CCGs were aware of how much criticism they may receive. Mr Hackwell believed that Solihull CCG were

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proceeding with the work (there is a Clinical Reference Group which we are supporting and there would be a Patient Reference Group shortly) but he too had concerns around the timings including completion of the public consultation.

Dr Newbold noted that the Walk-In Centre at Solihull was as high profile andpopular as the A&E department. He believed that the CCG was moving in the right direction. Mr Hackwell commented that the Walk-In Centre contract was driving the timetable in terms of timings.

The Chairman noted that should there be any changes to the A&E department,the Trust would be the focus of public opinion rather than the CCG.

The Chairman asked for a strategic discussion on the potential services changes at Solihull to be held at the September meeting.


13.070.02 Good Hope Hospital Site Report

Mrs Moore gave an oral update reflecting the progress made over the last twelve months and how this was aligned to the site strategy;

• On the 21 May the acute medical units (short-stay and assessment units) were finally separated (original proposal was in November 2012). There had been a few teething problems but overall feedback from the nursing staff has been positive with the issues relating to open visiting, short stay patients andpatients waiting for admission into base wards resolved. As a result of this separation, there has been a marked and hopefully sustained improvement on the site. There had also been a significant reduction in the number of patients being sent to base wards. However, those patients going to these wards are generally very poorly and have a more complex patient pathway which had impacted on our ability to discharge.

• The site did not achieve the A&E 95% target. However, it was noted that it had achieved 92.6% in June which was a significant improvement on the previous achievement of 84% in April.

• In order to create surgical identity on the site, Ward 17 has been moved intothe Richard Salt Unit and was co-located with Trauma & Orthopaedic Wards of 14, 15 and 16. This had also enabled GHH to have distinct male and female wards which was a regulatory compliance issue. The move has meant the site was able to take direct admissions which should assist with reducing breaches.

• Since the establishment of the virtual wards 453 patients had been through the service to date. The service had been one of the topics at the Challenging the Culture of Care Conference around how to extend the service including domicilary care.

• A tender for domiciliary care had been submitted with the closing date on 1 July.

• The Virtual Ward would now cover the acute medical unit and A&E. A number of patients stay or come into hospital because they have social care needs where there is no one at home to meet them. The Virtual Ward can help where minor safety adjustments are needed at home or for such tasks as moving patient furniture from the bedroom to downstairs and putting up

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handrails so that patients can get home quicker. We had commissioned a handyman service to do this.


13.070.03 Heartlands Hospital Site Report.

Dr Newbold presented the Heartlands Hospital site report and it was noted that:

• Carl Holland had been appointed to the substantive position as Head of Operations at Heartlands Hospital. He had appointed four managers to his team. His appointment has seen some improvements in the running of the site.

• Work on supporting discharge scheme was to commence.• Discussions around surgical pressures are to be held in order for the site to

function as a 24/7 acute site. • The office opening of the Pathology new build would take place on Monday 8

July, 2013 and Lord Carter of Coles had been invited to officiate at the opening ceremony.

• The building works for the extension on the Neo natal unit had almost finished and will comply with requirements on space. It would be ready for occupation within the next few days.


13.070.04 Pioneer Integrated Care Bid

Mr Hackwell presented a summary of the paper included in the board pack and highlighted the following:• The bid was in response to an invitation from Normal Lamb around

integration. • Key stakeholders in Solihull had until the end of June to submit their tenders.• The outcome of the bids would be known in September. • There is no funding attached to the bid to support the work; however, some

funding will be available for transformational change. • Dr Newbold believed that HEFT should be a front runner and the bid was a

strong contender.• Mr Lawrence had attended a Kings Fund learning set in relation to this and

compared to other invitees Solihull was very much in the forefront with a strong bid.

• Feedback from all parties involved in this bid had indicated they would like to carry on irrespective of the results of the tender.

The Board resolved “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.”

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Board of Directors Public Meeting - 8 January 2013 P a g e | 17

as a whole during a time of immense pressure and asked that the thanks of the Board were passed on to all staff.

The Board was asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” 13.016 PART THREE

This Section has been removed under Section 40(2) and 41 of the Freedom of Information Act 2000

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BOARD OF DIRECTORSSchedule of Matters Brought Forward and Action Points

Date raised

Minute No Detail Action Due Status Completed

6 Mar 2012 12.020.9 Francis Report Review SW Sep

2013

6 Nov 2012 12.074 Report on NHSLA Review SW Nov

2013Deferred from September

6 Nov 2012 12.075 Medical Revalidation Progress

Update AA Sep2013

Updates to all Board Meetings

7 Jan 2013 13.009.3 Hollier Team – Team STEPPS

Training Programme - update SW/SH Nov2013

Monitored via G&R Committee with 6-monthly updates to Board

7 Jan 2013 13.014.1 IM&T Investment Update (inc E-

Resources Bid) AL Sep 2013

5 Mar 2013 13.031.01 Pathology Tender – Board Approval SH Sep

2013Update on delay in process

7 May 2013 13.043 Review of Specialised Services SH Nov

2013

13.043 Staff Culture Strategy SW/HG Nov 2013

13.043 Stroke Services Implementation Plan SH Sep 2013

28 May 2013 13.055 Maternity Services Review –

Progress Update MN Nov2013

2 July 2013 13.055 Trust Transformation Update SH Sep

2013

13.059.01 CQC New Rating System SW Sep 2013

13.063.02 Mortality Rate Review – Feb 2013 SW Sep 2013

13.064.02 Transport Strategy – alternative methods review JS Jan

2014

13.067.01 Private Patient Income Generation AS/SH Jan 2014

13.067.02 Donated Funds Strategy –Independent Trustee Co Sec Sep

2013

13.070.04 Pioneer Integrated Care Bid SH Sep 2013

13.071.01 Winter Planning Update AA/AS Sep 2013

13.071.02 Distance Learning Strategy Review MS Jan 2014

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CHAIRMAN’S REPORT to the BOARD of DIRECTORS – September 2013

I am continuing to work with staff and members of the public to understand their concerns and learn about the improvements in safety and quality standards we are making across the Trust. Over the coming months I, along with my Board colleagues, will be taking part in a listening and learning exercise with frontline staff to understand what additional work we need to initiate in response to the Francis report. We aim to report back to the Board on this work later in the year which will look at how we create improvements in staff engagement and a positive culture for raising and acting on concerns at all levels.

Many of you will already be aware of the appointment of the new CQC Chief Inspector of Hospitals and that this Trust has volunteered to take part in the first round of the new inspections, including being shadow rated. We are looking forward to this process which will see inspectors visiting us in November. To help inform our progress and assess our overall performance Price Waterhouse Coopers have been asked to develop an information overview and this will be used to drive improvements in safety and quality.

I would like to congratulate Mandie Sunderland, Chief Nurse who has been voted onto the inaugural HSJ Inspirational Women list. The list celebrates 50 outstanding leaders or generous mentors who are driving change and innovation in service redesign or at the heart of influencing health policy. The list contains women from clinical or non-clinical backgrounds who stand out for their passion and ability to innovate and drive change. This honour is a testament to Mandie’s dedication and hard work. I would also like to officially congratulate Mandie Sunderland who is leaving us to take up a post at another trust and to thank her for the excellent work she has led at the Trust. She leaves us with a very strong nursing workforce having achieved many improvements in safety and quality of nursing care standards. On behalf of the organisation, the Board and especially our patients I would like to thank her and wish her every success in her new role. It is proposed that Sam Foster will take-up the Chief Nurse role for a period of 12 months and this is to be taken to the Appointments Committee for consideration.

Our Medical Director, Aresh Anwar, has advised us of that he will be leaving the Trust and emigrating to Australia with his family at the end of December 2013. I would like to take this opportunity to wish Aresh and his family all the best for the future and thank him for the excellent work he has done as Medical Director.

Trust nominated as an exemplar Trust for IT and Electronic Patient Record developments.

The Trust has been nominated as one of five top trusts cited as an exemplar Trust for IT and Electronic Patient Record (EPR) developments. EHI is launching a national ‘Hunt for EPRExemplars’: a search to find the UK hospitals that have made the greatest strides in using electronic patient records to improve patient care. The Hunt for EPR Exemplars is the next stage in The Big EPR Debate to find national leaders and to help share best practice. The readers of EHI are invited share their views on which UK hospitals they think are the leaders and have lessons to teach others. All the trusts nominated score highly on a new Digital Clinical Maturity Index, an NHS benchmarking tool that EHI’s research arm, EHI Intelligence, has developed and will launch this autumn.


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New state-of-the-art Hospital lab to open its doors

Lord Carter of Coles officially opened Heartlands innovative new laboratory medicine development on 8 July 2013. Jointly funded in partnership with Public Health England West Midlands, the world class development includes a two storey extension to the current pathology building on the Heartlands Hospital site and will accommodate a new centralised core laboratory. The new facility boasts investment in service redesign and new high state-of-the-art equipment, including 26 metre long automatic track, to increase efficiency and speed in processing a multitude of test results from blood tests to biopsies. Lord Carter of Coles and I,along with the Chief Executive, and non-executive directors, toured the facility where more than 5,000 samples will be turned around 24 hours a day, each day, every year, for the Hospital Trust and GPs in the surrounding community, with complete turnaround in less than 24 hours for some samples. Specialist testing of cervical cancer, HPV, Chlamydia and MRSA samples from across the region will take place at the new facility, as well as processing Tuberculosis tests from across the UK. Opening of new estates workshop building, Heartlands Hospital

I officially opened the new estates workshop building on Friday 12 July which is situated opposite outpatients. Over the coming months, the old estates workshop and office building (Bordesley House) will be demolished to provide a more pleasant visual entrance for patients and create space for the erection of a two-storey much-needed staff car park and the relocation of the existing waste compound.

Chairman’s Lecture

Professor Sir Bruce Keogh, NHS England’s Medical Director, gave the latest Chairman’s Lecture on Friday 16 August at Heartlands Hospital to a packed theatre which saw standing room only. His lecture entitled Pride and Prejudice in the NHS was very interesting and generated several questions and debates from our audience. Sir Bruce continued in his role as Medical Director of the National Health Service in England during the transition to new NHS structures, and maintains responsibility for clinical quality, policy and strategy and postgraduate education of doctors, dentists, pharmacists and clinical scientists.

Council of Governors

It has been a busy month or so for our Governors. The Chairman’s Breakfast Seminars continue to prove to be very popular. Erica Loftus, Head of Operations, came to talk and answer governor questions on the Surgical services at the Trust.

Governor Elections took place in July and we said ‘Thank You’ and ‘Goodbye’ to our Council of Governors at the meeting held on 15 July 2013.

I, along with other Board colleagues, welcomed our newly elected and re-elected Governors at a ‘Meet and Greet’ event held on the 16 August and very much look forward to working with our Governors over the coming months.

Our re-elected Governors are:Dr Olivia Craig, Public: ErdingtonMr Albert Fletcher, Public: ErdingtonMrs Arshad Begum, Public: Hodge HillMr Phillip Johnson, Public: LichfieldMr Barry Orriss, Public: Lichfield


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Mrs Kath Bell, Public: ROE & WalesMr Michael Kelly, Public: Rest of England & WalesMs Liz Steventon, Public: SolihullMrs Elaine Coulthard, Public: Sutton ColdfieldMr Richard Hughes, Public: TamworthMr David Treadwell, Public: YardleyMrs Heidi Lane, Staff: Nursing and Midwifery

Newly elected Governors are:Mrs Sue Hutchings, Public: Hall GreenMr Andrew Lydon, Public: Hall GreenMs Attiqa Khan, Public: Hodge HillMr Barry Clewer, Public: Perry BarrDr Mark Pearson, Public: SolihullMrs Joy Townsend, Public: SolihullMrs Anne McGeever Public: SolihullMr Ron Handsaker, Public: Sutton ColdfieldMr David O'Leary, Public: YardleyMr Michael Hutchby, Staff: Clinical SupportMr Matthew Trotter, Staff: Medical & DentalMrs Emma Hale, Staff: Non Clinical SupportMrs Margaret Meixner, Staff: Nursing and Midwifery

Our Stakeholder Governors are:Mrs Carol Doyle, Stakeholder Governor, Birmingham City UniversityCllr Jim Ryan, Stakeholder Governor, Solihull Metropolitan Borough CouncilCllr Mohammed Aikhlaq, Birmingham City Council

There are four Stakeholder Governor vacancies these are:University of Birmingham Warwick University Aston University Joint - Lichfield & Tamworth Borough Council

Company Secretary

I would like to welcome Kevin Smith as our new Company Secretary who joined the Trust on 7 August. Charlotte Jinks is leaving at the end of September and I would like to thank her for her commitment to the role over the last 15 months, which is gratefully appreciated. I wish her well for the future.

VISITS and MEETINGS

Since the last Board Meeting I have continued to go out and about, internally and externally, and these visits have included:

Northumberland NHS Foundation Trust

I travelled to Newcastle and met with Brian Flood, Chairman, and their executive team.Northumberland NHS Trust has achieved recommendations for its patient empowerment and the work of its Governors and I was very impressed with the work they had undertaken. They like HEFT had a large membership and I am pleased to advise that HEFT is on a par with them


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in how we engage and work with our Governors.

HEFT Faculty Visit to Westminster

I had the pleasure of hosting staff from the Faculty at the Palace of Westminster recently. The visits were an opportunity to share a behind the scenes look at the workings of the House of Lords and Commons including observing some of the debates around Francis and other planned health policy and issues.

GHH Retirement Fellowship

I was invited to attend the recent Good Hope Retirement fellowship meeting to share my experiences, both in my current and previous roles, including my role as Shadow Deputy Leader of the House of Lords.

Lord Philip Hunt of Kings Heath ChairmanSeptember 2013

September 2013

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6. Report from meeting held on 15 July 2013 (Oral)

September 2013

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CHIEF EXECUTIVE’S REPORT to the BOARD OF DIRECTORS

Emergency Care Pressures

All performance targets continue to be very closely monitored by the Executive Team and the Finance and Performance Committee. We are closely monitoring the implementation of ouraction plan, while ensuring the focus is on the maintenance of safe services. Progress and improved performance has been delivered across all sites despite a level of pressure continuing over the summer period. I have continued to increase Executive Director involvement for the period and we are continuing with our raised levels of safety surveillance. Each of the site plans will be subject to confirm and challenge events during September.

Hospital Inspection

HEFT will be one of the first 18 hospitals to be inspected by the CQC under the new Chief Inspector of Hospitals arrangements. The inspection will take place between August and December this year, with ours likely to occur in November. CQC is developing an Ofsted style of rating for hospitals and HEFT has volunteered to be one of three trusts that receive a ratingduring this first phase.

We know the process will be developed from the methodology used in the recent Keogh mortality reviews. It will mean:

• bigger inspection teams, headed up by clinical and other experts that include trained members of the public;

• longer hospital inspections, covering every site that delivers acute services and eight key services areas: A&E, maternity, paediatrics, acute medicine and surgical pathways, care for the frail elderly, end of life care and outpatients (including discharge arrangements and links with other sectors);

• a new surveillance framework to inform their key lines of enquiry;• a mixture of unannounced and announced inspections, including in the evenings and

weekends; and• a report which will be written primarily with the public in mind and should there be any

failures in care then the CQC will work with Monitor to oversee improvement.

The CQC is proposing to develop three tiers of indicators to measures hospitals:

• Tier 1 – indicators in relation to measuring FIVE DOMAINS - safety, quality, caring, responsiveness and well-led;

• Tier 2 – all nationally comparable indicators that are available to CQC at a trust level across all the five domains mentioned above; and

• Tier 3 – Indicators being developed that are not yet nationally comparable, in association with professional bodies e.g. royal colleges.

HEFT will be one of three hospitals receiving an Ofsted style rating: Outstanding; Good; Requires Improvement or Inadequate. We can expect, therefore, as well as assessment and rating of the Trust as a whole with separate ratings given to the services under scrutiny. In the past the CQC has been concerned about compliance with standards of quality and safety. These inspections will go beyond this and take a view on the quality and safety of care provided.



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The Trust welcomes this new approach and has actively volunteered to be part of the first phase of the programme. I, along with the managing Directors, am holding a succession of staff briefings. These will continue throughout September with the aim of encouraging staff to be open and to see this as an opportunity to review and improve our performance.

The Board will already be aware that Price Waterhouse Coopers has been invited to provide a background report to assist us with understanding the range of performance metrics that will be used to guide the assessment visit.

Francis Report

A programme of engagement events with frontline staff have been planned and are to take place over the coming months. The output from these events will inform our overall response to the Francis recommendations. This work will be brought back to the Board for approval. One of the main challenges we are facing in the Trust is the level of staff engagement, and this will form a major part of the work programme and plans going forward.

Chief Nurse’s update: VITAL training and HEFT nursing and midwifery badge

One year on form the introduction of the HEFT nursing badge, the nursing directorate has further developed the VITAL training and the applications for the next cohort of HEFT nurses wishing to apply for the nursing and midwifery badge. The badge is designed to recognise those demonstrating the highest standards of clinical practice, knowledge and professionalism. Staff can only apply for their badge on gaining 100% in their VITAL training. The process is open to nurses, midwives, children’s nurses, neonatal nurses and HCAs. I am very pleased to see that the VITAL training for community nurses’ pilot has just been completed and the training is expected to be officially launched early next year. We are looking forward to celebrating with those who achieve this quality marque later in the year with the award ceremony being planned for December.

Local Engagement and Fundraising

After the amazing success of last year’s charity sponsored walk event we are looking for willing fundraisers to get involved to walk the six mile scenic route from Heartlands Hospital to Solihull Hospital to raise money for a ward or department of their choice at the Trust. Money raised from the event will be used to directly benefit patients, their relatives and staff in all our Hospitals and Community. Last year, around 100 doctors and nurses joined members of the public to raise money for a wide variety of areas, including the Children’s wards, the Neonatal Unit and stroke care. The walk will be held on Sunday 29 September and I hope members of the Board will join me and staff in what promises to be a great event.

Sir Ian Kennedy Review

Sir Ian Kennedy is currently writing his report following meetings with staff and patients. It is anticipated that Sir Ian will present his report later this year.

Welcome to Junior Doctors

In August we welcomed a new cohort of junior doctors and the executive team have been meeting them at the corporate and local induction training sessions. They can take advantage



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of our new virtual training scheme, known as VITAL (Virtual Interactive Teaching and Learning) for doctors. The scheme is part of the national Better Training Better Care initiative commissioned by Health Education England (HEE). The modules include falls, better nutrition, fluid management and early safe discharge, with self-assessments, audio podcasts, and social networking forums to support their learning. Data from the scheme, collected anonymously, will be used to monitor any changes in doctors’ self-assessments scores and improvements in prescribing data. We are encouraging all of our new doctors to take up this training.

Meetings and Events attended:

9th Annual Disease Management

I was invited to speak at the 9th annual conference of the Australian Disease Management Association, a self-funded not-for-profit national resource centre for those involved in chronic disease management. I was asked to give a keynote presentation on The Fundamental Changes Needed to Meet the Challenges of the Future. In particular the focus of interest was on the changes needed to better cater for the needs of patients with chronic illnesses.

Health Care at Home

With Sue Moore I met the Healthcare at Home senior team to discuss the organisation’s support as part of our winter plans.

Hospital Inspection Programme

I was invited to attend the launch and briefing about the hospital inspection programme, hostedby Professor Sir Mike Richards, Chief Inspector of Hospitals. This was an extremely helpfulopportunity to learn more about the new process and will inform our preparation for the forthcoming visit.

Solihull Integrated Meeting

I have met with Patrick Brooks, Mark Rogers and John Short from across Solihull healthcare economy to progress our plans for integrated working and ensure progress is made against this important agenda.

South Staffs CCG Community Hospitals Meeting

Along with Sue Moore I met with Dr John James and Rita Symons to discuss community hospitals in South Staffordshire and how we might improve the range of services we provide from these sites.

Dr Mark NewboldChief ExecutiveSeptember 2013

September 2013

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8.1 Governance and Risk Committee Report (Enclosure)

Safety, Governance and Risk

8.2 Francis Report Review (Enclosure)

8.3 National Staff Survey (Enclosure)

(Enclosure)8.4 Safety SITREP Update

8.5 Governance and Risk Committee ToR (Enclosure)

8.6 Nurse Staffing (Enclosure)


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Governance & Risk Committee Report

These minutes are DRAFT until approved at the October Governance & Risk Committee 2013.

Minutes of a meeting of the GOVERNANCE AND RISK COMMITTEE

of Heart of England NHS Foundation Trustheld in the Education Centre, Room 2, Heartlands Hospital on 29th July 2013

Name Title Present HUNT, Phil Non-Executive Director/Chair

GUNTHER, Hazel,THOMSON, Lisa

Head of WorkforceHead of Corporate Affairs

KEOGH, Ann Director of Medical SafetySUNDERLAND, Mandie Chief Nurse WOOLLEY, Sarah Director of Safety and Organisational Development

In Attendance BLACKBURN, Rachael Head of Corporate Risk and ComplianceMCGRATH, Mary RAO, Jammi

Head of Organisational DevelopmentNon-Executive Director

RICHARDS-EVERTON, Lisa Expert Patient Volunteer RYDER, Clive Associate Medical DirectorSERRANT GREEN, LauraSHARRIF, DavidSMITH, Steve

Board MemberKPMG, Trust Internal AuditorsAssociate Medical Director

Minutes MARTIN, Sian EA/Sarah Woolley

1. Apologies for absence

Apologies were received from; Aresh Anwar, Matthew Cooke, Sam Foster, Alan Jones, Kiran Patel, Rex Polson, Sue Moore and Sue Nicholls.

2. Minutes of the meeting held on Monday 10th June 2013 / matters arising and standing agenda items

The minutes of the previous meeting were accepted as a correct record.

Matters Arising

The Chairman wished to clarify the guidance given that Chair of the Audit Committee is not permitted to be a full member of the Governance and Risk Committee.

SW confirmed that this was a corporate governance requirement and that she had sought guidance from the Company Secretary on this matter.

The Chairman asked for an update on the Francis Report staff engagement sessions.

SW and LT confirmed that scheduling was in process.

MATTERS FOR DISCUSSION

3. CQPG Minutes

SW updated on behalf of Aresh Anwar and said that whilst July’s minutes had been included in


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the materials sent electronically, the minutes for June were included in the hard copy given to attendees on arrival. SW went on to update on issues raised in the Heartlands site report. SW explained that the Executive Directors felt that the following issues needed to be discussed at Executive Management Board :

• Level 1a/Critical care capacity• Confusion around surgical reconfiguration and theatre capacity.

Action AA/MS/SWThese were noted by the Committee.

4. Quality Dashboard

SW presented the Quality dashboard. This data is retrospective and the latest data related to April 2012-March 2013.

A key point to note is the increased HSMR (Hospital Standardised Mortality Rate) during February and March 2013. The rise was evident across all three sites during this period. However, more recent data showed that this has decreased and was within control limits again. This increase coincided with an extreme capacity demand for hospital services and an extended rise in morality over winter/spring. We are currently undertaking a case note review to understand possible causes for this which will report to Trust Board in October 2013. This will include a review of care starting in the A/E department and continuing across the patient’s fullcare pathway.

The Chairman then asked what was meant by deaths in low risk diagnosis groups and what might be causing the high value.

SW clarified that these were category terms, which are described in the national outcomes framework.

AK clarified that the unexpected low risk category deaths had included deaths from conditions such as asthma but that the figures had only recently been received and that her team are investigating this category and will report back.

Action AK

SW wished to clarify the decubitus ulcer. The decubitus ulcer indicator was at significant variance to internal data and we are currently examining why the data produced by Dr Foster as this reports as a much higher figure than HEFT’s internal data.

Action AK

AK reiterated the need to investigate at site level and that there was also currently a question over the robustness of coding.

5. HEFT Mortality Update

AK gave a presentation which she had presented at July Executive Management Board to explain current approaches to mortality measurement. She also explained the steps we are taking to investigate the increased HSMR which we experienced across the sites over February and March.

There was significant discussion regarding the content of the presentation and the following points were made:

• It was difficult to get a clear picture as to what mortality measures a board should focus on and this debate has continued post Mid-Staffordshire (Chairman).

• There is significant noise about the use of mortality metrics which is not always helpful. There is a need to focus on poor standards of care and mortality associated with this. (JR)


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• HSMR and current measures of mortality are of value and useful tools. These need to be used with a range of other safety and quality measures and linked to other specialityspecific mortality measures. (SW)

• AK reiterated that the increased HSMR over February/March will be investigated through case note review. This will consider whether front door A/E emergency pressures had an impact on care/mortality and whether clinical processes likeadministration of antibiotics for chest infections/general infection were also affected.

In conclusion, SW explained that a paper on this will go to the Sep EMB and the October Board Strategy meeting. The Chairman confirmed he was content with this as long as a preliminary discussion could be held at the September Board meeting.

The minutes of this meeting, the Francis gap analysis and the Keogh review would also go to September Trust Board. SW suggested it would be helpful for the Trust Board to participate in a ‘mortality master class’ to explain different approaches to mortality measurement. It was agreed this could be done at the August strategy session.

6. The Keogh review

SW introduced this report and commented that the 8 ambitions that Bruce Keogh and NHS England have set were helpful. SW explained the need to make sure we are taking them into account in our overall strategy and our safety and quality improvement strategies. HEFT is already doing many of the things he suggests.

The Chairman commented that he felt it was a measured report and that it was linked to the new CQC approach.

MS said that one issue that came out of every single review was nurse staffing. Her directoratehave been doing an intensive nursing recruitment campaign which has already recruited 130nurses. There are more events planned for later in the year but it is clear that all hospitals are all recruiting out of the same diminishing pool, with nurses preferring jobs closer to home. Apersonal approach is being taken to retaining staff who have not yet started. Mentorship and induction are being used to ensure staff are being retained even before they start. A media campaign through local radio will be used to support the two upcoming recruitment events.

There was a discussion over the number of newly graduated potential recruits failing the drugs administration test and thus being rejected. There was some discussion over whether those who failed should be reported, and to whom and what feedback should be given. LSG reported that some student nurses do their drugs administration tests more than a year before they are interviewed and that this may contribute to this problem.

It was noted that the Keogh review ambitions will be reviewed by the Safety team and incorporated into current reviews of our safety and quality improvement approaches. This will be done in conjunction with the reviews we will be conducting in response to Don Berwick’s patient safety review due out next week.

7. Francis Gap Analysis

AK presented a gap analysis of the Francis Inquiry recommendations, conducted by the Safety and Compliance teams. There were 290 recommendations in total, with 80 defined as directly applicable to our organisation. Of the 80 actions:

• 57 were accepted/accepted in principle• 19 require further clarification• 3 we do not fully agree with


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The 3 we do not agree with as we have concerns regarding practicality and feasibility:

Recommendations 88 and 89: Use of RIDDOR information through serious untoward incident system to check consistency of trust’s reporting practices and escalate to HSE

• The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts’ practice in reporting fatalities and other serious incidents.

• Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive

Recommendation 115: Arms length investigation initiated by provider trusts for wide variety of complaints.

• Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; subject matter involving clinically related issues is not capable of resolution without and expert clinical opinion; a complaint raises substantive issues of professional misconduct or the performance of senior managers; a complaint involves issues about the nature and extent of the services commissioned

Recommendation 120: Realtime support and oversight role of commissioners in the complaints process (and realtime access to all complaints information)

• Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to do so.

Many of the other actions are already being implemented. The key areas requiring further improvement are:

• Staff engagement (covered later in the agenda)• Information and data management (volume and triangulation)• Monitoring duty of candour and openness.

AK explained that this gap analysis will be presented and discussed with the executive team over August where necessary actions will be developed. This will need to be considered in conjunction with the imminent staff/board engagement events taking place over autumn.

Following this presentation there was significant discussion regarding the approach to investigating serious adverse events/complaints, particularly with regard to completing independent reviews.

Concerns were raised regarding how organisations including HEFT developed a properly independent approach to investigating incidents (e.g. using investigators external to the organisations) and whether this was practical. It was acknowledged that this was not straight forward but it was an area which needed thinking about. AK and SW are actively considering better ways to create more independence within the investigation process.

In summary, GRC noted the gap analysis and the need for further discussion with EDs. Outstanding actions will be brought to GRC in October and a way forward for monitoring agreed then.


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8. Safety Sitrep

AK presented this report.

In summary the update was as follows:

Strategic risks: Not due for review but status noted.Red Risks: None to reportAmber Risks: Under management by local site teams.

SUI Investigations

All SUIs identified within the report are now closed with the exception of one case relating to a delay in treatment of sickle cell crisis patient in paediatrics. Since the report was prepared, there were two new SUIs under investigation; one related to the insertion of the wrong lens for a cataract treatment (this is a never event) and the second related to the death of a child seen at Solihull A/E.

It was noted that there have now been three never events since the beginning of the new financial year. AK also reported that the Medical Director, the Chief Nurse and Director of Safety would be meeting with the T & O Directorate and Theatre Directorate leadership teams to discuss the recent incident relating to the wrong knee implant at GHH theatres. There was concern as this was similar to a previous incident at Solihull Theatres about two years ago. At that meeting a monitoring and review process will be agreed.

Action SW

9. Patient Experience Report

LT presented a revised patient experience report. It was noted that this report will be developed further over coming months. In summary: The Trust Friends & Family score has decreased for June following the inclusion of the A/E Friends & Family Score.

LT explained that there is a lot of working going in A and E on patient engagement. These returns are from patients who are not admitted, but treated and discharged. This information has allowed us to understand what patients want from A and E. The main areas forimprovement relate to communications and environment (heat). A detailed report will be brought back.

Action LT

LT reported that younger people tend to be harder on a organisation. HEFT was using a text back service and those with mobiles tend to be younger. It has been very successful. It also gives interesting feedback. LT said that she had plenty of examples of changes that have been made as a result.

The report also highlighted the Friends & Family test by ward and triangulated this withcomplaints. Going forwards we will need to provide assurance on action being taken in ‘hotspot areas’. More data will also be included on complaints.

Action LT

The Chairman reminded the Committee that he had had a board discussion as to whether we welcome people to A/E but that no conclusion was reached at that time. He alsoacknowledged that the figures have improved.

10. Team Stepps

The report was taken as read.


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SW said that there had been good progress in maternity. Colo-rectal was still at the earlystages but there had been some movement over last month and agreement to focus on the GHH team. Similar problems had been faced in maternity during the early stages of implementation and the process took some time to gain traction.

11. Audit and Effectiveness Dashboard

CR presented the audit and effectiveness dashboard as chair of the Clinical Standards Committee. This is a new style report and provides an overview of: Trust-wide audit activity, clinical guideline programmes, compliance with NICE guidance and technology appraisals. This report also included a summary of clinical performance for national audits in which the Trust participates.

CR explained there had been significant development work over the last year to improve the focus of the Trust Audit Programme. This had involved a huge amount of engagement and there had been a recent workshop with clinicians. This workshop looked at what the audit leads wanted from the audit department and how this should be facilitated.

CR explained the main concern on the horizon was NICE guidance and quality standards.NICE are increasing number of guidelines and CR felt HEFT were in danger of being overwhelmed. The guidelines needed to be prioritised. Some guidelines are good and some of less value.

The Chairman challenged that these new guidelines will need to be costed and we will need to consider how they are implemented.

SW explained that once the report is in a more developed format, the information that these national audits give will provide an useful pointer as to quality of care which needs to be kept in view. In addition we will work to develop a better commentary for this report.

12. Staff Survey Report

SW reported on the 2012 staff survey report as follows:

• The survey ran between September-December 2012• 850 staff invited, 43% response rate (National annual requirement, led by CQC)• For 2012, HEFT did census as well 9,730 invited, response rate of 31%.

The survey was designed to address the 4 national pledges outlined in the NHS Constitution 2009

Our staff survey results were as follows:

Pledge *pledges related to NHS Constitution 2009

2012 survey status

Pledge 1: To provide all staff with clear roles, responsibilities and rewarding jobs

HEFT’s overall score was 73% (higher percentage is better) against the 5 key findings, (National Acute Trust average-74%). No key finding within this section where HEFT appeared an outlier when compared to other local Trusts.

Pledge 2: To provide all staff with personal development, access to appropriate training for their jobs, & line management support to succeed

HEFT’s overall score was 67% (higher percentage is better) against the 5 key findings, (National Acute Trust average-68%). HEFT’s score was lower than the national Acute Trust average, and other local Trusts for: staff receiving job-relevant training, learning or development in last 12 months and; staff having well-structured appraisals in last 12 months.

Pledge 3: To provide support and opportunities for staff to maintain their health, well-being and safety

HEFT’s overall score was 67% (higher percentage is better) against the 5 key findings, (National Acute Trust average-68%). HEFT’s score was lower than the national Acute Trust average, and other local Trusts for: staff receiving job-relevant training, learning or development in last 12 months and; staff having well-structured appraisals in last 12 months.


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Pledge 4: To engage staff in decisions that affect them, the services they provide & empower them to put forward ways to deliverbetter & safer services

HEFT’s overall score was 45% (higher percentage is better), (National Acute Trust average-48%). The main area for improvement related to the percentage of staff reporting good communication between senior management and staff.

Overall staff satisfaction HEFT’s overall score was 72% (higher percentage is better). (National Acute Trust average-73%). The Trust’s overall score was the same as that achieved by Mid Staffordshire, Leicester and Sandwell & West Birmingham Trusts.HEFT’s poorest performance against the 3 key findings in this section was against the “net promoter” question, regarding whether or not staff would recommend HEFT as a place to work or receive treatment.

Equality and diversity HEFT’s overall score was 38% (National Acute Trust average -51%.)The organisation is a significant outlier when compared with other local Trusts.

HEFT’s poorest performance against the 3 key findings in this section was regarding the percentage of staff having received equality and diversity training in last 12 months.

Data from the staff survey was triangulated on results from 28 key findings and the results of this were used to select our areas for focus over the next six months.

The following areas consistently gave good feedback; General management, Nurse management, Rheumatology, Clinical Compliance, Thoracic Surgery, R&D Directorate andFacilities Management

The Areas consistently highlighting concerns were: Vascular Surgery, Elderly Medicine(Solihull), Infectious Diseases, General Surgery (Solihull) and Acute medicine (BHH, GHH, SH)(N.B.only acute medical units flagged in 28 key findings).

An improvement programme has been developed which targets three levels of intervention:1. Organisation-wide corporate improvement goals and actions.2. Local service improvement programmes targeted at our areas of concern.3. Improvement programmes relating to Directorates with high-stress response rates.

SW explained that we will collaborate with management and site teams to design interventions that work for everyone. This improvement programme will be monitored by a newly established Live Well, Work well group which will report to the HR Committee and GRC.

The chairman expressed concern regarding General Surgery at Solihull. LT explained that work is ongoing with the site team and members of the surgery team.

LSG voiced serious concern over the issues surrounding Equality and Diversity and said she felt that more than looking at training was required. She said she lacked information on staffing diversity and felt that the Board did not have the assurance around Equality and Diversity Issues. She was concerned that the position seemed not to have changed since last year. MS suggested a task-force to address this and invited LSG to chair it.

The Chairman asked that it be dealt with urgently and asked MS and LSG to discuss outside the meeting.

Action MS

13. Health and Safety Annual Report

AK presented this report and explained that the report was presented for assurance. The only area causing concern is the quarterly H and S return process. However, dialogue is ongoing regarding this and this is being actively managed.


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The Chairman asked whether there had been any conclusion to the asbestos investigation. AK responded that we are still awaiting feedback from the HSE.

The GRC noted the work of the Health and Safety team and asked AK to pass on their thanks.

Compliance and Corporate Risk

14. CQC Compliance Update

RB updated on the CQC quarter 1 compliance report: the Trust has no ongoing compliance actions relating to CQC standard compliance. In terms of our internal quality sign off process,all standards have a green compliance rating with the exception of the following standards which are rated as amber:

6 Cooperating with other providers - this related to discharge processes.

9 Management of medicines – this related to the launch of the self-administration policy.

10 Safety and suitability of premises - this related to rented accommodation for the community services building.

11 Staffing – this related to staffing levels over our winter 2012/13.

16 Quality of service provision – this related to increased HSMR over February/March and concerns regarding BHH Q and S meetings.

Action plans are in place to address these issues and are monitored by Executive Directors and Executive Management Board.

Internal audit

No updates this month

Information and assurance

15. Reports from the sub Committees

Safety Committee – taken as readClinical Standards - taken as read (update included in audit and effectiveness dashboard)Information Governance Committee - taken as readTrust Infection Protection Committee - taken as read

Director of Safety and Governance report

16. HEFT Francis Response Update

SW presented a report on HEFT’s developing response to the Francis Inquiry. This included a summary of the key themes from Francis and a summary of the Government response, (Putting patients first and foremost). SW explained we were still awaiting the outcome of Professor Berwick’s National Patient Safety Review. This proposal still needs to be discussed more widely with Executive Directors. The HEFT response to Francis will include 5 strategic actions which will be developed further over the autumn period as follows:

• Gap Analysis against Francis report recommendations (previously discussed)• Engagement events with Board/Executive and frontline workforce• Review of whistleblowing, incident reporting and raising concerns framework.


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• Staff survey improvement plan• Organisational response to Francis and improvement programmes (i.e. strategic review

of organisational activities, improvement strategies based on above actions/reviews.

Once we have all this information we will need to do a stock take of our strategies and corporate position and revise our approach based on this. We will also need to take account of the Berwick safety review too.

The Chairman requested more time should be allocated at the August meeting to discuss Francis.

CR felt there needed to be a specific action relating to patient experience and listening to patients. The Committee agreed with this approach.

SW said she would include an action around reviewing our approach to listening to patients andcomplaints.

Action SW

The Chairman felt there needed to be more involvement of NEDs in complaints and patient experience but that we hadn’t worked out an approach to this. JR and CR sought clarity on complaints statistics.

LT explained that she was working with the Patients Association and that HEFT was a pilot site.As part of this process, HEFT is being benchmarked against seven other Trusts. LT said data on complaints resurfacing would start to come through in the reports.

HG commented that she had recently visited Derby to look at values-based recruitment and that patients had been involved in setting Trust values. The Committee felt this was a positive initiative and worth considering as part of our values development.

In summary GRC accepted the proposals for developing a response to the Francis Inquiry, with the addition of a further action relating to listening to patients. It was noted that this report needed to be discussed with Executive Directors and submitted to Trust board over August and September 2013.

17. Any Other Business

SW requested authority to amend the TOR to reflect the inclusion of HR Committee as a sub committee and to include staff engagement and cultural development of the responsibilities of GRC. SW requested authority to change the name of the committee to Quality and Risk Committee. This was agreed and revised TOR will be submitted to Trust Board with GRC draft minutes and the GRC report.

The Chairman requested clarity on improvement actions relating to the recent Deanery visit to the Trauma and Orthopaedics Directorate. AK updated that immediate rectification actions had taken place and that a meeting had been arranged with the medical Director to agree longer term actions. GRC will receive a progress report on implementing these actions at its next meeting.

Action AA

Date and Time of Next Meeting:The next meeting will be on Monday 14 October 09.00am in the Board Room of Devon House, BHH. Please send any apologies through to [email protected]


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GOVERNANCE & RISK COMMITTEE

Ongoing Actions – July 2013

Date ofMinutes Action Target

date Owner

June 2013 MS / HG to bring the Staffing report that is being submitted to Executive Management Board, to the July Governance and Risk Committee.

July 2013 MS / HG

July 2013 The September Board will be supplied with GRC minutes, a copy of the Keogh Review and the Francis Gap Analysis and coversheet.

Sept 2013 SW

July 2013 Francis update to include an action around stock-taking and listening to patients

Sept 2013 SW

July 2013 Review of GRC TORs to come to September Board Sept 2013 SW

July 2013Level 1a/Critical care capacity and confusion around surgical reconfiguration and theatre capacity to be discussed at September EMB.

Sept 2013 AA/MS/SW

July 2013 Meeting with MS and LSG to discuss points raised by LSG on equality and diversity points raised by LSG

Oct 2013 Chairman

July 2013 Francis Gap Analysis Strategic Action plan and sub action plans to return to October GRC

Oct 2013 AK

July 2013 The Safety Sitrep which will go to the September Board to include more commentary

Oct 2013 SW/AK

June 2013 AK to bring a paper on Severe Harm which also looks at roles and responsibilities to the July Governance and Risk Committee.

Oct 2013 AK

June 2013 Human Factors report to be circulated after the October GRC meeting.

Oct 2013 SW

July 2013 A detailed report on A and E patient engagement to be brought back to GRC

Oct 2013 LT

July 2013 More data on complaints to come back to Oct GRC Oct 2013 LT

July 2013 Investigation in the Low Risk Diagnosis groups to be brought back to October GRC

Oct 2013 AK

July 2013 Further investigation into the variance between Dr Foster decubitus ulcer figures and HEFT internal data and report back to October GRC.

Oct 2013 AK

July 2013 SW to include an action in the Francis response around listening to patients

Dec 2013 LT

June 2013 The action plan for the KPMG Clinical Outcomes Framework Audit report to be followed up by the Committee

Dec 2013 AA

June 2013 The KPMG revalidation report - Implementation of the recommendations to be kept under review

Dec 2013 AA


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Francis Report Review

From: Sarah Woolley

Gap Analysis of the 290 Francis report recommendations

Update Executive directorate on our analysis of the 290 Francis recommendations.

The report is provided to the Board for:

Decision: (N)

Discussion: (Y)

Assurance: (Y)

Endorsement: (Y)

Summary/Key points:

Of the 290 recommendations we have identified 80 as having action for the Trust. Of the remaining 210 the actions are for the Department of Health, Coroners or others

outside of HEFT. Of the 80 Trust actions;

o 57 were accepted or accepted in principle. o 20 we require further information/clarification. o 3 we do not agree with.

Positive messages: We feel we are making good progress with the majority of the 57. Key areas requiring improvement

o Staff Engagement o Information and data management (volume and triangulation of metrics) o Monitoring of Duty of candour and honesty

Next Steps

This Gap Analysis will be presented and discussed with the Executive Team over August where necessary actions will be developed to address key issues.

This Gap Analysis should be considered in conjunction with the imminent staff/board engagement events due to take place over August and early autumn. The Gap Analysis and the feedback from the engagement events will be used to modify and refine HEFT’s current strategic direction and organisational improvement programmes.

We have identified 80 Trust Actions

57 Trust Actions have been accepted or accepted in Principle by HEFT

20 Trust Actions require further clarification

3 Trust Actions we

do not agree with


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From: Sarah Woolley

Gap Analysis of the 290 Francis report recommendations

Strategic Risk Register (Anything to note?) Performance KPIs year to date: (Anything to note?) Resource Implications (e.g. Financial, HR): (Anything to note?) Assurance Implications: (Anything to note?) Information exempt from Disclosure: (Anything to note?)



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Heart of England NHS Foundation TrustDraft action plan response to Francis report recommendations

Trus

t Act

ion

No.

FR R

ec N

o.

Recommendation

Act

ion

for t

he T

rust

?

Trus

t Lea

d

Lead

Com

mit

tee

Com

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men

t to

reco

mm

enda

tion

Current SystemsAction(s) required to comply with the Recommendation

1It is recommended that: All commissioning, service provision regulatory and ancillary organisations in healthcare should consider the findings and recommendations of this report and decide how to apply them to their own work;

Y SW TB Accepted

2

Each such organisation should announce at the earliest practicable time its decision on the extent to which it accepts the recommendations and what it intends to do to implement those accepted, and thereafter, on a regular basis but not less than once a year, publish in a report information regarding its progress in relation to its planned actions;

Y SW TB Accepted

In addition to taking such steps for itself, the Department of Health should collate information about the decisions and actions generally and publish on a regular basis but not less than once a year the progress reported by other organisations;

N

The House of Commons Select Committee on Health should be invited to consider incorporating into its reviews of the performance of organisations accountable to Parliament a review of the decisions and actions they have taken with regard to the recommendations in this report.

N

3 2

The NHS and all who work for it must adopt and demonstrate a shared culture in which the patient is the priority in everything done. This requires: * A common set of core values and standards shared throughout the system;* Leadership at all levels from ward to the top of the DH, committed to and capable of involving all staff with those values and standards;* A system which recognises and applies the values of transparency, honesty and candour;* Freely available, useful and reliable and full information on attainment of the vaules and standards;* A tool or methodology such as a cultural barometer to measue the cultural health of all parts of the system.

Y SW TB Accepted

Trust and professional codes of conduct

Trust Core Values (of Safe and Caring, Innovative, Locally Engaged and Efficient) and suppoting business plan

Being open policy (including duty of candour)Incident reporting and whistle blowing processes

Annual Staff Survey (including engagement)

MapSaf completed in 2008)

Nursing 3P's

Development of organisational development framework for the Trust incorporating the specific requirements of this recommendation

Patient Safety Review #2 to be commissioned and inform the OD and patient safety strategy

4 3The NHS Constitution should be the first reference point for all NHS patients and staff and should set out the system‟s common values, as well as the respective rights, legitimate expectations and obligations of patients.

Y SW TB AcceptedNHS Constitution discussed within Trust Committees See points 4,5,6,7,8

5 4The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by this ethos.

Y SW TB AcceptedN/A Ensure HEFT values are founded on those within the NHS

Constitution.

6 5

In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: * Staff put patients before themselves;* They will do everything in their power to protect patients from avoidable harm;* They will be honest and open with patients regardless of the consequences to themselves;* Where they are unable to provide the assistance a patient needs, they will direct them where possible to those who can do so;* They will apply the NHS values in all their work.

N

6 The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance. N

7 7All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.

Y SW TB Accepted

Consideration of explicit reference to this within contracts of employment.

organisational development framework

8 8

Contractors providing outsourced services should also be required to abide by these requirements and to ensure that staff employed by them for these purposes do so as well. These requirements could be included in the terms on which providers are commissioned to provide services.

Y AS FPC Accepted Review of contracts by procuremnt to ensure that relevant statements are included for all Trust commissioned services

9 The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers. N

10

The NHS Constitution should incorporate an expectation that staff will follow guidance and comply with standards relevant to their work, such as those produced by the National Institute for Health and Clinical Excellence and, where relevant, the Care Quality Commission, subject to any more specific requirements of their employers.

N

9 11

Healthcare professionals should be prepared to contribute to the development of, and comply with, standard procedures in the areas in which they work. Their managers need to ensure that their employees comply with these requirements. Staff members affected by professional disagreements about procedures must be required to take the necessary corrective action, working with their medical or nursing director or line manager within the trust, with external support where necessary.

Y MS/AA G&R

Clinical guidelines adopted / developed by the Trust. Clinical Standards Committee.

Guidelines and Audit programmes including Participation in national and local audits

Metrics on key areas and performance dashboards

Ensure that relevant processes are in place

Develop mechanism for resolving local disputes in professional practice which impedes the developement of standardised practice (MS and AA)

Professional bodies should work on devising evidence-based standard procedures for as many interventions and pathways as possible. N

10 12

Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report they make, including information about any action taken or reasons for not acting.

Y SW G&R

? Partial acceptance/?

Incident reporting is currently an

encouraged but voluntary activity

Cannot provide meaningful

feedback on all incidents

Incident reporting policy in place

Recent project to simplify incident reporting system

Communication systems to share learning from the most serious incidents or key themes

Review of current incident reporting process to consider feasilbility of these recommendations

Define the expectations on how feedback can be achieved via existing operational structures and incident analysis as well as individual incidents

Explore how to improve and then mandate medical staff report incidents

13

Standards should be divided into: * Fundamental standards of minimum safety and quality – in respect of which non-compliance should not be tolerated. Failures leading to death or serious harm should remain offences for which prosecutions can be brought against organisations. There should be a defined set of duties to maintain and operate an effective system to ensure compliance;* Enhanced quality standards - such standards could set requirements higher than the fundamental standards but be discretionary matters for commissioning and subject to the availability of resources;* Developmental standards which set out longer term goals for providers - these would focus on improvements in effectiveness and are more likely to be the focus of commissioners and progressive provider leadership than the regulator;

All such standards would require regular review and modification

N

Gap analysis and action plan to be presented to G&R in July and approved by Trust Board September 2013

Schedule 6 monthly review of progress (G&R then TB)

N/A

NA - Action for DH

1

NA - Action for national regulators

NA - Action for DH and House of Commons Select Committee

NA - Action for DH

NA - Action for DH

NA - Action for DH

NA - Action for DHFinal outcome will be considered by Trust


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14

In addition to the fundamental standards of service, the regulations should include generic requirements for a governance system designed to ensure compliance with fundamental standards, and the provision and publication of accurate information about compliance with the fundamental and enhanced standards.

N

15All the required elements of governance should be brought together into one comprehensive standard. This should require not only evidence of a working system but also a demonstration that it is being used to good effect.

N

16

The Government, through regulation, but after so far as possible achieving consensus between the public and professional representatives, should provide for the fundamental standards which should define outcomes for patients that must be avoided. These should be limited to those matters that it is universally accepted should be avoided for individual patients who are accepted for treatment by a healthcare provider.

N

17

The NHS Commissioning Board together with Clinical Commissioning Groups should devise enhanced quality standards designed to drive improvement in the health service. Failure to comply with such standards should be a matter for performance management by commissioners rather than the regulator, although the latter should be charged with enforcing the provision by providers of accurate information about compliance to the public.

N

18 It is essential that professional bodies in which doctors and nurses have confidence are fully involved in the formulation of standards and in the means of measuring compliance. N

19 There should be a single regulator dealing both with corporate governance, financial competence, viability and compliance with patient safety and quality standards for all trusts. N

20

The Care Quality Commission should be responsible for policing the fundamental standards, through the development of its core outcomes, by specifying the indicators by which it intends to monitor compliance with those standards. It should be responsible not for directly policing compliance with any enhanced standards but for regulating the accuracy of information about compliance with them.

N

21

The regulator should have a duty to monitor the accuracy of information disseminated by providers and commissioners on compliance with standards and their compliance with the requirement of honest disclosure. The regulator must be willing to consider individual cases of gross failure as well as systemic causes for concern.

N

22

The National Institute for Health and Clinical Excellence should be commissioned to formulate standard procedures and practice designed to provide the practical means of compliance, and indicators by which compliance with both fundamental and enhanced standards can be measured. These measures should include both outcome and process based measures, and should as far as possible build on information already available within the system or on readily observable behaviour.

N

23

The measures formulated by the National Institute for Health and Clinical Excellence should include measures not only of clinical outcomes, but of the suitability and competence of staff, and the culture of organisations.The standard procedures and practice should include evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix. This should include nursing staff on wards, as well as clinical staff. These tools should be created after appropriate input from specialties, professional organisations, and patient and public representatives, and consideration of the benefits and value for money of possible staff: patient ratios.

N

24Compliance with regulatory fundamental standards must be capable so far as possible of being assessed by measures which are understood and accepted by the public and healthcare professionals.

N

25It should be considered the duty of all specialty professional bodies, ideally together with the National Institute for Health and Clinical Excellence, to develop measures of outcome in relation to their work and to assist in the development of measures of standards compliance.

N

26

In policing compliance with standards, direct observation of practice, direct interaction with patients, carers and staff, and audit of records should take priority over monitoring and audit of policies and protocols. The regulatory system should retain the capacity to undertake in-depth investigations where these appear to be required.

N

27

The healthcare systems regulator should promote effective enforcement by: use of a low threshold of suspicion; no tolerance of non-compliance with fundamental standards; and allowing no place for favourable assumptions, unless there is evidence showing that suspicions are ill-founded or that deficiencies have been remedied. It requires a focus on identifying what is wrong, not on praising what is right.

N

28

Zero tolerance: A service incapable of meeting fundamental standards should not be permitted to continue. Breach should result in regulatory consequences attributable to an organisation in the case of a system failure and to individual accountability where individual professionals are responsible. Where serious harm or death has resulted to a patient as a result of a breach of the fundamental standards, criminal liability should follow and failure to disclose breaches of these standards to the affected patient (or concerned relative) and a regulator should also attract regulatory consequences. Breaches not resulting in actual harm but which have exposed patients to a continuing risk of harm to which they would not otherwise have been exposed should also be regarded as unacceptable.

N

29

It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has been served and the notice has not been complied with. It should be a defence for the provider to prove that all reasonably practicable steps have been taken to prevent a breach, including having in place a prescribed system to prevent such a breach.

N

30

The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet to reach a concluded view or acquire all the evidence. The test should be whether it has reasonable grounds in the public interest to make the interim requirement or recommendation.

N

31

Where aware of concerns that patient safety is at risk, Monitor and all other regulators of healthcare providers must have in place policies which ensure that they constantly review whether the need to protect patients requires use of their own powers of intervention to inform a decision whether or not to intervene, taking account of, but not being bound by, the views or actions of other regulators.

N

32

Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary measures to ensure such protection while any investigation required to make a final determination is undertaken.

N

33Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.

N

34Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.

N

35

Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.

N

36

A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk of non-compliance. It must not only include statistics about outcomes, but must take advantage of all safety related information, including that capable of being derived from incidents, complaints and investigations.

N

11

Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to set out detail, this should be made available via each trust‟s website. Reports should no longer be confined to reports on achievements as opposed to a fair representation of areas where compliance has not been achieved. A full account should be given as to the methods used to produce the information.

Y LT

AC

/TB

Accepted

Quality account is prepared in line with DH and Monitor guidance - which includes ensuring that it gives a fair representation of the Trust's performance - both positive and negative

Ensure that the Quality Account and Quality Report is an accurate reflection of the Trusts current performance

37

NA - Action for CQC

NA - Action for NICE


NA - Action for regulators












NA - Action for NHSCB


NA - Action for Government

NA - Action for CQC

NA - Action for DH





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Financeand

Performance

CorporateGovernance


To make or be party to a wilfully or recklessly false statement as to compliance with safety or essential standards in the required quality account should be made a criminal offence N

38

The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local relationship managers. Any bureaucratic or legal obstacles to this should be removed.

N

39 The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes. N

12 40 It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers. Y LT GRC Accepted

A new site report (SitRep) has been developed to capture narrative contained within the complaints data.

This is shared at site Board meetings, Governance and Risk Committee

Individual specialty reports will also be available from Q3 2013

Ensure current process are reviewed to ensure that this recommendation can be implemented

41

The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety alerts should continue following the transfer of the National Patient Safety Agency‟s functions in June 2012 to the NHS Commissioning Board.

N

42 Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission. N

43 Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility. N

44

Any example of a serious incident or avoidable harm should trigger an examination by the Care QualityCommission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be derived has been successfully implemented.

N

13 45 The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners. Y SW

CQ

PG

AcceptedMonitor quarterly return (and SitRep) CQC and Monitor already receive copies of the quarterly

governance returns which include details of up coming inquests of concern

46The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.

N

47The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current „sounding board events‟.

N

48The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.

N

49

Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from:The QRP; The Quality Accounts; Reports from local Healthwatch; New or existing peer review schemes; Themed inspections

N

50 The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance. N

51

The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, including service user representatives, clinicians and any other specialism necessary because of particular concerns. Consideration should be given to applying the same principle to the independent sector, as well as to the NHS.

N

52The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.

N

53 Any change to the Care Quality Commission‟s role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided. N

54Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission‟s statutory role.

N

55The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.

N

56The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.

N

57

The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of the first inquiry, and open that evaluation for public scrutiny.

N

58

Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients‟ consultative council with which issues could be discussed to obtain a patient perspective directly.

N

59

Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.

N

60The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.

N

61

A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area of regulatory activity. It would be vital to retain the corporate memory of both organisations.

N

62For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.

N

63 Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence. N

64

The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation of the authorisation process and compliance with foundation trust standards should be transferred to the Care Quality Commission, which should incorporate the relevant departments of Monitor.

N

65The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.

N

66

The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust for foundation trust status and in particular on whether a potential applicant is delivering a sustainable service compliant with fundamental standards; an accessible record of responses received is maintained; the responses are made available for analysis on behalf of the Secretary of State and where an application is assessed by it, by Monitor

N

67

The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service delivered to patients, and the sustainability of a service at the required standard.

N

37

NA - Action for DH

NA - Action for NHS TDA

NA - Action for DH and NHS TDA

NA - Action for NHS TDA

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

LOCAL POSITION: Established monitoring system for compliance with CAS alerts within specified timeframes and exception reporting

NA - Action for CCGs / CQC


NA - Action for CQC

NA - Action for CQCFinal outcome will be considered by Trust

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC


NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

NA - Action for Secretary of State



NA - Action for Monitor

NA - Action for Monitor



.70

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


68

No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied that the organisation currently meets Monitor‟s criteria for authorisation and that it is delivering a sustainable service which is, and will remain, safe for patients, and is compliant with at least fundamental standards.

N

69

The assessment criteria for authorisation should include a requirement that applicants demonstrate their ability to consistently meet fundamental patient safety and quality standards at the same time as complying with the financial and corporate governance requirements of a foundation trust.

N

70

A duty of utmost good faith should be imposed on applicants for foundation trust status to disclose to the regulator any significant information material to the application and to ensure that any information is complete and accurate. This duty should continue throughout the application process, and thereafter in relation to the monitoring of compliance.

N

71

The Secretary of State‟s support for an application should not be given unless he is satisfied that the proposed applicant provides a service to patients which is, at the time of his consideration, safe, effective and compliant with all relevant standards, and that in his opinion it is reasonable to conclude that the proposed applicant will continue to be able to do so for the foreseeable future. In deciding whether he can be so satisfied, the Secretary of State should have regard to the required public consultation and should consult with the healthcare regulator.

N

72The assessment for an authorisation of applicant for foundation trust status should include a full physical inspection of its primary clinical areas as well as all wards to determine whether it is compliant with fundamental safety and quality standards.

N

73

The Department of Health‟s regular performance reviews of Monitor (and the Care Quality Commission) should include an examination of its relationship with the Department of Health and whether the appropriate degree of clarity of understanding of the scope of their respective responsibilities has been maintained.

N

74

Monitor and the Care Quality Commission should publish guidance for governors suggesting principles they expect them to follow in recognising their obligation to account to the public, and in particular in arranging for communication with the public served by the foundation trust and to be informed of the public‟s views about the services offered.

N

14 75

The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce an agreed published description of the role of the governors and how it is planned that they perform it. Monitor and the Care Quality Commission should review these descriptions and promote what they regard as best practice.

Y LT

TB/G

CC

Accepted

Governors Consultative Council and sub committees

Develop plan to ensure that the recommendation is met and identify how this will be monitored

15 76Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large – it is important that regular and constructive contact between governors and the public is maintained.

Y LT

GC

C

Accepted

This is being met and monitored by the Council of Governors Membership Committee

Develop plan to ensure that the recommendation is met and identify how this will be monitored

77Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust‟s services.

N

78

The Care Quality Commission and Monitor should consider how best to enable governors to have access to a similar advisory facility in relation to compliance with healthcare standards as will be available for compliance issues in relation to breach of a licence (pursuant to section 39A of the National Health Service Act 2006 as amended), or other ready access to external assistance.

N

16 79

There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a requirement to comply with a prescribed code of conduct for directors.

Y LT TB Accepted

Recruitment pocess for Board directors. Performance review and appraisal of Board members. Board Assessment against Monitor requirements and code of Governance

Review of current systems by Company Secretary. Modify Board development programme as required.

80A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications in the standard terms of a foundation trust‟s constitution.

N

17 81 Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence. Y LT TB Accepted

As above. Review of current systems by Company Secretary. Modify Board development programme as required.

82

Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is no longer a fit and proper person, regardless of whether the trust is in significant breach of its authorisation or licence.

N

83

If a “fit and proper person test” is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or suspension or disqualification of directors who did not fulfil it, and the procedure it would follow to ensure due process.

N

18 84

Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a post, licensed bodies should be obliged by the terms of their licence to report the matter to Monitor, the Care Quality Commission and the NHS Trust Development Authority.

Y LT TB Accepted

Arrangemenst to report to CQC in place

Ensure that appropriate mechanisms are in place for informing the regulator

Review role of HR in this recommendation

85

Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance of his or her office, and in particular with regard to the need to have regard to the public interest in protection of patients and maintenance of confidence in the NHS and the healthcare system.

N

19 86 A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors. Y SW/

LT TB AcceptedAs above. Need to reivew current systems and arrangements.

87

The Health and Safety Executive is clearly not the right organisation to be focusing on healthcare. Either the Care Quality Commission should be given power to prosecute 1974 Act offences or a new offence containing comparable provisions should be created under which the Care Quality Commission has power to launch a prosecution.

N

88

The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts‟ practice in reporting fatalities and other serious incidents.

Y SW GRC

Disagree with detail of

recommendation.

Not all RIDDOR incidents are SI's

Regulators need to share information in a different way

Report RIDDOR incidents to HSE

Consider incidents of severe of catastrophic harm through SI process (and therefore reported to STEISS)

Continue to report RIDDOR incidents and encourage staff awareness of need to report these types of incident

Continue to report appropriate incidents on STEISS

20 89 Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive. Y SW

GR

C

Disagree with detail of

recommendation

Regulators need to share information in a different way

Part of SI process considers need to inform HSE on a case by case basis

Seek guidance from HSE. Continue SI process

90

In order to determine whether a case is so serious, either in terms of the breach of safety requirements or the consequences for any victims, that the public interest requires individuals or organisations to be brought to account for their failings, the Health and Safety Executive should obtain expert advice, as is done in the field of healthcare litigation and fitness to practise proceedings.

N

91

The Department of Health and NHS Commissioning Board should consider what steps are necessary to require all NHS providers, whether or not they remain members of the NHS Litigation Authority scheme, to have and to comply with risk management standards at least as rigorous as those required by the NHS Litigation Authority.

N

NA - Action for non-FTs





NA - Action for DH


NA - Action for Monitor and NHSCB







NA - Action for HSE

NA - Action for DH, NHSCB and NHSLA


.71

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


92 The financial incentives at levels below level 3 should be adjusted to maximise the motivation to reach level 3. N

93

The NHS Litigation Authority should introduce requirements with regard to observance of the guidance to be produced in relation to staffing levels, and require trusts to have regard to evidence-based guidance and benchmarks where these exist and to demonstrate that effective risk assessments take place when changes to the numbers or skills of staff are under consideration. It should also consider how more outcome based standards could be designed to enhance the prospect of exploring deficiences in risk management, such as occurred at the Trust.

N

94As some form of running record of the evidence reviewed must be retained on each claim in order for these reports to be produced, the NHS Litigation Authority should consider development of a relatively simple database containing the same information.

N

95As the interests of patient safety should prevail over the narrow litigation interest under which confidentiality or even privilege might be claimed over risk reports, consideration should also be given to allowing the Care Quality Commission access to these reports.

N

96The NHS Litigation Authority should make more prominent in its publicity an explanation comprehensible to the general public of the limitations of its standards assessments and of the reliance which can be placed on them.

N

97 The National Patient Safety Agency‟s resources need to be well protected and defined. Consideration should be given to the transfer of this valuable function to a systems regulator. N

21 98Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.

Y SW

CQ

PG

AcceptedRegular uploads to NRLS already implemented

Regular uploads to NRLS already implemented

99The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.

N

22 100Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.

Y SWM

onito

r/CQ

C Q

uarte

rly m

eetin

gs

Accepted in principle

Current systems achieve this

recommendation

Any patient safety incident reported via incident reporting system are uploaded to NRLS

SUI briefings are shared with the CQC when the SUI is declared and the quarterly governance return (which includes all SUIs and never events) is shared & discussed with Monitor and the CQC quarterly

We will investigate potential serious incidents highlighed through other sources in information e.g. complaints, M&M, NHS choices or highlighted to our regulators. We will also consider why this may not have been reported at the time

Continue current processes

101

While it may be impracticable for the National Patient Safety Agency or its successor to have its own team of inspectors, it should be possible to organise for mutual peer review inspections or the inclusion in Patient Environment Action Team representatives from outside the organisation. Consideration could also be given to involvement from time to time of a representative of the Care Quality Commission.

N

102 Data held by the National Patient Safety Agency or its successor should be open to analysis for a particular purpose, or others facilitated in that task. N

103 The National Patient Safety Agency or its successor should regularly share information with Monitor. N

104

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying areas for focusing its attention. There needs to be a better dialogue between the two organisations as to how they can assist each other.

N

105 Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio. N

106The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider‟s performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.

N

107

If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider‟s management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients or public safety, they should immediately inform all responsible commissioners, including the relevant regional office of the NHS Commissioning Board, the Care Quality Commission and, where relevant, Monitor, of those concerns. Sharing of such information should not be regarded as an action of last resort. It should review its procedures to ensure clarity of responsibility for taking this action.

N

108Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers‟ infection control arrangements.

N

23 109

Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally led by the provider trust.

Y LT

GR

C

Accepted

Complaints process in place Review existing procedures and ensure that they are compliant with this recommendation

Plans are underway to centralise complaints which will ensure a single point of contact for all complainants.This is being trialled, initially, in the Women's and Childrens division and will be rolled out in all other areas shortly

24 110

Actual or intended litigation should not be a barrier to the processing or investigation of a complaint at any level. It may be prudent for parties in actual or potential litigation to agree to a stay of proceedings pending the outcome of the complaint, but the duties of the system to respond to complaints should be regarded as entirely separate from the considerations of litigation. Y LT

GR

C

Partial Agree: Cannot be entirely

separate as complaints

response may influence outcome

of litigation;

Where complaints responses contain admissions and causation we are required to inform the NHSLA prior to release.

Review existing procedures and ensure that they are compliant with this recommendation, national regulations, duty of candour and NHSLA requirements

25 111

Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation.

Y LT

GR

C

Accepted

The Trust has a suite of site specific information and posters as well as a section on the website for sharing information

Review existing procedures and ensure that they are compliant with this recommendation

26 112

Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as a formal complaint, whether or not the informant has indicated a desire to have the matter dealt with as such.

Y LT

GR

C

Partial Agree: Some methods of

feedback are anonymous e.g. NRI and ward

metrics

To be sustainable system need to allow reponse

proportionate to concerns raised

We respond to trends and themes from NRI and patient experience metrics

We will invite contact from complaints made on NHS choices

Process to investigate and respond to 'informa complaints'


27 113The recommendations and standards suggested in the Patients Association‟s peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.

Y LT

GR

C

AcceptedConsider these recommendationand and review existing procedures where apporopriate

28 114

Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation. Y LT

GR

C

Accepted

Liaison between complaints and investigations team where potential SI are highligted through complaints processes

Strenthen liaison processes

NA - Action for NRLS

NA - Action for NPSA or successor



NA - Action for CQC / NPSA (or successor)


NA - Action for HPA or successor

NA - Action for HPA or successor

NA - Action for Public Health England

NA - Action for NPSA

NA - Action for NHSLA






.72

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


29 115

Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; subject matter involving clinically related issues is not capable of resolution without and expert clinical opinion; a complaint raises substantive issues of professional misconduct or the performance of senior managers; a complaint involves issues about the nature and extent of the services commissioned

Y LT

GR

C

Disagree with criteria for arms

length independant investigation

Complaints involing SI's are handled through SI process

Internal independant experts involved in clinically related issues, external may also be appointed if required

Professional misconduct would be handled through HR processes

Proportionate use of external experts where concerns identified (though avenues not limited to complaints) about nature and extent of services provided

Continue current processes

30 116Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.

Y LT

GR

C

AcceptedPALS and ICAS offered to all complainants


31 117 A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases. N

32 118

Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust‟s response should be published on its website. In any case where the complainant or, if different, the patient, refuses to agree, or for some other reason publication of an upheld, clinically related complaint is not possible, the summary should be shared confidentially with the Commissioner and the Care Quality Commission.

Y LT

GR

C

Partial:

The assessment of whether

complaints are upheld or not is

open to interpretation and

requires further clarification

Recommendation has the potential

to be very resource intensive.

Consider how information about complaints can be shared with our commissioners, CQC and public in order to demonstate transparency

Consider this recommendation and develop new processes to be compliant where relevant

33 119Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.

Y LT

GR

C

See 118See 118 See 118

34 120

Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to do so.

Y LT

GR

C Disagree with recommendation

Is this for GP or include acute contracted services?


121The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.

N

122

Large-scale failures of clinical service are likely to have in common a need for: * Provision of prompt advice, counselling and support to very distressed and anxious members of the public;* Swift identification of persons of independence, authority and expertise to lead investigations and reviews;* A procedure for the recruitment of clinical and other experts to review cases;* A communications strategy to inform and reassure the public of the processes being adopted;* Clear lines of responsibility and accountability for the setting up and oversight of such reviews;* Such events are of sufficient rarity and importance, and requiring of ccordination of the activities of multiple organisations, that the primary responsibility should reside in the National Quality Board

N

123

GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so that they do not merely treat each case on its individual merits. They have a responsibility to all their patients to keep themselves informed of the standard of service available at various providers in order to make patients‟ choice reality. A GP‟s duty to a patient does not end on referral to hospital, but is a continuing relationship. They will need to take this continuing partnership with their patients seriously if they are to be successful commissioners.

N

124

The commissioner is entitled to and should, wherever it is possible to do so, apply a fundamental safety and quality standard in respect of each item of service it is commissioning. In relation to each such standard, it should agree a method of measuring compliance and redress for non-compliance. Commissioners should consider whether it would incentivise compliance by requiring redress for individual patients who have received substandard service to be offered by the provider. These must be consistent with fundamental standards enforceable by the Care Quality Commission.

N

125

In addition to their duties with regard to the fundamental standards, commissioners should be enabled to promote improvement by requiring compliance with enhanced standards or development towards higher standards. They can incentivise such improvements either financially or by other means designed to enhance the reputation and standing of clinicians and the organisations for which they work.

N

126

The NHS Commissioning Board and local commissioners should develop and oversee a code of practice for managing organisational transitions, to ensure the information conveyed is both candid and comprehensive. This code should cover both transitions between commissioners, for example as new clinical commissioning groups are formed, and guidance for commissioners on what they should expect to see in any organisational transitions amongst their providers.

N

127

The NHS Commissioning Board and local commissioners must be provided with the infrastructure and the support necessary to enable a proper scrutiny of its providers‟ services, based on sound commissioning contracts, while ensuring providers remain responsible and accountable for the services they provide.

N

128

Commissioners must have access to the wide range of experience and resources necessary to undertake a highly complex and technical task, including specialist clinical advice and procurement expertise. When groups are too small to acquire such support, they should collaborate with others to do so.

N

129

In selecting indicators and means of measuring compliance, the principal focus of commissioners should be on what is reasonably necessary to safeguard patients and to ensure that at least fundamental safety and quality standards are maintained. This requires close engagement with patients, past, present and potential, to ensure that their expectations and concerns are addressed.

N

130

Commissioners – not providers – should decide what they want to be provided. They need to take into account what can be provided, and for that purpose will have to consult clinicians both from potential providers and elsewhere, and to be willing to receive proposals, but in the end it is the commissioner whose decision must prevail.

N

131

Commissioners need, wherever possible, to identify and make available alternative sources of provision. This may mean that commissioning has to be undertaken on behalf of consortia of commissioning groups to provide the negotiating weight necessary to achieve a negotiating balance of power with providers.

N

NA - Action for other agencies and ICAS

NA - Action for CQC

NA - Action for CQC

NA - Action for CCGs










.73

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


132

Commissioners must have the capacity to monitor the performance of every commissioning contract on a continuing basis during the contract period: * Such monitoring may include requiring quality information generated by the provider;* Commissioners must also have the capacity to undertake their own (or independent) audits, inspections and investigations. These should, where appropriate, include investigation of individual cases and review of group cases;* The possession of accurate, relevant and useable information from which the safety and quality of a service can be ascertained is the vital key to effective commissioning as it is to effective regulation;* Monitoring needs to embrace both compliance withthe fundamental standards and with any enhanced standards. In the case of the latter, they will be the only source of monitoring, leaving the healthcare regulator to focus on fundamental standards

N

133

Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, while respecting the principle that it is the provider who has primary responsibility to process and respond to complaints about its services.

N

134Consideration should be given to whether commissioners should be given responsibility for commissioning patients‟ advocates and support services for complaints against providers. N

135

Commissioners should be accountable to their public for the scope and quality of services they commission. Acting on behalf of the public requires their full involvement and engagement: There should be a membership system whereby eligible members of the public can be involved in and contribute to the work of the commissioners.* There should be lay member on the commissioners board;* Commissioners should create and consult on patient forums and local representative groups. Individual members of the public (whether or not members) must have access to a consultative process so their views can be taken into account;* There should be regular surveys of patients and the public more generally;* Decision making processes should be transparent; decision making bodies should hold public meetings;* Commissioners need to create and maintain recognisable identity which becomes a familiar point of reference for the community

N

136

Commissioners need to be recognisable public bodies, visibly acting on behalf of the public they serve and with a sufficient infrastructure of technical support. Effective local commissioning can only work with effective local monitoring, and that cannot be done without knowledgeable and skilled local personnel engaging with an informed public.

N

137

Commissioners should have powers of intervention where substandard or unsafe services are being provided, including requiring the substitution of staff or other measures necessary to protect patients from the risk of harm. In the provision of the commissioned services, such powers should be aligned with similar powers of the regulators so that both commissioners and regulators can act jointly, but with the proviso that either can act alone if the other declines to do so. The powers should include the ability to order a provider to stop provision of a service.

N

138Commissioners should have contingency plans with regard to the protection of patients from harm, where it is found that they are at risk from substandard or unsafe services. N

139

The first priority for any organisation charged with responsibility for performance management of a healthcare provider should be ensuring that fundamental patient safety and quality standards are being met. Such an organisation must require convincing evidence to be available before accepting that such standards are being complied with.

Y SW / AS G

RC Accept (where we

commission third party services)

Framework for commissioning external healthcare service which is currently under review to reflect non bed based services

Consider this recommendation for any clinical services that the Trust Commissions

Strengthen the framwork for quality monitoring for contracted services

140

Where concerns are raised that such standards are not being complied with, a performance management organisation should share, wherever possible, all relevant information with the relevant regulator, including information about its judgement as to the safety of patients of the healthcare provider.

Y SW / AS G

RC

Accepted

Framework for commissioning external healthcare service which is currently under review to reflect non bed based services

For internal services information is already shared with our Commissioners viaCQRM with CCG'sCCG's invited to GRCCQC returnsMonitor returnsGMC and NMC returns where applicable

Consider this recommendation for any clinical services that the Trust Commissions

Strengthen the framwork for quality monitoring for contracted services

141

Any differences of judgement as to immediate safety concerns between a performance manager and a regulator should be discussed between them and resolved where possible, but each should recognise its retained individual responsibility to take whatever action within its power is necessary in the interests of patient safety.

N

142For an organisation to be effective in performance management, there must exist unambiguous lines of referral and information flows, so that the performance manager is not in ignorance of the reality.

N

35 143

Metrics need to be established which are relevant to the quality of care and patient safety across the service, to allow norms to be established so that outliers or progression to poor performance can be identified and accepted as needing to be fixed.

Y TBC FPCSeek further clarity

on recommendation

Internal performance metrics / sytems descibed elsewhere

Systems for services we commission also described elsewhere

Linked to other recommendations

144The NHS Commissioning Board should ensure the development of metrics on quality and outcomes of care for use by commissioners in managing the performance of providers, and retain oversight of these through its regional offices, if appropriate.

N

145There should be a consistent basic structure for Local Healthwatch throughout the country, in accordance with the principles set out in Chapter 6: Patient and public local involvement and scrutiny.

N

146

Local authorities should be required to pass over the centrally provided funds allocated to its Local Healthwatch, while requiring the latter to account to it for its stewardship of the money. Transparent respect for the independence of Local Healthwatch should not be allowed to inhibit a responsible local authority – or Healthwatch England as appropriate – intervening.

N

147Guidance should be given to promote the coordination and cooperation between Local Healthwatch, Health and Wellbeing Boards, and local government scrutiny committees. N

148The complexities of the health service are such that proper training must be available to the leadership of Local Healthwatch as well as, when the occasion arises, expert advice. N

149 Scrutiny committees should be provided with appropriate support to enable them to carry out their scrutiny role, including easily accessible guidance and benchmarks. N

150

Scrutiny committees should have powers to inspect providers, rather than relying on local patient involvement structures to carry out this role, or should actively work with those structures to trigger and follow up inspections where appropriate, rather than receiving reports without comment or suggestions for action.

N

151

MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.

N

152

Any organisation which in the course of a review, inspection or other performance of its duties, identifies concerns potentially relevant to the acceptability of training provided by a healthcare provider, must be required to inform the relevant training regulator of those concerns. N

153

The Secretary of State should by statutory instrument specify all medical education and training regulators as relevant bodies for the purpose of their statutory duty to cooperate. Information sharing between the deanery, commissioners, the General Medical Council, the Care Quality Commission and Monitor with regard to patient safety issues must be reviewed to ensure that each organisation is made aware of matters of concern relevant to their responsibilities.

N





NA - Action for ??





NA - Action for NHSCB

NA - Action for Healthwatch

NA - Action for Local Authorities

NA - Action for Local Authorities








.74

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


154

The Care Quality Commission and Monitor should develop practices and procedures with training regulators and bodies responsible for the commissioning and oversight of medical training to coordinate their oversight of healthcare organisations which provide regulated training.

N

155

The General Medical Council should set out a standard requirement for routine visits to each local education provider, and programme in accordance with the following principles: * The Postgraduate Dean should be responsible for managing the process at the level of the Local Educational Training Board, as part of overall deanery functions;* The Royal colleges should be enlisted to support such visits and to provide the relevant specialist expertise where required;* There should be lay or patient representation on visits to ensure that the patients interests are maintained as the priority;* Such visits should be informed by all other sources of information and, if relevant, coordinated with the work of the CQC and other forms of review.

The DH should provide appropriate resources to ensure that an effective programme of monitoring training by visits can be carried out.

All healthcare organisations must be required to release healthcare professionals to support the visits programme. It should also be recognised that the benefits in professional development and dissemination of good pratice are of significant value.

N

156 The system for approving and accrediting training placement providers and programmes should be configured to apply the principles set out above. N

157

The General Medical Council should set out a clear statement of what matters; deaneries are required to report to the General Medical Council either routinely or as they arise. Reports should include a description of all relevant activity and findings and not be limited to exceptional matters of perceived non-compliance with standards. Without a compelling and recorded reason, no professional in a training organisation interviewed by a regulator in the course of an investigation should be bound by a requirement of confidentiality not to report the existence of an investigation, and the concerns raised by or to the investigation with his own organisation.

N

158

The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, and should generally place the highest priority on the safety of patients.

N

159

Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the survey and routinely share information obtained with healthcare regulators.

N

160

Proactive steps need to be taken to encourage openness on the part of trainees and to protect them from any adverse consequences in relation to raising concerns.

Y SW

G&

R

Accepted

Incident reporting systems

being open framwork

Risky business forum

Whistle blowing process

Ensure that arrangements regarding Raising Concerns make medical trainees feel supported and protected should they wish to raise issues.

161

Training visits should make an important contribution to the protection of patients: * Obtaining information directly from trainees should remain a valuable source of information – but it should not be the only method used.* Visits to, and observation of, the actual training environment woudl enable visitors to detect poor practice from which both patients and trainees should be sheltered;* The opportunity can be taken to share and disseminate good practice with trainers and management;* Visits of this nature will ancourage the transparency that is so vital to the presentation of minimum standards

N

162

The General Medical Council should in the course of its review of its standards and regulatory process ensure that the system of medical training and education maintains as its first priority the safety of patients. It should also ensure that providers of clinical placements are unable to take on students or trainees in areas which do not comply with fundamental patient safety and quality standards. Regulators and deaneries should exercise their own independent judgement as to whether such standards have been achieved and if at any stage concerns relating to patient safety are raised to the, must take appropriate action to ensure these concerns are properly addressed.

N

163

The General Medical Council‟s system of reviewing the acceptability of the provision of training by healthcare providers must include a review of the sufficiency of the numbers and skills of available staff for the provision of training and to ensure patient safety in the course of training. N

164

The Department of Health and the General Medical Council should review whether the resources available for regulating Approved Practice Setting are adequate and, if not, make arrangements for the provision of the same. Consideration should be given to empowering the General Medical Council to charge organisations a fee for approval.

N

165The General Medical Council should immediately review its approved practice settings criteria with a view to recognition of the priority to be given to protecting patients and the public. N

166

The General Medical Council should in consultation with patient interest groups and the public immediately review its procedures for assuring compliance with its approved practice settings criteria with a view in particular to provision for active exchange of relevant information with the healthcare systems regulator, coordination of monitoring processes with others required for medical education and training, and receipt of relevant information from registered practitioners of their current experience in approved practice settings approved establishments.

N

167

The Department of Health and the General Medical Council should review the powers available to the General Medical Council in support of assessment and monitoring of approved practice settings establishments with a view to ensuring that the General Medical Council (or if considered to be more appropriate, the healthcare systems regulator) has the power to inspect establishments, either itself or by an appointed entity on its behalf, and to require the production of relevant information.

N

168The Department of Health and the General Medical Council should consider making the necessary statutory (and regulatory changes) to incorporate the approved practice settings scheme into the regulatory framework for post graduate training.

N

169The Department of Health, through the National Quality Board, should ensure that procedures are put in place for facilitating the identification of patient safety issues by training regulators and cooperation between them and healthcare systems regulators.

N

170Health Education England should have a medically qualified director of medical education and a lay patient representative on its board. N

171All Local Education and Training Boards should have a post of medically qualified postgraduate dean responsible for all aspects of postgraduate medical education. N

172

The Government should consider urgently the introduction of a common requirement of proficiency in communication in the English language with patients and other persons providing healthcare to the standard required for a registered medical practitioner to assume professional responsibility for medical treatment of an English-speaking patient.

N

36 173Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open and truthful.

Y SW TB

Accept the principle

Professional standards and codes pf conduct for nursing and medical staff

Development of organisational development framework for the Trust

37 174

Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be informed of the incident, given full disclosure of the surrounding circumstances and be offered an appropriate level of support, whether or not the patient or representative has asked for this information.

Y SW

GR

C

Partially accept: May be times

when ethics (e.g. mental health or patient choice) may need to be

considered

SUI processBeing open PolicyDuty of candourBereavement Service

SUI process and Being Open policy implementation

38 175

Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative). Y SW TB

Accept the principle


Development of organisational development framework

Ensure that all employees are aware of this and that this is embedded in HEFT culture

NA - Action for GMC

NA - Action Health Education England

NA - Action local education and training boards


NA - Action for GMC

NA - Action for GMC

NA - Action for GMC

NA - Action for DH/GMC

NA - Action for GMC

NA - Action for GMC

NA - Action for DH / GMC

NA - Action for DH / GMC

NA - Action for DH

NA - Action for GMC

NA - Action for CQC/Monitor

NA - Action for GMC

NA - Action for GMC

NA - Action for GMC


.75

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


39 176

Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.

Y SW TB Accepted


Ensure that all Directors employees are aware of this and that this is embedded in HEFT culture

40 177

Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.

Y SW TB Accepted

Professional standards and codes pf conduct for nursing and medical staff Ensure that all Directors and employees are aware of this

and that this is embedded in HEFT culture

178

The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly include and are consistent with above principles and these recommendations.

N

41 179

“Gagging clauses” or non disparagement clauses should be prohibited in the policies and contracts of all healthcare organisations, regulators and commissioners; insofar as they seek, or appear, to limit bona fide disclosure in relation to public interest issues of patient safety and care.

Y HG

HR

C

Accepted

No such clauses present in any HR contracts however do have rules around patient confidentiailty

HR need to consider local policies taking into account current and emerging natioinal strategies

42 180

Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.

Y SW

GR

C

Accepted

Being open policy in place

Communication about duty of candour underway

Contractual standards with CCG re:duty of candour

Being open policy being revised to include duty of candourand Trust's commitement to openess

43 181

A statutory obligation should be imposed to observe a duty of candour: * On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform that patient or other duly authorised person as soon as is practicable of that fact and thereafter to provide such information and explanation as the patient reasonably may request;* On registered medical practitioners and registered nurses and other registered professionals who believe or suspect that treatment or care provided to a patient by or on behalf of any healthcare provider by which they are employed has caused death or serious injury to the patient to report their belief or suspicion to their employer as soon as is reasonably practicable.The provision of information in compliance with this requirement should not of itself be evidence or an admission of any civil or criminal liability, but non-compliance with the statutory duty should entitle the patient to a remedy.

YSW/MS/AA G

RC

Accept the principle:

Disagree with need for statutory

obligation

Being open policy in place

Communication about duty of candour underway

Contractual standards with CCG re:duty of candour

Being open policy being revised to include duty of candourand Trust's commitement to openess

Improvement plans to support contractial duty of candour under development

44 182

There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory obligation on the organisation to provide it.

N

183

It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: * Knowingly to obstruct another in the performance of these statutory duties;* To provide information to a patient or nearest relative intending to mislead them about such an incident;* Dishonestly to make an untruthful statement to a commissioner or regulator knowing or believing that they are likely to rely on the statement in the performance of their duties

N

184

Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by monitoring undertaken by commissioners and others.

N

45 185

There should be an increased focus in nurse training, education and professional development on the practical requirements of delivering compassionate care in addition to the theory. A system which ensures the delivery of proper standards of nursing requires: Selection of recruits to the profession who evidence the:− Possession of the appropriate values, attitudes and behaviours;− Ability and motivation to enable them to put the welfare of others above their own interests;− Drive to maintain, develop and improve their own standards and abilities;− Intellectual achievements to enable them to acquire through training the necessary technical skills;- Training and experience in the delivery of compassionate care;- Leadership which constantly reinforces values and standards of compassionate care;- Involvement in and responsibility for the planning and delivery of compassionate care- Constant support and incentivisation which values nurses and the work they do through:− Recognition of achievement;− Regular, comprehensive feedback on performance and concerns;− Encouraging them to report concerns and to give priority to patient well-being.

Y SW/MS TB Accept

Values based recruitment trialed in some areas

Trust Nursing and Midwifery Values adopted

VITAL introduced for nurses. Midwives, children's nurses, HCA's, community nurses pending

Supervisoty ward sister 'go live' in October 2013

Nursing and Midwifery Badge

Complassion project with 'Dying Matters' coalition

National pilot for medical examiner role

Assess what further work wee need to do re: recruitment / training / development etc

186Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that aconsistent standard is achieved by all trainees throughout the country. This requires national standards.

N

187

There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care of patients, ideally including the elderly, and involve hands-on physical care. Satisfactory completion of this direct care experience should be a pre-condition to continuation in nurse training. Supervised work of this type as a healthcare support worker should be allowed to count as an equivalent. An alternative would be to require candidates for qualification for registration to undertake a minimum period of work in an approved healthcare support worker post involving the delivery of such care.

N

188

The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates‟ attitudes towards caring, compassion and other necessary professional values.

N

189 The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination. N

190There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of compassionate care.

N

46 191

Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates‟ values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.

Y HG

HR

C

Started with some HCA sn nurses

Roll out to full implementation by March 2014

Development of behavious and values (End of Feb 2014)

Roll out in recruitment processes by March 2014 (including all professional employees)

192The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.

N

193

Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They could be required to report to the Nursing and Midwifery Council on their performance on a regular basis.

N

47 194

As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice and its implementation. Alongside developmental requirements, this should contain documented evidence of recognised training undertaken, including wider relevant learning. It should also demonstrate commitment, compassion and caring for patients, evidenced by feedback from patients and families on the care provided by the nurse. This portfolio and each annual appraisal should be made available to the Nursing and Midwifery Council, if requested, as part of a nurse‟s revalidation process. At the end of each annual assessment, the appraisal and portfolio should be signed by the nurse as being an accurate and true reflection and be countersigned by their appraising manager as being such.

Y MS

NW

B

Accepted

Introduction of VITAL

Nursing and Midwifery Badges

Nursing and Midwifery Values

Facilitation of more robust appraisal process with supervisory ward sisters

Continue processes

NA - Action for DH

NA - Action for regulators and professional bodies


NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for government


.76

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


48 195

Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every patient on his or her ward. They should make themselves visible to patients and staff alike, and be available to discuss concerns with all, including relatives. Critically, they should work alongside staff as a role model and mentor, developing clinical competencies and leadership skills within the team. As a corollary, they would monitor performance and deliver training and/or feedback as appropriate, including a robust annual appraisal.

Y MS

NW

B

Accepted

Full implementation in October 2013

Participating in national evaluation with RCN

Robust KPI's developed to monitor effectiveness

Implement and monitor

196The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses‟ demonstrations of commitment to patient care and, in particular, to the priority to be accorded to dignity and respect, and their acquisition of leadership skills.

N

197

Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations that should be required under commissioning arrangements by those buying healthcare services to arrange such training for appropriate staff.

N

49 198

Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such as the “cultural barometer”.

Y MS/SW TB Accepted

Harm Free Care at HEFT initiative includes quarterly staff surveys by ward

Speak out safety

Patient Safety walkabouts

Staff survey

Patient Safety Review (1998) . Supernumery ward sisters agreed

Continue with current engagement activities and identify addtional measures through review of staff engagement systems. Supernumery ward sister initiatve will support improved engagement .

50 199

Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on duty should, whenever possible, be present at every interaction between a doctor and an allocated patient.

Y MS

NW

B

Accepted

SuI processBeing open PolicyDuty of candourBereavement Service

200Consideration should be given to the creation of a status of Registered Older Person‟s Nurse.

N

201The Royal College of Nursing should consider whether it should formally divide its “Royal College” functions and its employee representative/trade union functions between two bodies rather than behind internal “Chinese walls”.

N

51 202

Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions must regularly review the adequacy of the arrangements in this regard. Y MS

Seek further clarity on

recommendation

Supernumery ward sister agreed at TB level. Continuous, ongoing review of nurse establishment levels by Chief nurse.

Fully implement supernumery ward sisters. Maintian contiuos review of nursing establishment.

203A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession. N

52 204

All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors. Y MS TB Accepted

Have executive chief nurse

Have non executive director with nursing background

None

205

Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to nurse staffing arrangements or provision facilities, and to record whether they accepted or rejected the advice, in the latter case recording its reasons for doing so.

Y SW/MS TB Accepted

Quality impact assessment in place Review content, effectiveness and application of QIA in light of this recommendation

Organisational developement strategy to encourage culture of proactive risks assessment of quality for all changes in service

206

The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as a whole, able and empowered to give independent professional advice to the Government on nursing issues of equivalent authority to that provided by the Chief Medical Officer.

N

207There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title. N

53 208Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.

Y MS

NW

B Seek further clarity on

recommendation

Check with Mandie

209

A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are dependent on such care by reason of disability and/or infirmity) in a hospital or care home setting. The system should apply to healthcare support workers, whether they are working for the NHS or independent healthcare providers, in the community, for agencies or as independent agents. (Exemptions should be made for persons caring for members of their own family or those with whom they have a genuine social relationship.)

N

210 There should be a national code of conduct for healthcare support workers. N

211There should be a common set of national standards for the education and training of healthcare support workers. N

212

The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other regulators, professional representative organisations and the public.

N

213

Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care receivers from harm. This system should be supported by fair due process in relation to employees in this grade who have been dismissed by employers on the grounds of a serious breach of the code of conduct or otherwise being unfit for such a post.

N

214

A leadership staff college or training system, whether centralised or regional, should be created to: provide common professional training in management and leadership to potential senior staff; promote healthcare leadership and management as a profession; administer an accreditation scheme to enhance eligibility for consideration for such roles; promote and research best leadership practice in healthcare.

N

215A common code of ethics, standards and conduct for senior board-level healthcare leaders and managers should be produced and steps taken to oblige all such staff to comply with the code and their employers to enforce it.

N

216

The leadership framework should be improved by increasing the emphasis given to patient safety in the thinking of all in the health service. This could be done by, for example, creating a separate domain for managing safety, or by defining the service to be delivered as a safe and effective service.

N

217A list should be drawn up of all the qualities generally considered necessary for a good and effective leader. This in turn could inform a list of competences a leader would be expected to have.

N

218

Serious non-compliance with the code, and in particular, non-compliance leading to actual or potential harm to patients, should render board-level leaders and managers liable to be found not to be fit and proper persons to hold such positions by a fair and proportionate procedure, with the effect of disqualifying them from holding such positions in future.

N

219

An alternative option to enforcing compliance with a management code of conduct, with the risk of disqualification, would be to set up an independent professional regulator. The need for this would be greater if it were thought appropriate to extend a regulatory requirement to a wider range of managers and leaders. The proportionality of such a step could be better assessed after reviewing the experience of a licensing provision for directors.

N NA - Action for DH

NA - Action for NMC

NA - Action for NMC

What else do we currently have in plave that we want to showcaseNA - Action for NMC

NA - Action for DH

NA - Action for NMC

NA - Action for NMC

NA - Action for DH

NA - Action for DH

NA - Action for DH

NA - Action for DH

NA - Action for DH

NA - Action for DH / NMC

NA - Action for DH / NMC

NA - Action for RCN

NA - Action for NMC

NA - Action for NMC / DH / Social care agencies

NA - Action for DH / RCN


.77

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


220

A training facility could provide the route through which an accreditation scheme could be organised. Although this might be a voluntary scheme, at least initally, the objective should be to require all leadership posts to be filled by persons who experience some shared training and obtain the relevant accreditation, enhancing the spread of the common culture and providing the basis for a regulatory regime.

N

221

Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation trusts, of equivalent rigour to that applied to foundation trusts. N

222The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.

N

223

If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality Commission and other organisations such as the Royal Colleges to ensure that it is provided with the appropriate information.

N

224Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.

N

225

The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual concerns. Such reviews could be jointly commissioned with the Care Quality Commission in appropriate cases.

N

226

To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled to work closely with the systems regulators and to share their information and analyses on the working of systems in organisations in which nurses are active. It should not have to wait until a disaster has occurred to intervene with its fitness to practise procedures. Full access to the Care Quality Commission information in particular is vital.

N

227

The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide to seek the cooperation of the Care Quality Commission, but as an independent regulator it must be empowered to act on its own if it considers it necessary in the public interest. This will require resources in terms of appropriately expert staff, data systems and finance. Given the power of the registrar to refer cases without a formal third party complaint, it would not appear that a change of regulation is necessary, but this should be reviewed.

N

228

It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is still found by other reviews to be wanting. It is imperative in the public interest that this is remedied urgently. Without doing so, there is a danger that the regulatory gap between the Nursing and Midwifery Council and the Care Quality Commission will widen rather than narrow.

N

229

It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional protection to the public. It is essential that the Nursing and Midwifery Council has the resources and the administrative and leadership skills to ensure that this does not detract from its existing core function of regulating fitness to practise of registered nurses.

N

230

The profile of the Nursing and Midwifery Council needs to be raised with the public, who are the prime and most valuable source of information about the conduct of nurses. All patients should be informed, by those providing treatment or care, of the existence and role of the Nursing and Midwifery Council, together with contact details. The Nursing and Midwifery Council itself needs to undertake more by way of public promotion of its functions.

N

231

It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. This may require a review of employment disciplinary procedures, to make it clear that the employer is entitled to proceed even if there are pending Nursing and Midwifery Council proceedings.

N

232

The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will have to be engaged in filling this gap.

N

233

While both the General Medical Council and the Nursing and Midwifery Council have highly informative internet sites, both need to ensure that patients and other service users are made aware at the point of service provision of their existence, their role and their contact details. N

234

Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise the protection afforded to the public.

N

235

The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising out of the same event or series of events but involving professionals regulated by more than one body. While it would require new regulations, consideration should be given to the possibility of moving towards a common independent tribunal to determine fitness to practise issues and sanctions across the healthcare professional field.

N

54 236Hospitals should review whether to reinstate the practice of identifying a senior clinician who is in charge of a patient‟s case, so that patients and their supporters are clear who is in overall charge of a patient‟s care

Y AA TB AcceptedConsultant already identified for each patient

Further discussions needed to review recommendation and identify how this is displayed with the patient / on the ward

55 237

There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised and valued. Y SW

Consider how we accept this

recommendation

Need executive discussion Need executive discussion to consider how this recommendation can be taken forward

56 238

Regular interaction and engagement between nurses and patients and those close to them should besystematised through regular ward rounds: All staff need to be enabled to interact constructively, in a helpful and friendly fashion, with patients and visitors.

- Where possible, wards should have areas where more mobile patients and their visitors can meet in relative privacy and comfort without disturbing other patients.- The NHS should develop a greater willingness to communicate by email with relatives.- The currently common practice of summary discharge letters followed up some time later with more substantive ones should be reconsidered.- Information about an older patient‟s condition, progress and care and discharge plans should be available and shared with that patient and, where appropriate, those close to them, who must be included in the therapeutic partnership to which all patients are entitled.

Y SWConsider how we

accept this recommendation

Inherent in HEFT response and care managemetn of patient.

Need executive discussion to consider how this recommendation can be taken forward

57 239

The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time without absolute assurance that a patient in need of care will receive it on arrival at the planned destination. Discharge areas in hospital need to be properly staffed and provide continued care to the patient.

Y AA/MS C

QP

G

Accepted

Discharge loungeDischarge checklistAgreement not to discharge patient at night unless patient wish

Review existing systems to incorporate, communicate and monitor this recommendation.

58 240All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these. Y MS

IPP

C

AcceptedInfection control campaign relaunch imminent

Review existing systems to ensure that this recommendation can be met

59 241

The arrangements and best practice for providing food and drink to elderly patients require constant review, monitoring and implementation.

Y MS

NW

PB

Accepted

Regulary reported via nursing metrics and CQC compliance quarterly returns (Outcome 5)

'Eat, drink and Move campaign' quarterly mealtime audits

Regulary reported via nursing metrics and CQC compliance quarterly returns (Outcome 5)

NA - Action for DH

NA - Action for GMC/NMC

NA - Action for GMC/NMC

NA - Action for PSA

NA - Action for GMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for NMC

NA - Action for DH

NA - Action for GMC

NA - Action for GMC / Royal colleges

NA - Action for GMC

NA - Action for NMC


.78

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


60 242

In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or they are returned to the ward after treatment.

YSW/MS/TC

GR Accepted

Electronic prescribingPolicies and proceduresNursing Metrics

Project on missed doses to highlight at ward levelMoving to ward based pharmacistsMedication project to focus on medication safety

61 243

The recording of routine observations on the ward should, where possible, be done automatically as they are taken, with results being immediately accessible to all staff electronically in a form enabling progress to be monitored and interpreted. If this cannot be done, there needs to be a system whereby ward leaders and named nurses are responsible for ensuring that the observations are carried out and recorded.

Y MS

Clin

ical

IT

Com

mitt

ee

Accepted

Mews policiesMonthly Nursing MetricsIntroduction of electronic observations agreed

Implementation plan to be finalised

Agreed implementation plan for electronic observations

In the interim consider more realtime mechanism to ensure regular obs monitoring and availability

62 244

There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way

- Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to accurate recording of information on first entry.- Systems should include a facility to alert supervisors where actions which might be expected have not occurred, or where likely inaccuracies have been entered.- Systems should, where practicable and proportionate, be capable of collecting performance management and audit information automatically, appropriately anonymised direct from entries, to avoid unnecessary duplication of input.- Systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements.- Systems must be capable of reflecting changing needs and local requirements over and above nationally required minimum standards

Y AL

Clin

ical

IT C

omm

ittee

Accept in principle

Currently working towards shared records with GPs etc and in future toward patient access

All records are available to patients on request via access to medical records policy

A fully integrated alerts system has been developed and deployed and new alerts added as and when deemed necessary for safe care.

Audit informatin is available where collected with full collaboration of clinical and operational teams (e.g. dendrite, TNIS, handover etc)

Capability to collect new sata sets can be added as required

Evaluation of current and propsoed processes need to be considered in the light of this recommendation

Evaluation of local regional and national strategies to manage and share electronic patient records

63 245Each provider organisation should have a board level member with responsibility for information. Y AL

TB

AcceptedChief information officer who is executive director

Chief information officer who is executive director

64 246

Department of Health/the NHS Commissioning Board/regulators should ensure that provider organisations publish in their annual quality accounts information in a common form to enable comparisons to be made between organisations, to include a minimum of prescribed information about their compliance with fundamental and other standards, their proposals for the rectification of any non-compliance and statistics on mortality and other outcomes. Quality accounts should be required to contain the observations of commissioners, overview and scrutiny committees, and Local Healthwatch.

Y LT

AC

/TB

Accepted

Quality account published in line with Monitor prescribed framework

External audit of quality account undertaken

Quality account published in line with Monitor prescribed framework

65 247Healthcare providers should be required to lodge their quality accounts with all organisations commissioning services from them, Local Healthwatch, and all systems regulators. Y LT

AC

/TB

AcceptedQuality account developed, consulted upon and shared in line with national guidance

Quality account developed, consulted upon and shared in line with national guidance

66 248Healthcare providers should be required to have their quality accounts independently audited. Auditors should be given a wider remit enabling them to use their professional judgement in examining the reliability of all statements in the accounts.

Y LT

AC

/TB

AcceptedExternal audit of quality account undertaken

External audit of quality account undertaken

67 249

Each quality account should be accompanied by a declaration signed by all directors in office at the date of the account certifying that they believe the contents of the account to be true, or alternatively a statement of explanation as to the reason any such director is unable or has refused to sign such a declaration.

Y LT

AC

/TB

Accepted

Already required to do this for CEO.

Will just need extending for remaining directors

Already required to do this for CEO.

Will just need extending for remaining directors

68 250

It should be a criminal offence for a director to sign a declaration of belief that the contents of a quality account are true if it contains a misstatement of fact concerning an item of prescribed information which he/she does not have reason to believe is true at the time of making the declaration.

N

251

The Care Quality Commission and/or Monitor should keep the accuracy, fairness and balance of quality accounts under review and should be enabled to require corrections to be issued where appropriate. In the event of an organisation failing to take that action, the regulator should be able to issue its own statement of correction.

N

69 252It is important that the appropriate steps are taken to enable properly anonymised data to be used for managerial and regulatory purposes. Y LT

/AL IG AcceptedReview informationm governance toolkit compliance in light of this recommendation

253

The information behind the quality and risk profile – as well as the ratings and methodology – should be placed in the public domain, as far as is consistent with maintaining any legitimate confidentiality of such information, together with appropriate explanations to enable the public to understand the limitations of this tool.

N

254

While there are likely to be many different gateways offered through which patient and public comments can be made, to avoid confusion, it would be helpful for there to be consistency across the country in methods of access, and for the output to be published in a manner allowing fair and informed comparison between organisations.

N

70 255

Results and analysis of patient feedback including qualitative information need to be made available to all stakeholders in as near “real time” as possible, even if later adjustments have to be made. Y LT

GR

C

Accepted

Patient experience metricsWide range of patient experience reports

Review the realtime availability of this information toeme stakeholder including any necessary adjustments

Work with CCG's and other key stakeholder to agree process and arrangements

71 256

A proactive system for following up patients shortly after discharge would not only be good “customer service”, it would probably provide a wider range of responses and feedback on their care.

Y LT

GR

C Accept the principle

We don't routinely follow up with every patient after discharge. However every patient is provided with a feedback card and asked to highlight whether they would recommend the service to friends or family

Review existing systems to ensure that this recommendation can be met

257

The Information Centre should be tasked with the independent collection, analysis, publication and oversight ofhealthcare information in England, or, with the agreement of the devolved governments, the United Kingdom. The information functions previously held by the National Patient Safety Agency should be transferred to the NHS Information Centre if made independent.

N

258The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.

N

259The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns of clinically related complaints.

N

260

The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied to, and processed by, the Information Centre and, through them, made publicly available in the same way as other quality related information.

N

261The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case. N

NA - Action for HSCIC





NA - Action for CQC

NA - Action for CQC

NA - Action for CQC

N/A- Action for DH


.79

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


72 262

All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards;* Effective real-time information of the performance of each of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient satisfaction.* In doing so, they should have regard, in relation to each service, to best practice for information management of that service as evidenced by recommendations of the Information Centre, and recommendations of specialist organisations such as the medical Royal Colleges.* The information derived from such systems should, to the extent practicable, be published and in any event made available in full to commissioners and regulators, on request, and with appropriate explanation, and to the extent that is relevant to individual patients, to assist in choice of treatment. Y

AA/SW/LT/MS

TB

Depends upon definition of real

time.

Currently processes are

timely but not real time,

Morbidity & Mortality meeting look at outcome data on a speciality basis.

Safety Thermoment data

Nursing and Midwifery Performance Committee

Patient experience data provided by ward

Nursing Metrics provided by ward and department

SitRep provide overall view of patient safety information

Governance framework and repoprts

Harm Free care at HEFT Initiative

Currently working with CRAB and dr foster to development meaning full realtime dashboards and monitoring tools encompassing these recommendations

Review the reporting arrangements from M&M to CQPG to identify and monitor exceptions

Continue evolution of CQPG outcomes dashboard

Consider how to agreee and monitor minimum quality standards speciality

73 263It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.

Y MS/AA Accepted

Link with other standards Link with other standards

74 264In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review. N

265

The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and use in performance oversight, revalidation, and the promotion of patient knowledge and choice.

N

266

In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about the information needed by them.

N

267All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission. N

75 268

Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.

Y AS Accepted

In addition to our coding department, some specialties have employed data clerks

Clinicians input this data in other specialties

Need trustwide review of sufficiency of resources in place to facilitate data collection nationally and locally

76 269

The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.

Y AS Accepted

PbR audits on coding. Internal audit.

In some areas data is checked by clinicians

Needs overall better engagement

Incorporate into internal audit programme

270

There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration of the extent to which these statistics can be published in a form more readily useable by the public.

N

271

To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor hospital mortality figures, and other patient outcome statistics, including reports showing provider-level detail.

N

272

There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon as practicable. N

273

The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest.

N

274There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness over any perceived material interest.

N

275It is of considerable importance that independent medical examiners are independent of the organisation whose patients‟ deaths are being scrutinised. N

276Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload. N

277National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal. N

77 278

It should be a routine part of an independent medical examiners‟s role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or not referred to in the medical records.

Y AA Accepted

Medical Examiners on each site

Attendance at Trust quality and safety forum

Feed back through mortality and morbidity meetings

Develop a framework and communication process for Medical Examiners to identify incident

Developing medical examiners role to feedback learning across the trust underway

Standardisation of the ME role across the Trust

All ME‟s to talk to bereaved relatives (or request MEO to do so on their behalf)

78 279

So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient‟s case or treatment.

Y AA Partial

Process requiring junior doctors to confirm and document all cause of death with consultant / senior colleague before issuing MCCD

Discussion with Medical Examiner re cause of death and feedback provided directly to juniors as part of the medical examiner role.

ME discussion with admitting consultant if required

Seek confirmation of effectiveness and compliance of process

Standardisation of the ME role across the Trust

79 280

Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner.

Y AA Accepted

Medical Examiners officers have discussion with all bereaved relatives

In the process of setting up bereavement follow up compassionate care telephone service (which will also enable escalation of concerns)

Mandate that all Medical Examiners have a discussion with bereaved relatives – or ask the MEO to do so on their behalf

Issues and concerns raised in the bereavement office should be escalated to the ME for support and guidance

Staff should be made aware of the ME service in a variety of ways

NA - National organisationsTrust will contribute as required

NA - Action for HM Coroners


NA - Action for DH and HSCIC










.80

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance


80 281

It is important that independent medical examiners and any others having to approach families for this purpose have careful training in how to undertake this sensitive task in a manner least likely to cause additional and unnecessary distress.

Y AA Accepted

All medical examiners to undertake the e-learning training for Medical examiners (on Royal College of PathologistsSimilar training exists for MEO and all MEO‟S will have undertaken this prior to taking on the role

System will be reviewed as part of the annual appraisal

When system is live Oct 2014 it is understood that there will be a robust interview process whereby attitudes and behaviours are appropriate

282 Coroners should send copies of relevant Rule 43 reports to the Care Quality Commission. N

283Guidance should be developed for coroners‟ offices about whom to approach in gathering information about whether to hold an inquest into the death of a patient. This should include contact with the patient‟s family.

N

284The Lord Chancellor should issue guidance as to the criteria to be adopted in the appointment of assistant deputy coroners. N

285The Chief Coroner should issue guidance on how to avoid the appearance of bias when assistant deputy coroners are associated with a party in a case. N

286

Impact and risk assessments should be made public, and debated publicly, before a proposal for any major structural change to the healthcare system is accepted. Such assessments should cover at least the following issues: * What is the precise issue or concern in respect of which change is necessary?* Can the policy objective identified be achieved by modifications within the existing structure?;* How are the successful aspects of existing systems to be incorporated and continued in the new system?;* How are the existing skills which are relevant to the new system to be transferred to it?;* How is the existing corporate and individual knowledge base to be preserved, transferred and exploited?;* How is flexibility to meet new circumstances and to respond to experience built into the new system to avoid the need for further structural change?; * How are the necessary functions to be performed effectively during any transitional period?;* What are the respective risks and benefits for service users and in particular are there any risks to safety and welfare?

N

287

The Department of Health should together with healthcare systems regulators take the lead in developing through obtaining consensus between the public and healthcare professionals, a coherent, and easily accessible structure for the development and implementation of values, fundamental, enhanced and developmental standards as recommended in this report.

N

288The Department of Health should ensure that there is senior clinical involvement in all policy decisions which may impact on patient safety and well-being. N

289

Department of Health officials need to connect more to the NHS by visits, and most importantly by personal contact with those who have suffered poor experiences. The Department of Health could also be assisted in its work by involving patient/service user representatives through some form of consultative forum within the Department.

N

290

The Department of Health should promote a shared positive culture by setting an example in its statements by being open about deficiencies, ensuring those harmed have a remedy, and making information publicly available about performance at the most detailed level possible. N

NA - Action for DH


NA - Action for Chancellor


NA - Action for DH

NA - Action for DH

NA - Action for DH

NA - Action for DH



.81

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

From: Sarah Woolley, Director of Safety and Organisational Development

Title: Developing a response to Francis

At the July Governance and Risk Committee, a presentation was received outlining the summary findings from Francis and a plan of activities that are in progress to develop an organisational response to Francis for December 2013. Governance and Risk Committee requested submission of this report to Trust Board for discussion and assurance.

Summary/Key Points:

This paper sets out a 6 point activity programme to develop our response to Francis as follows:

1. Gap analysis against Francis report (2013), Keogh review & Berwick safety review recommendationsAssess current HEFT activities against findings and recommendations: identify improvement actions for Board, Executive and organisation as a whole.

2. Review HEFT approach to engaging, listening to and acting on patient concerns. Review gap analysis status for patient engagement, assess &map current activities, identify further opportunities to improve systems and outcomes.

3. Engagement events with Board/Executive and frontline workforce. Commence conversation with frontline staff about their views of Francis Inquiry, their view of HEFTs position in relation to this and identify action staff feel is required to respond and drive organisation forward.

4. Review of whistle blowing, incident reporting and raising concerns framework Assessment of effectiveness of current systems & areas for improvementRevised and aligned raising concerns and incident reporting frameworksImproved support and clarity for staff

5. Staff engagement improvement plan Develop & improve current arrangements for staff engagement Implement staff survey improvement programme

6. Organisational response to Francis and improvement programme Strategic review of current organisational activities, improvement strategies (e.g. Reshaping HEFT), based on 1, 2, 4 and modification/alignment as required.Develop improvement programme based on strategic review and actions 1, 2, and 4.Commence implementation of improvement programme.

Trust Board is asked to:• Note the actions identified to develop our response to Francis

Strategic Risk Register: N/A

Performance KPIs year to date: N/A

Resource Implications (e.g. Financial, HR): None

Assurance Implications: Key requirement for meeting CQC regulatory requirements

Information Exempt from Disclosure: Nil

Developing a Response to Francis


.82

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

Developing a response to Francis

Sarah WoolleyDirector of Safety and

Organisational DevelopmentHeart of England Foundation

Trust



.83

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

How did we get here?

• The Reports

– Mid Staff Crisis 2005-2009– Francis Report 2010– Patients First & Foremost 2013– NHS Constitution 2013



.84

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

Francis Summary “The business of the hospital was more important than the patients” Robert

Francis, QC.

• Achieving Foundation Trust status & Trust's financial recovery plan and associated staff costs • Lack of focus on responding to adverse external clinical reviews (e.g. Cancer peer review; Royal

College of Surgeons report; HCC review), corporate reports (Auditors reports, staff survey): failed to appreciate enormity of events; reacted too slowly or downplayed significance

• The Trust prioritised finances and FT application over its quality of care and failed to put patients at centre

Board & organisational

priorities

• A culture focussed on doing the system’s business - not that of the patients.• An institutional culture which ascribed more weight to positive information about the service

than to information capable of implying cause for concern. • A failure to tackle the challenges to building a positive culture within nursing and medical

professions• A culture of self promotion vs critical analysis & openness (e.g. FT application; approach to high

HSMR & inaccurate self-declaration)

Leadership & culture

• Patients and relatives felt excluded from effective participation in patient care• Patients’ surveys identified concerning trends; no action was taken • Board was not aware of the reality of care being provided on its wards• Trust management did not have culture of listening to patients

Listening to patients

• Clinicians did not pursue management about their concerns• Trust lacked sufficient sense of collective responsibility for engagement for ensuring that quality

of care was delivered at every level• Staff exhibited poor morale in responses to staff surveys

Listening to staff

• Poor leadership and staffing policies resulted in inadequate standard of nursing on some wards• Inadequate staffing levels, poor leadership, recruitment and training led to declining

professionalism and tolerance of poor standardsNursing

standards

• Standards & methods for assessing/measuring compliance which did not focus on the effect of the service on patients

• Too great a tolerance of poor standards and risks to patients• A failure of communication between the many agencies to share their knowledge of concerns• Assumptions that monitoring, performance management or intervention were the responsibility

of someone else• A failure to appreciate the risk of disruptive loss of corporate memory/focus as a consequence

of repeated, multi-level reorganisation

System failure



.85

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

Patients First & Foremost (NHS England, 2013 )

•National review of patient safety•New NHS constitution•Board level leadership for culture of: Safety; Effectiveness, Compassion; Ambition; Openness; Innovation

Preventing problems

•Chief inspector of hospitals, Expert Assessors, Quality Surveillance Groups

•New CQC rating system, Speciality Outcomes•Duty of Candour•Review of Complaints

Detecting problems

•New definition of Quality•NICE & CQC to develop standards for: Caring, Safe, Responsive , Effective care, Well led Taking action

•Referral to HSE for clinical negligence. •NMC & GMC to review and improve regulation•Consider barring failed Managers/ Directors•Failure regime for quality

Robust Accountability

•HCA training & barring system•?? Revalidation for nurses •CQC to regulate staffing levelsTraining and

Motivation



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Performance

CorporateGovernance

HEFT Response to Francis: High level action plan (Draft)

Action Deliverables Timescale & ownership*

1. Gap analysis against Francis report (2013), Keogh review & Berwick safety review recommendations .

Assess current HEFT activities against findings and recommendations: identify improvement actions for Board, Executive and organisation as a whole.

Sarah Woolley & Lisa ThomsonFrancis Gap analysis to July 2013 GRC & September 2013 TB.Berwick & Keogh gap analysis to GRC October 2013.

2. Review HEFT approach to engaging, listening to and acting on patient concerns.

Review gap analysis status for patient engagement, assess &map current activities, identify further opportunities to improve systems and outcomes.

Lisa Thomson Present findings to GRC October 2013.

3. Engagement events with Board/executive and frontline workforce.

Commence conversation with frontline staff about their views of Francis Inquiry, their view of HEFTs position in relation to this and identify action staff feel is required to respond and drive organisation forward.

Sarah Woolley/Lisa Thomson6 engagement events (2 per Site (August-September 2013).

4. Review of whistle blowing, incident reporting and raising concerns framework

Assessment of effectiveness of current systems & areas for improvementRevised and aligned raising concerns and incident reporting frameworksImproved support and clarity for staff

Sarah WoolleyDecember 2013

5. Staff engagement improvement plan

Develop & improve current arrangements for staff engagement Implement staff survey improvement programme

Sarah WoolleyCommence implementationAugust 2013

6. Organisationalresponse to Francis and improvement programme

Strategic review of current organisational activities, improvement strategies (e.g. Reshaping HEFT), based on 1, 2, 4 and modification/alignment as required.Develop improvement programme based on strategic review and actions 1, 2, and 4.Commence implementation of improvement programme.

Sarah WoolleySubmit improvement programme TB December2013Commence implementation January 2014. Monitoring via GRC and EDs

* NB: Sarah Woolley will act as lead Executive Director for overseeing & coordinating this response. All Board members & Executive Directors will participate in the development & delivery of improvement programmes in relation to their areas.



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Performance

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National Staff Survey Report


Title: National Staff survey results 2012

Following a summary report at its June meeting, the Governance and Risk Committee received a further more detailed analysis of the national staff survey results in July. This report included a supporting governance framework and action plan to respond to the issues raised. The GRC requested that this report was provided to the Trust Board for assurance

Summary/Key Points:

The national staff survey ran between September and December 2012.For the national NSS (annual requirement led by the CQC) 850 staff were invited, with a response rate of 43%. For 2012, HEFT extended the NSS to invite 9730 staff to participate with a response rate of 31%. Survey was designed to address the pledges in the NHS constitution, 2009 (Please note, however, this was revised in 2013). In summary, HEFT performed slightly lower than average in comparison to that national acute Trust average, for many indicators.

• The Trust’s overall engagement score was 73% (national acute Trust average was 74%).• 49% of staff responded that they would recommend the organisation as a place to work• 52% of staff responded that they would be happy with the standard of care provided by HEFT if a friend or

relative needed treatment.• HEFT is a significant outlier in relation to staff responses regarding equality and diversity training (Only 19% of

staff reported receiving training for Equality and Diversity)

An improvement programme has been developed which targets three levels of intervention:• Organisation-wide corporate improvement actions• Local service improvement programmes targeted to our areas of concern• Improvement programmes related to Directorates with high stress response rates.

A governance monitoring and review framework has been put in place to monitor delivery of these actions and to develop a wider programme of staff engagement activities. This will be chaired by the Director of Safety and OD and supported by the Chief Nurse and Director of Workforce.

Trust Board is asked to:• Note the contents of the report• Note the action plan to respond to the issues raised• Note the governance and monitoring framework• Discuss the report

Strategic Risk Register:It has been proposed that our results from the NSS identify a strategic risk to the organisation and this has been proposed as a new risk to be added to the Trust strategic risk register.

Performance KPIs year to date:N/A

Resource Implications (e.g. Financial, HR): None

Assurance Implications: Key requirement for meeting CQC regulatory requirements

Information Exempt from Disclosure: Nil


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HEFT National Staff Survey 2012 results


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Staff survey design

• Ran between September-December 2012

• 850 staff invited, 43% response rate (National annual requirement, led by CQC)

• For 2012, HEFT did census as well– 9,730 invited, response rate of 31%.

• Designed to address the following 4 national pledges*:– Pledge 1: To provide all staff with clear roles,

responsibilities and rewarding jobs– Pledge 2: To provide all staff with personal

development, access to appropriate training for their jobs, and line management support to succeed

– Pledge 3: To provide support and opportunities for staff to maintain their health, well-being and safety

– Pledge 4: To engage staff in decisions that affect them, the services they provide and empower them to put forward ways to deliver better and safer services

*pledges related to NHS Constitution 2009



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Overview of ResultsPledge 1: To provide all staff with clear roles, responsibilities and rewarding jobs

•HEFT’s overall score was 73% (higher percentage is better) against the 5 key findings, (National Acute Trust average-74%).

•No key finding within this section where HEFT appeared an outlier when compared to other local Trusts.

Pledge 2: To provide all staff with personal development, access to appropriate training for their jobs, & line management support to succeed

•HEFT’s overall score was 67% (higher percentage is better) against the 5 key findings, (National Acute Trust average-68%).

•HEFT’s score was lower than the national Acute Trust average, and other local Trusts for: staff receiving job-relevant training, learning or development in last 12 months and; staff having well-structured appraisals in last 12 months.

Pledge 3: To provide support and opportunities for staff to maintain their health, well-being and safety

•HEFT’s overall score was 39% (higher percentage is better), (National Acute Trust average-42%. ). •HEFT achieved the lowest overall score when compared to other local Trusts in the following areas: the percentage of staff receiving health and safety training in the last 12 months; the percentage of staff saying hand washing materials are always available and; the reported fairness and effectiveness of incident reporting procedures.

Pledge 4: To engage staff in decisions that affect them, the services they provide & empower them to put forward ways to deliver better & safer services

•HEFT’s overall score was 45% (higher percentage is better), (National Acute Trust average-48%). •The main area for improvement related to the percentage of staff reporting good communication between senior management and staff.

Overall staff satisfaction

•HEFT’s overall score was 72% (higher percentage is better). (National Acute Trust average-73%). •The Trust’s overall score was the same as that achieved by Mid Staffordshire, Leicester and Sandwell & West Birmingham Trusts.

•HEFT’s poorest performance against the 3 key findings in this section was against the “net promoter” question, regarding whether or not staff would recommend HEFT as a place to work or receive treatment.

Equality and diversity

•HEFT’s overall score was 38% (National Acute Trust average -51%.)• The organisation is a significant outlier when compared with other local Trusts. •HEFT’s poorest performance against the 3 key findings in this section was regarding the percentage of staff having received equality and diversity training in last 12 months.



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CorporateGovernance

Trust-wide ThemesAreas of good performance HEFT Acute

Average

% of staff working extra hours(Lower % is better)

63% 70%

% of staff experiencing physical violence from patients, relatives, public(Lower % is better)

13% 15%

% of staff witnessing potentially harmful errors(Lower % is better)

30% 34%

% of staff appraised(Higher % is better)

87% 84%

% staff experiencing harassment and bullying from staff*(Lower % is better)

22% 24%

Areas requiring improvement HEFT Acute Average

% of staff having equality and diversity training(Higher % is better)

19% 55%

% of staff having health and safety training(Higher % is better)

57% 74%

% of staff having job relevant training(Higher % is better)

77% 81%

% of staff reporting good communication between senior management and staff(Higher % is better)

21% 27%

Fairness and effectiveness of incident reporting procedures(Higher % is better)

68% 70%



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CorporateGovernance

HEFT Engagement ScoreThe Trust's score was 73%, slightly below average (average is 74%) when compared with Trusts of a similar type, but has seen a very slight internal improvement from 72% in 2011, to 73% in 2012.

This overall indicator of staff engagement is calculated using questions that make up 3 of the key findings. These Key Findings relate to the following aspects of staff engagement:

• staff members’ perceived ability to contribute to improvements at work (INVOLVEMENT);

• their willingness to recommend the trust as a place to work or receive treatment (ADVOCACY) and;

• the extent to which they feel motivated and engaged with their work (MOTIVATION.)

Engagement score by professional group

Adu

lt /

Gen

eral

N

urse

s

Oth

er

Reg

iste

red

Nur

ses

HC

As

Med

ical

/ D

enta

l

Oth

er A

llied

Hea

lth

Prof

essi

onal

s

Oth

er

Sci

entif

ic &

Te

chni

cal

Adm

in &

C

leric

al

Cor

pora

te

Ser

vice

s

Mai

nten

ance

72% 75% 79.2% 72.8% 72.4% 68.8% 70% 77.4% 73.4%



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Engagement by DirectorateMost engaged Directorates

Area

Overall Engagem

ent Score

Response rate %

(R

espondents / total staff

Involvement

Advocacy

Motivation

General Management 88%

64% (14/22)

93%86%

89%

Rheumatology82%

62% (13/21)

85%80%

82%

Infectious Diseases -Sexual Health 81%

33% (43/132)

88%79%

83%

Nurse Management 81%

47% (20/43)

90%74%

83%

Thoracic Surgery 80%

35% (23/65)

73%78%

84%

Clinical Compliance 78%

67% (16/24)

81%75%

79%

Facilities Management 78%

77% (24/31)

83%77%

78%

Community Services -Dental

77%71%

(22/31)64%

82%

75%

Public Affairs77%

34% (23/67)

83%71%

79%

R&D Directorate 77%

50% (12/24)

75%73%

77%

Least engaged Directorates

Area

Overall Engagem

ent Score

Response rate %

(R

espondents / total staff

Involvement

Advocacy

Motivation

Elderly Medicine, Solihull*

68%21%

(15/73)47% 68% 72%

ENT*68%

34% (43/128)

58% 63% 73%

Obs &Gynae**

68%26%(198/

679)59% 60% 74%

Pharmacy68%

28% (62/218)

73% 62% 68%

Critical Care* 67%

25% (62/252)

61% 61% 68%

Infectious Diseases** 67%

34% (43/128)

60% 60% 73%

Information** 67%

34% (78/227)

51% 67% 68%

Laboratory Medicine 67%

23% (88/378)

56% 64% 69%

General Surgery, Solihull*

65%25%

(12/49)58% 61% 73%

Radiology*64%

35%(115/331)

48% 60% 68%



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Staff friends & family test• 49% of staff that replied to the survey

advised that they would recommend the organisation as a place to work.

• 52% of staff that replied to the survey indicated that if a friend or relative needed treatment, they would be happy with the standard of care provided by HEFT.

• The FFT is incorporated into the NSS through the following questions, which then form the previously mentioned advocacy score:

– I would recommend my organisation as a place to work

– If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation



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Staff recommender Index “I would recommend HEFT as a place to work”

Highest

Area

Response R

ate(R

espondents /staff group)

Recom

mender

rate

Critical Care 25% (62/252) 38%

Dermatology 48% (25/52) 36%

Trauma & Orthopaedics

18% (54/308) 35%

Clin Haem / Oncology

27% (43/160) 35%

Healthcare Governance

65% (20/31) 35%

Pharmacy 28% (62/218) 35%

Obs & Gynae26%

(198/679)34%

Radiology35%

(115/331)30%

Vascular Surgery

50% (11/22) 27%

Acute Medicine,

Good Hope10% (27/266) 26%

Lowest

Area

Response R

ate(R


Recom

mender

rate

R&D Directorate

50% (12/24) 83%

General Management

64% (14/22) 79%

Thoracic Surgery

35% (23/65) 78%

Facilities Management

77% (24/31) 71%

Nurse Management

47% (20/43) 70%

Rheumatology 62% (13/21) 69%

Clinical Compliance

67% (16/24) 69%

Community Services –

Out of Hospital

28% (64/226) 67%

Catering 31% (50/160) 67%

Community Services –

Dental71% (22/31) 64%



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CorporateGovernance

Staff recommender Index“If a friend/relative needed treatment I would be happy with

standard of care in this organisation”

Highest Lowest

Area

Response

Rate

(Respondents

/staff group)

Recom

me

nderrate

General Management

64% (14/22) 85%

Community Services –Dental

71% (22/31) 81%

Thoracic Surgery

35% (23/65) 78%

Facilities Management

77% (24/31) 75%

Nurse Management

47% (20/43) 75%

Community Services – Out of Hospital

28% (64/226) 71%

Community Services –Planned Care

30% (45/150) 71%

Rheumatology 62% (13/21) 69%

Catering 31% (50/160) 69%

Infectious Diseases–Sexual Health

33% (43/132) 67%

Area

Response R

ate(R


Recom

mender

rate

Radiology 35% (115/331) 42%

Ophthalmology 47% (54/114) 41%


18% (54/308) 41%

Clin Haem / Oncology

27% (43/160) 40%

Healthcare Governance

65% (20/31) 40%

Pharmacy 28% (62/218) 40%

Obs & Gynae 26% (198/679) 40%

Human Resources

67% (89/132) 38%

Infectious Diseases

34% (43/128) 37%

General Surgery, Solihull

25% (12/49) 9%



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HEFT additional engagement questions (Trend over time)

Statement 2011

2084 Respondents

2012

3036 Respondents

I would say that my job is satisfying 61% 69%

I feel valued and recognised for the work I do

30% 46%

I am always willing to go the extra mile to deliver the best service

91% 92%

I would recommend HEFT as an employer

57% 48%

I am proud of this organisation 59% 42%

I feel motivated at work 59% 53%



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Stress auditTo support the undertaking of the NSS and in tandem with the census, HEFT commissioned a “Stress Audit” in 2012 which focused on 8 stress contributing areas:• Demand of role• Control – covering staff member’s level of

autonomy with regards as to how they undertake their role

• Manager support• Peer support• Relationships – covering bullying, harassment

and abuse• Role – covering clarity of staff member’s

responsibilities, goals and objectives• Change -– covering staff member’s level of

involvement• General – covering staff member feeling unwell

due to work related stress• There is correlation between half of our least

engaged departments/directorates and the highest levels of stress being reported.



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Directorate stress response rates

Directorates with highest stress scores (Low score)

Area

Score

Response rate %(R

espondents /total staff)

Radiology 48% 35% (115/331)

Elderly Medicine, Solihull

49% 21% (15/73)


50% 18% (54/308)

Theatres/DSU/SSU 51% 26% (89/344)

ENT 52% 34% (34/128)

General Surgery, Solihull

52% 25% (12/49)

Acute Medicine, Good Hope

53% 10% (27/266)

Critical Care 53% 25% (62/252)

Elderly Medicine, Good Hope

53% 17% (24/145)

Hotel Services 55% 34% (113/336)

Directorates with lowest stress scores(High score)

Area

Score

Response rate %

(Respondents / total

staff)

Admissions & Discharge, Heartlands 76% 31% (15/49)

R&D Directorate75% 50% (12/24)

Clinical Compliance73% 67% (16/24)

Facilities Management73% 77% (24/31)

General Management72% 64% (14/22)

Nurse Management71% 47% (20/43)

Finance71% 54%

(123/228)

Rheumatology70% 62% (13/21)

Infectious Diseases - Sexual Health 70% 33%

(43/128)

Public Affairs69% 34% (23/67)



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Triangulation

• The collation of Departmental/Directorate scores against our 4 core areas, were used to calculate our areas of good performance and areas requiring improvement as a whole as follows:

– Overall ranking against the 28 “Key Findings” within the NSS

– Overall Staff Engagement Score ranking within the NSS (N.B – this includes the FFT/ “Net Promoter” results)

– Local Stress Audit ranking, undertaken at the same time as the NSS and Census

– Overall Staff Engagement ranking within the Census

• These were used to select our areas for focus over the next 6-9 months



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Triangulation cont’d

Areas consistently giving positive feedback

• General management

• Nurse management

• Rheumatology• Clinical

Compliance• Thoracic Surgery• R&D Directorate• Facilities

Management

Areas consistently giving highlighting concerns

• Vascular Surgery• Elderly Medicine,

Solihull• Infectious Diseases• General Surgery,

Solihull• Acute medicine

(BHH, GHH, SH)(N.B.only flagged in 28 key findings)



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Next steps• As all NHS organisations, ours is a “people business” in every sense of

the term. Our services are provided by people for people. All of our staff,whether front-line or corporate, either directly or indirectly provide orsupport the provision of clinical services. There is a vital connectionbetween the quality and engagement of our workforce and the quality ofour services.

• Continually improving our levels of staff engagement will enable us to recruitand retain the workforce that we need, and is key to the continued success ofour organisation in a competitive marketplace.

• Improving our approach to staff engagement needs to become a top priority forus going forwards. We have much to do to improve our National Staff Surveyresults, and, more importantly, the way our staff feel about working within it.

• To improve, we need to focus on 3 levels of intervention:– Organisation –wide corporate improvement plans.– Local Service improvement plans working with our 5 focus areas– Improvement programmes for Directorates identified as experiencing high

stress response rates, in conjunction with the HR management team

• These improvement Plans will be created in partnership with appropriatecorporate, operational and clinical colleagues.

• Delivery will be monitored by the “Live Well, Work Well” Steering Group, withperformance and assurance reporting, as described in the supportinggovernance framework.



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Improvement Governance Framework

Directorates and local management teams

Local action and delivery of staff engagement programmes

Live well work well GroupSupport for directorates

with improving engagement

Trust wide delivery of staff survey & staff

engagement programmes

Performance improvement for corporate issues

Monitoring & review of deliverables & improvement programmes

HR Committee

Assurance of performance delivery integrations, alignment with other workforce & HR programmes

Governance & Risk Committee

Board Assurance of staff engagement activity

Trust Board



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Trust-wide Corporate actions Staff feedback (Staff Survey 2012 Analysis Report) Improvement Area/ Actions Delivery

Date

1. Only 49% of staff surveyedwould recommend the trust as a place to work and only 52% to receive treatment

Lead Director: Sarah Woolley, Director of Safety & Organisational Development

Implement Quarterly Staff Engagement Pulse ChecksReview and assess current reward and recognition approach and identify opportunities for improvementLaunch revised NHS Constitution (including Trust Values and Behaviours)Review, assess and develop strengthened staff involvement mechanismsWork with staff and management teams to understand reasons for this in hotspot areas (see actions overleaf)

Jan 2014

Apr 2014Apr 2014Jun 2014

2. Only 21% of staff surveyed felt there was good communication with senior management

Lead Director:Sarah Woolley, Director of Safety & Organisational Development

Delivery will require support from members of the Executive Team

Review existing communications mechanisms for effectiveness, identify areas for improvement and implement required actionsReview Directors and Band 8c+ visibility and approaches to communicating with front line staff, assess effectiveness, identify opportunities for improvement and implement required improvementsIdentify systems for improving leadership and senior management communications cascade.Work with staff and management teams to understand reasons for this in hotspot areas (see actions overleaf)

Dec 2013

3. 68% of staff reported incident reporting procedures were fair and equitable

Lead Director:Sarah Woolley, Director of Safety & Organisational Development

Review Incident Policy and Training provisionConsider training provision for incident managersReview Whistleblowing Policy, Procedure and internal management, improving alignment with incident reporting mechanisms

Jan 2014

4. Only 19% of staff reported receiving training for Equality & Diversity

Lead Director:Mandie Sunderland, Chief Nurse

Undertake analysis of current Equality and Diversity training provision and identify programme of improvements to be delivered

Dec 2013

5. 57% of staff reported receivingHealth & Safety training

Lead Director:Hazel Gunter, Director of Workforce

Review and analyse current mandatory training system and uptake, identify areas for improvement and implement required actions

Dec 2013

6. 77% of staff reported receiving job relevant training

Lead Director:Hazel Gunter, Director of Workforce

Review and analyse current professional/staff group training system and uptake, identify areas for improvement and implement required actions

Dec 2013



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CorporateGovernance

Approach to Directorate/Local improvement

programmesDirectorate focus areas• Radiology• Vascular Surgery• Elderly Medicine, Solihull• Infectious Diseases• General Surgery, Solihull• All Acute Medical Units

(BH, GHH, SHH)And...• High stress response rate

(A/E, O & G, Therapies, Pharmacy, Lab med, Theatres, T & O, ENT, Critical Care, Elderly Medicine-GHH, Hotel Services, )

Intervention approach

Actions Timescales

Meet with Local Management and Front-Line Staff (utilizing different mechanisms such as Focus Groups) to confirm the issues / concerns.Undertake a diagnostic incorporating a review of:•Clinical activity•HR Parameters (i.e. absence, turnover, T&D )•Quality Metrics (i.e. net promoter score, outcomes, processes)•Staff communication & engagement systems

Completed in each priority area between August and the end of November 2013.

Collaborative work with priority areas to devise improvements to local staff involvement and engagement

Commencementof implementation in each priority area from December 2013

Improvement programmes for Directorates and teams identified at high risk from stress audits

In progress with HR &local directorates.

Lead Directors:Hazel Gunter, Director of Workforce Sarah Woolley, Director of Safety & Organisational Development.

Work will be undertaken in partnership with the relevant Site Teams, Directorate Management Teams and frontline staff.



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July 2013 (with Aug update) For August Trust Board

Safety SituationReport

ED Status Next due

Strategic, red and amber operational risks.

LT No red operational risksStrategic risks to be updated in Sept

Sept CQPG

SUIs and incidents SW Updates of 2 new SUI’s from June and July (Attachment 1)New incident analysis report for information Incident themes information under review

Sept CQPG

Regulation, coroner SW CQC visits expected in NovemberWMQRS review of critically ill children in October 2013No pending inquests of concern

Sept CQPG

Corporate governance LT Corporate governance information to be updated in Sept Sept CQPG

Lesson of the Month SW June: Routine HIV testing can save LivesJuly: Smarter antibiotic use

SeptCQPG

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Summary risk profile

STRATEGIC RISKS-Monitoring by EMB, GRC & TB (as at May 2013)

Summary & score

Future tariff efficiency: 15% CIP across the NHS(↑20)

Patient flow (↑20)

18 week waits (↔12)

Re-shaping HEFT (↓12)

Workforce transformation (↔12)

^Date risk rated as red (≥15)

*Score with mitigation in place: mitigating action to reduce the risk needs to take place within one month in order to reduce the risk to acceptable level (i.e. Amber).

RED OPERATIONAL RISKS-Monitoring by sites / division. Escalated to CQPG GRC and TB (as at Aug 2013)

Risk Summary: Red Site Division Date^ Initial Score

Current Score *

No validated red operational risks currently open

•W&C – Women's and Children's Services•CSS – Clinical Support Services

2

(v) Red risk that has been validated through risk forum

(p) Red risk that has been proposed and awaits further info / review# Profiles may have changed since created 4 January

Hot topics

Issues arising from surgical practice of a breast surgeon employed by the Trust. External independent review, commissioned by the Trust, has commenced. Processes in place to manage current media attention and legal matters

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Summary SUI profile July 2013

SUI profile by management team (at 28/08/13)

Site/Division 10/11 11 / 12 12/ 13 13/14

BHH 5 5 3 (1x N) 2 (1xN)

GHH 0 2 (2xN) 2 (1xN) 1 (1xN)

SHH 1 (1xN) 2(2xN) 1 1 (1xN)

W&C 5 3(2xN) 5 (1xN) 0

CSS 2(1xN) 5 0 0

Never Events 2 of 14 6 of 17 3 of 11 3 of 4

OPEN SUI INVESTIGATIONS (as at 28/08/13)

Site / Division* Directorate Date Description (N = Never Event) Status

BHH W&C Paediatrics Mar 13 Unexpected child death Open

SH (NEW) ED Jun 13 Unexpected child death Open

SH (NEW) Ophthalmology Jul 13 (identified) N Incorrect strength lens inserted Open

•W&C – Women's and Children's Services. CSS – Clinical Support Services. Please see Att.1 for more detail

Never events in 2012/13 relate to:1 wrong site surgery (General Surgery)1 Inappropriate administration of daily oral methotrexate (T&O)1 retained tampon (O&G)

Never events in 2013/14 relate to:1 wrong implant (T&O / theatres)1 retained Swab (gen surg/theatres)1 wrong implant (Ophthalm/ Theatres)

3

SUI profile by location (at 28/08/13)

Site/Division 10/11 11 / 12 12/ 13 13/14

BHH 8 11 7 (2x N) 0

GHH 5 1 3 (1xN) 2 (2xN)

SHH 0 5 1 2 (1xN)

Total 14 17 11 4

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Summary incident themes profile

4

THEMES FROM SUIS / (TIER 3 Investigations)

Theme Trust Actions

Falls/Slips Trust and Site falls groups in place, reviewing trends and learning from incident investigations. Nursing falls scorecard. New Fall RCA under development

Medication Safer practice medication working group. Think Glucose diabetes campaign. Nursing alert reminders issued. 2 year improving medicine safety project. Review of EP system

Information / Communication

SBAR campaign. Nursing safety manual developed. Electronic handover. Changing patient safety culture by Safety walk arounds.Safety, learning & engagement manager recruited. Lesson of the month campaign.

Delay in treatment Learning from specific incidents / risk management recommendations

Surgical “Never Events “

Themes reviewed, no common root causes. Safety summit taken place. Regular audit and response to compliance with WHO checklist.

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Summary profile for corporate functions: July 2013

CORPORATE RED RISKS: There are no validated red risks for non clinical areas.

OPEN Non-clinical Severe Incidents

Directorate Date Description (N = Never Event)

Status

No open investigations

Statutory compliance risks

No assurance from the PCT or their Landlords, that their buildings are compliant with statutory requirements. Now in discussion with Propco and commissioned an audit to assess the scale of the issue.

Seek assurance from PCT of their compliance with Statutory Instruments, PPMs etc. Allocate a dedicated resource – Estates Technical Officer to monitor compliance in Community buildings.

Corporate Risk profile (*)

Significant Risk

Moderate Risk

(*): Currently no risks approved for Corporate Affairs

Health and Safety

Regulatory Standards

Staffing

42 1

2

1

Estates

Capacity Health and Safety

Regulatory Standards

Staffing

11

2

1

Safety & OD

Equipment ICT Regulatory Standards

1 1

1

1

ICT

Capacity Regulatory Standards

Staffing

1 11

HR

Infection Control

2

Corporate Nursing

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Corporate Incidents profile

Trust wide regulatory issues

Quality Account - The final copy was published on NHS choices in June 2013. Work has began on the Quality Account for 2013/14 incorporating 7 priorities for the Trust.

CAS Alerts – 25 new safety alerts were received during quarter 1. 2 alerts are open past the deadline for completion date both relate to safer spinal devices. Mitigating action is being taken to manage the risk until suitable devices become available.

Update on other external inspections

WMQRS – The final report into the care of adults with long term conditions and young children with diabetes was been published in May. All teams have been asked to develop an action and identify the committee responsible for monitoring implementation of these action. A Trust review of critically ill children will take place on the 3rd and 4th of October 2013 by WMQRS.CQC – The CQC visited Good Hope Hospital again to check compliance with Outcome 1 (Dignity & Respect) and Outcome 17 (Complaints) after failing these standards in February 2013. The site is now compliant with both outcomes after the revisit. CCG – The CCG visited Solihull AMU and Ward 18 in June 2013. Overall the reports were positive. Any recommendations from the report will be discussed at the Solihull Site Clinical Governance Forum

The above graph details the Directorates reporting the highest number of the top 5 corporate categories of incidents.“Security” is the highest category of corporate incidents. A recent Trust report forwarded to NHS Protect, indicated that in 2011/12, there were a total of 299 reportable physical assaults. Of these, 298 were attacks on staff by patients lacking capacity.

0

20

40

60

80

100

120

140

11 5 10 14

18 23

5411 12

8

43

13

55

11

10

8

8

9

T&O

Obstetrics

Elderly

Acute Med

A&E

0

20

40

60

80

100

120

140

160

180

10 20 292111

51

198

50

33

24

12 8

16

Q4 12/13Q1 13/14

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Domain BHH GHH SHLast visited 24 Jan-13 05 Feb-13 17 May-13 28 Nov-12 18-Mar-

13

1- Treating people with respect and involving them in their care

Outcome 1 Respect &Dignity √ X

(Moderate)√ X

(Moderate)√

Outcome 2 Consent √ N/A N/A N/A N/A

2- Providing care, treatment and support that meets people’s needs

Outcome 4 Care & welfare √ N/A N/A √Outcome 6 Co-operating

with providersN/A N/A N/A √

3- Caring for people safely and protecting them from harm

Outcome 7 Safeguarding N/A √ N/A N/A

4- Staffing

Outcome 13 Staffing √ N/A N/A N/A N/A

5- Quality and suitability of management

Outcome 17 Complaints N/A X(Moderate)

√ N/A N/A

Compliance status: CQC targeted inspections

√ = Compliant, X = Non Compliant, N/A = Not assessed during the visit

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8

Safety SITREP


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#

1. SUIs

210

*Figures do not include TV/Falls/MRSA/C.diff related SI's and are correct as of

Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-130 0 2 1 0 1 1 4 1 0 1 1 00 0 0 0 0 0 0 0 0 0 0 0 02 0 0 1 0 1 1 1 1 2 1 2 10 0 0 0 0 0 0 0 0 NA NA NA NA0 0 1 0 0 0 0 0 1 1 0 0 10 0 0 0 0 0 0 0 0 0 0 0 0

As of April 2009, the following performance indicators are being recorded:

Performance Against Target(2011/2012)

100% (17/17)100% (17/17)29% (5/17)

100% (17/17)

1.3 Summary of Open SUIs (excluding HCAI) as of

Day 45 Days OpenStop clock as HMC

40

08/102012Day 60 (as never event)

33

Performance Against Target(2012/2013)

Target

29 August 2013

Issue Description & Organisational Impact StatusImmediate Management Plan

29 August 2013

Performance Indicator Performance Against Target(2013/2014)

100% (11/11)1 day from identificationTime for submission of formal brief to PCT

100% (4/4)

1.2 Performance Indicators*

Number of Over-Running SUIs

SCC/TBAuthor

1.1 GeneralThe new Serious Untoward Incident reporting protocol was formally introduced at the end of 2007/2008 in order to help provide assurance to our commissioners that the services it commissions from Foundation Trusts are safe and of high quality. The report provides a summary of SUI reporting.

Date data prepared 29-Aug-13

Receiving committee CQPG

Sarah Woolley

Number of Open SUIs

ED Lead

Safety "SITREP"

Number of SUI's with 'Stop the Clock' agreed

Date Reported CCG Owner

100% (7/7)

100% (7/7)

Time for verbal notification of SUI to PCT

Time to close of investigation (Closed SUIs) 45 days from identification(or agreed extension)

3 days from identification 100% (4/4) 100% (11/11)100 (4/4)

Time to submit action plan to PCT (Closed SUIs) 5 days from closure of investigation To be confirmed with Commissioners

None to report

2. Shedule 5(7) formerly known as Rule 43 / Coroner's Concerns / Comments

None to report

2. Inquests (potential for adverse outcome)With Inquest Date set over next three months (August - Julyy)

Description Management Plan Owner

SUIs Opened

SUIs Closed

Never Events

AcuteCommunityAcuteCommunityAcuteCommunity

15/07/2013 Datix ID:162532 Wrong strength lens insertedPatient complaint identified problems following surger which had taken place in February. Wrong strength lens inserted during cataract surgery.

Invetigation commenced. Patient has had corrective procedure.

NEVER EVENT

HEFT:ED, BHH

PCT:

Investigation commenced

Iinvestigation underway. Family aware of investigation04/07/2013 Datix ID:1 61735 Unexpected Child Death15 mo boy attended ED at Solihull on 27th June with presenting history of fever, vominiting and history of passing out. Following assessment clinical impression was tosilitis and child was discharged home with oral antibiotics. The next morning child was found unresponsive in his cot and resus attempts were unsucessful. Concerns regarding level of assessment of child at ED attendance

Investigation commenced and appropriate local action have been taken

HEFT:Paeds BHH

PCT:BEN

Attachment 1

Page 1 of 1

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Title: Governance and Risk Committee Terms of Reference

The Governance and Risk Committee Terms of Reference have been reviewed following incorporation of the HR and /staff engagement activities into the Trust Quality and Safety framework.

Summary/Key Points:

Summary changes are as follows:

• Change of name of Committee to Quality and Risk Committee• Changes to committee reporting arrangements incorporating HR Committee as a sub-

committee

Trust Board is asked to:• approve the revised Terms of Reference

Strategic Risk Register:

N/A

Performance KPIs year to date:

N/A

Resource Implications (e.g. Financial, HR):

None

Assurance Implications:

Key requirement for meeting CQC regulatory requirements and Monitor Quality Governance Framework

Information Exempt from Disclosure:

• Nil

Governance and Risk Committee ToR


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GOVERNANCE & RISK COMMITTEE(QUALITY & RISK COMMITTEE-subject to Trust Board approval)

TERMS OF REFERENCE

ACCOUNTABLE TO:

OVERALL AIM:

Trust Board

To provide specialist advice and support to the Trust Board on the following matters:

• Clinical Governance• Risk Management• Patient Safety• Health and Safety• Infection Control• Patient Experience• Information Governance• Clinical Audit and Effectiveness• Workforce strategy, staff engagement & involvement

KEY DRIVERS: Care Quality Commission (CQC), NHS Litigation Authority (NHSLA), Department of Health (DH), National Safety Campaigns, National Quality Board. Internal and External Audit Activity, The National Commissioning Board.

ACCOUNTABILITY & SCHEME OF DELEGATION

The Governance & Risk Committee/Quality & Risk Committee is chaired by a Non-Executive Director and is directly accountable to the Trust Board. The Governance & Risk Committee/Quality & Risk Committee delegate responsibility for specific aspects of work to a number of Sub-Committees. These are:

Safety CommitteeResponsible for the Trust risk management programme (including Health & Safety; incident investigations; claims, learning lessons; risk register management); Resuscitation; Blood transfusion and Medicines Management.

Clinical Standards CommitteeResponsible for Clinical Audit and effectiveness, NICE guidance; National Confidential Enquiries, Novel Techniques

Information Governance CommitteeResponsible for Information Governance – Information Governance Toolkit; Data Protection Act.

Governance and Risk ToR (App1)


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Clinical Quality Performance GroupResponsible for overseeing site and divisional quality (i.e. safety, patient experience and clinical effectiveness) arrangements and ensuring an appropriate infrastructure is in placeto monitor, maintain and improve all aspects of clinical quality and safety across the organisation. To advise Governance & Risk Committee/Quality & Risk Committee of significant concerns in relation to clinical quality, when and where they arise.

Trust Infection Prevention CommitteeResponsible for overseeing the Trust arrangements for infection prevention and control.

Safeguarding Committees (Adults and Children)Responsible for overseeing the Trust arrangements for Children and Adult safeguarding.

Human Resources CommitteeResponsible for driving and monitoring the development and implementation of the Trust’s Workforce Strategy, associated Employment Policies and Standards, People KPIs, Workforce Plans, Implementation Programmes, staff engagement programme and organisational development programme.

The Committees identified here are directly accountable to the Governance and Risk Committee for the work programmes identified.

Consultative Healthcare CouncilThe Governance & Risk Committee/Quality & Risk Committee will also receive assurance and scrutiny reports from the Consultative Healthcare Council in relation to patient experience. Whilst this is not a formal Sub-Committee, this group will provide independent assurance in relation to patient experience which will be used to inform the work of the Governance & Risk Committee/Quality & Risk Committee.

Attachment 1 summarises the Committee structure.

FREQUENCY OF MEETINGS

The Committee shall meet bi-monthly and at such other times as the Chairman of the Committee shall require.

RESPONSIBILITIES

• To provide specialist advice, support and assurance to the Trust Board on all matters relating to Clinical Governance; Risk Management; Patient Safety; Health and Safety; Patient Experience, Information Governance and Clinical Audit and Effectiveness.

• Develop and direct the Trust’s governance and risk management strategies, policies and procedures. This will include responsibility for directing and approving the following programmes of work (via relevant sub-committees where required):

Risk Management, including investigations and NPSA requirementsHealth and SafetyClinical Effectiveness (including NICE) and AuditClinical Governance



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Patient SafetyInfection ControlPatient ExperienceAccreditations (including Care Quality Commission registration requirements and the NHSLA Risk Managements Standards for Acute Trusts and Maternity Services)Information Governance

• Monitor the overall risk management strategy and profile (making recommendations for change as appropriate) and be responsible for ensuring the adequacy of the Trust’s overall risk management arrangements and system (encompassing [financial], clinical, organisational and strategic issues), including appropriate priorities, risk control approaches, performance indicators and management plans. In particular, it will approve and monitor the Trust’s Strategic Risk Register;

• Review and monitor compliance with national statutory standards, legislative and regulatory compliance requirements and accreditation standards. The Committee will also review new guidance and legislative and regulatory compliance which may have a significant impact on the Trust, and will advise on the relative priority for implementation of guidance and the appropriate speed of implementation.

• Inform the Board where it has significant concerns about:

o the standards of care in the Trust or where it considers any service (or part of) to be unsafe;

o the allocation of resources by the Trust and by other organisations to the Trust that is having a significant adverse impact on the standards of patient care, the environment of care or to the delivery of the Trust’s core business function;

• Review and report serious untoward incidents, complaints, claims and incidents (including action plans to prevent recurrence).

• To ensure and provide assurance that the organisation’s workforce strategy meets the needs of the organisation. To oversee and monitor the arrangements that are in place;and to ensure the organisation’s workforce can support effective delivery of the Trust’s strategy, are enabled to provide high quality services and that they are involved and engaged in the delivery of these services.

• Monitor and guide the development of systems of governance to monitor standards and outcomes of care, including benchmarking schemes (e.g. Dr Foster);

• Recommend to the Trust Board the appropriate levels of insurance cover to be taken out and to consider alternative strategies and approaches;



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REPORTING

The Committee Chairman shall report formally to the Trust Board on its proceedings bi monthly - after each meeting.

The Committee will receive copies of the minutes from all of the meetings of its sub-committees depending on the frequency with which they meet – as defined in their Terms of Reference.

The Committee will receive the minutes from the Consultative Healthcare Council and the Chairman of the Council will be invited to report to the Committee.

The Director of Corporate Affairs will provide a bi-monthly report in relation to patient experience.

MEMBERSHIP and ADMINISTRATION

Members of the Committee shall be appointed by the Board and shall be made up of at least 6 members, at least 3 of whom shall be Non-Executive Directors. The initial members of the Committee are as follows:

Chairman of the Committee (Non-Executive Director)Non-Executive Directors (3)Director of Safety and GovernanceDirector of Corporate AffairsChief NurseMedical Director

Only members of the Committee have the right to attend Committee meetings. However, other individuals, including external advisers, may be invited to attend for all or part of any meeting, as and when appropriate.

Non-Executive Directors shall be appointed to the Committee for a period of up to three years, which may be extended for two further three-year periods.

The Board shall appoint the Committee Chairman who should be an independent Non-Executive Director. In the absence of the Committee Chairman and/or an appointed deputy, the remaining members present shall elect one of their number to chair the meeting. The Chair of the Audit Committee shall not be a member of the Committee but is authorised to attend any meeting of the Committee if (s)he so wishes. There is an open invitation to all Non-Executive Directors to attend when they wish to.

Membership will be reviewed every 3 years.

Employees invited to attend each meeting are:

• Director of Medical Safety• Director of Workforce• Associate Medical Directors (sites and divisions)• Head of Corporate Safety, Risk and Compliance



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External representatives invited to attend each meeting are:

• Medical Director and Nursing Director from the lead Clinical Commissioning Group

• Expert patient representative for clinical safety

Attendees may not send deputies unless specifically approved by the Committee Chairman. All papers submitted to the committee must be presented by a suitable member of the committee or a speaker invited by the committee.

Members and employees are expected to attend each meeting – and are required to attend at least 4 meetings per year.

MINUTES and ACTIONS SHEET

Minutes shall be produced for the transactions of the committee. The minutes will include all decisions made by the committee and at least a concise summary of all discussions; they will refer to the papers as appropriate. The meeting papers will not be summarised/reproduced in the minutes.

An actions sheet, in the prescribed format, will be circulated within a week of the committee meeting with the actions agreed upon at the committee.

QUORUM

The quorum necessary for the transaction of business shall be 3, one of whom must be an independent Non-Executive Director. A duly convened meeting of the Committee at which a quorum is present shall be competent to exercise all or any of the authorities, powers and discretions vested in or exercisable by the Committee.Where the Chairman has approved, Deputies must have full delegated authority.

OTHER

The Committee shall, at least once a year, review its own Terms of Reference to ensure it is operating at maximum effectiveness and recommend any changes it considers necessary to the Board for approval.

The Committee is authorised to seek any information it requires from any employee of the Trust in order to perform its duties.

The Committee is authorised to obtain, at the Trust's expense, outside legal or other professional advice on any matters within its Terms of Reference.

Compliance with the requirements outlined above will be monitored by the Director of Safety and Governance by way of an activity log. This will be reviewed bi-monthly. Following each meeting, by the Director of Safety and Governance and any areas of non compliance will be escalated to the Chair of the Committee for action with the relevant attendees and Committee chairs.

Date of last review: August 2013Date of next review: February 2014



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Attachment 1

= Assurance Report = Sub-Committee

Clinical Quality

Performance Group

Information Governance Committee

Safety Committee Trust

Infection Prevention Committee

Morbidity & Mortality Group*

Medical Records Group

Clinical Ethics Committee Report

Novel Therapeutics

Committee

Security Sub-Group

Resuscitation Committee

Emergency Planning Committee

Consultative Healthcare

Council

Safeguarding Committees

Governance and Risk Committee/Quality and Risk Committee Bi-monthly

Clinical Standards

Committee

Hospital Transfusion Committee

Drugs & Therapeutics Committee

Manual Handling Advisory Group

Safer Medications Practice Group

Facilities Report

Fire Policy Group

Medical Devices Committee Report

Site & Divisional Quality & Safety Groups x 5

Directorates

HR Committee

*Morbidity & Mortality Group=Expert Advisory Group-escalates and reports via Director of Medical Safety



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Nurse Staffing

Nursing and Midwifery staffing position paper September 2013

Introduction

This report updates the Trust Board of the current position in relation to Nursing and Midwifery staffing levels at HEFT. This paper is in preparation for the final report and recommendations of a nurse staffing review of wards and Accident & Emergency departments which will be presented at the November Trust Board.

Summary /Key points:

• The Executive Management Board endorsed the 2012 Nurse Staffing review that was presented in June 2012- the review recommended planned staffing levels for adult in patient wards –following this a budgetary alignment exercise was undertaken and all staffing plans locked down on the trust e-rostering system.

• Winter 2012 saw a requirement for extra bed capacity that was not forecast in the 2012 winter plan – this resulted in a requirement to staff up to eighty extra beds.

• Nurse staffing levels are receiving significant national attention following the publication of several high profile reports in 2013.

• Current absence/staff unavailable for planned staffing levels is high – this is due to sicknessturnover, vacancies, approximately 84% fill rate for temporary staff requests, and leave.

• Workforce data is now presented in an integrated dashboard to enable robust timely intervention.

Background

Nurse staffing levels are receiving significant national attention following the publication of several high profile reports in 2013. The most high profile of these has been the Francis Report which details the findings of the public inquiry into failings at Mid Staffordshire NHS Foundation Trust and these have been followed more recently by the following:

Keogh Reviews:Ambition 6 – Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness in the patients they are caring for and be transparently reported by Trust Boards.

The Berwick Review into patient safety:Recommendation 4 – Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS’s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well supported.

The Cavendish Review – an independent review into healthcare assistants and support workers in the NHS and social care settings.


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Recommendations

• Health Education England should develop a ‘Certificate of Fundamental Care’ in conjunction with Employers, Nursing & Midwifery Council and sector skills bodies.

• Trusts should empower Directors of Nursing to take greater Board level responsibility for the recruitment, training and management of HCA’s from day one.

• NHS England should include the perspective of HCA’s and support workers in its review of the impact of 12 hour shift patterns on patients and staff.

In addition to the afore mentioned reports NHS England will shortly be publishing national guidance on nurse staffing levels and it is envisaged that this report will make recommendations re shift patterns andskill mix ratio’s.

HEFT Position:

Winter 2012/13 proved to be particularly challenging across our hospitals resulting in high levels of nursing sickness and vacancies. The Trust Winter Plans did not foresee the amount of extra bed capacity that the Trust subsequently needed. This meant that the Trust did not recruit additional staff. Winter 2012 required approximately 80 additional beds to be opened across our three sites, these beds were staffed by substantive staff released from base wards and backfilled by bank and agency staff. In addition, corporate nurses and clinical nurse specialists supported staffing levels. All wards were risk assessed daily and staff were re-deployed to mitigate risks. On a number of occasions flexible capacity was reduced due to the unavailability of staff.

From winter 2012 onwards the Trust has recorded high sickness levels in nursing at times as high as 9% for non-registered and 7% for registered nurses (e-rostering data). The nurse bank were unable to sufficiently meet the increased demand.

Workforce data has not historically been presented in an integrated format therefore planned vs actual staffing was not presented intelligently to enable understanding of the issue in a timely manner.

Current Position

Nurse staffing continues to be challenging due to staff turnover, short term absence (this is reducing) and the creation of additional posts e.g. 50 wte required to introduce supervisory ward sisters. The senior nursing team are very mindful of the current situation and in order to maintain quality and safety the following measures have been instigated and remain in place.

Daily site risk assessment by Head Nurses and re-deployment of staff to areas of greatest need, this is a regular occurrence and is a significant area of dissatisfaction amongst the nursing workforce.

Bank/agency / pay to grade – Whilst being mindful of financial constraints the sickness, maternity and vacancy position has necessitated the need to utilise agency staff and pay to grade options to optimise safe staffing levels. These decisions are risk assessed by the Head Nurses on a day to day basis.

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E-Rostering compliance – To date there are 150 nursing and midwifery units on E-rostering. This accounts for approximately 80% of all nurses and midwives. The Trust currently reports on the following KPI’s for each 4 week roster – unfilled duties, additional duties, lost cohort hours and unavailability. Nursing & Midwifery Board has recently endorsed centralised rostering (following a pilot at Solihull) to maximise safe and efficient rostering across the Trust.

Fast track recruitment – Band 5 and band 2 straight replacement posts are fast tracked which bypasses the EVAS system and any vacancy panel arrangements for the sites, this has reduced the period for authorising vacancies for front line nursing staff from an average of 9 working days to 0 working days as the hiring manager notifies recruitment directly through the fast track system.

Recruitment and retention – There have been four recruitment days for Band 5 nurses since April 2013 resulting in 242 offers of employment across all divisions. However, local Trusts are all recruiting from the same pool of available nurses and therefore we will continue to need robust recruitment campaigns. To minimise the numbers of qualified staff who withdraw from offers of employment a ‘keep in touch’ approach has been introduced where one of the Associate Head Nurses e-mails all of the new recruits with regular updates on what is happening with the Trust and also acts as a point of contact for all of these staff to address any issues or concerns they have leading up to the start of their careers with HEFT.

The Trust currently has a high turnover rate for qualified nurses, which over the last 12 months have averaged at 10.6% against a national average of 7.38% and retention strategies are being developed to slow down the turnover. Recruitment and retention will also be improved through the introduction of Supervisory Ward Sisters in October 2013 and an agreed KPI is to improve the staff experience in their area, this will include effective appraisals, staff support, sickness management, proactive recruitment, quarterly staff surveys and clear ‘you said, we did’ actions.

Staffing and Acuity reviews A comprehensive review of staffing levels has been completed across all of the adult inpatient wards involving mixed methodology: IT IS IMPORTANT THAT NONE OF THESE SHOULD BE TAKEN IN ISOLATION.

AUKUH: (association of UK university hospitals) acuity and dependency tool:Early results demonstrate that the Trust overall funded WTE is sufficient for the levels of acuity and dependency.

Benchmarking:

An exercise, led by HEFT comparing actual ward establishments of 11 Trusts, reviewed nurse to bed ratio; qualified nurse to bed ratio and qualified to unqualified nurse ratio. Results indicate an overall average of 1.34 nurses per bed at HEFT, with an average of 1.28 nurses per bed amongst the benchmark group of 11 trusts.

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Professional judgement and peer challenge

The final element of the 2013 review currently in progress is professional judgement and peer review, this includes a review of numbers of patients exhibiting challenging behaviours, any changes in ward activity (for example some surgical areas were staffed for 5 days activity and now operate over 7 days)and any historic budgetary alignment requirements. This is the area where some gaps have been identified and are currently being peer reviewed. The final recommendations will be provided in the formal Review of Nurse Staffing 2013 paper, which will be presented to the November Trust Board.

Non-adult ward reviews:

The Accident and Emergency Department has undergone a nursing workforce review and the proposedmodel is due to be agreed at the beginning of September. Since the last investment into A&E staffing there has been an increase in activity, acuity and dependency of our patients, and increased ambulance conveyances. The reviews are likely to recommend increased nursing numbers in resuscitation, assessment and majors in addition to ensuring that the nurse co-ordinator is supervisory.

The review of Paediatric nurse staffing was completed in May 2013. The review did not indicate any shortfalls in current staffing levels or levels needed for forthcoming service developments including the paediatric winter plan.

The neonatal service is currently compatible with staffing levels across regional neonatal services however there is recognition of a national shortage of neonatal nurses. There are plans to increase the intake to the HEFT Neonatal course to twice a year, which will equate to an increase of 12 neonatal nurses per year.

Vacancies within Community Nursing are subject to active recruitment. One of the five Community Nursing teams is actively managing any risks associated with low staffing levels due to maternity leave and vacancies and is receiving support from the other teams. Community nursing has now implemented a dependency and capacity tool, which is supporting decision making. Health Visiting is continuing to recruit against the nationally set trajectory for an increase in Health Visiting establishment. There are some isolated issues in relation to specialist service areas of provision, which are being actively managed due to the impact of maternity leave, vacancy and sickness on small specialist teams.

There are a number of issues in the midwifery service from a staffing perspective; this has included a shortfall in the midwifery funded establishment, an aging workforce, difficulty in recruiting and retaining midwives in the West Midlands and role redesign. The Trust commissioned a Birth Rate Plus study of the midwifery workforce 2010-11. Birth Rate Plus is a nationally recommended workforce tool and is endorsed by the Department of Health. Further work was commissioned by the SHA in 2012 and a Birth Rate Plus desktop review was undertaken across East and West Midlands and East of England. Both workforce analyses identified a shortfall to the funded establishment in the midwifery service at HEFT. After detailed work between finance and the midwifery management team it was recommended that there be an investment of;-

• 44.16 wte midwives • 21.63 wte midwifery assistants• 15.07 wte maternity support workers

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and that a 90/10 skill mix would be introduced into the midwifery workforce due to the above factors. The Trust has committed to this investment over a four-year period. The first year investment equates to 17 wte band 6 midwives, and 13.36wte support workers. A project lead has been appointed to introduce the 90/10-skill mix and create a role of a midwifery assistant who can support midwives in their roles in alternative ways than a midwifery support worker. Plans are in place to recruit and train Midwifery Assistants in the community setting in the first phase of introducing this role.

Due to the increase of wte equivalents to the funded establishment there are currently 36.34 wte midwifery vacancies within the midwifery service. There is an intensive recruitment programme in place and 20 midwives have had job offers and are in the recruitment process. Further interviews continue to take place. There are 13 wte MSW vacancies and this is part of a project plan in the adjustment in skill mix with midwifery assistants and midwifery support workers, this project is being undertaken in conjunction with the Faculty Workforce Redesign and Development Team.

There are currently no vacant nursing posts within Gynaecology. Pressure from maternity leave (5.19WTE) has been negated by cover with short term contracts. Staff turnover has been high with staff leaving to commence midwifery or health visiting but all vacant posts have been recruited to.

Future Developments:

The mass recruitment days have proved successful, at week end 25th August the total August and future Nursing starters was 242 staff. It is anticipated that a minimum of a further 50 Band 5 posts will be offered at the recruitment event on the 31st August 2013. There is an expected attrition rate from offers of employment, as many of the individuals are in their last six months of nurse training and go for multiple interviews before deciding on where they want to work. Anecdotally it is felt that the ‘keep in touch’ approach has reduced attrition rates and this will be measured at the end of this current recruitment campaign.

Induction / Preceptorship plans:

The majority of the new Band 5 Staff Nurses will be newly qualified and in preparation for this the Nursing Faculty has increased the number of Preceptorship courses and the Ward Sisters are proactively nominating to these. The Faculty have the names of all of the new recruits and have sent text messages to them to encourage them to meet with their Ward Sisters and get booked onto these courses before they commence with the Trust. In addition the Faculty will hold a monthly action learning session on each site for the new recruits to come together and share their experiences and concerns. Corporate Nursing in conjunction with the Faculty are also planning skill station days where new recruits can be assessed for core competencies, this will help the wards to induct these staff and concentrate on welcoming them to the team and supporting them in their new environment

Winter planning 2013/14 – The agreed winter plans from each site equate to the following increase across the Trust for Band 5 and HCA staff as at 12th August 2013:

Band Requirement Current positionBand 5 Staff Nurse 51WTE Recruiting on 31st August 2013 Band 2 HCA 42WTE Recruiting on 17th August 2013

20 posts offered

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Workforce transformation:

The Project Mandate for the introduction of a generic Assistant Practitioner role was agreed by EMB and the full Business Case is currently being prepared for presentation at the EMB meeting in October. This role will give access to current HCA’s and those that do not have the academic qualifications to enter a foundation degree programme to become an Assistant Practitioner. Part of the first year of the foundation programme is planned to be joined with the first year of the General Nurse training course.The Assistant Practitioner role will concentrate on the delivery of skilled, compassionate, high quality patient care and the foundation degree will be delivered by HEFT in conjunction with a local University. The business case will cover the training of an initial 100 generic Assistant Practitioners which will result in a review of the skill mix and a more cost effective nursing resource that also improves quality and patient experience.

Conclusion:

• HEFT does currently fund a planned establishment for adult in patient wards that meets the caseload of our patients.

• The gap between planned vs actual staffing levels is causing issues, due to absence, and lower than required bank fill. The planned ward establishments have an additional 20% funded headroom to cover a level of expected absence such as annual leave, sickness etc. The current absence at HEFT on the adult wards averages between 25-30% with some areas experiencing up to 40% absence

• The senior nursing and midwifery team on a daily basis is proactively managing Nursing and Midwifery staffing levels across our 3 hospitals.

• The Trust continues to actively recruit to vacant positions and is proactively preparing for winter although the pool of available nurses is reducing. Various innovative schemes are being explored to identify HEFT as an attractive employer and a proactive media campaign will takeplace in September 2013.

Recommendations:

• Nursing and Human Resources Department to develop an improvement plan to reducesickness. A sickness summit was held recently to identify issues with a follow up summit planned for September.

• Nursing and Human Resources Department to develop an improvement plan to increase pool of staff available for temporary work.

• Head Nurses to assess specific risk areas and work with the directorate and site teams to plan to over establish these areas until absence position improves.

• Head nurses to continue to work with site teams to ensure robust recruitment and retention plans meet requirements.

• Integrated workforce dashboard to be included in monthly nursing performance report at Executive Management Board.

• A final report and recommendations for adult in patient wards and Accident and Emergencynurse staffing levels is finalised for presentation to November Trust Board 2012.

• Trust Board receive this report and endorse the recommendations.

Sam FosterActing Chief NurseSeptember 2013

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Finance and Performance

9.1 Finance & Performance Committee Report (inc Progress Report on Monitor Action Plan, Winter Planning, Committee Report & Minutes)

(Enclosure)


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Finance and Performance Committee Report

EXECUTIVE SUMMARY

Finance

The Trust is forecasting a likely year end surplus of £2m, with shortfalls in CIP and excessive pay expenditure being partially offset by some non recurrent gains, access to the JMRA risk pool and an underspend against reserves.

The recurrent position of the Trust entering 2014/15 is currently a small deficit and further work is required on rectification plans and CIP delivery, both being actively managed through Finance and Performance Committee, to ensure financial stability going into next year.

Next year’s efficiency planning started in July and the Board will be appraised of progress at November’sTrust Board. This is the area of most concern given the growing difficulty in delivering CIP, and the scale of the challenge.

The Trust is commencing conversations with CCG’s to see whether a longer term JMRA could provide longer term financial security and will manage these discussions through Finance and Performance Committee in the first instance.

Performance

The Trust achieved 95.5% for the A&E standard. The key focus of Finance and Performance Committee is ensuring sustained performance through implementation of the four hour governance framework and winter plans. If the Trust achieves Quarter 2 performance then we would approach Monitor to review our risk rating over ride.

The infection control targets contained within the Monitor compliance framework remain very tight. The Trust has had 27 cases of C Diff in the first four months against a target of 22. The Trust Infection Prevention Committee is actively pursuing a number of actions to bring performance back to trajectory but given the very low numbers this should be considered a risk. For MRSA we have had 4 cases in the first four months, if the Trust exceeds 6 cases then we would breach the Monitor target.

Whist we continue to achieve the 18 week targets at Trust wide level we are missing in two individual specialties (Orthopaedics and General Surgery) and the backlog of patients waiting in excess of 18 weeks continues to hover around 1000. Both Finance and Performance Committee and the CCGs are actively managing a rectification plan for those two directorates around reducing cancelled operations, improved bed availability and theatre utilisation. An 18 week recovery group is being formed and headed by Heads of Operations.

The Friends and Family test score for inpatients for July was 66 (June 58) and for A&E 29 (June 39). An action plan is to be discussed at F&PC on 23rd August.

Conclusion and Recommendation to Trust Board:

Trust Board to review an efficiency forecast for future years looking at potential for savings through transformation and a steer on decisions that the Board all need to be involved with early on.

Adrian StokesFinance Director and Deputy Chief ExecutiveSeptember 2013

FINANCE EXECUTIVE SUMMARY & KEY PERFORMANCE INDICATORSMonth 4 to 31st July 2013


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Finance and Performance Committee Minutes

Minutes of the Finance & Performance Committee meetingheld on 26th July 2013 at 13.00hrs,

in the Board Room, Devon House, Heartlands Hospital

Present: Mr Carl HollandLord Phillip HuntMr Les LawrenceMs Sue MooreProf Edward PeckMr Adrian StokesMr Steve Smith

Head of OperationsChairmanNon Executive Director (Chair)Managing DirectorNon Executive DirectorFinance & Performance DirectorMedical Director – Emergency Medicine

CHPHLLSMPKASSS

In Attendance:

Mr Jonathan GouldMrs Sue KingMr Aidan QuinnMrs Lisa ThomsonMrs Sam FosterMrs Mary Vaughan

Finance Operations DirectorHead of PerformanceDeputy Finance DirectorExecutive Lead for SolihullDeputy Chief Nurse BHH (p/t)Personal Assistant (Minutes)

JGSKAQLT

SFMV

1. APOLOGIES FOR ABSENCE ACTION

Apologies were received for Dr Aresh Anwar, Mrs Jones and Mrs Gunter.

2. MINUTES OF THE MEETING HELD ON 21ST JUNE 2013

The minutes of the meeting held on 21st June were accepted as an accurate record.

3. MATTERS ARISING

There were no matters arising discussed that are not noted for action at this or a future meeting.

Mr Lawrence asked for the Workforce Update meeting between HG, AS and LL to take place prior to the next Finance & Performance Committee meeting.

AS

4. FINANCE POSITION UPDATE

4.1 Finance and Performance Directors Report Month 3

Mr Stokes confirmed a small I&E loss for quarter one with some delivery on rectification from those sites with previously acceptable plans. For the remainingsites:

BHH - re-submitted an acceptable plan including a governance process and it is recommended this is now monitored monthly.

SOL - plan to be presented to next month’s meeting including governance.

W&C – resubmitted plan declined and now escalated to CEO. Meeting to include Mr Stokes, Mr Ryder and Mr Holland.

Mr Holland confirmed he would be assisting W&C’s in the short term.Mr Lawrence expressed concern over some Divisions not getting the importance


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of the plans and the detrimental effect on the Trust.Mr Smith mentioned concern regarding Mr Holland being pulled away from BHHto cover W&C as well.

Following discussion regarding efficiency planning Mr Quinn confirmed the CIP 3 year programme had been launched in July with an initial view of risk to be identified end of September.

Mr Stokes stated a forecast will be produced over the next month taking into account rectification plans, JMRA performance, impact of pension auto-enrolment and winter planning.

In relation to performance Mr Stokes stated that the Trust was likely to meet the 95% for July the improved performance at GHH was acknowledged. Lord Hunt asked if it was now possible to forecast for the winter at this stage. Mr Stokes stated it would be difficult to forecast but was confident that we were on track. Mr Stokes confirmed to Lord Hunt the Solihull A&E figures included the walk-in centre.

Mr Stokes stated the Trust has missed the C.Diff Q1 target by 2 cases, set in the context of a yearend target of 67 delivery of this target remains tight. Mr Stokes stated the overall 18 week backlog in June is 1057 up from 1008 last month. None delivery of the reduction in the backlog has been further exacerbated by an increased number of cancelled operations across the Trust with the Trust cancelling 0.98% of patients on the day against a target of 0.8%.

Mr Lawrence requested that the scheduled meeting with Mr Newbold also included T&O and Surgery which places responsibility on the operational framework and to report back to the next meeting.

Mr Stokes informed the Committee early feedback of A&E & Inpatient benchmarking data re Family and Friends the Trust did not compare well against a number of other organisations with the Trust in the bottom 5 or 6 for both inpatients and A&E performance.

Mrs Thomson confirmed a report being presented to EMB and to note this is a new scheme and not fully embedded and an action plan had been put in place. It was agreed that at the next meeting a report looking at individual ward performance for nursing metrics, Friends and Family Test and Staff Satisfaction Survey in relation to the ‘net recommender ‘ question would be provided.

Mrs King reported the HEFT Operations Management Board (HOMB) had met and it was agreed that accountability for the delivery of CQUINs sits within that board and that leads for the CQUINs will be expected to provide reports on progress. This follows CCG concerns about the Trusts governance arrangements for the delivery of the CQUINs. A governance framework to support this will be presented at the next HOMB, which will include escalation to the F&PC for ongoing failure to deliver. This will be presented to next F&PC once it has been approved at HOMB

The committee noted the recommendations.

AS(Aug)

SK(Aug)


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5. CURRENT MATTERS

5.1 CIP 2013/14 Update

Mr Lawrence raised concern regarding the monitoring and oversight of CIP delivery.

Mr Stokes noted the next steps in Mrs Moore’s report which appeared a logical approach has also been previously reported but felt nothing had moved forward.Mrs Moore agreed and understood and stated she had met with Mr Quinn to agree an approach at HOMB.

Mr Stokes highlighted W&C CIP delivery arrangements. Mr Holland confirmed twice weekly meetings now in place with managers to arrange CIP delivery.

Mrs Moore suggested management teams to attend the rectification plan meetings and take HOMB through and will ensure the message is getting through.

Mrs Moore agreed to update the options for the next meeting.

SM

SM(Aug)

5.2 Winter Report Update

Mr Stokes believed the report was over complicated and needed to address 3key points; of the 100 additional beds how easy are the beds to access, are they the right beds and is it driving to bring down the LOS. Mrs Moore agreed and explained further detail of the report. Mr Stokes requested a specific update and to include an indicative financial framework.

Mrs Moore confirmed the winter report incorporates 100% of the recommendations of the ECIST/ McKinsey report. Mrs Moore stated she had received written and verbal confirmation from Mr Hay stating no capacity would close before next May re intermediate care and they had commissioned a further 32 beds to open in the last week October /first week November of intermediate care and committed to no patient going into long term residential care without going through those units,

Lord Hunt clarified response to Monitor, if required, would be that the Trust have implemented all of the recommendations and we had built in extra 25 beds.

Mr Smith mentioned worst case scenarios do not include factors as flu epidemic.

SM(Aug)

5.3 T&O – Response to 18 weeks RTT

Agreed a full update of the outcomes and actions of the meeting scheduled with Mr Stokes and Mr Newbold be reported to the next meeting.

SM(Aug)

5.4 Pressure Ulcers Update

Mrs Foster gave a high level overview of the paper and confirmed zero tolerance as a philosophy and not a target. Key points highlighted below:

• HEFT is expected to deliver the national CQUIN of a 50% reduction of all


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pressure ulcers- (inc hospital and non-hospital acquired, avoidable and non avoidable)

• The measurement of reduction is measure by the National tool – The Safety Thermometer, this tool is a point prevalence tool used to measure harm.

• The trust is also subject to contractual KPIs around the incidence of pressure ulcers and compliance with the CCG Serious incident policy –of which grade 3 and 4 pressure ulcers are reportable.

• To date the Trust is on track with delivery of this CQUIN• The Senior Nurses and performance team hold a monthly CQUIN

implementation group.• The CQUIN implementation group have developed a robust action plan

with all milestones on track

5.5 Patient Communication / Discharge Update

Mrs Thomson gave an over view of the report and highlighted the home for lunch project which focuses around communicating discharge to patients. This is now being led by the Nursing and Midwifery Committee which will, in turn, report progress and be monitored through the Nursing and Midwifery Performance Board. The Trust also measures the views each month of at least 15 patients in the majority of clinical areas; asking patients (and, where appropriate, relatives) whether they recall staff speaking to them about going home along with the Jonah discharge planning tool.

Agreed the report covered the aspects requested and an update in January covering the remaining year whereby the committee could view the overall improvement and Mrs Thomson confirmed would include figures from the national survey.

LT(Jan ’14)

5.6 Income Risk

Mr Gould confirmed the key risks to income are the tariff deflator, SHA tender for pathology, sexual health review and the specialised services review. Lord Hunt asked for time to be set aside at Trust Board to now discuss growth opportunities.

Mr Gould to obtain a pipeline of commercial opportunities from Mr Hackwell. Mr Gould and Mr Stokes to further discuss a 3 – 5 year JIMRA and when time should be set aside to discuss growth opportunities at trust board.

AS(Oct)

5.7 Monitor Compliance Framework Update

Mrs King informed the Committee that Monitor have changed the compliance framework, from reporting each quarter on the outturn to the average quarterly performance. If a target is missed then the lowest monthly performance is reported. Mrs King to keep the Committee updated on any possible changes following the publication of the new Risk Assessment Framework in August.

SK(Aug)

5.8 Purchase Orders & Contract Awards

Members of the Committee noted the contents of the paper and approved all of the purchase orders and contract awards.



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5.9 Pension Auto Enrolment Update

Members of the Committee noted the contents of the paper and Mrs Gunter to keep the Committee updated on progress.

6. RECTIFICATION REPORTS

6.1 Financial Rectification Reports (BHH/GHH/W&C/CORP/FAC)

It was noted this item had been discussed in sufficient detail earlier in meeting however Mr Stokes concerned about BHH governance process.

Mr Smith stated confident the governance process will be followed with Mr Holland leading. Agreed all Divisions would ensure governance arrangementsare adhered to with process for holding people accountable in place.

6.2 CQUIN Rectification Plans Update

Mrs King confirmed the CQUIN Rectification plans was now being reported through the Operations Management Board, the Finance & Performance Committee and would receive escalation updates only.

7. FOR INFORMATION

All items marked for information were noted.

8. AOB

The Chairman confirmed a Board meeting was scheduled for 16th August to discuss the CQC visits and Mr Stokes was compiling the relevant information.The Committee noted BHH was one of three Trusts being shadowed.

DATE AND TIME OF THE NEXT MEETING

The next meeting is scheduled to take place on 23rd August 2013 at 09.00am in Committee Room 3,Devon House, Heartlands Hospital.

Chairman…………………………….. Dated ......................................


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External and Strategic Review

10.1 External & Strategic Review (Enclosure)


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EXTERNAL AND STRATEGIC REVIEW

1. Solihull Integrated Care Pioneer Bid

As previously reported the Health and Well Being Board in Solihull recently submitted an expression of interest to DoH to achieve ‘Pioneer’ status around its integration plans.

Over 100 expressions of interest were received but unfortunately the Solihull bid was unsuccessful. The feedback stated:

“The Panel considered that overall the application demonstrated a good track record in integrated care and support, with a commitment to a person centred approach based on the National Voices narrative and ‘I’ statements. There is clear evidence of good local engagement and a whole system approach. However, the Panel considered that the application could have benefited from more detail as well as identifying more innovative approaches that move away from traditional delivery models.”

While disappointing it should be noted that this was not a bid for funding rather a bid for recognition. As such it should not – and will not – deter progress. The commitment of all parties (CCG, SMBC, HEFT and the Mental Health Trust) remains strong. A new Integrated Care Executive has been established with membership from the CEOs of the stakeholders. This body will oversee the development of a plan to move forward the concept of Whole System Working and Integrated Care. The first meeting will have taken place before the Trust Board meeting.

In our view the next move should be to develop a business case – a 5 year plan with savings, investment and expected payback. This should then drive the creation of an Operations Plan which sets out the new models of care using risk stratification to identify patients, establishes common information systems and models the reimbursement for providers.

2. GP Pathology Procurement

The Trust Board will recall that we have been preparing for several months for the tender for processing GP blood tests across the East and West Midlands. After much delay it was recently announced that the procurement for Lot 2 (Birmingham, Black Country and North West Midlands) had been abandoned.

Lot 3 (South West Midlands) has been put on hold until September but looks unlikely to proceed. However Lot 1 (East Midlands) is still scheduled to go to full procurement.

The scheme was being driven by the Strategic Projects Team (part of NHS England) but ultimately fell apart because some of the local CCGs were unconvinced about the risks and benefits arising from the project. Ultimately it is a CCG decision.

This is extremely disappointing news and very frustrating, not just because of the costs involved but due to the fact that we believe we had (with our partners) developed an innovative offer which would have help transform pathology services and offer significant price reductions.


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Plan B is that we intend to approach the individual CCGs ourselves and make our case for change. This will happen over the forthcoming weeks.

3. Sexual Health Services

From April 2013 the responsibility for commissioning sexual health services (not including HIV treatment) has transferred from the NHS to the new Directors of Public Health in Local Government.

In Birmingham there is a stated commitment to tender this service (worth about £20m across the City) so that it can be better co-ordinated and integrated. At present HEFT and UHB are the main providers of these services in the City and the Director of Public Health is also clear about the need for new service models (away from hospital settings) at lower cost.

A dialogue has now commenced with providers in the City and while the final procurement approach has not been agreed, it appears that a ‘Prime Contractor’ model is favoured. In essence this would be a contract with one provider who would then have responsibility for integrating the supply chain of other providers (via sub-contracts) to meet the expected outcomes and financial envelope. This is an example of the model of delivery I discussed with the Board at our recent away day at Warwick.

As this is likely to be a competitive commercial procurement, I will restrict mycomments in this report to the fact that HEFT is actively preparing for this.

4. Diabetic Retinopathy Service

This is another important procurement for the Trust. Diabetic retinopathy is damage to the retina caused by complications of diabetes, which can eventually lead to blindness. It affects up to 80 percent of all patients who have had diabetes for 10 years or more. Despite these intimidating statistics, research indicates that at least 90% of these new cases could be reduced if there was proper and vigilant treatment and monitoring of the eyes. This service therefore involves an annual screening and grading of diabetic patients’ retina.

HEFT currently provides this service (with the exception of the Wolverhampton area) across Birmingham and the Black Country. The contract is now due for retender (for the whole area) and HEFT is currently responding to this. The service is worth around £4m per annum with a contract length of five years. It is a flagship service for the Trust.

The tendering process is underway and the new service will commence on 1st July 2014. It is likely that the procurement will receive bids from the commercial sector.

5. Reshaping HEFT – Stroke Implementation

Following the decision to centralise Hyper Acute stroke services at Heartlands in 2012, a project team was established and a project plan developed to reconfigure stroke pathways and plan the movement of services.



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As reported previously to the Board, progress has been less than satisfactory. The three key reasons for this are:

• Impact of winter 2012/13: the focus on daily operational management and concerns about bed capacity across all three sites

• The complexity of reconfiguring multiple specialist rotas across three sites (stroke physicians typically also work in general or elderly medicine)

• Assessing the financial impact of the changes in a constrained financial environment

However the project group has recently made some progress and the Trust is now in a position to commence the movement of services. The dedicated Hyper Acute unit has now been established at Heartlands and a training plan for the nursing staff involved has commenced. The Trust has now agreed the key deadlines for the development of the hyper acute service. These are:

• End of September - relocation of the Out of Hours service from Solihull to Heartlands

• November – relocation of the In Hours service from Solihull to Heartlands• March 2014 - Movement of Good Hope patients to Heartlands

These changes are for patients who present as a stroke or suspected stroke.

While the transfer of the Solihull Out of Hours service is feasible by the end of the month, there are some important factors that still require resolution prior to November. These are:

• Finalisation of the medical staffing model for the Hyper Acute unit, and in particular the need to provide a seven day service. This is likely to involve some additional investment in personnel and the Medical Director is in the process of finalising this with the stroke clinicians

• Robust protocols around repatriation. It is crucial that both Solihull and Good Hope are able to take both stroke patients (after 48 hours) and non-stroke patients from Heartlands. This will be challenging during winter and the pressure on medical beds, but it is felt that this should not further delay progress. The Hospital Managing Directors will need to ensure appropriate protocols are in place, with close monitoring and if necessary ring fenced beds.

The situation will continue to be closely monitored by the Trust.

6. Transformation Support

The Trust is in the process of securing an external partner to support its transformation work. This follows a discussion with the Board about the need to increase the pace of change work in the Trust. The Executive Team is keen to secure a partner who works with the team (rather than on behalf of) around tackling some the challenges involved in this work.

In the Autumn some key outputs from Reshaping HEFT will be available and it is important that these are supported by both strong implementation plans and an approach which engages staff in the changes required. These outputs include:

• Options around future surgical configuration



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• Assessment against acute and emergency standards and how this will shape the three hospitals

• Options around the future model of urgent care in Solihull• Proposals for further development of HEFT@Home• A business case to underpin future integration work in Solihull.

Recognising the strategic importance of this work to the Trust and the recognition that to date day to day operational management has often hampered progress, the Board is asked to give consideration as to whether establishing a Transformation Group reporting direct to the Board would be advantageous. This Group would give the transformation agenda a higher profile and assist in driving forward progress. Such a Group might helpfully contain representation from the Non-executive Directors.

If this is considered a sensible development, terms of reference will be drawn up and presented to the next Board meeting.

The Board is asked to give consideration to the establishment of a Transformation Group reporting to the Board.

7. Real World Evidence Therapeutic Lab

An opportunity has arisen for the Trust to participate in a new venture with external partners to build a Therapeutic Lab around Diabetes.

This concept seeks to collect Real World Evidence from disparate sources in the local health economy about patients with Diabetes. The ‘Lab’ concept is around creating a virtual informatics capability which will then assess the impact of current and new healthcare interventions.

A partnership model is proposed to fund and deliver this. The key partners would be HEFT, Monitor Deloitte (a sub brand of Deloitte) and MSD (a subsidiary of Merck one of the largest global pharma companies) as illustrated below:



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The key benefits to HEFT from involvement in the partnership are:

• The opportunity to design and pilot new service models and therapies using sophisticated evaluation techniques

• Improved patient outcomes through enhanced condition management• The opportunity to undertake clinical research in an area where HEFT already

has an international reputation• Demonstrates the value (or not) of existing HEFT services using a robust and

consistent evidence base• The reputational benefits from being associated with a leading edge approach

to the management of a long term condition.

The scale of this opportunity should not be under estimated and this would be a long-term partnership lasting several years. Discussions are at an early stage (and HEFT is competing with other hospitals), but I expect a decision in principle to be made quickly. I will keep the Board informed of progress.

It would help our position if the Board would provide commitment in principle to participating in this project.

Simon HackwellCommercial & Strategy DirectorSeptember 2013


September 2013

Board of Directors

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Patient and Public Feedback Report


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PATIENT and PUBLIC FEEDBACK REPORT

This document provides an update on the Trust’s Patient and Public Experience Activity, with a particular focus on the Friends and Family Test (FFT), and highlights views with regard to patient and public perceptions of cancer services. Following the Patient and Public Board Report presented in June, this report also details the current Parliamentary Health Service Ombudsman (PHSO) position and provides a summary of a current case concerning an overseas patient, as well as a high-level breakdown of complaint numbers (formal / informal) by service and by site.

Summary/Key Points:

• Overall, PHSO cases remain stable with existing cases ongoing. So far this year, there have been no instructions to pay compensation to claimants as a result of cases under review by the PHSO.

• The FFT continues to gain momentum with the text-back service fully operational in A&E. Plans are in place to introduce the text-back service in Maternity from September in preparation for this becoming a CQUIN from 1st October. The Trust is under the NHS England average on collection rates and responses over the first quarter of this year.The published figures as at March 2013 from the NHS Strategic Projects Team FFT Interactive Dashboard, scored the Trust at 65 (national average 71) based on a response rate of 10.9%.

• National Cancer Survey results have recently been released with comparative data, due in September. The Trust has eight areas where it falls in the lower 20% of performing trusts. These will be picked up with the teams as part of ongoing improvement programmes.

• The Trust received 90 pieces of positive coverage over the last month which is 20 more than the same time last year.

• The rankings of Solihull on NHS Choices have moved from fifth to sixth place with Good Hope remaining 10th in the league table and Heartlands maintaining first place. Numbers of responders remain small at 99 for Good Hope, 37 for Solihull and 77 for Heartlands.



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SUMMARY OF PARLIAMENTARY HEALTH SERVICE OMBUDSMAN CASES

There are still four cases ongoing from 2012/13 although, depending on the outcomes, the Trust has not had to provide compensation and, to date; there have been no findings of maladministration or service failure.

The PHSO has been invited to attend one of our Grand Rounds (3rd October 2013). This follows on from a successful presentation to clinical staff last year, and our aim is to hold these briefings covering lessons from other organisations every six months. No other trust is adopting this approach which is fully supported by the PHSO; recognising our continual drive for improvement.

PHSO cases of special interest

The Board is asked to note one current case relating to a patient who approached the PHSO following an invoice for treatment (as an overseas patient), which she subsequently refused to pay.

Discussions are currently underway with the PHSO, as this patient originally presented as an emergency in A&E (which overseas patients do not have to pay for) and was then transferred to the ward as an ‘urgent’ case which overseas patients are eligible to pay for. The Trust’s stance is that following the transfer of this patient from A&E, this patient was no longer classed as an ‘emergency’ and therefore needed to pay for subsequent care. The Trust is awaiting the PHSO’s final report although anticipating an instruction to write a letter of apology to the patient and cancel the invoice for £6,533.



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NHS CHOICES

In total, 28 patients / visitors gave feedback during June 2013. The table below gives a summary of activity on each site during June.

The table below shows each local NHS Trust and how many patient / visitors have rated the hospital to date and, out of those, how many would recommend the hospital to a friend or relative. This information has been taken from the NHS Choices website.

A new scoring system has been introduced where patients are able to rate each hospital on a number of care measures; each hospital is given a score out of a maximum possible five points based on this feedback.



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PATIENT FEEDBACK SUMMARY

The FFT continues to be monitored closely, with scores reported each month and moving along the low to mid 60 mark (average for the region). June’s data shows the results at 44 which reflects the inclusion of lower A&E scores (illustrated in table 2 following). A summary of these results is provided on a ward-by-ward basis and have been shown to provide a high-level sensitive indicator, where issues need to be investigated. To support this approach work has commenced within the nursing team to review staff perception based on the same methodology.



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Monthly FFT reports are shared widely with all staff (via email and, where requested, printed reports) outlining individual FFT ward scores, whether the ward is above or below the site average and whether the ward has achieved the minimum 15% of discharged patients (rising to 20% April 2014 in line with the CQUIN requirements). Feedback is also included relating to the three optional additional questions patients can complete:

- What have we done well?- What could we do better?- Can you nominate a member of staff who has delivered excellent service?

The responses to the three questions, including whether patients can nominate a member of staff who has delivered excellent service, will be key to ward-level improvement plans. Comments specifically about staff are also being used to create personalised congratulatory letters. These will be countersigned by the Chief Executive and Chief Nurse (for nursing staff) and Medical Director (for clinical staff).

FRIENDS AND FAMILY: QUARTER 1 REGIONAL DATA

The FFT was introduced in April this year and the summary below provides regional and national figures for the first quarter. The survey, which will grow into the most comprehensive ever undertaken, covers around 4,500 NHS wards and 144 A&E services. It allows hospital trusts to gain real time feedback on their services down to individual ward level and increases the transparency of NHS data to drive up choice and quality.

Quarter 1: Regional Data

(Birmingham & Black Country, Shropshire & Staffordshire, Arden, Herefordshire & Worcestershire)

The two tables following show scores and response rates for the first quarter, for three local commission groups in The Midlands. Both tables are ranked from the highest to lowest response rate. In table 1.0 HEFT secured just under the NHS England average for responses (24%) with a 21% response rate. Conversely, the regional average for the FFT score (70) was slightly higher than the HEFT quarterly score of 63.



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Quarter 1 scores and response rates for INPATIENT Midlands Cluster(Birmingham & Black Country, Shropshire & Staffordshire, Arden, Herefordshire & Worcestershire)

Total Responses

Total Eligible

Response Rate

FFT Score

THE ROBERT JONES AND AGNES HUNT ORTHOPAEDIC HOSPITAL NHS FT 473 1,685 28% 92BIRMINGHAM WOMEN'S NHS FOUNDATION TRUST 213 503 42% 90THE ROYAL ORTHOPAEDIC HOSPITAL NHS FOUNDATION TRUST 732 1,311 56% 84WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 2,162 7,894 27% 81SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 1,365 7,345 19% 81SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 1,095 3,551 31% 80BURTON HOSPITALS NHS FOUNDATION TRUST 1,175 3,917 30% 80GEORGE ELIOT HOSPITAL NHS TRUST 519 2,763 19% 79UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 2,563 8,647 30% 79UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST 1,524 8,595 18% 77WYE VALLEY NHS TRUST 768 2,640 29% 75THE ROYAL WOLVERHAMPTON NHS TRUST 1,279 8,647 15% 74THE DUDLEY GROUP NHS FOUNDATION TRUST 1,486 5,821 26% 72NHS ENGLAND 240,842 995,919 24% 70MID STAFFORDSHIRE NHS FOUNDATION TRUST 1,249 4,179 30% 69WALSALL HEALTHCARE NHS TRUST 2,964 4,724 63% 67SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST 2,812 8,332 34% 66HEART OF ENGLAND NHS FOUNDATION TRUST 3,166 15,150 21% 63UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 1,886 8,725 22% 60

Table 1.0

Table 2.0 below shows the scores for A&E with, over the quarter, the Trust showing a response rate of 7% (against NHS England Average of 8%) and FFT score of 45 (against an NHS England Average of 53). These results reflect the trial and subsequent introduction of a SMStext-back service in A&E, where patients who are not admitted are set a retrospective text asking them to rate their experience. Response rates primarily using texts over the last month were between 11% (SHH) and 27% (GHH) and 15% at BHH. This shows a marked improvement on April’s FFT response rate which was 6% (SHH) 3% (GHH) and 2% (BHH) respectively.

Combined results for the sites broken down by month are shown in table 3.0 following.



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Quarter 1 scores and response rates for A&E Midlands Cluster(Birmingham & Black Country, Shropshire & Staffordshire, Arden, Herefordshire & Worcestershire)

Total Responses

Eligible Patients

Response Rate

FFTScore

MID STAFFORDSHIRE NHS FOUNDATION TRUST 733 7,026 10% 68BURTON HOSPITALS NHS FOUNDATION TRUST 717 9,686 7% 67WALSALL HEALTHCARE NHS TRUST 757 10,113 7% 66SHREWSBURY AND TELFORD HOSPITAL NHS TRUST 1,074 19,088 6% 66WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 2,359 18,669 13% 65THE DUDLEY GROUP NHS FOUNDATION TRUST 432 12,782 3% 60NHS ENGLAND 163,815 2,093,426 8% 53GEORGE ELIOT HOSPITAL NHS TRUST 222 10,136 2% 52UNIVERSITY HOSPITALS BIRMINGHAM NHS FOUNDATION TRUST 402 18,365 2% 52SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST 1,810 35,107 5% 50UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE NHS TRUST 546 15,331 4% 49HEART OF ENGLAND NHS FOUNDATION TRUST 2,307 35,076 7% 45SOUTH WARWICKSHIRE NHS FOUNDATION TRUST 16 8,039 0% 36THE ROYAL WOLVERHAMPTON NHS TRUST 3,074 20,629 15% 35UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST 3,692 18,387 20% 34WYE VALLEY NHS TRUST 1,012 6,425 16% 27

Table 2.0

HEART OF ENGLAND FOUNDATION TRUST

FFT SCORES

INPATIENTS A&E COMBINEDA

pr-13

May-13

Jun-13

QTR

1

Jul-13

Apr-13

May-13

Jun-13

QTR

1

Jul-13

Apr-13

May-13

Jun-13

QTR

1

Jul-13

HEARTLANDS 63 66 56 62 48 39 67 23 28 20 59 66 37 51 25GOOD HOPE 66 67 59 64 72 81 81 48 53 39 68 69 51 59 51SOLIHULL 65 63 60 63 82 60 68 44 49 30 63 64 48 55 33TRUST 64 66 58 63 66 59 73 39 45 30 63 66 45 55 38

Table 3.0



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COMPLAINTS UPDATE

The Trust is required to provide annual data returns to the Health and Social Care Information Centre. This annual collection is a count of written complaints made by (or on behalf of) patients, received between 1 April 2011 and 31 March 2012 is collected via two forms; KO41a (NHS Hospital & Community Health Service (HCHS)) and KO41b (Family Health Service (GP including Dental) (FHS)).

Prior to 2011-12 Foundation Trusts only supplied data voluntarily.

The total number of all written complaints reported (HCHS and FHS combined) in 2011-12 was 162,129 the equivalent of more than 3,000 written complaints a week, an increase of 12,364 (8.3%) from 2010-11. For organisations providing data in both years the total number of complaints (HCHS and FHS combined) has increased by 1.3% from 148,940 to 150,859 in 2011-12.

The reported regional average is 46.2% of complaints which are upheld by a Trust. The reported data shows:

West Midlands (inc PCTs) Complaints Complaints %Received Upheld

10,273 4,747 46.2%Worcestershire Health and Care NHS Trust 138 30 21.7%Shropshire Community Health NHS Trust 54 19 35.2%Staffordshire and Stoke on Trent Partnership 127 75 5 9.1%Walsall Healthcare NHS Trust 322 0 0%South Warwickshire NHS Foundation Trust 199 40 20.1%Mid Staffordshire NHS Foundation Trust 492 0 0%University Hospital of North Staffordshire 634 0 0%Burton Hospitals NHS Foundation Trust 351 240 68.4%University Hospitals Coventry and Warwickshire 497 497 100.0%Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust 88 43 48.9%Royal Wolverhampton Hospitals NHS Trust 417 22 5.3%Wye Valley NHS Trust 228 126 55.3%George Eliot Hospital NHS Trust 271 167 61.6%Birmingham Women's NHS Foundation Trust 149 74 49.7%North Staffordshire Combined Healthcare 88 39 44.3%Dudley Group NHS Foundation Trust 375 347 92.5%Birmingham Children's Hospital 111 64 57.7%Heart of England NHS Foundation Trust 682 682 100.0%South Staffordshire and Shropshire 115 58 50.4%Royal Orthopaedic Hospital 140 66 47.1%University Hospitals Birmingham 797 547 68.6%Worcestershire Acute Hospitals NHS Trust 706 689 97.6%Sandwell and West Birmingham Hospitals NHS 771 126 16.3%Birmingham and Solihull Mental Health 267 100 37.5%Shrewsbury and Telford Hospital NHS Trust 734 179 24.4%West Midlands Ambulance Service NHS Trust 314 143 45.5%Coventry and Warwickshire Partnership 128 52 40.6%Dudley and Walsall Mental Health Partnership 59 49 83.1%



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Birmingham Community Healthcare 214 99 46.3%Black Country Partnership NHS 166 0 0%

Whilst it is important to note this data, it is equally important to note that the Trust submitted data in its last KO41 submission in April 2013 (referring to written complaints about the Hospitals and Community Services received over the previous 12 months) which reported 804 (whilst The Information Centre’s document has reported 682) written complaints with 687 (85%) being recorded as upheld. What is classified as upheld is decided against a set criteria,including an apology to the complainant.

Since 1st April 2013, the Patient Services Team has been recording against all investigated complaints, whether the issue of concern was upheld, partially upheld or not upheld. There are 383 currently, which have been graded, and the results so far show that 47% of all complaints have been upheld in line with the regional average of 47%. It should be noted that the data issues, which include some organisations being shown to uphold no complaints when they are shown to have upheld complaints via the PHSO, will have driven the average percentage downwards. A further 28% of complaints received by the Trust have been recorded as partially upheld and 25% of complaints have been recorded as not upheld.

Monthly reporting of complaints is in place to highlight the numbers and severity of complaints ranging from green (no harm caused) through to yellow, orange and, finally, red for the most severe and complex complaints.

These are broken down (by site) as:

Heartlands



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Top 5 reasons for complaints receive at Heartlands:

1. All aspects of clinical care2. Rudeness of staff3. Decision made regarding treatment 4. Misdiagnosis 5. Poor/lack of verbal communication/information

Good Hope

Top 5 reasons for complaints received at Good Hope:

1. All aspects of clinical care2. Delay in treatment3. Rudeness of staff4. Information and written communication5. Problems with discharge



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Solihull

Top 5 reasons for complaints received at Solihull:

1. Problem with discharge2. All aspects of clinical care3. Delay in treatment – Outpatient4. Misdiagnosis5. Listening skills (Complainant outlined the consultant did not have the results and was not

listening to them)

Community Services

Only 3 community complaints had been received since 1st May 2013, to date. One complaint was in July and related to District Nursing (alleged poor attitude of District Nurse). Two complaints were in August and related to Podiatry (both delays in appointments). The three complaints have all be dealt with informally and resolved in an appropriate and timely manner.



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NATIONAL CANCER PATIENT EXPERIENCE PROGRAMME 2012/13 NATIONAL SURVEY

The Cancer Patient Experience Survey 2012/13 (CPES) follows on from the successful implementation of the 2010 and 2012 CPES, designed to monitor national progress on cancer care. The 2013 survey is congruent with the National Operating Framework (NOF) for the NHS 2012/13, which defines quality as those indicators of safety, effectiveness and patient experience that indicate that standards are being maintained or improved; with the NHS England Business Plan 2013-16; and ‘Everyone Counts’, Planning for Patients 2013-14. The CPES provides information that can be used to drive local quality improvements, both by trusts and commissioners, and is consistent with the objectives of NHS policy.

155 acute hospital NHS trusts providing cancer services took part in the survey, accounting for every trust that provides adult cancer care in England. The survey included all adult patients (aged 16 and over), with a primary diagnosis of cancer ,who had been admitted to an NHS hospital as an inpatient or as a day case patient, and had been discharged between 1st September 2012 and 30th November 2012. Patients eligible for the survey were taken from trust patient administration systems and a postal survey was sent to patients’ home addresses,following their discharge.

1,559 eligible patients from this Trust were sent a survey, and 896 questionnaires were returned completed (response rate 62%). The national response rate was 64% (68,737 respondents). In 2012 the national response rate was 68%.

Percentage scores are displayed on benchmark bar charts (see link to full survey results below)

RR1 Heart of England 2012-13 Nati

Each bar (from page 6 onwards of the main report – see PDF) represents the range of results across all trusts that took part in the survey for one question with the black circle representing the score for this Trust. .

The bar is also divided into: • A red section: scores for the lowest-scoring 20% of trusts in 2012/13;• A green section: scores for the highest-scoring 20% of trusts in 2012/13;• An amber section: scores for the remaining 60% of trusts in 2012/13.



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Initial results show the Trust was in the red section (lowest 20% of trusts in 2012/13) for the following areas:

• Patient told sensitively they had cancer• Patient given a choice of different types of treatment• Patient views definitely taken into account by doctors and nurses discussing treatment• Taking part in cancer research discussed with patients• Patient got understandable answers to important questions most / all of the time• Hospital staff did everything they could to control pain• Patient given the right amount of information about condition and treatment • Patient rating care as ‘excellent’ / ‘very good’.

Further analysis, benchmarking of results and a full action plan will be developed with relevant clinical teams. Full details of the survey method will be in the National Report of the Cancer Patient Experience Survey 2012/13, which will be available at www.quality-health.co.uk from August 2013; further details of survey development, nationally agreed methodology, and cognitive testing are also available at www.quality-health.co.uk.

MEDIA REPORT SUMMARY – JUNE 2013

The communications team generated 90 pieces of positive coverage during June 2013 – this is 20 more pieces than in June 2012. Coverage included print, broadcast and online media, both regionally and nationally.

National coverage was gained, with an article in the Daily Mail about immunodeficiencies, with expert comment from Heartlands Immunology consultant, Dr Aarn Huissoon, and case study featuring patient Margaret Bennett. A second article in the Daily Mail included expert opinion about food allergies in children from Heartlands consultant paediatrician, Dr Scott Hackett. Comments from Chief Executive, Mark Newbold, as an advocate of spreading health information via Twitter, was published in an article in the Times, and Trust researchers findings that the number of under-40s developing type-2 diabetes is increasing, was published in the Daily Mail.

A live broadcast from Heartlands A&E department on Radio 5live took place, including interviews about the pressures on A&E departments with Trust chairman, Lord Philip Hunt; Clinical Lead for the department, Aidan MacNamara; Elderly Care Consultant, Niall Fergusson and other nurses and consultants from the department.

The top Twitter highlights include:

• The Trust's account had a total of 3,144 followers.

• We have gained 200 new followers this month.



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• We were mentioned 186 times, retweeted 71 times and the various links posted gained 221 ‘click-throughs’.

There were two sets of filming across the sites during June:

• There was an interview on ITV Central news with patient Mark Westworth, who is being treated at Heartlands for cystic fibrosis, to raise awareness of the need for lung donors.

• Heartlands Hospital baby care was discussed on ITV’s Daybreak.

If the Trust were to purchase the positive coverage for June as advertising space (AVE) it would cost £219,477.

The team issued press statements on three separate subjects during June around:

• Emergency department pressures.• Diabetes medication prescribing errors.

*This chart was calculated using Precise and Meltwater media monitoring services.*



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Key Messages:

The Communications team aims to get at least one key message in every press release issued. This is to promote certain values that the Trust is associated with.

RECOMMENDATION

The Board is asked to:

• Note the contents of this report and the work being undertaken to continue improving levels of engagement, learning from complaints and engaging with local communities.

• Receive the information published by The NHS Information Centre with the caveats highlighted by the differing information presented by surrounding trusts.

• Note the work done to improve the numbers of patients feeding back their FFT rating. Further work is being monitored on activities and actions to drive improvements against the actual score, via the Finance and Performance Committee, and the results of this will form part of ongoing reports to the Board.

Lisa ThomsonDirector of Corporate Affairs and Corporate GovernanceSeptember 2013

September 2013

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Corporate Governance

12.1 Review of Board Committees (Enclosure)

12.2 Donated Funds Structure (Enclosure)

12.3 Board Assurance Framework (Enclosure)


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Review of Board Committees

Board Committees – Proposed Membership – September 2013

Appointments Committee

Chairman NEDs EDs Philip Hunt Patrick Cadigan

Les Lawrence

David Lock

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Mark Newbold

Audit Committee

Chairman NEDs ED support Alison Lord David Lock

Jammi Rao

Laura Serrant-Green

Adrian Stokes

Finance & Performance Committee

Chairman NEDs EDs Les Lawrence Philip Hunt

Edward Peck

EDs Aresh Anwar

Adrian Stokes

Sarah Woolley ED support Hazel Gunter

Sue Moore

MD Solihull Hospital


Chairman NEDs EDs Jammi Rao Patrick Cadigan

Philip Hunt

Les Lawrence

Sam Foster

Lisa Thomson

Sarah Woolley




Les Lawrence

David Lock

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Mark Newbold

Audit Committee


Jammi Rao

Laura Serrant-Green

Adrian Stokes



Edward Peck

EDs Aresh Anwar

Adrian Stokes


Sue Moore




Philip Hunt

Les Lawrence

Sam Foster

Lisa Thomson

Sarah Woolley




Les Lawrence

David Lock

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Mark Newbold

Audit Committee


Jammi Rao

Laura Serrant-Green

Adrian Stokes



Edward Peck

EDs Aresh Anwar

Adrian Stokes


Sue Moore




Philip Hunt

Les Lawrence

Sam Foster

Lisa Thomson

Sarah Woolley




Les Lawrence

David Lock

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Mark Newbold

Audit Committee


Jammi Rao

Laura Serrant-Green

Adrian Stokes



Edward Peck

EDs Aresh Anwar

Adrian Stokes


Sue Moore




Philip Hunt

Les Lawrence

Sam Foster

Lisa Thomson

Sarah Woolley




Les Lawrence

David Lock

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Mark Newbold

Audit Committee


Jammi Rao

Laura Serrant-Green

Adrian Stokes



Edward Peck

EDs Aresh Anwar

Adrian Stokes


Sue Moore




Philip Hunt

Les Lawrence

Sam Foster

Lisa Thomson

Sarah Woolley

David Lock

Laura Serrant-Green

Monitor Standing Committee

Chairman NEDs EDs Philip Hunt Les Lawrence

Jammi Rao

Mark Newbold

Adrian Stokes

Lisa Thomson

Nominations Committee

Chairman NEDs EDs Philip Hunt Les Lawrence Mark Newbold

Research Committee

Chairman NEDs EDs and others Edward Peck Patrick Cadigan

Les Lawrence

Laura Serrant-Green

EDs Aresh Anwar

Sam Foster

Simon Hackwell

Mark Newbold Others - support Bethan Bishop

Don Milligan

Dean of Medicine UoB and

UoW

Remuneration Committee

Chairman NEDs ED support Philip Hunt Patrick Cadigan

Les Lawrence

David Lock

Mark Newbold


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David Lock

Laura Serrant-Green

Monitor Standing Committee

Chairman NEDs EDs Philip Hunt Les Lawrence

Jammi Rao

Mark Newbold

Adrian Stokes

Lisa Thomson

Nominations Committee

Chairman NEDs EDs Philip Hunt Les Lawrence Mark Newbold

Research Committee

Chairman NEDs EDs and others Edward Peck Patrick Cadigan

Les Lawrence

Laura Serrant-Green

EDs Aresh Anwar

Sam Foster

Simon Hackwell

Mark Newbold Others - support Bethan Bishop

Don Milligan

Dean of Medicine UoB and

UoW

Remuneration Committee

Chairman NEDs ED support Philip Hunt Patrick Cadigan

Les Lawrence

David Lock

Mark Newbold

Alison Lord

Edward Peck

Jammi Rao

Laura Serrant-Green

Review of Board Committees


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Changes to Donated Funds Structure

PROPOSED CHANGES TO DONATED FUNDSTRUCTURE

Directors will be aware that Heart of England NHS Foundation Trust (“HEFT”) operates a charitable fund called Heart of England NHS Foundation Trust General Charitable Fund (“the Charity”). HEFT and the Charity are, technically, separate legal entities. The Charity is operated under trust and in accordance with both DoH NHS Charity requirements and the regulations of the Charities Commission. HEFT is the corporate trustee of the Charity and the Board’s Donated Funds Committee (“DFC”) has been delegated with full authority to operate and manage the Charity.

As an independent charity, the Trustee(s) of the Charity must take decisions solely in the interests of the Charity. However, where a charity is inextricably linked with another body by trusteeship or through a funding relationship, that charity’s independence – and therefore its ability to continue to operate as a registered charity – can be called into question.

In late 2012, the Charities Commission issued guidance to NHS charities and consulted upon future governance arrangements for NHS charities particularly around the area of independence of the charity. The DFC reviewed the DoH consultation paper in January 2013 and decided that as no change was mandated at that time and the committee was satisfied with its current operating arrangements that no action should be taken.

Although the DoH has not yet published the outcome of its consultation on the topic, I believe that HEFT should now be proactive in taking steps to move towards a more independent structure for the Charity. An independent structure would allow more focus and scrutiny of its fundraising strategy and greater management and control of individual fund-holding arrangements. Exactly what shape or form this structure might take will become clearer over the next few months but initially I would recommend to the Board that DFC undertake a review, led by an independent person, to review and consider the implications in the context of developing guidance. To that end, I propose that, now he has relinquished his directorship of HEFT, Paul Hensel should be invited to chair DFC and undertake a review of available structures and implications with a view to establishing the Charity as a completely independent body. The outcome of this Review will bereported to the Board so that it can be implemented with effect from 31 March 2014.

Will the Board please consider and approve the recommendation to undertake a Review and bring to the Board a Report?

Lord Philip Hunt of Kings HeathChairmanSeptember 2013


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Board Assurance Framework Review

Board Assurance Framework Quarterly Review

This document provides the Board with it quarterly opportunity to review the Trust’s strategic risks. It is recognised that work is needed to strengthen the engagement of the whole Board in the development of the Trust’s strategic risk register and this will follow on from the Board meeting.

Summary/Key Points:

• Strategic risks are defined as those that represent a major threat to achieving the Trust’s strategic objectives or its continued existence.

• There are currently six risks on the register, two of which are proposed as new risks:

Future tariff efficiency Patient flowReshaping HEFTWorkforce transformationPatient engagement (SR13 - NEW)Winter plans (SR14 - NEW)

• In addition to two new risks, the following changes have been made to the register since the Q4 Trust Board review:

o EMB agreed at its July meeting to add a new strategic risk relating to staff engagement. o EMB agreed at its July meeting to add a new strategic risk relating the lack of assurance

from the CCGs regarding their ability to provide robust winter plans.o EMB agreed at its July meeting to remove the risk relating to delivery of the 18-week

target.o EMB agreed at its July meeting to reduce the score of the patient flow risk to 12 (4*3).

Strategic Risk Register:

The Board is responsible for reviewing, discussing and agreeing the Trust’s strategic risk register.

Resource Implications (e.g. Financial, HR):

None known at this stage.

Information Exempt from Disclosure:

The strategic risk register is to be made public following approval by the Trust Board.

1. Background

The Board Assurance Framework provides a structure and process that enables the organisation to focus on those risks that might compromise it achieving its strategic objectives. It also aims to map out the controls that have been put in place to ensure that the Board has sufficient assurance, regarding the effectiveness of these controls.

2. Current Position

The strategic risk register has continued to be reviewed quarterly. The review takes place with each of the Executive Directors - and is presented to Executive Management Board, followed by Trust Board,quarterly. It is also presented to Audit Committee six monthly - in line with the Trust Annual Governance Statement.


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There are currently six risks on the register (Attachment 1):• Future tariff efficiency• Patient flow• Reshaping HEFT• Workforce transformation• Patient engagement (SR13 - NEW)• Winter plans (SR14 - NEW)

3. Update

The following changes have been made to the register since the Q4 Trust Board review:

• EMB agreed at its July meeting to add a new strategic risk relating to staff engagement.

• EMB agreed at its July meeting to add a new strategic risk relating the lack of assurance from the CCGs regarding their ability to provide robust winter plans.

• EMB agreed at its July meeting to remove the risk relating to delivery of the 18 week target.

• EMB agreed at its July meeting to reduce the score of the patient flow risk to 12 (4*3)

The changes outlined above are reflected in Attachment 1.

In addition to the updates outlined above at its July meeting, EMB agreed that site integrity, mortality rates, lack of community and social care capacity, lack of operational capacity and risk of regulatory action should not be included on the strategic risk register.

Chronology of strategic risk scores (Current risk score)

Risk Description 2011/12 2012/13 2013/14

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2

Tariff efficiency 16 16 12 12 16 20 20 20 20 20

Patient flow 20 20 12 12 12 16 16 20 20 12

18 week wait 12 12 12 12 12 12 12 Close

Reshaping HEFT 15 15 15 15 12 12 12 12

Workforce transformation 12 12 12 12 12 12 12

Clinical Commissioning groups 6 9 9 9 Close Close Close

Staff Engagement 12

Winter planning 16



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3. Recommendation

• Trust Board is asked to review the strategic risk register and provide any updates required for approval.

• An engagement programme with the Board to assist in improving the debate on the Trust’s strategic risks is to be developed and take place during the Autumn. The Board is asked to support this activity.

Lisa ThomsonDirector of Corporate Affairs and Corporate GovernanceSeptember 2013



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SR RefExec Lead

Strategic Risk Description Controls Assurances Gaps in ControlsGaps in

AssuranceAction Plan Timeframe

C L Score C L Score

SR1 AS

Future tariff efficiency - 15%CIP globally across the NHS

There is a risk that this will be too big to respond approriately without an impact upon existing services. This is compounded by a potential reduction in activity from other sectors as they seek to deliver their own CIPs

Without careful management, this could impact upon the quality and safety of the services provided.[Note: This risk relates to years 2 and 3 - and is not a current year 1 risk for the Trust]

Linked Strategic Priority: EfficientLinked Goal: 15% Cost reduction

4 4 16

* Finance Committee* Audit Committee* Trust Board Away day to discuss 3 year savings plan* Relationship building with external partners - including Birmingham City Council* CIP Board* Tighter controls on bank and agency staff* Job plan review* New escalation policy* Finance sub-committee of Executive Management Board* Pay bill challenge* Transformation partner for reshaping HEFT* Escalation process - dirctorate to site to finance and performance to Chief Executive and Director of Finance

Internal:* Regular CIP reports to Finance Committee (Monthly)* Annual Timetable approved at Trust Board (August 2012)* Detailed CIP plans discussed at CIP Board (Fortnightly)* Trust Board finance reports (Monthly)* Jointly managed risk agreement agreed by Trust Board (April 2012)

4 5 20

* Directorates under new reporting lines slow to gain momentum

* CIP slow to start in year* Pay controls weakened * Directorates and divisions are not accepting the scale of the challenge

Executive oversight group established

Rectification plans escalation to continue

Apr-15

Initial Risk Score April

2012

Current Risk Score April

2013


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SR RefExec Lead



C L Score C L Score

SR2 AA

Patient Flow

Failure to successfully address discharge planning arrangements resulting in poor patient flow and unecessary delays to admissions, transfers and discharges. Leading to increased risk in urgent care pathway, including significant impact upon the capacity of A&E department and the use of additional flex capacity.There is a risk to the corporate strategic priority of 'Safe and Caring' if performance does not improve

Linked strategic priority: Efficient, Safe and CaringLinked goal: Consistent delivery of targets

4 3 12

* Work with commissioners to develop single point of access* 18/7 working (Good Hope)* Project group established to address 'expected date of discharge' as part of SOP* Monthly meetings with commissioners* Transformation Board* Funding (£2m) set aside for winter plan provision* Urgent care pathway agreed as a priority for the Trust* Expansion of community capacity for GHH and BHH* Reconfiguration of acute care flow at BHH and GHH* Rebuild and review of urgent care at SH

Internal:* Reports to Finance & Performance committee, EMB and TB (Monthly)* Site specific winter plans (October 2012)

4 3 12

* Clarification of accountabliity between directorate and site teams needs further strengthening* Clarity of escalation plans* Bed capacity in the community* Lack of operational management capacity

* Failure to achieve sustained delivery* Review of acute care strategy document* Winter plans

* System change in conjunction with CCGs for management of the acutely ill patient* Internal management changes for managing the acutely ill patient* Single A&E rectification plan* Evaluation of single point of access* Review of ambulance activity* Seek clarity on patient acceptance and achieving expectation re BCHC and social

TBC


2012


2013



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C L Score C L Score

SR8 SH

Ability of organisation to undertake strategic reconfiguration and development of new business models in response to longer term economic environment and reduction in health economy spending.

The economic environment means that there will be reduced income for the Trust in the future. The impact of the QIPP agenda will require the Trust to embark on a transformation programme to ensure that it provides safe, quality services to patients in the most appropriate setting. Such an ambitious programme is not without risk - including reputational and financial.

Linked Strategic Priority: Safe & Caring; Locally engaged; efficient and InnovativeLinked goals: All

3 5 15

* Trust Board agreed (December 2012) transformation programme* Clinical transformation Programme Board (Re-shaping HEFT)* Business transformation board* Workforce productivity group* Transformation Partner

Internal: * Presentation to Trust Board away day (December 2012) regarding plans for transformation programme* Annual Business plan (April 2012)* Monthly reporting to EMB of reshaping HEFT progress and business transformation agenda

3 4 12

C L Score C L Score

SR10 HG

Workforce Transformation - the proposed service changes, including reshaping HEFT, requires a redesign of the current workforce - specifically in terms of appropriate skill mix. There is a risk that this is not happening fast enough to deliver the level of operational transformation that is required

Linked priority: Safe and CaringLinked goals: All

3 4 12

* Workforce plans* Strategic workforce plan project groups (December 2012)* Strategic plan for workforce changes (December 2012)* Workforce transformation committee reporting to ops committee* Business case for upskilling of Band 4 nurses* Supervisory sisters programme* Midwifery support work

Internal: * Presentation to EMB (December 2012) of strategic workforce plan including timeframes, project leads and governance structures for each project;* Updates on workforce plans reported to EMB monthly and to ops committee quarterly

3 4 12

* Implementation of project plans for each workstream

Dec-13


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C L Score C L Score

SR13 SW

Staff EngagementFeedback from the Trust 2012 staff survey indicates that HEFTs overall performance in terms of staff satisfaction and overall engagement is below the national average and there is therefore room for significant improvement. There is a risk that staff may experience increased stress and reduced well being leading to an increase in staff turnover and an organisational inability to retain and attract the workforce we need to deliver our services

3 4 12

* Staff survey results improvement plan* Reestablishment of the 'live well, work well' steering group* Governance and performance management framework* Fully recruited OD team

* Update monitored by HRC and GRC. * Issues and concerns escalated to EMB

3 4 12

* Staff survey results improvement plan* OD team not yet fully in post

Apr-14

SR14 SM

Winter planningThere is a risk that winter planning is not robust enough due to a lack of response from non acute providers regarding their own winter plans, lack of preparedness and experience to procure required capacity

4 4 16

* Trust winter plans* Ongoing discussions with community and primary care partners

* Scrutiny and challenge of site winter plans

4 4 16

* Fully articulated and funded capacity plans from non acute providers

* Robust plans from partners in the wider health economy

Oct-13


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Board Committee Reports

13.3 Monitor Standing Committee (Enclosure)

13.1 Audit Committee (Enclosure)

13.2 Donated Funds Committee (Enclosure)


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AUDIT COMMITTEE

Minutes of a meeting of the Audit Committeeheld in the Board Room, Devon House, Heartlands Hospital

on 31 July 2013

PRESENT: Ms A Lord (Chair)

IN ATTENDANCE:

Mr P Hensel (Non Executive Director)Prof E Peck (Non Executive Director)Prof L Serrant-Green (Non Executive Director)

Ms R Blackburn (Head of Corporate Risk and Compliance)Mr A Bostock (KPMG)Ms C Jinks (Company Secretary)Mrs A Jones (Chief Financial Controller)Mr J Howse (PwC)Mr D Sharif (KPMG)Ms K Sharrockss (KPMG)Mr A Stokes (Director of Finance)Mrs L Thomson (Director of Corporate Affairs & Corporate Governance)

13.013 WELCOME & APOLOGIES

Apologies were received from Dr S Woolley (Director of Safety & Organisational Development).

Alison Lord welcomed everyone to the meeting and, as the new Chair of the Committee, explained her expectations for future meetings;

• Bi-monthly meetings would continue to ensure the meetings were focussedand effective. Meetings should last no more than 2-2.5 hrs

• The Committee Terms of Reference were being reviewed regarding membership and she would look for high NED attendance.

• Board Directors or Executive Directors other than the Director of Finance would not routinely be required to attend unless requested.

• Deadlines for papers were expected to be met at all times. Any papers submitted after the deadline without prior agreement of the Chair would beheld over to the next meeting.

• No papers should be tabled on the day except by prior agreement by the Chair.

• To improve clarity and focus within committee papers, it was requested that all future reports begin with a statement explaining why the paper wasbeing brought to the committee, especially where approval was required;and a short paragraph summarising the key messages contained within the report, what action was being taken, which committee/s it had already been to and action / deadlines they were taking; and concerns for Audit Committee. This should not be more than 200-300 words (eg the size of this section of the minutes).

It was agreed that this would help ensure that meetings were more effective and efficient and that the committee understood what was expected from them.

Audit Committee Minutes


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13.014 MINUTES OF PREVIOUS MEETINGS

13.004.5 Draft Accounts. Amend to refer to revaluation to read…”£76m had been written off the balance sheet as a consequence of the revaluation of the estate.”

Following this amendment the minutes of meeting held on 30 April 2013 wereapproved by the meeting and signed by the Chair.

13.021 Maternity Services Review. The minutes noted that this report was due to be brought back to this meeting. However, it was confirmed that the final report would now be presented at the next meeting as detailed on the Schedule of Matters.

Following this amendment the minutes of meeting held on 28 May 2013 wereapproved by the meeting and signed by the Chair.

13.015 SCHEDULE OF MATTERS ARISING

The Schedule of Matters Arising was discussed and the following actions noted;

Patient Safety Review.The Chair requested an update on this item at the next meeting. Adrian Stokes confirmed that no tender had been sent out yet.

Action: SW to provide update to next meeting

It was noted that all other matters due for reporting in July were addressed within the agenda.

SW

13.016 FINANCE DIRECTOR’S REPORT

13.016.1 Finance Director’s Update Report

Mr Stokes presented a summary of his pre-circulated report which was taken as read. He highlighted the following key points of his report as follows;

• External Audit. Due to the some additional work that was required on the 2012/13 Quality Report and year end, there were some outstanding final costs that needed to be agreed with PwC.

• Internal Audit. It was highlighted that the procurement process for re-tendering the Internal Audit contract would need to begin in September.

• 13/14 Annual Reporting Manual Consultation. There had been a number of minor amendments required as a result of moving to Monitor licence but these did not have any significant impact for the Trust.

• Internal Audit - Outstanding Recommendations. The Chair noted that there were 79 outstanding recommendations and requested clarification on which of them were still valid. David Sharif confirmed that there were only 18 which had exceeded their deadlines. It was requested that further effort be made to cleanse the list as much as possible as the Committee would hold relevant people to account for overdue actions in future. Where actions were delayed or superseded by wider system changes, these should be reflected in amended actions or deadlines. It was agreed that the schedule would be



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reviewed again at the November meeting.

Action: Finance to continue to cleanse action list, with updated schedule brought to next meeting


AJ

13.017 EXTERNAL AUDIT REPORT – PWC

Progress report

James Howse presented the external audit report commenting on key points as follows:

• Audit Cycle. Following completion of the 2013/13 audit, a meeting had been held with the HEFT finance team as a de-brief following completion of the annual accounts. A number of lessons had been learnt and a mutual set of objectives for the year ahead had been agreed together with enhanced ways of working. There would be a further de-brief session in September to discuss the Quality Accounts and data.

• Planning for the 2013/14 audit. Meeting will be held in August to begin planning for their 2013/14 audit. Due to a change in accounting requirements, the Trust’s Charitable Fund accounts will be consolidated with those of the Trust. This will require additional input and oversight from management and external auditors will work alongside the finance team to ensure the work is properly planned and delivered.


13.018 INTERNAL AUDIT REPORT – KPMG

13.018.1 Draft Annual Plan – 2013/14

Andy Bostock presented the plan. Committee members raised a number of concerns:

• Clarity was requested around how the planned activities mapped to the key risks and issues facing the organisation, particularly the Trust’s capability and capacity to deliver service change as there did not appear to be any reviewsaddressing this.

• It was noted that the risk assessment contained within the draft plan appeared quite generic, essentially applying to any hospital whilst not addressing the specific risks the trust faced eg the outcome of the Paterson review.

• The plan also did not appear to take into account the forthcoming CQC inspection, and how activities could be scoped to fit around this to include key areas in the inspection such as mortality rate reviews, A&E issues, Quality Governance etc.Adrian Stokes advised that the inspection had only been confirmed a week ago and therefore would not have been included in any of the papers submitted. The relatively short timescale for the inspection would mean any review work would fall outside of the plan and probably be carried out by PWC as they had supported the Keogh Reviews and should be able to indicate the key lines of inquiry that the inspection would undertake.



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Andy Bostock confirmed that the Audit Plan would need to be adjusted as concern had already been expressed about the availability of Trust staff to be involved in internal audit reviews whilst the inspection was underway.

• It was questioned whether the Terms of Reference for the various reviews were scoped sufficiently to address key strategic risks rather than operational targets.For example, the CIP Review had received Significant Assurance although there were significant outstanding targets across the Trust.

• The Chair requested that the revised plan include a review of the assurance framework and supporting processes, as this was the key assurance tool for the work of the Audit Committee.

Action: Include review of Assurance Framework in revised plan

• Increased involvement of NEDS in the internal audit planning process in future would help to ensure reviews were understood, supported and relevant to the risks facing the Trust. It was agreed that in future the Committee should review draft terms of reference in advance, subject to the Chairman’s view.

• The involvement of KPMG in providing support to the Trust in developing its IT and Data Quality Strategy was queried as there was a concern that this was not governant as it would conflict with their ability to subsequently objectively audit these areas. Andy Bostock advised that this was more in relation to advising on best practice and providing a view having worked with other Trusts. However, he accepted the point made.

• The table on Performance Measures was referred to and welcomed although it was queried as to how the measures were determined. Andy Bostock confirmed that these were included in the Annual Report submitted at April’s meeting. Itwas requested that this table be included in future progress reports brought to the meeting, evidencing Internal Audit’s active management of the process and delivery of reports to ensure they came to the committee at the agreed time.

• It was requested that the annual plan include an indication of the numbers of days allocated to each review to help identify areas of focus

Andy Bostock welcomed the feedback and suggested specific time with the NEDS either together or individually to ensure their involvement and that the process was not just led by executive management.

It was agreed that the Chair would seek the views of all NEDS on the draft plan and respond to KPMG with summarized comment within a week. The plan should be re-visited and brought back to the next meeting although existing work on reviews should continue.

Action: Chair to seek NED views on plan and advise KPMGAction: Revised Audit Plan to be brought to next meeting

KPMG

ALKPMG

13.018.2 Progress Report

David Sharif presented the report and highlighted the following: • The total number of outstanding recommendations was 68. The Trust had made

continued progress towards clearing the backlog) and were progressing high priority actions. However, the Trust had 18 remaining actions passed their due date – two of which were deemed high priority (reviewing guidelines and compliance with clinical guidelines). It was confirmed that the first had been completed and the second superceded although the tracker had not yet been



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updated.• It was noted that the IT Strategy Review fieldwork was already underway

although the terms of reference had not been seen at EMB or IM&T committee. Given the trust-wide scope of the review and with reference to the earlier discussion, it was essential that there was full input from EDs and NEDs to ensure the Terms of Reference were appropriately scoped. It was agreed that in future all Terms of Reference were circulated or presented at the Committee so, time permitting, NEDs could comment.

Action: Future terms of reference for internal audit reviews to be to be circulated to all NEDs or brought to Audit committee for review

• The review of Mandatory Training had been given Significant Assurance despite the Trust being a performer for this area. The process of assurance rating was questioned and David Sharif confirmed that there was a meeting following Audit Committee to review the report in light of concerns raised at the Governance & Risk Committee meeting on Monday.

David Sharif then drew the Committee’s attention to two reviews which had bothreceived Limited Assurance as follows;• Medical Revalidation Review. This report had been given Limited Assurance

as Internal Auditors because the Trust’s Medical Appraisal and Revalidation Policy had yet to be formally adopted, development of a common system to provide clinical outcome data to feed into individuals appraisals was required, and a process to quality assure information used for revalidation needed to be considered.Concern was expressed that there was no routine information provided toappraisers to guide their discussions when appraising a doctor for accreditation; and that the Board had received assurance twice that this project was going well. It was queried how this had been reviewed at Governance & Risk Committee and the committee was advised that it had not been raised at G&RCommittee and that no specific discussion had taken place. There was general concern echoed about the role and provision of assurance provided by the G&R Committee and information that had been provided to the Board. It was agreed that the Chair would report the issue to the Board as part of the Audit Committee report highlighting the disparity between the reports. In addition , the Chair of G&R would be invited to AC to provide assurance that appropriate action was being taken in relation to this review

Action: AL to report to Board on this issue Action: Chair of G&R to provide assurance that appropriate action is being taken in relation to this report at next meeting

• Clinical Outcomes Report. This report had been given Limited Assurance because significant improvements were required to improve the adequacy and effectiveness of risk management, control and governance before reliance could be placed on the system for corporate governance assurance.

It was agreed that the Chair of G&R would be invited to AC to provide assurance that appropriate action was being taken in relation to this review

Action: Chair of G&R to provide assurance that appropriate action

KPMG

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is being taken in relation to this report at next meeting

The Chair asked the committee to agree the process for providing assurance where future reports provided limited assurance and it was agreed that the Chair of the relevant committee would be invited to submit and present a report to Audit Committee to confirm appropriate action was being taken in addressing the issues in the report and thus provide assurance to the Committee.

13.018.2.1 Community Services Integration Review

David Sharif presented the review of Community Services Integration which had been given Limited Assurance. Whilst there was progress in the integration, particularly in relation to the back office function, integration of the operational side had not moved very far forward.

The committee expressed disappointment with report and the slow integration process. This was a high profile issue and progress reports were provided to the Board on a regular basis, which it was not felt had flagged that there was an overarching issue with the integration, although issues around finance had been raised.

Lisa Thomson agreed with the comments made and advised that the hospital needed to integrate into community rather than vice versa and there needed to be understanding of this. There were currently very many workstreams underway which was part of the problem and she had therefore developed an overarching action plan to move forward and progress this in a structured way. There was much work to be done in moving forward with the integration one of which was to integrate the management structure to integrate job roles. This process would start in September.

The committee felt that it was important to identify which departments and key areas were priorities to be moved forward as this would demonstrate the integration proceedings to the rest of Solihull. These needed to be determined and deadlines attached to the integration plan. Adrian Stokes supported this responding that there were clear key indicators that the integration was not going well. For example, the finances were off track, bed stays were extended, activity was rapidly growing. He felt that these areas needed to be brought together and workstreams needed to be reviewed to ensure they were supporting and benefitting the integration. Simon Hackwell was preparing KPIs for financial and non-financial change which would beused on the integration of SCS and then monitored through F&P

The Chair requested that a report be brought back to the committee in November as by this time we should be in a better position to provide assurance about progress on the action plan and specifically around which services are being prioritized for integration and progress made in this regard.

Action: Update report to be brought to next meeting LT

13.018.2.2 Cost Improvement Programmes Review

David Sharif summarised the key points in relation to the pre-circulated CIP Internal Review as follows;A detailed review was carried out in 2011-12. This follow up review covered the three elements of the CIP lifecycle: Identification, Implementation and Assessing



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progress. A sample of seven CIP schemes were selected from all of the sites and divisions within the CIP reporting model and reviewed a range of schemes.

A rating of Significant Assurance was allocated. There is some risk that objectives may not be fully achieved. Slight improvements are required to enhance the adequacy and / or effectiveness of risk management, control and governance.

The committee requested clarification on whether the review had looked at the process undertaken around individual CIP plans or whether the terms of reference focused on the whole process around Cost Improvement Programmes as it was a concern that a Significant Assurance rating had been given when the Trust was not meeting its CIP targets. It was confirmed that the review looked at the processes behind the development of CIPs not their achievement.

13.018.2.3 Performance Arrangements Review

David Sharif presented the Internal Review on Performance Arrangements which had received a Significant Assurance rating. He confirmed that the report had focused on performance at site level, assessing the extent to which its financial and operational performance were effectively managed.

The report noted that during the year the Trust had struggled to meet a number of its key performance targets including A&E 4 hour wait, 18 week wait and 62 day cancer targets however, the review was allocated Significant Assurance reflecting that the Trust had established monitoring arrangements from site to Board level which the Trust supports with robust information. Some recommendations had been made in relation to streamlining systems, monitoring arrangements and ensuring appropriate support for services as well as identification of measures to further develop performance management measures.

There was a general discussion around the focus of this report and clarification was requested around the review criteria. KPMG confirmed that it was the measurement of targets at site based level. However, there appeared to be some confusion around whether report was advising that targets were being effectively measured and reported, or, effectively managed.

It was requested future internal audit reports improve clarity around the original criteria of the review and the results against these areas as this had been an issue on both this and the previous report. Terms of Reference should be clear and detail the area/s being addressed (including identifying where there was a narrow focus). There was concern that reports might be misleading as the conclusions do not appear to relate to the areas being reviewed as detailed in the Terms of Reference.

KPMG agreed that future reports would give more clarity on the focus and purpose of the review to ensure that there was clear definition as to areas being reviewed and measured.

The Chair requested that both the CIP and Performance Reviews were re-drafted on the above basis, because without clarity over the limited focus of the reviews the Significant assurance provided could be misleading

Action: KPMG to re-draft CIP and Performance Reviews andcirculate before next meeting KPMG



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13.018.2.4 Trauma & Orthopaedics Directorate Review

Two updates had been brought to the Audit Committees on this area.

An independent review of the T&O Directorate was requested of KPMG in November 2011 to specifically look at the directorate’s approach to finances. Several workstreams were identified as a result of this review. The review also identified recurrent and non-recurrent initiatives to help address the overspends anticipated to deliver savings of between £7.4 - £10.3m which were grouped into 9 opportunities. Whilst the Directorate has achieved its target of operating within 48 hours for Fractured Neck of Femur in each of the first three months across all sites, it continues to experience significant financial and performance pressures in 2013-14.

KPMG had recently completed a further review of the T&O directorate against the initial action plan and summarised the findings of their updated review noting that there was evidence of progress in many areas. However, there was limited delivery across the key metrics albeit since the report had been completed there had been further progress in relation to private patient income where some modeling work had been undertaken.

Sue Moore, Managing Director for Good Hope Hospital responded to the above review and supported that there had been progress in 7 out of the 9 recommendations and provided detail and clarification around the progress made although she recognized that considerable more progress needed to be made.

Administration and Clerical was flagged as an outstanding recommendation and Sue Moore confirmed that a proposal had been taken to the Operational Management Board around 21st century administration which identified what the service requirements should look like going forwards embracing administration developments/software etc, an approach that will also be taken trust-wide.

Private Patient income was the other outstanding recommendation and Sue Moore confirmed that she had commissioned a piece of work on this area which would look at three specific categories of patients. She confirmed that there was definitely amarket in this area but that the Trust needed to take a view on how far they wish to proceed in this regard. A paper was being taken to EDs to discuss overall strategy and external partnership opportunities and specific private patient markets.

Adrian Stokes expressed concern that a potential c£10m saving had been identified in the initial report and yet, to date, c£200K savings been made. A lengthy discussion took place around whether the original assumptions were correct in relation to Length of Stay and Theatre Productivity which had been identified at themajor areas for cost savings. Sue Moore advised that all T&O wards would have to be closed to achieve the savings identified. KPMG agreed to revisit the assumptions made in relation to Length of Stay and Theatre Productivity to determine if they were still valid. The committee emphasised that it was important that any financial targets set were credible and that the assumptions behind them were valid.

Adrian Stokes confirmed that the F&P Committee would review the revised assumptions and that he expected that the revised number would be much lower. The Chair requested that this information was circulated to the committee and it would then be determined as to whether the matter needed to come back to the



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Audit Committee again.

13.018.2.5 CQC Compliance ReviewDavid Sharif summarised the pre-circulated CQC Compliance Review which was a follow-up report to the review completed in 2011-12, where the Trust’s arrangements for the transition to a ‘live’ declaration from an annual retrospective exercise were reviewed.The 2011-12 review identified areas where the Trust could strengthen its approach and five recommendations were raised. None of these were high priority and the conclusion of the review was significant assurance over the CQC compliance process.

This follow up review had been undertaken 12 months since the previous review in order to assess the Trust’s progress in implementing the recommendations. The review focussed on the following four objectives:

1. systems and processes; 2. accountability; 3. reporting;4. assurance

A number of further recommendations were made but in particular the ongoing issues with regard to fully resolving records management [CQC Outcome 21].However, they were reassured that work was underway to address this.

Lisa Thomson confirmed that progress had been made in relation to record management but referred to the Information Governance paper brought to this committee at Agenda item 8.2 to provide clarity around reporting structures and responsibilities in relation to this area.

13.019 COUNTER FRAUD REPORT

13.019.1 Progress Report

Karen Sharrocks presented the pre-circulated Counter Fraud Progress Report which was brought to the Committee for assurance as well as information. She confirmed that the Counter Fraud Team had;

• continued to liaise with the Trust to investigate the Trust’s National FraudInitiative (NFI) data matches

• Issued two fraud alerts• submitted the Trust’s 2012-13 Annual Report, 2013-14 Annual Plan and Self

Review Toolkit to NHS Protect, prior to the 31st July 2013 deadline. These documents would now be reviewed against the requirements of the Standards for Providers 2013/14 - Fraud, Bribery and Corruption

• delivered fraud awareness training sessions across the Trust.

In relation to current investigations, Karen Sharrocks confirmed that there remained five open cases. An update was given on two of the open cases. Investigations were underway on both cases however there were delays.

A detailed technical update entitled Pre-contract Procurement Fraud and Corruptionhad been included in the Technical Update section and Karen Sharrocks confirmed that a review of the impact on the Trust was to be undertaken as part of the 2013/14 plan.



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In relation to the Investigations Report, the Chair requested that approximate value of the fraud under investigation and time spent on a particular case be included infuture reports. Karen Sharrocks confirmed that time spent on each case is recorded and that this would be included in future reports.


13.019.2 Counter Fraud Annual Report for 2012/13

Karen Sharrocks presented the Counter-Fraud Annual Report 2012/13 and summarised its key points as follows;

The Trust was required to comply with NHS Protects Standards for Providers: Fraud, Bribery and Corruption. The overall level for HEFT based on the Self Review Toolkit is Green.

The Counter-Fraud Annual Report was required to be approved and signed by a Trust Director and submitted on 31 July (day of the meeting). The report was in a set format as dictated by NHS Protect and meets the new assessment guidelinesissued in April 2013. NHS Protect will pick a sample of Trusts in the next 12 months and review their self assessment ratings.

Karen Sharrocks confirmed that Adrian Stokes, Finance Director, had signed the report and that it had been submitted earlier that day.

13.020 SAFETY & GOVERNANCE

13.020.1 Clinical Coding Review UpdateSue King, Head of Performance, joined the meeting to provide an update on the Clinical Coding Review and restructure which had been implemented following the Audit Commission’s annual report (Right Data, Right Payment) where the organisation had been placed in the bottom 10 poorly performing Trusts. Whilst considerable action had been taken which had improved performance, further workwas ongoing, particularly strengthening the cohort of trained staff and a programme of educating clinical staff to make coding easier.

Payment by Results Audit 2012/13Only Trusts selected by the CCG are audited. From this year, three areas were audited including A&E and Out-patient records (not previously reviewed) in addition to inpatient episodes. The audit took place in November 2012 with data for Q1 2012/13 being reviewed. 225 records were audited across 5 inpatient areas with a net undercharge of £4,285. The overall error rate was 9.5% which was an improvement on the previous year. The result did bring the Trust out of the bottom 10% poor performers although we still did not meet the national average of 7.5%.

A&E scored an overall HRG error rate of 26%. Some of this was historical andrelated to mapping of local codes. Work has been undertaken with the department to improve processes and we are looking at moving Clinical Coders into A&E (currently existing staff within the dept complete coding).

The committee queried whether the data had been re-tested following the changes we have made to see if we have improved on this figure. Sue King confirmed that a



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repeat review had been included as part of the Audit Plan for this year.

In relation to Out Patients review, the overall HRG error rate was 7% which was in line with the national position.

Sue King advised that the Trust was being audited again in February 2014 but only in relation to In patient data.

Clinical Team Re-structureSue King advised that the restructure of the team had taken almost 2 years to complete and finished in March 2013.

The Chair requested assurance that the issues raised had been addressed, in particular relation to A&E dept where they used their own coders. Sue King advised that action plans were in place for A&E and Out Patients and these areas would be internally re-audited to ensure they were meeting the requirements of the plan.

The committee expressed concern at the 26% error rate and queried why coders were not altogether thereby ensuring consistency of quality, particularly if data with 10% error rate was being used by Dr Foster and HSMR.

Sue King advised that only senior coders code deaths and that there were a number of workstreams underway to address issues such as clinician coding errors, training in Out Patient departments, mapping of local codes to national codes etc.

The committee recognised that a significant amount of work was underway and it was agreed that a further brief update would be brought to the Audit Committee in January 2014. In the meantime, some of the internal audit results would be brought to F&P Committee and G&R Committee to ensure improvements were being monitored.

Action: update to January meeting SK

13.020.2 Information Governance Review Update

Charlotte Jinks introduced the pre-circulated report which provided clarification around the scope and responsibilities of the current Information Governance [IG]function following transfer to the Corporate Affairs Directorate. An IG Consultant had been brought in to complete a full review of IG within HEFT. Upon completion of the review [which will include looking at whether the Trust’s existing IG function was ‘fit-for-purpose’], an overarching IG Strategy and Action Plan would be prepared highlighting priorities for the organisation going forward.

Adrian Stokes raised queries around the statutory responsibilities of the SIRO and Caldicott Guardian. Charlotte Jinks confirmed that these roles would be reviewed as part of the overarching IG strategy.

The committee welcomed the approach that was being taken with IG as he felt that given the changes in IT and data management technologies as well as the recent reviews such as Francis Report and Caldicott 2 Review, it needed the profile to be raised and ensure any issues addressed. Charlotte Jinks confirmed that IG would become very high profile with CQC and Monitor in the coming 12 months and we needed to be in a position to embrace the changes.



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It was agreed that an update on the progress of the review would be brought back to November’s meeting.

Action: Progress Report on Information Governance Review LT

13.020.3 Trauma & Orthopaedic Review – Update

Refer to combined minute at 13.018.2.4 above.

13.021 CORPORATE GOVERNANCE

13.021.1

13.021.2

The Review of the Audit Committee’s Effectiveness was taken first in order that Auditors could contribute to this discussion and then leave the meeting in order that Agenda items 9.1 and 9.2 could be discussed by the committee.

Review of Effectiveness of External Audit Function

Adrian Stokes advised that a new Account Manager, James Howse, had been appointed following the departure of Cat Little who had been Account Manager for the Trust for 5 years. There had been some teething problems mainly around thecompletion of the Annual Accounts and meetings had taken place to resolve the issues raised. The Contract was not due for review for a further two years. In general, the Committee were satisfied with the performance of PwC.

Review of Effectiveness of Internal Audit Function

Adrian Stokes confirmed that a questionnaire would be circulated for feedback on effectiveness. This would be sent to all members of the Audit Committee, Executive Directors, Non Executive Directors and any manager involved in an Internal Review.

There was a general concern around the objective, clarity and content of some of the reports provided which would go into the public domain and therefore needed to be correct.

With regard to finance related audit element of the contract, this was perceived as being carried out satisfactorily. Some members of the KPMG administration team had changed and things were running much better this year.

Concerns were expressed in relation to the accuracy of the T&O Review (as discussed earlier in the meeting in terms of benchmarking and identifying realistic savings that could be achieved), and the Maternity Review which could have been carried out and managed better. It was felt that KPMG appeared to lack the internal expertise to carry out reviews on some specialist areas.

The 3 year contract was due to finish at end of March 2014 and the committee agreed that it was appropriate to go out to tender. The process would need to get underway in September. Adrian Stokes confirmed that he would take this forward following the Audit Committee recommendation.

Action: Internal Audit Contract to be re-tendered AS



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13.021.3 Review of Committee Effectiveness & Self Assessment Update

It was recognised that the committee had had a number of chairs in the past 12 months and had struggled with continuity. The new Chair was keen to ensure the structure and governance of the committee was strengthened going forwards. The Self Assessment Questionnaire with revised responses was reviewed and identified areas where further clarification were required including;

1. Membership There was a view expressed that all NEDs should be member of the committee. It was noted that there may be difficulties with attendance in this regard and given this, lack of consistency. Alison Lord agreed to raise this with the Chairman.

2. Terms of ReferenceIt was understood that the Terms of Reference had been re-drafted to include a number of other updates. It was agreed that following further discussion with the Chairman regarding committee membership and quorum, the Terms of Reference would be amended and brought back to the committee for approval.

3. Meetings – timings and frequencyMeetings would continue to be held on a bi-monthly basis in order that they were short and focussed. It was suggested that the time of the meetings could be changed in order to facilitate NED attendance i.e. early evenings.

Action: Terms of reference and membership of the committee to be reviewed

AL/CJ


No other business was raised.

13.023 DATE OF NEXT MEETING

16 October 2013, Boardroom, Devon House, Heartlands Hospital

.......................................Chairman


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Minutes of a meeting of the DONATED FUNDS COMMITTEE of Heart of England NHS Foundation Trust

held in the Boardroom, Devon House, Heartlands Hospital on 19 July 2013

PRESENT: Mr P Hensel (Chairman)Mr A FletcherMr L LawrenceMrs L Thomson

IN ATTENDANCE: Ms A EvansMrs E Hale Ms C Jinks Mrs A Jones

Mrs A Hudson (Minutes)

13.036 APOLOGIES

Apologies were received from Mr Stokes.

13.037 MINUTES OF MEETING

The minutes of the meeting held on 24 April 2013 were approved and signed by the Chairman.

The minutes of the meeting held on 24 May 2013 were approved and signed by the Chairman

13.038 MATTERS ARISING

11.21 Staff- giving Opt-out Scheme. Mrs Hale confirmed that to date 150 members of staff had signed up to the opt-in scheme which was now being actively marketed with roadshows planned at BHH. Mrs Hale believed that it had not been as successful as first thought. Mr Hensel advised that as this was now an ‘opt-in’ campaign it could now be discharged from the agenda.

12.46 Fund Holder Invitations. Mrs Jones advised that an increase in monies being spent with a number of orders going through at the present time. Mr Hensel was pleased to see the improvement in spending plans. Mr Fletcher was also pleased that spending plans had improved but was of the opinion that those fundholders where no improvement had been seen should still be invited to report on their plans to the Committee. Mrs Jones reminded the meeting that it was only fundholders with balances over £50k without spending plans in place/no monies being spent that wererequired to attend this meeting. Mr Fletcher asked if the limit ought to be lowered to £30k to encourage better spending plans. Mr Hensel was of the view that the current level of £50k should remain as it would keep the pressure on fundholders to spend appropriately.

13.020 Fundraising Dashboard Mrs Hale advised that progress was being made to create a dashboard in order to monitor current activity against plan. At the present time progress was off track but the situation was being actively managed. Mr Hensel asked

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that a prototype dashboard was bought to the next meeting.

13.33.1 ISO 260 Report. Mrs Evans advised that all the issues highlighted by that PWC has highlighted in relation to internal controls had been completed.

DFC Business Plan. Charitable Donations Policy. Mrs Jones advised that the policy was being revised. As part of the revision there was a Counterfraud investigation recommendation around the current practice by the Trust of issuing vouchers for distribution to staff. HRMC were not happy with the use of vouchers as there were potential taxation issues in that all vouchers are taxable. There was also the issue of it being difficult to prove if the person who was signing for an amount of vouchers was distributing them and to whom. The only caveat to this would be the purchase of vouchers to be given as prizes to schools for such events as competitions. The Trust, therefore, had taken a decision to no longer use vouchers. As a result of this decision the Committee was asked for authorisation to change the policy to reflect this.

The Committee approved the request.

13.039 FUNDRAISING REPORT

13.039.1 Mrs Hale presented the pre-circulated report highlighting the following key item:• The Fundraising Department had had a slow start to the financial year due to staff

attrition, maternity and sick leave which had left the resource significantly depleted. Approval had been received for a replacement member of staff to focus entirely on trusts and foundations which would increase the skill base of the team. The recruitment process for this had been agreed and was underway place. Following a discussion it was suggested that in the short-term it may be advantageous to get a professional fundraiser in post until a more permanent solution could be finalised.

• A fundraising plan is in place and had been agreed by this committee and will be monitored on a quarterly basis against performance. It was noted that the figures submitted differ from those in the final report due to the need to submit the written report prior to annual leave and it was noted that the figures generated by Mrs Evans were the definitive position.

• Income is significantly down on plan due to changes in staffing arrangements and reduction in resource available. However, these issues are being closely managed and will hopefully be resolved in the near future.

• Budget had been agreed for marketing of the charity and a plan is in development to increase the physical presence of charity marketing material across each of the sites to increase awareness.

• Individual fundraisers are met with on a monthly basis and a review of activity takes place against income received. This process has highlighted a number of issues which are actively being managed and processes changed as a result.

• The development and implementation of a comprehensive legacy strategy and plan has been put on hold until resource issues have been resolved. However, opportunities for media coverage are still being utilised wherever possible.

• The Health Foundation had recently launched a new fund called ‘Closing the Gap’ to improve patient safety. They are seeking Expressions of Interest and will fund 9 separate projects across the UK up to a value of £450k each. A meeting has taken place with the Simulation Centre and a decision taken to take forward TeamStepps as a proposal. An Expression of Interest has been registered and work is underway to complete the initial application process. The TeamStepps project is closely aligned to the criteria set out by the funders which particularly mentions human factors training and is a tried and tested means of improving patient safety



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which the Trust can implement at scale through the project as well as evaluate its success.


13.040 OPERATIONS COMMITTEE REPORT

Ms Jinks gave a verbal update on the meeting that had taken place on 24 May 2013 and it was noted that: • The meeting had met to solely discuss the Women’s and Children’s fundraising

strategy. • Dr Clive Ryder, Associate Medical Director, had been in attendance at the meeting

to support the business case. • The Committee has been very much in support of the appeal but asked for work to

be undertaken to support the business case including:o Completion of the Trust Justification Case to include clarity around strands

of Project Pelican. o Further details and financial information around the options set out in the

business case. o Clarity around the spending plans for the requested £25k - £50k funds

including forecasting in order to give assurance on projected costs and confirmation from where/which fund the funding will be underwritten

o Clarity on the feasibility study including the scope of work.• Dates for future meeting to be agreed and circulated.

Mrs Thomson asked, in addition to the minutes, if an action log could be circulated to this committee for information. Ms Jinks agreed to action this.


13.041 WOMENS & CHILDRENS APPEAL – BUSINESS CASE

13.041.1 NEONATAL & MATERNITY APPEAL – Business Case

Mrs Hale presented the pre-circulated Business Case to deliver a capital fundraising appeal through the utilisation of external consultancy.

Mr Lawrence queried why the Business Case was being raised at this point when the Board had not yet given approval for the Maternity Project.

Mrs Hale explained that unless the process of engagement with fundraising was started well in advance of the project there would be a significant lag which would almost certainly impact negatively on the amount of funds that could be raised as many fundholders are happy to fund new projects but are less likely to fund projects which already have approval and funding.

The Committee discussed the Business Case in further detail and advised that it needed further work in order to satisfy the stringent Trust requirements. It was therefore referred back for further work to be completed in this regard.

Mr Hensel indicated that this work should be undertaken promptly as any unnecessary delay which could result in the loss of funds may not reflect well on the Trust.



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13.041.2

However, he acknowledged that this was an unusual business case for Trust to undertake.

FUNDRAISING CONSULTANT

The Committee discussed the report circulated by Mrs Hale and following a robust and lengthy discussion it was agreed that:• No decision for fundraising provision would be made by this committee until the

Business Case had been though the Trust approval process with ultimate agreement by the Board.

• It was understood that in following this process appropriate governance procedures would be adhered to and there would be a clear audit trail and thus the Board and Trust would be protected should significant donated or public monies be spent but the project did not proceed.

• The fundraising strategy would be attached to the business case for review and agreement by the Board of Directors and then further presented to the Council of Governors for endorsement.

As a result of the earlier discussion this item was deferred.

13.042 STRATEGIC REVIEW OF INVESTMENTS UPDATE

Ms Jinks presented the pre-circulated report on behalf of Mr Pye. The report was taken as read. The following key items were noted:• At its April 2013 meeting, the Committee approved the draft Invitation to Quote

(“ITQ”) and to the formation of a sub-committee for the purposes of appointing Investment Managers.

• Following discussion with the Procurement Department, the ITQ was issued on 10 April 2013 through the Trust’s procurement portal with a closing date of 8 May 2013. For technical reasons, this date was subsequently extended to 15 May 2013.

• There were five formal responses to the ITQ.• The original membership of the sub-committee was subsequently discussed and it

was thought that it would be more appropriate to have at least one person on the sub-committee who would remain with the Trust and so it was agreed that Mrs Jones would also join the sub-committee in place of someone from the Procurement Department. Mr Fletcher had been consulted and was content not to be directly involved in the workings of this sub-committee. It was confirmed that the sub-committee now comprised of Paul Hensel, Angeline Jones and Malcolm Pye.

• Copies of relevant papers had now been submitted to sub-committee members and agreement reached to shortlist three organisations to formally interview as soon as practicable. Interviews were in the course of being set up.

The Committee approved the revised sub-committee membership.

13.043 FINANCIAL REPORT

13.043.1 Mrs Jones presented a summary of the pre-circulated report.

In the three months to June 2013, the general charity fund had spent £161k less than the income received. The plan was for a deficit of £54k so this generated a positive variance of £70k.



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13.043.2

Key points of note were as follows: • Legacy income was £2k, £51k less than planned but with approximately £102k of

legacy income pending. • Donations had a negative variance of £79k and included £31k from individual

donors and £15k from companies. Fundraising income was £3k more than planned.

• Expenditure was £284k for the three months, £258k less than planned. • Losses on revaluation of investments amounted to £93k YTD. The cumulative

reserve of historic gains has decreased from the opening balance at 1 April 2013 of £750k to £657k at 30 June 2013

• Investment income was slightly behind plan by £6k.• £1,563k is held in the RBS Deposit account at a rate of base +0.92%. • There was a 0.69% decrease in the value of Schroder investments and a 1.63%

decrease in the value of M&G investments for year. This compares to a decrease in FTSE100 index of 3.06% over that same period, which has a different ethical and risk profile to the investments HEFT holds. At June the split of M&G investments is 77.55% equities and 22.45% bonds. Schroders hold 73.40% equities, 13.65% bonds, 5.45% hedge funds and 7.501% property funds.

Mrs Thomson requested that the committee recognised the c£10k contribution to the charity that the small business and stallholders generate through the stalls they have on each of the site. The committee noted their thanks and very much appreciated the contribution made by these small businesses and to the staff involved for their efforts in raising these funds and it was agreed that a letter of thanks should be sent.

Group Funds.

There are a total of 342 funds holding just over £7.8million. The Charitable Fund Manager confirmed that funds were reviewed on an on-going basis to ensure monies were being spent and where no longer used the funds are transferred to other funds.


13.044 RISK REGISTER REVIEW

Mrs Jones presented the Risk Register Review and the committee considered the risks and the following key points were noted:

• The first five risks were as per the previous risk register and reviews undertaken. • Risks 6 and 7 had been added following discussion at the previous meeting

around the reputational risks if donated monies were spent incorrectly or not at all.• Risk 7 in particular highlighted the risk relating to fundraisers and ensuring that

there is a clear and intended purpose for the funds they are raising.• The DF Operations Committee were to discuss the risk register in detail at their

next meeting. • The Donated Funds Risk Register would be presented to the Board for approval.




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Mr Hensel advised that this was his last meeting as Chair of the Donated Funds Committee as he had reached the end of his second term of office as a Non Executive Director. He thanked the Committee for their contribution and dedication during his time as Chair. Mr Hensel paid particular thanks Mr Albert Fletcher, Deputy Lead Governor for his valued contribution to the committee. This was potentially Mr Fletcher’s last meeting as a Governor for the Trust given that Governor elections were underway.

Mrs Thomson thanked both Mr Hensel and Mr Fletcher on behalf of the Committee for their commitment to the Donated Funds Committee and to fundraising at the Trust and believed that without their commitment the Trust would not have progressed fundraising to that of its present status.

12.46 DATES OF NEXT MEETING

18 October 2013 17 January 201415 April 2014

.......................................Chairman


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Monitor Standing Committee Minutes

1

Minutes of a meeting of the MONITOR STANDING COMMITTEE of the Boardof Heart of England NHS Foundation Trust

held in the Boardroom, Devon House, Heartlands Hospitalon 26 July 2013

PRESENT: Lord P Hunt (Chairman)Mr L Lawrence Mr A StokesDr S Woolley

IN ATTENDANCE: Mrs A Hudson (Minutes)Ms C Jinks

12.13 APOLOGIES

Apologies were received from Dr M Newbold.

12.14 MINUTES OF THE MEETING HELD ON 26 April 2013

The Minutes of the meeting held on 26 April 2013 were approved by the Committee and signed by the Chairman.

12.15 SCHEDULE OF MATTERS BROUGHT FORWARD

There was no Matters Arising.

12.16 APPROVAL OF MONITOR QUARTER 1 RETURN

Mr Stokes confirmed that the Monitor Q1 Return had been completed in accordance with the Compliance Framework.

The meeting reviewed in detail the pre-circulated papers. The following points were noted;• The Quarter 1 (30 June 2013) Monitor return had been completed in line with the

Compliance Framework. The financial risk rating (frr) was 3 and the Governance rating was red due to the failure to achieve the A&E waiting time target for three consecutive quarters. It was noted that there were clear signs of an improvement since last quarter particularly in respect of both Good Hope and Solihull Hospitals.

• The Trust had failed to meet the challenging C.Difficile quarterly trajectory of 16 with 20 cases in the quarter.

• There had been three MRSA cases in this quarter, however, the Trust remained compliant with target as the annual six de minimus had not been exceeded.However, it was noted that keeping within the target of 6 would be a challenge for the remainder of the financial year.

• The quarterly cancer targets would not be fully validated until August but it wasanticipated that this target would be achieved.

• The Trust had received an unannounced CQC visit to Good Hope Hospital in May. This was the follow up from the inspection in February where the Trust was found to be non-compliant with Outcome 1 (Respecting and Involving Services Users) and 17 (Complaints). The CQC have confirmed that the Trust is now compliant with both of these outcomes.

• It was noted that the Trust had volunteered to be one of the pathfinders for the CQC’s new hospital inspection scheme and it had now been confirmed that it would be one of the 18 pathfinders for the inspections which were scheduled to start at the end of August.

• It was noted that the Board were expected to sign a new combined governance statement confirming that:• The Trust expected to achieve a minimum finance risk rating (frr) of 3 over the

next twelve months;


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2

• The Trust had plans in place to ensure continuing compliance with targets;• There were no matters arising in the quarter requiring an exception report to

Monitor which had not already been reported.

Following due consideration, the Committee approved the Q1 Return for signature by either Lord Hunt or Mr Stokes for immediate submission to Monitor.


None was raised.

12.19 DATES OF NEXT COMMITTEE MEETINGS25 October 2013 31 January 201424 April 2014

………………………………Chairman

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Any Other Business

Dates of Future Meetings

• 5 November 2013 - St John’s Hotel, Warwick Road, Solihull

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PART TWO

16. Good Hope Hospital Report (Enclosure)

15. Solihull Hospital Report (Enclosure)

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SOLIHULL HOSPITAL – September 2013

Quality Improvements

Work is continuing to improve performance with much focus over the past two months on the facilities and environment. This follows up on the reinvigoration of Solihull’s estates strategy. August has certainly been a busy month for the teams on the site which has included:

The planning and start of the move for the discharge lounge to the main entrance of the Hospital. This will give this service much higher visibility and enable the team to work closer with the ward staff. It will also be easier for our patients and relatives collecting them. Contractors are programmed to start work on site week beginning 26 August .We aim to have the new discharge lounge (the old site for phlebotomy) open by mid-September. Once the discharge move has been completed, physiotherapy from Ward 9 will move into the old discharge lounge providing a larger area in which to see patients.

Work on Ward 9 is planned and will commence in days as we change this facility from theDay Hospital into our AMU and Ambulatory Care facility, incorporating rapid access clinics and elderly care. This will be completed by the end of October and will be a much improved facility with additional space (an additional four bays) to see and treat our patients over the busy winter period. RADs and Rheumatology will be moving into the current AMU footprint,which provides a more suitable facility for their service. Once all of this work is completed we will be holding a number of open sessions for Hospital staff to see the facilities.

We are in the process of planning the move of Ward 12 to 20A and then a refurbishment of Ward 12 to make it ready for potential additional winter flex capacity. We are aiming for opening Ward 20A by the first week in October. Once Ward 12 is empty, that the ward will then be refurbished to get it ready for winter to be opened as a 26-bedded flex-capacity ward, if needed, and then a decant ward in the summer, to start the ward refurbishment programme across Solihull next year.

CCU and Ward 7 are to be developed into hybrid CCU/HDU providing a Level 2 and 3 facility with retrieval trolley for Level 3 patients. This work is to be completed by the end of October.

The replacement flooring within the cardio area is taking place and is due to be completed in a matter of days and the programme for the Ward 10 garden is progressing; we are looking forward to starting this scheme shortly.

The replacement of the existing CT facility has been planned, with a new CT scanner (Toshiba) enabling works required to provide a temporary CT scanning service whilst the “prime unit” is being replaced. This involves stripping out one of the existing radiology rooms, making this appropriate and electrically screened against any CT radiation before we can install the temporary CT scanner within the area. This work is programmed to begin at the end of August and will run for a period of about eight weeks.

In addition to this work, we are developing the full business case for moving dermatology into new premises and moving out of Union Road, which will be completed by the end of the financial year.

As with all sites, we have welcomed our new cohort of junior doctors onsite in August and we are looking forward to 24 new nurses joining us this month with a further 30 to follow.

Integration of hospital and community services is a focus of our work. Form this month we have in place an integrated management team. We have commenced work on delivering an

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Solihull Hospital Report

integrated therapies service which will deliver improvements in patient care and greater flexibility and job opportunities for staff.

Finance and Performance

Solihull Hospital continues to face financial challenges, due to over spend on pay and non-pay and also non-delivery of CIP plans. Some progress has been made, including a rectification plan, which has recently been approved by Finance and Performance Committee.The financial position continues to be the focus of the team as does improving safety and quality for our patients. I am delighted to be able to report that the site is the first to achieve a week with no pressure sores and the nursing teams are looking to improve on all areas of the safety thermometer.

Concern remains, as per the last report, around the Dementia target. The team has a strong action plan in place and this includes mandatory completion of electronic forms, as it is believed that the screening is taking place but the issue has been with recording.

Priorities

Delivering a safe and quality service, within a financial stable position, will remain the focus priority for the management team as we are now starting to look to CIP planning for the next three years.

The Board will remember that the site was part of theSolihull Integrated Care Pioneer Bid.Here the Hospital alongside health economy organisations made an expression of interest to become an integration pioneer. However, this bid was unsuccessful. Initial feedback suggests that one of the issues was that our joint working would continue with or without the bid and that, collectively, work was already underway. Our programme of integrated working is continuing and I look forward to reporting back progress against this important agenda.

Urgent Care Review Bid

The review of urgent care across Solihull is continuing, led by the CCG. The Clinical Reference Groups have met several times comprising representatives from across the health economy in Solihull. We are anticipating a ‘Case for Change’ document to bepresented later this month and the aim of it is to inform future decision making. Initial feedback from those taking part is that there remains confusion on the emergency provision across the health economy and a question as to whether all parties will address the issue of how A&E/minors will operate going forward at Solihull.

Lisa ThomsonManaging Director - Solihull HospitalSeptember 2013


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GOOD HOPE HOSPITAL – SEPTEMBER 2013

1. DOMICILIARY CARE SERVICESince my last update, we have successfully awarded the contract for our Domiciliary Care Service - Cedar Wood, which will open on 5 November and will provide 29 single rooms, day centre style activity to develop both confidence and physical ability to return to the home setting. The service is carer led and in partnership with Midland Heart Housing Association.

2. EMERGENCY CARE PRESSURESEmergency Care pressures started to abate. However, we have been hit quite hard in the latter part of August with numerous delays across the hospital reducing daily discharge numbers. The reduction in discharge numbers really shows how sensitive the system is to even the smallest of changes. In context for Good Hope, the difference is as small as 5discharges per day separating the pass/fail of delivery.

3. ACUTE MEDICAL UNITOn a very positive note, the estates changes for the Acute Medical Unit are progressing – we have relocated the Short Stay Ward to a much better but temporary facility, over the next months the physical plan will be to match our acute medical bed base to the daily demand,with Wards 18 and 19 becoming Short Stay and Ward 20 Assessment

There are further plans to develop the Ambulatory Care Unit and Short Stay Assessment Unit too. The key themes being;

i. Working with the Acute Medical Team to translate the clinical vision into reality as already described

ii. With nursing colleagues ensuring our new starters are welcome and have preceptorship support in their new roles. We have established a supportive forum comprising of nursing staff, the Faculty, HR and site team members.

iii. A further aim of this group is to develop the clinical skills in the units, particularly the Band 6 Nurses and Healthcare Assistants.

iv. To support Clinical Managers to review sickness, capability and flexible working.

4. RECONFIGURATION OF SURGICAL WARDSDuring August we also reconfigured our surgical wards to be co-located on the site with the next step in this process being to establish the Surgical Assessment Unit.

5. WINTER PLANSA detailed set of plans including escalation triggers and actions have been developed. We have modelled our bed requirements on 95% occupancy. To work at this occupancy level,the site needs an additional 45 beds, which will comprise of 29 from the Domiciliary Care Unit, 10 via additional care packages, 10 via admission avoidance plus the Recovery @ Home service 6 places. This approach is focussed on matching our patients’ requirements to available capacity rather than the traditional acute bed model.

Sue MooreManaging Director - Good Hope HospitalAugust 2013

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Heartlands Hospital Report

BIRMINGHAM HEARTLANDS HOSPITAL REPORT – SEPTEMBER 2013

Thank you following major internal incident at BHH

I and the Heartlands site management team would like to sincerely thank the staff involved in ensuring all patients and visitors were kept safe, and the interruption to service minimised, at 12.30am on Bank Holiday Monday morning when a small fire (caused by a mechanical fault on a fan on a pump) broke out in the Princess of Wales Maternity Unit. The fire, not in a patient area, was immediately extinguished and the Fire Service quickly attended. As a precaution, some patients and staff were evacuated to the Emergency Department and other areas.

As a result of the efforts of our staff, the fire service, and indeed our patients, there was no harm to any individual and normal service was resumed by 4am.

New junior doctors

Carl Holland, Head of Operations, Steve Smith, Associate Medical Director, and I would like to extend a very warm welcome to our new junior doctors who joined us in August. We hope they will enjoy working here and find it a valuable experience. We wish to learn from the experiences of our junior doctors, and we run a ‘Risky Business’ forum specifically for this purpose.

New multi-storey car park for staff at BHH

The new multi-storey car park on Yardley Green Road will be completed during October, creating an additional 318 spaces for staff. Some staff may need a new swipe card for the barrier and forms will be available from the security team who will man the car park in the first few weeks, and help those through the barrier that don’t yet have the correct swipe card!

HEFT visitor car parking

Visitor car parking charges will increase in September, for the first time in 6 years. This will help fund£15m investment to create 1,318 parking spaces over three years. The current congestion is stressful for patients, visitors and staff, and these plans will significantly improve the situation.

Heartlands Team Meeting

We have instituted a Heartlands Team Meeting, chaired by the Deputy CEO or myself. This brings together the Heartlands Team, Clinical Services, and the Medical and Nursing Directors twice a month to address the clinical and operational issues on this our largest site.

Strategy Presentations

I have given two presentations this month that describe the journey we have followed over the last three years and our strategy for moving forward. These are difficult times for the NHS and the aim of the sessions is to raise awareness and allow staff to discuss our plans with me. I am setting up additional sessions across the Trust throughout September and October.

Dr Mark NewboldSeptember 2013

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Reports from CommitteesPART THREE

The Board will be asked to resolve “That representatives of the press and other members of

the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to

be transacted, publicity on which would be prejudicial to the public interest”

18. Safeguarding Children - Serious Case Findings (Enclosure)

19. IP Review 19.1 Launch Plan 19.2 Proposed Indemnity

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Board of Directors Public Meeting - 8 January 2013 P a g e | 17

as a whole during a time of immense pressure and asked that the thanks of the Board were passed on to all staff.

The Board was asked to resolve “That representatives of the press and other members of the public be excluded from the remainder of the meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.” 13.016 PART THREE

This Section has been removed under Section 40(2) and 41 of the Freedom of Information Act 2000

....................................... Chairman

September 2013

Board of Directors

.199

AgendaPart Two

Declarationof


Matters Arising

Chairman'sReport

Chief Executive's

Report

External and

Strategic Review

Patient and Public

Feedback

Safety, Governance

and Risk

Council of

Governors Report

Any Other

Business

Board Committee

Reports

Part Three

Financeand

Performance

CorporateGovernance

Date and Venue of next meeting5 November 2013St John’s Hotel, Warwick Road, Solihull

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