Formal Council of Governors Meeting... · Council of Governor Meeting Dates and Venues 2016/17 Date Time Venue . Wednesday 13 April 2016 (Chief Executive Briefing) 09:00 – 11:00

Formal Council of Governors

Thursday 09 February 20179.15am - 9.45am Governors pre-meet

10.00am - 2.00pm Council of Governors formal meeting

Balmoral Room, Farington Lodge, Stanifield Lane, Farington, Leyland, PR25 4QR

Council of Governors


Public Staff Nominated

Alan Ravenscroft East Lancashire Lead Governor

Jacqui Sutton West Lancashire

Mike Wedgeworth East Lancashire

Keith Holt NHS Blackpool

Max Oosman Nursing

James Harper Other

Yvonne Guilfoyle Nursing

Helen Scott Nursing

Steve Sansbury Lancashire

Constabulary

Teresa Jennings NCompass

Pamela Beswick Young Lancashire

Julia Kay Horn

Out of Area

Katharine Wykes Lancashire North

Lorena Dumitrache Central Lancashire

Bernadette Ashton Central Lancashire

Debbie Wisby UCLAN

Emma Allen Corporate

Adnan Gharib-Omar Medical

Christopher Johnson East Lancashire

Philip Thomas Curwen

Central Lancashire

Vacancy x1

Lancashire North

Pauline Walsh Blackburn with

Darwen

Council of Governor Meeting Dates and Venues 2016/17

Date Time Venue

Wednesday 13 April 2016

(Chief Executive Briefing) 09:00 – 11:00

Blackpool FC Hotel and Conference Centre,

Bloomfield Road, Seasiders way, Blackpool, Lancashire,

FY1 6JJ Thursday 05 May 2016

(Formal CoG) 10:00 – 14:00

Balmoral Room, Farington Lodge, Stanifield Lane,

Farington, Leyland, PR25 4QR

Thursday 09 June 2016

(Informal CoG) 10:00 – 14:00

Thursday 04 August 2016

(Formal CoG) 10:00 – 14:00

Thursday 08 September 2016

(Informal CoG) 10:00 – 14:00

Wednesday 12 October 2016

(Chief Executive Briefing) 10:00 – 12:00

Thursday 03 November 2016

(Formal CoG) 10:00 – 14:00

Thursday 08 December 2016

(Informal CoG) 10:00 – 14:00

Thursday 09 February 2017

(Formal CoG) 10:00 – 14:00

Thursday 09 March 2017

(Informal CoG) 10:00 – 14:00

Council of Governors Sub-Committee Membership 2016/17

Standards and Assurance Committee (SAC)

Alan Ravenscroft Philip Thomas Curwen

Public Governor (Chair) Public Governor (Member for February and March 2017 meetings only)

Max Oosman Staff Governor Helen Scott Staff Governor Yvonne Guilfoyle Emma Allen

Staff Governor Staff Governor (Member for February and March 2017 meetings only)

Patient Experience and Oversight Group (PEOG)

Mike Wedgeworth Public Governor (Chair) Alan Ravenscroft Public Governor Katharine Wykes Public Governor Keith Holt Public Governor James Harper Staff Governor Max Oosman Staff Governor Teresa Jennings Nominated Governor

Membership and Governance Committee (MEMB)

Pamela Beswick Nominated Governor (Chair) Lorena Dumitrache Public Governor Bernadette Ashton Public Governor Keith Holt Public Governor

Nominations and Remunerations Committee (Nom/Rem)

David Eva Trust Chair Alan Ravenscroft Public Governor Mike Wedgeworth Public Governor James Harper Staff Governor


Meeting Council of Governors Formal Meeting

Location Balmoral Room at Farington Lodge, Stanifield Lane, Farington, Leyland, PR25 4QR

Date Thursday, 09 February 2017

Time 09:15am – 9.45am Governors Pre-Meet 10:00am – 2.00pm Council of Governors Formal Meeting

Reference Item Lead Action Enc FOIA

Exempt

PROCEDURAL ITEMS

COG 001/17 Welcome and opening comments

Chair Verbal

COG 002/17 Apologies for absence and confirmation of quoracy

Chair Verbal

COG 003/17 Declarations of Interest Chair Verbal

COG 004/17 Minutes of the previous meeting Chair Decision Paper

COG 005/17 Action Tracker Chair Noting Paper

CHAIR AND CHIEF EXECUTIVES REPORT

COG 006/17 Chairs Report Chair Noting Paper

COG 007/17 Chief Executives Report Chief Operating Officer Noting Paper

GOVERNANCE AND ASSURANCE

COG 008/17 Quality Account Choice Selection of Indicators

Head of Performance

Noting Discussion

COG 009/17 Terms of Reference for Governance Working Group

Assistant Company Secretary

Decision Paper

COG 010/17 Lead Governor role description/election process

Chair Decision Paper

COG 011/17 CQC Report Update Deputy Director for Nursing

Noting Presentation

COG 012/17 Membership Strategy Delivery Stakeholder Engagement Manager

Noting Paper

COG 013/17 Annual Election Report Stakeholder Engagement Manager

Noting Paper

OTHER COMMITTEE ACTIVITY

COG 014/17 Any Other Business Chair Verbal

DATE AND TIME OF NEXT MEETING

COG 015/17 Council of Governors Informal Meeting Thursday, 09 March 2017 09:15am – Governors pre-meet 10:00am – Council of Governors Meeting

Chair

UNCONFIRMED

COUNCIL OF GOVERNORS Minutes of the formal meeting of the Council of Governors held on Thursday 08 December 2016

Present David Eva, Trust Chair Alan Ravenscroft, Public Governor Ashok Khandelwal, Public Governor Helen Scott, Staff Governor James Harper, Staff Governor Mike Wedgeworth, Public Governor Pamela Beswick, Nominated Governor Yvonne Guilfoyle, Staff Governor Max Oosman, Staff Governor Debbie Wisby, Nominated Governor

In Attendance Peter Ballard, Deputy Chair Gwynne Furlong, Non-Executive Director David Curtis, Non-Executive Director Louise Dickinson, Non-Executive Director Isla Wilson, Non-Executive Director Sue Moore, Chief Operating Officer Jo Alker, Company Secretary Mark Grimshaw, Assistant Company Secretary (Minutes) David Keddie, Stakeholder Engagement Manager

CG078.16 WELCOME AND OPENING COMMENTS

The Chair welcomed everyone to the meeting and explained that a formal part of the business required approval from the full Council and therefore an additional formal meeting had been added.

CG079.16 APOLOGIES FOR ABSENCE

Governor apologies were received from Bernadette Ashton, Jacqui Sutton, Katharine Wykes, Keith Holt, Lorena Dumitrache, Steve Sansbury and Teresa Jennings. Board apologies for absence were received from Heather Tierney-Moore, Damian Gallagher, Dee Roach and Steve Winterson.

CG080.16 DECLARATIONS OF INTEREST

There were no declarations of interest. CG081.16 APPOINTMENT OF NON-EXECUTIVE DIRECTOR

The Chair noted that following the resignation of Non-Executive Director Naseem Malik which created a vacancy on the Board of Directors from July 2016, the Council of Governors’ Nomination and Remuneration Committee (CoG Nom/Rem) had taken a decision to undertake an in-house recruitment process recognising the resource now available to the Trust and the cost of appointing a recruitment agency.

Following an advertisement and shortlisting process (involving members of CoG Nom/Rem); six candidates were invited to interview on 6th December 2016. The interview involved two stages; a ‘formal’ panel consisting of the Chair, Chief Executive, Lead Governor and a Public Governor which was intended to test the competency of the candidates. The other stage was an ‘informal’ panel involving Governor representatives, Non-Executive Directors, Executive Directors and the Trust’s Equality and Diversity lead. The discussions with each candidate for this panel were based on the Trust’s values, testing whether they could demonstrate that they would be the right ‘fit’ for the organisation. In both panels Governors had a prominent role and took the lead in asking questions to elicit evidence from the candidates.

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UNCONFIRMED

The Chair reported that two strong candidates emerged from the informal panel but allied with the technical evidence from the formal panel, a recommendation had been made to appoint Julia Possener subject to the appropriate pre-employment checks being made. The Chair noted that Julia had a legal background and experience of being a Non-Executive Director at Calderstones Partnership NHS Foundation Trust. The Chair noted that the start date for Julia would be circulated to governors once known.

A Public Governor commented that the recruitment process had been truly governor led and that the opportunity to participate to such a large extent was appreciated.

The Council of Governors approved the appointment of Julia Possener as Non-

Executive Director subject to the necessary pre-employment checks being made.

CG082.16 DATE AND TIME OF NEXT MEETING

The Trust Chair confirmed the date of the next meeting would be the Council of Governors meeting on 9 February 2017.

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Agenda Item COG 006/17 Date: 09/02/2017

Report Title Chair’s Report

FOIA Exemption No Exemption Not Applicable

Prepared by Umme Batan, Corporate Governance Support

Presented by David Eva, Trust Chair

Action required Noting

Supporting Executive Director Chief Executive

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Governors with an overview of the activity undertaken by Non-Executive Directors in addition to Board meetings. An overview is also provided on the activity of Governors.

Strategic Objective(s) this work supports

To become recognised for excellence

Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence

CQC domain Well-led

1.0 BOARD OF DIRECTOR SESSIONS Since the last formal Board of Directors meeting held on 25th October 2016 Board members have attended a Board Development session and the Board away day. Further details can be seen below.

Board Development Session – 22nd November 2016 The Board considered the month 7 financial position and received an overview of the performance. The Board received presentations on the Lancashire and South Cumbria Sustainability and Transformation Plan in particular focussing on the mental health and workforce workstreams. The Board expressed their commitment to the direction of travel around the STP and sign up to the plans. A presentation was also received on the delivery and achievements made in relation to the Research Plan for 2016/17.

Board of Directors Meeting – 20th December 2016 In the additional Board meeting the two year Operational Plan 2017/18 and 2018/19 was signed off prior to submission to NHS Improvement including the Trust’s financial control total which require a surplus position for both years. The Board approved the E-Patient Record business case and strategic land disposals. An updated financial position as at month 8 was also considered.

Board of Directors Meeting – 31th January 2017 The Board considered the quarterly Chair Reports from each of the Board level Committees; Quality, Finance & Performance and Audit. The month 9 financial position was scrutinised alongside the Quality Performance Report and Workforce Report for quarter 3. Improvements to

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the financial position were noted although focus on achieving the control total would continue. Discussions relating to an increase in staff sickness levels are being considered further outside of the meeting. The Board also discussed the impact of the Apprenticeship Levy.

2.0 NON-EXECUTIVE DIRECTOR APPOINTMENT Following the in-house recruitment exercise led by Governors, at the full Council of Governors meeting held on 8th December 2016 the Council approved the recommendation made by the Nomination/Remuneration Committee to appoint Julia Possener as a Non-Executive Director for an initial term of three years. The appropriate pre-employment checks have all been cleared and the fit and proper person’s requirements have been met. Julia has had introductory meetings with the Chair, Chief Executive, and the Company Secretarial team. She has also met all the Non-Executive Directors and some of the Executive Directors and further meetings are scheduled. Julia has attended the mandatory corporate induction. She also attended the Engage event.

3.0 GOVERNOR ELECTIONS 2016 The results for the 2016 Council of Governor elections have been received and are formally submitted to the Council of Governors for noting as below. Further details on the annual election report can be seen under agenda item COG014/17.

Constituency No. of

Candidates No. of

Vacancies Elected/

Re-elected Turnout

PUBLIC GOVERNORS

NHS Blackburn with Darwen 3 1 Pauline Walsh 20.88%

NHS East Lancashire 1 1 Christopher Johnson NA unopposed

NHS Out of Area 3 1 Julia Kay Horn 17.85%

NHS Central Lancashire 6 1 Philip Thomas Curwen 24.73%

STAFF GOVERNORS

Corporate Staff 5 1 Emma Allen 34.81%

Medical 1 1 Adnan Gharib-Omar NA unopposed

4.0 GOVERNOR RESIGNATION

Governors were notified of the resignation from Public Governor Ashok Khandelwal due to personal circumstances. This vacancy for Lancashire North constituency will be carried into the 2017 Governor Elections.

5.0 DIRECTOR ACTIVITY In addition to the usual Board business, Non-Executive Directors (NED) have been involved in their areas of special interest during the period of November 2016 – January 2017: All Non-Executive Directors have been attending the Board Committee meetings of which they are a member and apologies have been given where they were unable to attend.

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All Non-Executive Directors had telephone calls with the external facilitator Phil Glanfield prior to the Board Away Day. Non-Executive Directors had their quarterly meeting with the Chair and they also attended a QPR session. Gwynne Furlong attended several meetings including an LCFT Land meeting with Ryhurst, the Trinity Property Workshop with the Red Rose Corporate Services, the Land Committee meeting and the Hearing Feedback Panel Development Workshop meeting. He attended a meeting with the Chair and Executive Directors to discuss housing association and health services. Gwynne took part in the Good Practice Visit to Chorley and South Ribble Single Point of Access Service. Gwynne met with several colleagues around finance and property. Gwynne and Peter attended the Charitable Trustee Funds Committee meeting. Peter Ballard deputised for the Chair and attended the Pennine Lancs Transformation System Leaders Forum and deputised for the Chief Executive at the Lancashire Sports Awards panel. He delivered the live team talk via skype in November. Peter was on the panel for the Clinical Excellence Awards panel. Louise attended the Sustainability and Transformation Plans event which was organised by The Kings Fund. She met with several colleagues to discuss the Audit Committee agenda and also attended the Network & Corporate Risk Forum meeting. Louise had a monthly catch up meeting with the Chief Executive and also met with the Company Secretary. Louise and David attended the Audit Committee Members Network organised by MIAA. David Curtis attended the Mental Health Law Sub-Committee meeting and the People sub-committee as an observer. He attended the North West NED and Lay Member Network event and the NHS North West Leadership Academy Board meeting. David met with the Director of Nursing and Quality to discuss the Quality Committee agenda. He also met with the Head of Strategic Resourcing to discuss recruitment and the Health & Wellbeing Project Manager to discuss Health and Wellbeing. David attended the Network Recruitment Event. Isla Wilson met with the Associate Director of Compliance and Assurance and she also met with the Chief Executive for a catch up meeting Peter, Gwynne and Louise attended the Financial Recovery Group meetings and a meeting to consider the EPR Business Case. David Curtis and Isla Wilson attended the LCFT Annual Equality and Diversity Event. Peter, Gwynne, Isla and David attended the Membership Conference and the Annual Members Meeting.

6.0 CHAIRS ACTIVITY The Chair attended the Board meetings, Council of Governors meeting and the Council of Governors Nomination Remuneration Committee meetings. David attended the NED shortlisting session and led the interview panel for the Non-Executive Director post. The Chair had his quarterly meeting with the Non-Executive Directors. He met with a member of the communications team for a session on twitter and has an LCFT twitter account. The Chair has been having weekly catch up meetings with the Chief Executive and monthly meetings with the Company Secretary and has met with several Board members and Senior

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Managers. The Chair facilitated the CoG Information Flow Working Group in November and the CoG Governance Working Group in January and the Governor Induction. He has also met and had a tele-call with Phil Glanfield who facilitated the Board Away Day. The Chair attended a meeting with the Chief Executive to meet with NHS South Sefton CCG and NHS Southport and Formby CCG’s Chair and Chief Executive. The Chair attended a session with the NEDs on the Quality and Performance Report (QPR) which was delivered by the Head of Delivery. The Chair delivered a live team talk via skype for the month of December and attended the My Place Launch. He opened the LCFT Annual Equality and Diversity Event and the Membership Conference and the Annual Members Meeting. He attended several external events including the NHS Providers Mental Health Group Network event, the Business Skills: Financial and Professional Services in the Northern Powerhouse and the Decision Making Workshop for Lancashire & South Cumbria Governance arrangements. David attended the HFMA Annual Chair’s Conference. The Chair continues to have his introductory meetings with MPs, CCGs and Local authorities. David met with the Non-Executive Directors who chair the Board sub-committees.

7.0 GOVERNORS ACTIVITY In addition to attending the Council of Governors formal and informal meeting, and the sub-committee meetings, governors have individually been involved in additional activities since the last formal Council of Governors meeting.

Public Governors Mike Wedgeworth and Katharine Wykes attended the Clinical Excellence Awards panel.

Max Oosman and Keith Holt attended the Lancashire Sports Awards 2016 Yvonne Guilfoyle attended the Good Practice Visit in November and Mike Wedgeworth

attended the January 217 visit. The Equality and Diversity Conference took place on 23 November and Staff Governors

Max Oosman and James Harper were in attendance. Alan Ravenscroft, Lorena Dumitrache and Mike Wedgeworth attended the January 2017

Board of Directors meeting.

8.0 FUTURE INVOLVEMENT The following opportunities are available to Governors over the next few months:

Internal Events

Programme/Event

Event: Whittingham Lives Opening Ceremony Date: 1 March 2017 Time: 13.00 – 14.00 Venue: UCLan, Preston

Event: Contraception and Sexual Health (CaSH) service meeting with Trust Colleagues Date: February 2017 (Date and venue details to be confirmed by David Keddie)

Event: Opening of ‘The Cove’, new Child and Adolescent Mental Health service (CAMHS) Tier 4

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inpatient facility in Lancaster . Date: Further details on the date and timings to be confirmed by David Keddie, Stakeholder Engagement Manager.

External Events

Programme/Event Date(s)

GovernWell Training programmes with NHS Providers

Core skills

This one-day course is suitable if you are a governor in your first year or if you require a refresher. At the end of the course you will have:

• an understanding of the structure of the NHS and the your role within this context • knowledge of the statutory role and associated duties • an understanding of public accountability and local ownership • an understanding of NHS finance • the skills to hold the board to account.

Upcoming courses

16 March – London

13 July – Birmingham

26 October – Newcastle

21 November – London

16 March 2018 - London

Member and public engagement

This half-day workshop will help you to gain an improved appreciation of the importance of member, staff, carer, and public engagement. At the end of the course you will:

• be clear on your duties in this area as laid out in the Health and Social Care Act 2012 • understand the reasons behind why trusts have members and need to engage with them • explore examples of good practice • recognise the challenges to member/patient engagement • reflect on what you as governors can do to support engagement activities.

Upcoming courses

15 June – London

28 February 2018 – London

Accountability

This one-day course will help you to build a dynamic and effective accountability relationship with their board of directors. Using a range of interactive learning methods, we will look at how you can be effective in holding non-executive directors to account for board performance.

Upcoming courses

28 February – Leeds

1 June – Newcastle

11 October – London

17 February 2018 - York Effective questioning and challenge

This one-day course will help you work confidently and effectively with your directors in posing effective questions to hold the board to account. Using a range of interactive learning methods, we will look at listening skills, questioning styles, and how to frame effective questions, specifically within the context of the governor role.

Upcoming courses

17 February – Durham

18 May – Birmingham

28 November - London NHS finances and business skills

This one-day course will help you learn more about the detail of a provider's finances and their business operations, through a range of interactive learning methods and shared experience. We will look at funding flows, analysing financial information and asking questions of the financial reports. We will explore the external factors influencing a provider's operations and how they might respond strategically - including making decisions on increasing non-NHS income and significant transactions, viewed specifically within the context of your governor role.

Upcoming courses

16 February – London

25 May - Birmingham

16 November - York

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Recruitment: the governor role in non-executive appointments

This one-day course, aimed at governors serving on nomination committees and/or sitting on selection panels, will help you to understand the process and procedures for the appointment of non-executive directors and the chair. It offers practical ‘how to’ advice, includes an update on relevant legislation, and provides an opportunity to practise formulating interview questions and participate in a mock interview.

Upcoming courses

9 March 2017– London

22 September 2017 – York

7 December 2017 – London

Governor Focus Conference

Date: 4 May 2017 Venue: Central London Place for one Governor only, Governors who are interested please register your interest with Umme Batan.

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COUNCIL OF GOVERNORS


Report Title Chief Executive Assurance Report

FOIA Exemption Part Exemption Section 43: Commercial Interests

Prepared by Mark Grimshaw, Assistant Company Secretary

Presented by Sue Moore, Chief Operating Officer


Supporting Executive Director Chief Executive PURPOSE OF THE REPORT:

Report purpose The purpose of this report is to provide Governors with an overall summary of the Trust position and highlight areas for further discussion.


To provide high quality services

Board Assurance Framework risk 2.1 – The Trust does not receive assurance of the accuracy, timeliness and consistency of data and reporting with the potential to compromise decision making and service quality

CQC domain Well-led Introduction This report aims to give Governors an overview of the activity undertaken since the last formal Council of Governors meeting, both within the Trust and externally. Following feedback from Information Flow Working Group held on 11 November 2016, the report has been enhanced from previous iterations to provide further detail on the actions being taken by the Trust and how the Board has been involved / assured. This is considering the Council of Governors duty to hold the Non-Executive Directors, individually and collectively, to account for the performance of the Board of Directors. Outlined below is a brief snapshot of the ‘highlights’ and ‘lowlights’ from the reporting period. Again, this is provided in response to a suggestion from the Information Flow Working Group. More detail on these issues is provided in the main body of the report. The report remains in development and feedback from governors on its content and format is welcomed to drive further improvements. Highlights and Lowlights

Following a CQC re-inspection held during September 2016 the Trust has received a rating of ‘Good’.

Good progress is being made with the Trust’s Organisational Reset. The formal consultation period for the network structure has ended and senior management interviews have commenced.

The funding for our main contracts with CCGs and NHS England have been agreed for 2017/18 and 2018/19.

The use of Bank and Agency workforce has reduced through Quarter 3 and continues the steady reduction in spend during the 2016/17 operating year

! Financial Performance - Month 9 sees a year to date operating deficit of -£4.4m, £3.3m behind plan for the year.

! Sickness Absence has increased through Quarter 3 and reports a closing rate of 6.88%.

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QUALITY AND SAFETY

CQC Re-inspection of the Trust Narrative: Governors will be aware that the Trust was re-inspected by the CQC in September 2016 following a rating of ‘Requires Improvement’ in 2015. The re-inspection reports were published on 10 January 2017 and the Trust received a rating of ‘Good’. This rating reflects the significant work undertaken by the Trust to improve quality and safety over the last 18 months. The re-inspection report, and ratings, provides a renewed baseline of quality which will support the ongoing and continual quality improvement work within the Trust. Action being taken: The Trust is now working through an action planning process in advance of the Quality Summit on 21 February 2017. This will address all of the areas which the CQC has identified as requiring action and the already established governance and assurance process will be used to monitor the delivery of actions.

Board Assurance: The action plan will be approved by the Executive Management Team and will form part of the assurance processes undertaken by sub-committees with assurance of progress being reported from them to the Board’s committees and their respective Non-Executive Director Chairs. The Board also noted that the positive CQC result had helped to reduce the following BAF risk score from 16 to 12: ‘1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC's standards for the quality and safety of services’.

Harm Free Care Dare to Share / Time to Shine Event

Narrative: An organisational Dare to Share / Time to Shine event took place in October 2016. The aim of the event was to help us all to re-focus on the value of the Harm Free Care agenda with care and compassion as the drivers and data as the end product. A number of teams showcased the quality improvement work they had undertaken in relation to the Harm Free care agenda.

Board Assurance: The Board was updated on the event and the feedback provided was highlighted. This demonstrated that the event had been successful and that those attending would be exploring how to implement the lessons learned within their own areas of work. Development of the 2016/17 Quality Account

Narrative: A proposal was presented to and subsequently agreed by the Quality and Safety sub-committee in November 2016 to develop a separate public friendly “Our Quality Story” publication for 2016/17. This will be in addition to the Quality Account which will focus on meeting the regulatory requirements placed on NHS providers. It is intended to provide an open, honest, informative, interesting and easy read overview of the quality improvement work across the Trust via a “Quality Improvement Conference” in May 2017. Feedback from the auditors is that this new approach will not impact on the audit outcome. Action being taken: The Quality Team, plus colleagues who contribute to the Quality Account, met with the Quality Committee Chair and a Non-Executive Director to review the feedback received from the process and content of the Quality Account 2015/16 to ensure that all opportunities to improve are progressed. The Council of Governors will be involved in the development of the Quality Account through the Standards and Assurance Committee. Board Assurance: The Trust’s Audit Committee will review the Trust’s Quality Account and receive assurance from the External Auditor that its content meets the necessary regulatory requirements. The Quality Committee will provide oversight on the development of the “Our Quality Story” publication. Both Committees will provide assurance to the Board prior to final approval and sign off during the year-end process.

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Time to Change – Organisational Pledge

Narrative: It is recognised that in order to deliver high quality care the NHS needs people who are healthy, well and at work. Time to Change is England’s largest and most ambitious programme to change public attitudes about mental health. They aim to empower people to challenge stigma and speak openly about their own mental health experiences, as well as changing the attitudes and behaviours towards those with mental health problems. Encouraging our employees to talk about mental health can make a real difference.

Action being taken: The Trust is committed to improving the health and wellbeing of our people and therefore will be making an Employer Pledge and will be utilising the support offer from ‘Time to Change’.

Board Assurance: The Quality Plan commits the Trust to accreditation of the Workplace Wellbeing Charter and health and wellbeing is a common thread throughout our People Plan. The Board receives assurance on progress against the objectives in the Quality Plan and People Plan on a regular basis.

The Board Approved Pledge

Narrative: On the 22nd July Tommy Whitelaw, from Dementia Carer Voices, attended the Dementia Awareness Day at the Harbour. Tommy spoke from the heart about his experiences whilst caring for his mum Joan. He described the privileged role we have in health care to really make a difference and transform the lives and experiences of people with dementia and their carers. Tommy described the importance of hearing people’s stories, understanding what matters to them and giving people a voice. His call to action was a request that people make their pledge to make a difference.

Action being taken: Many people from Lancashire Care made a pledge and these have been shared with Tommy and published on the Dementia Alliance website: https://dementiacarervoices.wordpress.com/2016/07/29/lancashire-pledge-to-make-a-difference/ Tommy visited the Trust again on 24th November to support our thinking and inform our quality improvement journey. Board Assurance: On the 22nd November 2016, the Trust Board pledged:

To always take the time to ask “what matters to you”, and to listen to you with care and compassion

To encourage everyone to pledge their “making a difference” commitment to always being the best that they can be

CQC Inspection of HMP Wymott

Narrative: Governors will be aware that the CQC undertook an unannounced inspection of the healthcare service at HMP Wymott as part of a wider inspection with Her Majesty’s Inspectorate of Prisons. The Trust received initial feedback from the inspection team and has received the draft report. The inspection identified a number of concerns including staffing, medication safety and management of quality issues. The Trust is still awaiting the final report from the CQC as well as an HM Inspectorate of Prisons report of the prison itself. Action being taken: The Trust has submitted minor factual accuracy points in response to the draft report and is continuing work to implement the required actions following the inspection. The action plan takes into account the current position in respect of the de-mobilisation of the Lancashire offender healthcare service.

Board Assurance: The Board will continue to be appraised of progress against the action plan with any risks being escalated if necessary.

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https://dementiacarervoices.wordpress.com/2016/07/29/lancashire-pledge-to-make-a-difference/

The National Community Mental Health Survey 2016

Narrative: The Community Mental Health Survey forms part of a series of mandated Care Quality Commission (CQC) annual surveys, the purpose of which is to understand peoples’ experiences of mental healthcare provision in England and inform improvement. In total 58 organisations participated in the national survey, with 13000 responses (28% response rate). A total of 850 people from Lancashire Care received the questionnaire between September and November 2015. 158 returned a completed questionnaire, giving a response rate of 20%. The CQC reporting does not provide a ranking of Trusts, however a review of the 58 Trusts included in the survey shows Lancashire Care NHS Foundation Trust in the middle group of 18 Trusts with 12 being rated as better and 6 as worse. The best organisation is Navigo Health and Social Care CIC with 6 ‘better than scores’ which is our aspirational goal. Action being taken: The results are being used to inform network Quality Improvement Framework (QIF) plans. Two main themes were identified as QIF (Quality Improvement Framework) opportunities:

A perception that users of the services did not always feel that professionals understood, or adequately took account of, the issues that were important to them.

Professionals need to communicate in a more effective way, part of that is about listening more and taking account of the wishes and views of those using the service.

Networks have selected two teams who will lead the way in developing two Quality Initiatives to respond to these opportunities. Board Assurance: The Board has been apprised of the survey result and action being taken in response. Any further risks will be escalated if necessary / appropriate.

Serious Incidents

Narrative: Serious Incidents during the period: October 2016 - 11 November 2016 – 4 December 2016 – 4 Action being taken by the Board: The Trust has now fully established the Investigations and Learning team. This new team will undertake the investigation of all serious incidents across the Trust, providing expert capability and capacity to identify learning and support improvement in safety and quality. The establishment of this team is in-keeping with national directions to improve the effectiveness of the serious incident process and ensure that families and staff are fully involved. There are plans underway to review the serious incident process in early 2017 and introduce a Serious Incident Learning Panel. Executive Directors, Non-Executive Director members and commissioners will review and scrutinise improvement plans following investigations. This approach will provide a further level of robustness and openness to the process.

Board Assurance: Each month the Board is apprised of the Serious Incidents that have occurred and is informed whether a formal investigation is underway and whether the incidents have been reported to commissioners, NHS England and regulators as required under the NHS Serious Incident Framework. The Board also receives assurance from the Quality Sub-Committee Chair’s report which outlines the discussions held on the Serious Incidents Bi-Annual Report. The Chair of the Quality Sub-Committee has expressed his own interest in the issues and has encouraged the Non-Executive Directors to become involved in the development of the serious incident process.

Safeguarding - The Sudden and Unexpected Death in Childhood (SUDC) Service Evaluation

Narrative: An independent Service evaluation was commissioned by the Lancashire Child Death Overview Panel (CDOP) into the Sudden and Unexpected Death in Childhood (SUDC) Service which is

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hosted and provided by LCFT. The review highlighted areas to strengthen in respect of out of hours provision and provided recommendations for improving working practices and evidence of service compliance with statutory processes across all localities.

Action being taken: Meetings are taking place between the CDOP & Commissioners to agree service model delivery. Findings suggest that the team should be expanded to provide a 24 hour/7 day service.

Board Assurance: The Board has been apprised of the evaluation and any further risks will be escalated if necessary / appropriate.

Safeguarding – NHS England (NHSE)

Narrative: A review of Health services for Children Looked After and Safeguarding in Lancashire County Council resulted in a combined Health Economy action plan which is being coordinated by NHSE. Action being taken: The Trust is a key partner in this plan and we are represented at the monthly meetings by the Associate Director of Safeguarding. The Trust reports on the actions quarterly and monitors these through its existing processes to ensure comprehensive services for children in Lancashire

Board Assurance: The Board has been apprised of the processes to monitor the action plan and any risks relating to the actions will be escalated to the Board if appropriate.

Safeguarding - Pennine Footprint Review

Narrative: A review of the Pennine footprint service specification is underway. A formal Contract Variation (CV) has been received detailing the CCG’s intention to withdraw funding from the BwD “Looked After Children” post. Service specifications are being updated and amendments have been accepted by Commissioners. This has meant a change in the level of service we provide and the implications of this have been formally identified to the Commissioners.

Action being taken: A Quality Impact Assessment has been undertaken to identify risks to the CCG. The contract value has been agreed, but proposals will impact on the “Looked After Children” (LAC) provision across the footprint.

Board Assurance: The Board has been informed of the CV and any risks resulting from the changes will be escalated to the Board if necessary / appropriate. Safeguarding - Lancashire County Council Funding

Narrative: The Trust has been informed by LCC of their intention to withdraw £42k from the Central Team Looked after Children (LAC) funding. This funding is received via the CCG who are aware of this withdrawal of funding and negotiations are underway to ensure safety for this group of children. Currently the LAC review health assessments across LCFT and these continue to be completed within the statutory timeframes and performance is currently above 90+% across the BwD, Central and East localities. This will be impacted unless alternative service provision is identified by LCC.

Board Assurance: The Board has been apprised of the situation and any risks resulting from the funding withdrawal will be escalated to the Board if necessary / appropriate.

Good Practice Visit

Narrative: A Good Practice Visit took place on 12 October 2016 with the district nurses who are part of the LCFT Adult Community Services network based at St Georges GP Surgery in Blackburn.

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Board Assurance: The Board was informed that team meets each day to discuss current patient activity and to ensure that complex patient cases are discussed with decisions about current care activity shared across the team. The team also took a pro-active approach to problem solving and that the team leader proactively engages with their staff listening to ideas for improvement. The visiting team felt that the team should be commended and complimented on their solution focused approach to overcoming day to day challenges.

Nursing Associate Role

Board Assurance: The Board was informed on 15 December 2016 that The Secretary of State for Health had made an important announcement on the future regulation of the new Nursing Associate role. As recommended by Senior Nurses in England, the role will be regulated by the Nursing Midwifery Council. The new Nursing Associate role will bridge the gap between health and care support workers (who have a care certificate), and graduate registered nurses. This exciting post offers opportunities for health care assistants to progress into nursing roles. These staff will be a real benefit to the nursing and care workforce, across a range of settings, and play a key role in the delivery of patient care. The Trust was accredited to provide training places at the end of January 2017 and is now recruiting to posts.

FINANCE AND PERFORMANCE

Quality and Performance Report

Board Assurance: In relation to performance, all NHSI indicators were met for Month 9. The Board considered the full Quality and Performance Report on 31 January 2017.

Financial Position

Narrative: Month 9 sees a year to date operating deficit of -£4.4m, £3.3m behind plan for the year. It is projected that the full year deficit after mitigations would be £1.4m, but this is not without risk and without mitigation the Trust is in line for a £5.3m overspend. This is an improvement of c£1.8m on Month 8. The month to month position also shows some improvement with a stabilising OATs position. Staffing remains an issue particularly on secure wards and in the prisons.

Action being taken: The Trust continues to drive progress with the financial recovery programme and to identify additional mitigations to help to achieve the Control Total.

Board Assurance: A Finance Recovery Group was established in August 2016 to allow the Board to scrutinise the financial data in more detail. The meeting is Chaired by Peter Ballard (Trust Deputy Chair) and other members of this Group include NEDs Louise Dickinson, Gwynne Furlong and David Curtis and Executive Directors. The Finance Recovery Group continues to scrutinise the financial position on a monthly basis. There was agreement at the Finance Recovery Group held on 13th January that the Trust should still be projecting achievement of its Control Total but the significant risks to this were discussed and noted.

Commissioner Contracts FOIA Exemption 43 – Commercial Interest

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PEOPLE AND LEADERSHIP

Organisational Reset

Narrative: Governors will recall Sue Moore (Chief Operating Officer) presenting recently about the work that is being undertaken to change the configuration of our clinical networks from 4 to 3 which are; mental health, children & young people and community wellbeing. Whilst the emphasis at this stage appears to be on the configuration of the clinical networks it is important to highlight that the changes occurring in the wider health economy will require our entire organisation to do things differently in the future. Therefore, the re-design of the networks should be seen as stage one in re-aligning our organisation and doing things differently in the future to support transformation both within the Trust and on a broader basis across Lancashire and South Cumbria.

Action being taken: The formal consultation relating to Organisational Reset took place between 25

November 2016 and 8 January 2017. Interviews took place for Heads of Operations and Clinical Directors from 12 January and 27 January. This management team will then interview for their deputies/tier 2 management team from 20 February until 31 March. Therefore the new structures will be in place by 1 April and will align to the emerging Lancashire health economy that has an increased locality focus.

Board Assurance: The Board received a detailed paper at the meeting held on 31 January 2017 which provided an update on the Organisational Reset Business Case for Change following the staff consultation.

Quarterly Workforce Report

Narrative: The use of Bank and Agency workforce has reduced through Quarter 3 and continues the steady reduction in spend during the 2016/17 operating year. Acuity of patients and sickness absence are the key reasons identified for the use of peripheral workers.

Sickness Absence has increased through Quarter 3 and reports a closing rate of 6.88%. The upward trend is in line with the normal seasonal increases experienced by the Trust in this period. Approximately 59% of the total absences are attributable to Long Term Sickness (Absences lasting 28 days or more in one episode) which is a slight increase from the Quarter 2 position.

Compliance in recruiting and employment, across the Core Workforce, continues to perform well with 100% compliance in Safer Recruitment practice and 98% for Safer Employment practice. Compliance within the Bank Only Worker population for Safer Recruitment Practice also continues to perform well and is reporting 100% compliance in Quarter 3.

Quarter 3 of the 2016/17 performance year presents the mid cycle of PDR information and includes an indicator to demonstrate the number of PDR quarterly reviews that have been completed. The overall Trust Appraisal compliance rate for Quarter 3 (inclusive of the Medical Workforce) is 71.94%. Although overall compliance remains below the Trust target of 85%, Quarter 3 has seen another good improvement on the Quarter 2 positon and the Children and Families Network achieve the 85% Trust Target this period.

Action being taken: Work is on-going to continue to reduce the use of Bank and Agency staff in line with regulatory requirements and all Networks have targeted improvement plans and continue to work hard to understand how this element of workforce expenditure can be more effectively managed whilst managing and maintaining safe operational delivery. Work is also on-going to monitor sickness absence and several actions such as increased training for managers, the use of toolkits and a continued focus on long term sickness absence are in place to drive improvements. The Trust is also continuing to implement the ‘People Plan’ which is a key enabler for quality improvements.

Board Assurance: The Board received the Quarterly Workforce Report on 31 January 2017 and noted

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the overall positive position against the workforce indicators. There was a discussion around the on-going work to drive improvements in terms of sickness absence and an additional piece of work has been commissioned by the Chief Executive to undertake a detailed review of how the actions are being brought together under the ‘People Plan’.

GOVERNANCE AND ASSURANCE

Managing Conflicts of Interest in the NHS

Narrative: Earlier in the year NHS England announced the establishment of a Task and Finish Group that would look at issues around how conflicts of interest are managed in the NHS.

Action being taken: The Trust responded to the consultation that was published both individually and collectively through NHS Providers. The final proposal is expected in June 2017.

Board Assurance: Implementation of required changes will be reported through and monitored by the Corporate Governance and Compliance Sub-Committee. Any issues / risks will then be escalated to the Audit Committee and through to the Board if necessary / appropriate. It is not anticipated that the changes will affect this year’s year-end reporting requirements.

Single Oversight Framework: segmentation

Narrative: The Single Oversight Framework (SOF) is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework doesn't give a performance assessment in its own right. The framework came into force from 1 October 2016, replacing the Monitor 'Risk Assessment Framework'. Under the SOF, NHSI ‘segments’ trusts according to the level of support each trust needs across the five themes of quality of care, finance and use of resources, operational performance, strategic change and leadership and improvement capability. The segments run from 1 (most autonomy) to 4 (special measures).

Board Assurance: The Trust is currently in segment 2 which means that “Providers offered targeted support: there are concerns in relation to one or more of the themes. We've identified targeted support that the provider can access to address these concerns, but which they are not obliged to take up. For some providers in segment 2, more evidence may need to be gathered to identify appropriate support”.

The main area for concern for the Trust has been the financial position. The Chief Executive and Chief Finance Officer have been working closely with NHSI to ensure that the Trust is taking all appropriate action and that NHSI are satisfied that this is the case. The Trust has made links with a high performing trust of a similar nature in order to share good practice.

The Corporate Governance and Compliance Sub-Committee monitors the Trust’s segmentation rating and any risks are escalated through the Trust’s governance structure.

Board Assurance Framework

Board Assurance: The Board considered the BAF at the meeting held on 31 January 2017 and noted that it had undergone a full review. During Q3, the assurances provided through the corporate governance meetings have resulted in the following three risks reducing in score:

1.1 The Trust does not protect service users from avoidable harm and fails to comply with theCQC's standards for the quality and safety of services.

o Q2 score = 16, Q3 score = 12 The risk rating has been reduced in Q3 due to an overall reduction in serious

incidents as well as the outcome of the CQC re-inspection in January 2017which rated the Trust as ‘good’ whilst at the same time recognising that thereare some areas for improvement.

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2.2 The Trust's ability to address and meet service demands is affected by uncertainty andinconsistency of commissioning arrangements.

o Q2 score = 15, Q3 score = 10 This risk has reduced in score during Q3 as a result of contract adoption of NHS

benchmarking and productivity, contract sign off in line with national timescales,which has in effect marginalised the risk to our LCC contracts. This has resultedin the achievement of the target score for this risk.

7.3 The Trust does not comply with Mental Health Legislationo Q2 score = 16, Q3 score = 12

This risk has reduced during Q3 due to improvements in the quality androbustness of assurance reported to the Mental Health Law Sub-committee fromNetwork groups. This is supported by the findings of the CQC re-inspection.

During Q3, the challenges of delivering holistic whole person care has impacted on the scoring of BAF risk 3.1 and the score has increased from 12 to 16.

Risk Appetite Statement

Board Assurance: Following on from the Board Development Session in September, a further session is planned in February 2017 to provide Board with the opportunity to consider whether the risk appetite statement requires a refresh to reflect the Trust’s strategy update as well as the changing external environment.

Well-Led

Narrative: NHSI and the CQC are currently jointly consulting on the future assessment of the Well-Led domain. At the moment both the CQC and NHSI assess the Trust on whether it is ‘well-led’ through their respective regulatory regimes. Whilst the CQC and NHSI are independent organisations with distinct legal duties, they are committed to reducing duplication between their organisations and minimising the requirements that they place on trusts. The consultation is therefore seeking views on a joint approach to assessing whether Trust’s are ‘well-led’.

Board Assurance: The Board was informed on 31 January 2017 that the Trust is actively responding to the consultation. Any changes emerging from the consultation will be monitored by the Corporate Governance and Compliance Sub-Committee with any implications / risks escalated through the Trust’s governance structure as appropriate.

BUSINESS DEVELOPMENT FOIA Exemption 43 – Commercial Interest

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Report Title Terms of Reference for Governance Working Group


Prepared by Mark Grimshaw, Assistant Company Secretary

Presented by David Eva ,Trust Chair

Action required Decision

Supporting Executive Director Jo Alker, Company Secretary


Report purpose To seek approval from the Council of Governors for the Terms of Reference for the Governance Working Group.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence and other regulatory requirements under NHS Improvements 7.2 The Trust does not comply with statutory legislative requirements

CQC domain Well-led

1. Introduction

1.1 The Governance Working Group, established following the Informal Council of Governors meeting on 8 December 2016, met on 12 January 2016 to consider the attached Terms of Reference (Appendix 1). The Working Group has been formed to take forward the findings from the Information Flow Working Group held on 11 November 2016 and to support governors to ensure key systems and processes remain fit for purpose and effective. The Working Group has approved a detailed improvement plan and this will be monitored to ensure that governors have what they need to discharge their statutory duties.

1.2 On reviewing the Terms of Reference the Working Group requested that an amendment be made to make reference to the need for the governance structure to be representative and take inclusion and diversity into account. It was also agreed that a quorum of three core members should be set.

1.3 It is the intention that at the Informal Council of Governors meeting on 9 March 2017, the Working Group will put forward for recommendation a proposed governance structure for the Council of Governors together with Terms of Reference for the respective meetings / bodies.

2. Recommendation

2.1 The Council of Governors is asked to approve the recommendation of the Governance Working Group to approve the Terms of Reference.

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Appendix 1 Council of Governors

Governance Working Group

TERMS OF REFERENCE VERSION 1.0

PURPOSE A Governance Working Group has been established to support governors to ensure key systems and processes remain fit for purpose and effective. The Working Group will approve and monitor a detailed improvement plan that will ultimately ensure governors have what they need to discharge their statutory duties.

DUTIES AND RESPONSIBILITIES The Governance Working Group will ensure that the following outputs are achieved:

To develop a strengthened governance framework for the Council of Governors. Thiswill include a refreshed structure – both formal and informal – that is representative andtakes inclusion and diversity into account.

To develop improved reporting mechanisms and processes which will ensure that theinformation received is relevant and contextualised to the needs of governors.

To ensure that robust processes are in place to support governors in discharging theirstatutory duties e.g. process for appointing Lead Governor.

To develop effective mechanisms for engaging with key stakeholders and ensuring thatthis information is fed back and utilised.

To develop a training programme to ensure that governors are adequately trained andsupported to discharge their statutory duties.

To review and refresh the Governor Handbook to ensure that it reflects and bringstogether the newly developed systems and processes.

REPORTING ARRANGEMENTS Quarterly updates will be provided to the full Council of Governors meetings.

Regular updates will be provided via other mechanisms such as the Council of Governors Bulletin and the Weekly Update to ensure that all governors have a chance to input into the process.

MEMBERSHIP Whilst the following members have been identified, there is an open invitation to all governors who may wish to attend in order to contribute to a meeting. Dates of the meetings will be circulated to all governors.

Core Committee Member

Name Title

David Eva Trust Chair (Chair)

Alan Ravenscroft Public Governor

Mike Wedgeworth Public Governor

Pamela Beswick Nominated Governor

Max Oosman Staff Governor

Yvonne Guilfoyle Staff Governor

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QUORUM The quorum for meetings will be three core committee members.

FREQUENCY OF MEETINGS Meetings will initially be scheduled to take place on a fortnightly basis. It is envisaged that this frequency may reduce as relevant to the needs of the delivery of the improvement plan.

REVIEW The Terms of Reference for the Governance Working Group will be considered for approval by the Council of Governors on 9th February 2017.

Once the improvement plan has been completed, the Governance Working Group will be disestablished.

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Report Title Lead Governor Role Description and Election Process


Prepared by Mark Grimshaw (Assistant Company Secretary)

Presented by Jo Alker (Company Secretary)

Action required Decision

Supporting Executive Director Jo Alker (Company Secretary)


Report purpose To seek approval from the Council of Governors to approve a new role description and election process for the position of Lead Governor. To also seek approval to initiate a timetable for the appointment of a Lead Governor under the new role description and election process.



Board Assurance Framework risk 7.1 The Trust does not comply with Monitor Licence and other regulatory requirements under NHS Improvements

CQC domain Well-led

1. Lead Governor Role

1.1 The designation Lead Governor was introduced by Monitor (now NHS Improvement – NHSI) with the principle duty of leading the Council of Governors (CoG) where it is not considered appropriate for the Chair or another Non-Executive Director to do so and to provide a point of contact for NHSI in circumstances where it would not be appropriate for the Chair to contact NHSI, or NHSI to contact the Chair (these occasions are infrequent). NHSI guidance provides for each Trust to establish further functions that may be fulfilled by the Lead Governor and the Trust has in place a role description which establishes such further functions. This is included within the Governance Handbook.

2. Lead Governor Role in new Council of Governors Governance Structure

2.1 Feedback from the Information Flow Working Group held on 11 November 2016 underlined that governors recognise the importance of the role of Lead Governor in the effective functioning of the CoG. In response to this feedback a draft role description has been drafted which further strengthens the Lead Governor role with a particular emphasis on ensuring effective information flows between the Chair and the CoG.

2.2 The Governance Working Group considered the draft role description at a meeting on 12 January 2017 and it was recommended that it be put forward for approval by the CoG. The draft role

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description can be found at Appendix 1. If approved, the new role description will be included within the Governance Handbook.

2.3 The Trust was informed on 25 January 2017 that the Independent panel for advising governors has been disbanded by NHSI. The panel was introduced by the Health and Social Care Act 2012 and its role was to answer questions from NHS foundation trust governors about whether a trust has failed or is failing to act in line with; its constitution and / or Chapter 5 of the NHS Act 2006. The panel has been disbanded as a result of governors (nationally) choosing not to make use of the Panel’s facility (including raising substantive questions) in accordance with the referral criteria laid out in legislation. The Lead Governor would have had a key role to play in this process but this will no longer be applicable. Despite this, the Lead Governor will still act as a point of contact for NHSI should the regulator wish to contact the Council of Governors on an issue for which the normal channels of communication are not appropriate (for example the appointment or removal of the Chair). It is worth noting that the Trust has not historically referred an issue to the independent panel so the impact on the Council of Governors of this decision will be minimal. Additionally, the Company Secretary and the Senior Independent Director also remain available to governors in an advisory capacity.

3. Appointment Process

3.1 The current process for the appointment of the Lead Governor was adopted on 16 October 2014 and involves the Company Secretary, as an independent advisor, proposing a suitable candidate to the Trust Chair who subsequently seeks ratification for appointment at a full CoG meeting. This process was used for the appointment of the current Lead Governor, Alan Ravenscroft, who has been in post since 1 December 2014.

3.2 Feedback was provided from the Information Flow Working Group which suggested that a more governor led approach for appointing the Lead Governor should be adopted. In response to this, a new election process has been developed. This was considered by the Governance Working Group on 12 January 2017 and it was recommended that it be put forward for approval by the CoG. The draft election process can be found at Appendix 2. If approved, the new appointment process will be included within the Governance Handbook.

3.3 As the role description for the Lead Governor is proposed to change, it is suggested that an election process is undertaken so that the implementation of the new role description aligns with the application of the new governance structure in the new financial year.

The timetable for this election would be as follows:

Date Action

9 February 2017 Agreement to hold an election for the Lead Governor and Deputy Lead Governor

15 March 2017 Deadline for nominations through the submission of a short statement to the Chairman.

17 March 2017 Chairman to circulate submitted statements from suitable governors to all governors for consideration.

12 April 2017 At the Chief Executive Briefing, a one item formal agenda will be held to: Ratify appointment if only one suitable governor nomination is

received. If more than one nomination is received, election will be held which

will be determined by secret ballot of all governors each having one

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vote. Governors who wish to be considered for the role will address fellow governors (for 3 minutes) and explain why they wish to be Lead Governor. All governors attending the meeting will vote for their preferred candidate by way of ballot paper. Proxy votes will not be permitted. The governor polling the most votes shall be offered the position of the Lead Governor for a period of two years or the remainder of the individual’s term as a governor, whichever is shorter.

May 2017 The following formal CoG meeting will ratify the appointment. The newly appointed Lead Governor and Deputy Lead Governor will shadow the current Lead Governor until the expiry of their term in December 2017.

3.4 Deputy Lead Governor

3.5 Considering the importance of the role of Lead Governor within the new governance structure and the size of the portfolio it was agreed at the Governance Working Group that it would be appropriate to elect a Deputy Lead Governor to provide support and capacity. The Deputy Lead Governor shall be the governor who receives the second most votes in the election.

4. Recommendation

4.1 The Council of Governors is asked to: Approve the Lead Governor role description as set out in Appendix 1 and approve its

inclusion in the Governance Handbook Approve the Lead Governor election procedure as set out in Appendix 2 and approve its

inclusion in the Governance Handbook Approve the election of a Deputy Lead Governor as part of the Lead Governor election

procedure. Approve the initiation of the process to appoint a Lead Governor in line with the timetable

outlined in the report.

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Appendix 1 Council of Governors

LEAD GOVERNOR ROLE DESCRIPTION

The Role The main duties of the Lead Governor will be to:

Support governors in holding the Non-Executive Directors to account. Act as a point of contact and liaison for the Chair and Senior Independent Director. To provide input into the appraisal of the Chair and the Non-Executive Directors, including through

membership of the Nomination and Remuneration Committee. The Lead Governor will liaise with theSenior Independent Director in respect of the Chair’s appraisal.

Take a leading role with governors on the Council of Governors’ Nomination and RemunerationCommittee in the process for appointing a Chair and Non-Executive Directors.

Support governors in the process for appointing an external auditor. Act as a point of contact for NHSI should the regulator wish to contact the Council of Governors on an

issue for which the normal channels of communication are not appropriate (for example the appointmentor removal of the Chair).

Be the conduit for raising with NHSI any Governor concerns that the Foundation Trust is at risk ofsignificantly breaching the terms of its authorisation, having made every attempt to resolve any suchconcerns locally.

Chair such parts of meetings of the Council of Governors which cannot be chaired by the Trust Chair orDeputy Chair due to a conflict of interest in relation to the business being discussed.

Chair informal governor only meetings e.g. Sub-Committee Chair’s Meeting and the Council ofGovernors Pre-Meet.

Meet routinely with the Chair to plan and review the agendas for the Council of Governors. Hold regular one-to-one meetings with the Chair to discuss emerging issues and facilitate effective

communications between the Council of Governors and the Trust Board Act as an alternate point of contact for Governors if they wish to raise issues of concern, which the Lead

Governor can then discuss with the Chair on their behalf. With support of the Company Secretarial Team, take a lead role in co-ordinating governor responses to

relevant consultations. Act as a point of contact for the Care Quality Commission (CQC). Contribute to the induction of new governors and work with individual Governors who need advice or

support to fulfil their role as a Governor. With support of the Company Secretarial Team and the Head of Communications take a role in

informing the process regarding any press releases involving the work of the Council of Governors. Present the membership report to the annual members meeting.

The Person To be able to fulfil this role effectively the Lead Governor will:

Have the confidence of Governor colleagues and of members of the Board of Directors A willingness to challenge constructively Have the ability to influence and negotiate Be able to present well-reasoned arguments Be committed to the success of the Foundation Trust Have the ability to Chair meetings showing leadership in areas where views are divided Understand the role of NHSI and the basis on which NHSI may take regulatory action Be able to commit the time necessary

General Provisions

The Lead Governor must be a public governor who should have been in post for at least one year. The term of office will be two years or the remainder of the individual’s term as a Governor, whichever is

shorter. The Council of Governors reserves the right to replace the Lead Governor if a majority of members

present at a general meeting resolve to do so. Such action would follow from a written resolution to thiseffect submitted by a member of the Council at a general meeting.

The Lead Governor may terminate their appointment at any time by means of a written notice to theChair.

The Lead Governor role description will be reviewed by the Council of Governors on the occasion of anychange in the Lead Governor.

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Appendix 2

Council of Governors LEAD GOVERNOR ELECTION PROCEDURE

This procedure outlines how the election for the Lead Governor will be enacted. This procedure will apply in the following circumstances:

On the impending expiry of the Lead Governors term in post. On the resignation of the existing Lead Governor. On the removal of the Lead Governor from the Council.

If the Council of Governors agree to elect a Deputy Lead Governor, this procedure will also apply (the Deputy Lead Governor will be the governor who receives the second most votes). This procedure should be read in conjunction with the Lead Governor role description and the Governance Handbook.

a. Interested public governors submit a short statement (200 words maximum) on howthey are suited to the role (referencing the role description) to the Chair for circulation tothe Council of Governors (form in appendix A).

b. Nominations must be submitted to the Chair by no later than four weeks prior to theagreed election date.

c. If only one suitable governor nomination is received the governor nominated will beratified at the next Council of Governors meeting.

d. If more than one nomination is received, the election will be determined by secret ballotof all governors each having one vote.

e. Governors who wish to be considered for the role will address fellow governors (for 3minutes) at the scheduled meeting and explain why they wish to be Lead Governor.

f. All governors attending the meeting will vote for their preferred candidate by way ofballot paper. Proxy votes will not be permitted.

g. The governor polling the most votes shall be offered the position of the Lead Governorfor a period of two years or the remainder of the individual’s term as a governor,whichever is shorter.

h. In the event of a tie, the Trust Chair will have the casting vote.

i. After the election process the Trust Chair will ask the next meeting of the Council ofGovernors to ratify the election of the successful candidate.

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EXPRESSIONS OF INTEREST FORM FOR ROLE OF LEAD GOVERNOR

I would like to be express an interest in the role of Lead Governor

Name:

Constituency:

Date:

Interested governors submit a short statement (200 words maximum) on how they are suited to the role (referencing the role description) to the Chair for circulation to the Council of Governors.

I have read the requirement of the role and I am able is able and willing to meet the requirements

Signature --------------------------------------------------------------------------------------------------

Please return this form to the Chair four weeks in advance of the day of the vote.

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Report Title Membership Strategy Delivery


Prepared by David Keddie, Stakeholder Engagement Manager

Presented by David Keddie, Stakeholder Engagement Manager


Supporting Executive Director Chief Operating Officer


Report purpose The purpose of the report is to summarise the progress of the Trust membership strategy 2016-2020



Board Assurance Framework risk The Trust does not comply with statutory legislative requirements (7.2)

CQC domain Responsive to people's needs

BACKGROUND

The 2016-2020 Trust membership strategy was approved by the Council of Governors at its formal meeting on 4 August 2016. Delivery of the membership strategy is based on five key objectives which are set out in turn below. A formal sub-committee of the Council of Governors, the Membership and Governance Committee has responsibility for overseeing the delivery of the membership strategy and reporting key messages to the Council of Governors. The Membership and Governance Committee last met on 22 September. It is anticipated that the Membership and Governance Committee will be reconstituted as the Membership Engagement Committee as part of the revision of the Council of Governors Committee structure instigated by the ‘Information Flows’ review and that it will meet in its new form at the start of the new financial year.

ISSUE

Objective 1 Refresh the profile of the membership

The 2016 public and staff Council of Governor elections provided a useful litmus test of the relative vibrancy of engagement with members across the constituencies in which there were governor vacancies. The overall picture in terms of both numbers of members standing for election as governors and voter turnout of members in constituencies where there were contested elections was encouraging in comparison with previous elections. The elections produced their own version of a ‘digital divide’ between those members for whom the Trust has a valid email address and via which the Trust communicates on a regular basis e.g. through Foundation News, the membership newsletter which is distributed electronically twice a year, and those members without an email address who for reasons of cost effectiveness receive communications from the Trust on an infrequent basis. The newly constituted Membership Engagement Committee will need to consider whether a process of active

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membership renewal is required through which existing members are asked to confirm their continuing commitment to membership while stopping short of insisting on a valid email address as a pre-requisite of membership.

The schedule of 2017 Trust governor elections includes a public governor vacancy in West Lancashire. The constituency is interesting in the context of the Trust’s recent success in winning the contract to provide community services in Southport and Formby from May 2017. A case could be made for extending the boundaries of the West Lancashire constituency to include Southport and Formby. This would be consistent with the principle of having public governor constituencies that are co-terminous with Clinical Commissioning Group boundaries, in this case, NHS Southport and Formby and could be a way of both strengthening relationships and providing a wider range of potential candidates.

Any decision to change the boundaries of West Lancashire would impinge on the geographical footprint covered by the Out of Area public governor. From a communications and marketing viewpoint, it can be argued that the term ‘North West’ governor would more clearly convey to members, the responsibilities of the Out of Area governor than the term ‘Out of Area’, particularly since as things stand constitutionally, only members in the North West (Cheshire, Cumbria, Greater Manchester and Merseyside) are entitled to stand as candidates and vote at governor elections. The Trust has members who live outside of the North West notably in London and Yorkshire and if these members were allowed to stand as candidates and to vote, then the term ‘Out of Area’ would continue to be appropriate or perhaps replaced by a new term such as ‘Rest of England and Wales’.

Objective 2 Membership engagement activity must be cost effective

As in 2015, the Trust’s membership conference and Annual Members Meeting was held on the same day and at the same venue (Preston Marriott Hotel, 30 November). The costs of the membership conference were shared equally between the Trust and the Lancashire and South Cumbria Change Programme. All of the speakers and workshop facilitators who participated in both the membership conference and Annual Members Meeting met their own expenses and invited stallholders participated at their own cost.

The focus of the membership conference on the Change Programme and Lancashire and South Cumbria’s Sustainability and Transformation Plan (STP) and Local Development Plans (LDPs) was both timely and highly topical. The conference brought together stakeholders from across the Lancashire and South Cumbria health and social economy to engage with the forwarding-looking agenda that the framework of the STP provides and offered a valuable opportunity to help shape the direction of that work. The conference delivered reputational benefits to the Trust by demonstrating its leadership role in facilitating engagement on how best Lancashire and South Cumbria can meet its future health and social care challenges and allowed Trust members to see clearly how Lancashire Care’s organisational role and influence played an integral part in this wider debate.

The Annual Members Meeting was both quorate and effectively delivered, allowing participating members the opportunity to hear from members of the Board about the Trust’s past achievements and future challenges and to comment and ask questions about the presentations they received at the Meeting.

The Chief Executive answered questions from members about the Trust’s decision not to bid for the Lancashire prisons contract, whether are plans for inpatient mental health services in Lancashire, prospects for the merging of health services in Lancashire and South Cumbria and the potential for greater integration of mental health services with primary care.

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Attendance at the Annual Members Meeting was driven by participation in the preceding membership conference. Attendance was also driven by the timing of the Annual Members Meeting relative to the 2016 public and staff governor elections. Voting in the 2016 governor elections was underway at the time of the Annual Members Meeting. Candidates for election were encouraged to attend as a means of meeting Trust members and members to meet candidates. A representative from Mi-Voice, the external organisation that oversaw the governor elections on the Trust’s behalf attended the Annual Members Meeting.

100 public, staff and affiliate members participated in the membership conference, which was positively evaluated, and 50 attended the Annual Members Meeting.

Objective 3 Further develop the use of social media as a vehicle for engaging with current and

potential members

The Trust has recently reviewed its social media policy and replaced a previous version which was introduced in 2014. The purpose of the policy is to provide guidance for all employees about the appropriate use of social media in order to uphold and protect the Trust’s reputation. The policy sets out clear expectations for employees in relation to the use of social media and includes governors in its scope. At a future meeting of the Membership Engagement Committee, the Head of Communications will deliver a masterclass on the use of social media which will include the recently published guidance on ‘Using Twitter in the Workplace’.

Objective 4 Involve Governors more in representing the Trust at forums

Opportunities for involving governors more in representing the Trust at forums continue to be actively sought by the communications and engagement service and communicated to governors through the Governance and Compliance Team. The following potential opportunities have been identified for the final quarter of 2015-16 and the first quarter of 2016-17:

● Whittingham Lives opening ceremony, 13.00 – 14.00, 1 March (tbc), UCLan, for Central

Lancashire public governors

Whittingham Lives is a two year project which will use music and the arts to explore the history and legacy of the Whittingham asylum near Preston which opened in 1873 and closed in 1995. The project is receiving financial support from the Heritage Lottery Fund and the Arts Council. Lancashire Care is one of the main stakeholder partners in the project and formally owns the Whittingham archive. The launch event will provide governors with the opportunity of discovering more about Whittingham Lives as well as a chance to meet members of the Whittingham Lives Association who are managing the project, the project manager and representatives of both other stakeholder partners e.g. UCLan, Lancashire County Council and funding bodies.

● Meeting with Trust colleagues from the Contraception and Sexual Health (CaSH) service, date

in February tbc, for the governor for Blackpool and North Lancashire (Trust Chair also to be

invited);

Lancashire Care is contracted by Lancashire County Council to provide Contraception and Sexual Health (CaSH) services across Lancashire including Fleetwood. CaSH services in Fleetwood are provided from the Mountcroft site which has been recently refurbished. Governors will have the opportunity to meet Trust clinical colleagues who deliver services from the site and to see the newly refurbished premises.

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● Opening of ‘The Cove’, new Child and Adolescent Mental Health service (CAMHS) Tier 4

inpatient facility in Lancaster, date tbc, priority for North Lancashire governor but other

governors can be invited.

Trust premises at Moss View, Lancaster have been extensively refurbished to provide a new Child and Adolescent Mental Health service (CAMHS) Tier 4 inpatient facility which will meet demand for services from both Lancashire and South Cumbria. The site will provides 18 beds with associated support accommodation. It is anticipated that the site will be handed over from the contractors (Equitix) to the Trust on 17 March and that after that date, service users from the sites of existing provision, The Platform and the Junction will begin to move into the Cove. The opening ceremony for The Cove will provide an opportunity for governors to meet with service users, clinical colleagues, commissioners, local politicians and the contractors to celebrate the new provision and understand more about how it will help to meet the needs of the children and young people who will be cared for there.

Objective 5 Align the membership strategy with the strategic intentions of wider stakeholder

engagement activity

The co-hosting of the Trust’s most recent membership conference with Healthier Lancashire and South Cumbria and its focus on the Sustainability and Transformation Plan (STP) supports the objective of aligning the membership strategy with the wider strategic intentions of wider stakeholder engagement activity.

Additionally, individual colleagues in the communications and engagement service are each given responsibility for developing a constructive relationship between the Trust and either the STP for Lancashire and South Cumbria or one of the five Local Development Plan (LDP) areas. The head of the communications and engagement service, the Director of Strategic Partnerships and Engagement has the strategic lead for this area of the Trust’s work.

The most recent edition of the Trust’s membership newsletter, Foundation News, published and distributed electronically in January 2017, included a feature on the STPs and LDPs, explaining the principles behind the plans and indicating to members how they can get involved in shaping the direction of LDPs in the area in which they live. The key generic messages in Foundation News have been supported by bespoke communications with Trust members in a specified LDP area e.g. Our Health, Our Care in Central Lancashire highlighting opportunities for participation in engagement events.

Communications with members and engagement activity are consistently recorded on the Trust’s Customer Relationship Management (CRM) system. The communications and engagement service and health informatics colleagues are currently negotiating with external providers to upgrade the CRM system which was first installed in 2011. Membership data will continue to be stored on the CRM and through the upgrade, the Trust will seek to ensure that the functionality of the upgraded system supports the alignment of membership activity recorded on the system with the goals of wider stakeholder engagement activity both externally at regional and sub-regional levels and internally with the reshaped clinical Networks after the organisational reset.

RECOMMENDATION

The Council of Governors is asked to note the progress of the 2016-2020 Trust membership strategy.

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Report Title Annual Election Report


Prepared by David Keddie, Stakeholder Engagement Manager

Presented by David Keddie, Stakeholder Engagement Manager


Supporting Executive Director Chief Operating Officer


Report purpose The purpose of the report is to analyse the results of the 2016 Council of Governor elections, identifying both key trends and emerging challenges from the analysis.



Board Assurance Framework risk The Trust does not comply with statutory legislative requirements (7.2)

CQC domain Well-led

BACKGROUND

The Foundation Trust organisational model, Lancashire Care’s Constitution and relevant regulatory bodies notably NHS Improvement require that membership elections to the Council of Governors are held at regular intervals and undertaken according to prescribed rules which ensure that the election process and outcomes are free and fair.

In 2016, there were Council of Governor vacancies in the following public and staff constituencies: ● Blackburn with Darwen● Central● East● Out of Area● Corporate● Medical

Within the Trust, the elections were managed by the communications and engagement service who appointed an independent organisation, Mi-Voice to oversee the election process. The elections took place between 5 October (opening of nominations) and 9 December (close of voting) 2016.

Most formal pre-election engagement took place by email with the exception of the Out of Area public constituency where a letter was sent to members without email addresses.

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A total of 13 public and 6 staff candidates were nominated. All candidates used the online nomination form provided by Mi-Voice.

Elections were required in three public constituencies (Blackburn with Darwen, Central, Out of Area) and one staff constituency (Corporate). Only one nomination was received for the East Lancashire public constituency and the Medical staff constituency.

Members with email addresses were sent a secure link to vote online, other members received a postal voting pack that enabled them to vote by post or online.

Analysis

The turnout in the 3 public constituencies was just over 23%. The turnout for the Corporate staff constituency was 35%.

The overall turnout was the highest it has been since the 2008-2009 governor elections.

The number of candidates per vacancy (3.25) was the highest it has been since at 2012. The number, diversity and profile of candidates in the contested constituencies are likely to have had a positive impact on turnout.

Voting turnout among members receiving voting information by email was nearly 12% higher than among members receiving voting information by post. The precise figures are provided at Appendix A.

ISSUES FOR CONSIDERATION

Membership

Members with email addresses showed a greater willingness to participate in the election than those receiving information by post. This could be due to the speed and convenience of voting online but it could also be because members with email addresses receive more communications from the Trust than members without email addresses. The only regular communication that members without email addresses receive is the election voting pack. Although turnout among postal members increased at the 2016 election, there is a hard core of approximately 75% of postal members who do not participate in elections.

A strategy to reconnect with postal members can be considered but it is essential that this takes place without significantly increasing long term engagement costs. Possible approaches to addressing the postal membership issue include:

● Maintaining a record of which members vote in elections over a full electoral cycle (and potentiallymembers who participate in other Trust events such as the membership conference, Annual Members Meeting and other membership events). Postal members who do not vote in at least one election could be removed from membership after a certain period (a statement to this effect could be included in voting material). The exact timing of this would need consideration as some members theoretically have more opportunities to vote than others (i.e. constituencies with multiple seats).

● Writing to all postal members and inviting them to confirm their Trust Membership. Members wouldbe given the opportunity to register an email address (or possibly a mobile number) for future communications. Postal members without email addresses would be able to continue as members but would need to take positive action to do so. It is important that members without email addresses are

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not excluded from membership. This communication could ask members to reconfirm what sort of activities and Trust services they are interested in.

In order to encourage committed members without email addresses to continue as members, consideration might be given to sending a single annual communication by post (timed to coincide with the annual elections). This could take the form of a very brief summary of the Trust’s annual performance and could incorporate information about elections for those constituencies where they are taking place in a particular year.

Pursuing either of the above options would probably result in a significant reduction in the overall number of public members. The Trust needs to consider whether having a large but relatively unengaged membership is desirable or if a smaller membership that is more committed to participation in Trust activities is preferable.

Whichever approach is pursued (or even if it is decided to maintain the status quo) every possible opportunity needs to be taken to build up the number of members who can be contacted by email (and possibly text message). However, it is important to recognise that this could be a slow process. As an example of this, only eleven members who received ballot information by post at the 2016 election provided an email address while voting online (although more members who received information by post actually voted online, suggesting that some members are happy to engage electronically but not to share their email address).

East Lancashire

For the second successive election, no election was required in the East Lancashire public constituency. In 2015 only 2 candidates were nominated for 3 vacancies and in 2016 only 1 candidate was nominated for a single vacancy. Compared with Central Lancashire where candidate numbers have remained relatively high, there has been a decline in candidate numbers in East Lancashire (10 candidates contested the 2012 election).

A specific strategy is required to engage with potential candidates as two of the three current governors in East Lancashire will complete their second term of office in December 2018 and will not be eligible to stand for re-election. A list of previous candidates in East Lancashire has been drawn up that can be used as a starting point to explore why members appear to have become reluctant to put their names forward for election.

2017 Council of Governor Elections

There is a current vacancy for a public governor in North Lancashire. This vacancy does not currently affect the public governor majority on the Council of Governors and it is recommended including this vacancy in the autumn 2017 round of elections.

There are scheduled elections in the following constituencies in 2017: A public governor for West Lancashire (1 seat – membership approximately 250). In 2014, 2 candidates contested the West Lancashire seat.

Staff Nursing (1 seat) and Staff Other Clinical and Social Care Professionals and Clinical Support Staff (1 seat). In 2014, the Nursing seat was unopposed (although 4 candidates were nominated for 2 vacancies in this class in 2015). The Other Clinical and Social Care Professionals and Clinical Support Staff constituency was contested by 2 candidates in 2014.

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With reference to the West Lancashire constituency, the Trust is providing an increasing number of services to communities beyond but close to West Lancashire e.g. Southport and Formby, St Helen’s. With this in mind, it is possible to consider whether amending the West Lancashire constituency boundary to include areas where the Trust is providing services may bring long term benefits. At present there are only a few members in places like Southport and St Helen’s but this is a potential area for membership growth. Given the Trust’s increasing presence in this area, extending the constituency boundary of West Lancashire may be a way of strengthening relationships and providing a wider range of potential candidates.

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Appendix A

Lancashire Care NHS FT Public Governor Elections 2016: Turnout by Ballot Delivery Method

Name Overall

Electorate Overall Turnout

% Overall Turnout

Postal Electorate

Postal Turnout

% Postal Turnout

Email Electorate

Email Turnout

% Email Turnout

Differential Turnout

BwD 685 143 20.88% 533 101 18.95% 151 42 27.81% 8.87%

Central 2,050 507 24.73% 1,516 327 21.57% 534 180 33.71% 12.14%

OOA 381 68 17.85% 281 40 14.23% 100 28 28.00% 13.77%

Overall 3,116 718 23.04% 2,330 468 20.09% 785 250 31.85% 11.76%

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Documents

Formal Council of Governors Meeting... · Council of Governor Meeting Dates and Venues 2016/17 Date Time Venue . Wednesday 13 April 2016 (Chief Executive Briefing) 09:00 – 11:00