Meeting Date: 22 May 2014 SUMMARY REPORT Agenda Item ... · Strategic Priorities this report relates to: To exceed expectations in the quality of care delivered To transform our services

1 Accountable Director: Lead Executive Director for each Committee Board Meeting Date: 22 May 2014

SUMMARY REPORT

Meeting Date: 22 May 2014 Agenda Item: 11 Enclosure Number:

12

Meeting: Trust Board

Title: Approved Board Committee Minutes

Author: Lead Executive Director from each Committee Accountable Director: Committee Chairs

Other meetings presented to or previously agreed at:

Committee Date Reviewed Key Points/Recommendation from that Committee

Each Committee as shown

Meeting dates as shown

Purpose of the report

To provide Board members with the most recently approved minutes from Committees of the Trust Board.

Decision/ Approval

Assurance Discussion Information

Strategic Priorities this report relates to:

To exceed expectations in the

quality of care delivered

To transform our services to offer more care closer to home more productively.

To deliver well co-ordinated effective care

by working in partnership with

others.

To provide the best services for patients by

becoming a more flexible and sustainable organisation

Summary of key points in report

Main Issues discussed at each Committee & implications for overall Trust business A summary of key issues from the most recent Committee meetings can be found in the relevant

reports to the Trust Board (ie prior to the minutes being approved and being available)

2 Accountable Director: Lead Executive Director for each Committee Board Meeting Date: 22 May 2014

Key Recommendations

To note the content of the minutes for information.

Is this report relevant to compliance with any key standards? YES OR NO

State specific standard or BAF risk

CQC No

NHSLA No

IG Governance Toolkit No

Board Assurance Framework

No

Impacts and Implications? YES or NO

If yes, what impact or implication

Patient safety & experience N

Financial (revenue & capital) N

OD/Workforce N

Legal N

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Minutes of the Resource and Performance Committee held on

Monday 27 January 2014

Present: Mike Sommers (Chair) (MS) Rolf Levesley (RL) Peter Phillips (PP) Jan Ditheridge (JD) Trish Donovan (TD) Tessa Norris (TN) Steve Gregory (SG)

In Attendance: Mike Ridley Angela Saganowska

(MR)

Minute Secretary: Jan Cox (JC)

1. Apologies: Maggie Bayley Alastair Neale

(MB) (AN)

2. Declarations of Interest

There were no new declarations of interest recorded at this meeting.

3. Minutes of the Meeting held on 7 January 2014

The minutes of the meeting held on 7 January 2014 were agreed as a correct record.

The Committee noted and agreed the commentary reported on the Burdett checklist from the meeting held on 7 January 2014 with the following amendments:

Section ‘During the meeting’ – bullet point 6 – remove the word “investment”.

Section ‘Review’ – bullet point 3 – replace “nothing new” with “the scale of challenge next year was identified and reinforced”.

4. Noes of the EPR Workshop

The notes of the EPR Workshop were agreed as a correct record.

TD reported that CSC who supply Lorenzo have requested a meeting with the Trust. The Trust is in the process of liaising with procurement to see if it is possible to meet with CSC without compromising the tender process.

It was agreed to update the Committee on progress.

5. Matters Arising

5.1 Action Log

Capital – It was noted that the Capital & Estates Strategy Implementation Group had been established and would report to the Transformation and CIP Programme Board. The group will inform the development of strategy

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as well as implementing plans for the business plan – Closed Outpatient Clinics run against plan – report attached enclosure 4 - Closed Community Trust features in the reconfiguration of all acute and adult

services – noted that the Trust are members of the Clinical Services Review and this has been discussed at Board – Closed

Corporate Services non-healthcare income showed an adverse variance relating to Occupational Health (OH) – it was noted that the budget had remained similar to historic levels and income levels for service provision to other organisations were reducing. The budget would need to be reset and a full review undertaken to establish whether they are in line with their plans going forward - Closed

M9 TDA submission complete – Closed Waiting Times across all services – report attached enclosure 5 - Closed

5.2 Consultant Outpatients Utilisation

TN presented a paper which updated the Committee on the current position in relation to the Consultant Outpatient Utilisation Project including progress on the SLA with SaTH for Consultant Outpatient Provision. Work is on-going looking at the financial impact to the SLA; new capacity for outpatients and how full utilisation will be achieved. The Committee will be updated on progress. MR queried private pay for consultations – It was noted that due to increased demand within the SLA one of the options could be to explore consultants undertaking extra work, however, this would have to be within the rules and regulations of the SLA.

5.3 Waiting Times for Non RTT Services

TN presented the paper on waiting times for non RTT services and the following key points were noted:

This paper was a position statement as no waiting list data was available at the time of writing the report.

It was noted that the Trust is working with the CSU and CCGs on a new Price Activity Matrix and the wide variation on waiting times for non RTT services should be agreed as part of the Service Specification.

A Task and Finish Group had been established to identify data quality issues. Data quality reviews on the quality of data around patient referrals had been undertaken and a number of issues were identified which need to be addressed.

It was noted that the cleansing of inaccurate waiting time data on the system of all open referrals would take a WTE approximately 11 years to clear the backlog however the cleansing of none of the data would leave the Trust with unusable waiting list data.

The preferred option would be to cleanse the data on open referrals from an agreed point in time whereby all new referrals would be cross checked and all old referrals would be closed down. Some patients have lots of open referrals with data attached and the cleansing process would put the Trust in a robust position going forward. The data cleansing process from a given date would check against historical data and where additional open referrals or old activity was identified the episode would be updated or closed.

It was noted that all new patients would have clean data going forward.

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TN referred to the Standard Operating Procedure (SOP) and that services would be monitored on compliance with data quality standards going forward. There would be historical data once the system starts cleansing and it could take a year before this data is closed off.

It was noted that there would need to be agreement from the CCG and CSU prior to commencement of the data cleansing exercise.

PP queried if the Trust could ring-fence this data and make it new data. TN agreed to ask Lee Osborne outside the meeting and report back.

ACTION: TN to discuss with Lee Osborne the possibility of ring fencing the data. MR asked how many referrals would be closed down. TN replied that the

number would be fairly large but would not be patients waiting for surgery or visits only ones with 2/3/4 or more open referrals. Only historic referrals would be closed down when activated and active ones would remain open.

A start date of 1 April 2014 was suggested to the Committee. This would allow the Task and Finish Group time to set up the process and arrange refresher training for staff.

JD said we need a robust plan; ensure patient care was not compromised; no harm around compliance; check against our own quality QIA process; important that we have commissioner buy in from a quality and business perspective; must be able to do large searches to find duplicates.

Concerns around performance were noted. This will be monitored through Operations, Performance and the Quality and Safety Committee – closed from a Resource & Performance point of view.

It was noted that it was agreed at Board that Data Quality would go higher up on risk register

The Resource & Performance Committee noted the impact that poor data quality was having on the Trust’s ability to accurately report and manage waiting lists; noted the monitoring processes proposed going forward. The Committee approved Option 3 as the way to move this issue forward and agreed a start point of 1 April 2014.

6. Financial Monitoring for 9 Months to 31 December 2013

TD presented the Financial Monitoring report for Month 9 to 31 December 2013 and the following key points were noted:

The financial position was reported to be a deficit of £116k at month 9 against a planned deficit of £131k, which was a favourable variance from plan of £15k.

The previous month’s deficit was £286k and the position had moved favourably by £170k in line with plan, but reflecting non-recurrent benefits.

The Trust is continuing to forecast that it will achieve its control total of £212k surplus based on the assumption that the remaining CIP requirement is fully delivered or replaced with other measures which is a significant financial risk.

Key point that in the position there are some significant non recurrent benefits relating to closing stock adjustments and a review of historical creditors on the balance sheet.

It was noted that the executive summary had been shortened and all appendices would be reviewed going forward.

The forecast indicators for overall delivery of the plan and for the shadow FRR are now reporting amber in the RAG status which reflects the forecast overall remains on plan. This is a significant risk to the Trust and was recognised by the Committee.

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TD also identified prison income and FP10 charges being significant risks for the Trust, which have been reported to the TDA.

TD referred to table 2: pay spend by month that showed agency spend dropping; demonstrating CIP impact; and substantive costs in total. The increase in June related to the first quarter was noted however spend was now at a lower level. The funded establishment showed 89 vacancies but this was not translated into spend on WTE’s. TN confirmed that across all Community Hospitals the Trust is 6 registered nurses short. JD questioned why spend was so high. TN explained that work on registered nurses had been undertaken but healthcare and supervision still needed to be addressed to drive down costs. It was noted that an advert for healthcare was running at the moment. TN confirmed that the Trust was only using agency to cover sickness absence or where there was a vacancy for registered nurses, however it was noted that shifts are moved around before going to bank and finally agency for cover.

MR referred to appendix 6 and was concerned that pay expenditure was not reducing. TD explained that the Trust was spending in total £100k less per month. TN said that during the phase 2 budget setting round 20 additional posts were agreed and to date the Trust had employed about 15 WTE Band 5’s. JD queried the associated cost.

MR said the Trust was going to be £400k overspent at year-end and he was struggling to understand how the figures were calculated was there a net statement for a particular month where we have employed staff and savings had been achieved. TD replied that the overspend was against budget but the improvement was based on spend levels coming down and at the moment we are looking at £100k less per month. The budget variance is offset by centrally held budget. Whilst we can say total spend is coming down it a result of many different variables. Work is on-going the pragmatic view is if spend is coming down we need to recognise this in savings which is a challenge to demonstrate due to a variety of reasons, but it is as a result of on-going work.

MS referred to appendix 6 pay expenditure and acknowledged that there had been a substantial reduction. TN said that the December recruitments were due to commence employment and were not yet shown in the position. It was noted that the figures and forecasts up to December were actual.

Once the substantive position is recruited to we should need less bank and agency. Bank runs from £70k per month; last month £66k; so quite static. Establishment should cover holidays so bank would only be required to cover sickness.

AS said that in the Francis Report staffing has to be on display on wards on a monthly basis. SG declared an interest in reporting staff levels across all our services.

SG referred to the CIP and said in reducing agency staff it is removing the cost pressure, but at the moment the central budgets are propping up pressures across budgets and in the future this would be available for development.

TD reported that the total pay expenditure for December was £100k lower than the previous month’s pay bill and if this continues each month the pressure will come down. It was noted that this figure excludes commissioner funded agency expenditure where CCGs have separately funded an initiative.

MR referred to page 15 centrally held budgets and the balance of £835k and asked if it was committed in the overall outturn. TD confirmed that it was all committed in the forecast.

MR queried £1,025k relating to non-recurrent transformation funding anticipated from the two main CCGs. TD explained that it was money that the Trust potentially received from CCGs for specific transformation initiatives. At the moment we assume if we receive income we have costs to match or if we don’t it

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will not be a cost pressure. Commissioners are working with the Trust on other pressures re patient transport.

MS referred to the Board papers which showed £225k for the integrated team in North Shropshire and asked if this was funded and was it a total or incremental cost. It was noted that this related to a special project being piloted under winter funds with the assumption that if it was successful it would be rolled out. The aim of the project being to discharge complex patients directly to the home environment so that their needs could be catered for.

MR commented on the Minor Injuries activity and the over performance equating to £171k. Oswestry MIU is currently showing the highest over performance. TD confirmed that this over performance was included in the PbR over performance. MR commented on Oswestry being a key area with a slightly more important location than MIUs based in the hospitals. He said the Trust needs a clear view from the CCGs on whether we see a MIU in Oswestry in the future.

MS questioned if the £171k was part of the PbR overachievement. TN confirmed that some of the other MIUs were under performing and Oswestry was offsetting this however there seems to be a lot of services there that are not being used.

MS expressed concern around CIPs generally. A large amount was not budgeted for in the first place. We were supposed to know the next 22/24 months CIPs specifically and we don’t even know the next 2 months let alone saving £5m next year. TD commented there needs to be some recognition on how we are managing the current year there is some CIP achievement; there is income; changes in contracting and spend it is not the way you would plan your CIP but the CIP was not developed until halfway through the year therefore other replacement measures, often non-recurrent are being implemented. For next year we have to make changes. We have an initial list of CIPs and are strengthening the processes internally plus working across the health economy to make those changes.

TD said we are working on the plan internally looking at every area with a national requirement of 4%. Looking at corporate and back office functions on how we might progress wider service discussions across the health economy which will impact in the future but some not before 1 April. JD said we need a structured approach there are still some improvements required in terms of good housekeeping as well as the transformation work. With regards to Community Hospitals we need to work up options to demonstrate to the health economy what our efficiency is and then need to understand what is possible through dialogue with commissioners. Directors are committed to addressing the gap.

MS queried community equipment stores – TD confirmed that it was on the list for review.

MS said that the Trust may achieve this year but at some stage we would have to consider viability.

TD said the plan that was submitted to the TDA on 13 January went in with a £4.2m gap but she genuinely believed this could be improved via CIP development. JD said that we must demonstrate what is achievable.

MR commented that what we were seeing was developing into a health economy problem. We may be in a position to be clear on plans in September when we have formalised the Future Fit Programme but how do we bridge the gap between now and September. JD said we are required as an organisation to submit a plan even if it is a deficit position.

TD referred to a letter from the Director of Finance at the TDA on the joint assurance process from NHS England regarding the planning process and wider sessions for challenged organisations and economies in going forward.

JD commented on the reviews of estates and any services that are running at a loss.

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MS referred to the Audit Committee and the Health & Wellbeing Board where he was alerted to £20m transformation for Shropshire. He was nervous that there was no vision on how services would look or on the whole health economy change of programme.

SG commented on the efficiency challenge, the productivity opportunities and an overall shortage of nursing staff in the system.

AS whilst good to look at options in terms of CIP can you take over a 2 year period there needs to be a paper to do all the things internal and joint strategic statements that are honest. Maybe a private paper to say as a health economy we are not sustainable next year. JD asked what as a Board should we do. AS suggested a ½ day to look at a strategy with strategic statements across the health economy.

PP said 95% of costs relates to payroll. There is no way we can save £4m next year need restructuring plan over next 2/3 years.

MR as a Board we need to see the health economy financial position in context to be able to say we are left with a deficit and these are our contributions. All Boards need to realise the position so we are not in isolation.

AS asked what is the strategy that lies behind the vision. JD replied the strategic intent is that there will be more community services to reduce admissions and help reduce pressure on acute services.

MR referred to a conversation with Mike Innis at Telford CCG about the Future Fit Plan.

The challenge of making efficiency via community beds whilst the longer term plan is to increase community provision and in advance of the outcome of future fit was discussed.

AS commented on the need to do more work as a Trust holding sessions to work out our strategy and then all key partners in the health economy need to meet and be honest. We are still breaking up into lots of groups because there is no finalised strategy in place or timeframe.

JD referred to a discussion at Board and agreed there would need to be a health economy solution but would first need to understand the money available.

JD agreed that there would need to be a transition plan we need to think through what we can do. One of the community hospitals could become an urgent care centre; we could lose some of our community beds. Discussions are taking place but there is not a firm plan yet.

MS referred to EPR £3m; District Nurses team require mobile technologies; a large amount of money is needed across the whole health economy to make these changes.

JD raised how we best take this forward and whether a B2B would be helpful. The Committee noted the financial position at 31 December: a deficit position of £116k against a planned deficit of £130k and the requirement to deliver a surplus of £212k at year end (after adjusting for donated assets, government grants and impairments); that achievement of the planned surplus is predicated upon successful delivery of the CIP, or other replacement measures; and resolution of the key risks relating to funding described above and that significant risk remains that this can be achieved by year-end.

7. Risks and Opportunities

TD tabled the summary of 2013/14 Risks and Opportunities and the following key points were noted: The opportunities secured from the original list showed a rag status of green with

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£725k included within the December position and forecast outturn. £939k of opportunities not anticipated within the December ytd position but

included within the forecast outturn. The total amber opportunities not included within the December position or

forecast outturn show £561k with a potential opportunity of £281k. TD reported that in achieving the £939k the Trust is progressing and there are

degrees of confidence. AQP income – it was noted that commissioners had reviewed the position and

recognised the activity. Shropshire had indicated their agreement that funding would be reinstated.

Patient Transport - agreed a way forward with the Provider on the higher rates and that the additional costs would be recharged to SCCG (£481k). It was noted that the overall contract for the county is going through a tender process lead by Shropshire CCG.

PBR income - over performance on activity for months 7 to 12 in the sum of £213k remains a potential risk to the Trust, however it was noted that under the rules this should be paid and there is the possibility that activity could change over the next couple of months.

Noted that the HIMP redundancy costs funded by TWCCG/TW Council were RAG status red and it was unlikely that funding would be secured to cover these costs per legal advice.

Other items listed under opportunities not included within the December financial position or the forecast outturn were continuing to be explored.

It was noted £609k 2013/14 total financial risk has been included at December. There is a significant risk regarding additional prisons funding in the sum of

£386k. This income is assumed within the Trust’s financial position and if it is not received the Trust’s financial position will deteriorate. The issue has been raised with the SCCG and the TDA and a meeting has been arranged between commissioners for early February to try and resolve the situation.

PbR income over performances months 1 to 6. SCCG has been invoiced for £175k but the amount remains outstanding, however TWCCG has paid in full. Anticipating a continuation for the second half of year but until resolved there is a significant risk to the Trust. It was noted that the TDA would be supportive of the Trust pursing this funding per national rules.

£227k risks not included within the December position mainly relate to FP10 charges.

Small risk around CQUIN as the Trust did not hit the target so potentially we may lose a small amount of income.

MR referred to the estates rationalisation and asked what could be the worst position. TD explained that NHS Property Services tried to impose a charge that the Trust was not funded for. We are in the process of commencing a review on some of our properties where we are able to vacate premises on shorter notices. This work has not been quantified to date for a combination of reasons.

MR questioned the general position of CCGs. TD explained that the CCGs position was difficult; Shropshire have reduced their targeted surplus in the last month they are trying to finalise a position around SATH. We are discussing with them our position and they are working with us and recognise the pressure and where they can pay they will. MR should we not be putting more into red and amber with the worst possible case £4/5m at end of year. TD did not think we were looking at that scale we said we would need to improve by £700k to hit the £200k surplus we have identified prisons and FP10s on top of that so it would be over £1m if these risks went in the wrong direction.

MR said a lot of this is predicated in the Trust receiving money and at some point if there is no intention of this income being received we need to reduce the

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activity and staff. TD agreed that any areas that are activity driven need to be looked at as we cannot continue to provide services that are not being funded.

PP questioned prison funding being 65% of total risks and asked if the Trust would expect to write-off £386k. TD confirmed that the Trust had invoiced for the amount but because of changes across NHS commissioners it was unclear where the funding sits. It is assumed in the Trust’s forecast but flagged as a level of risk.

The Resource & Performance Committee noted the risks and opportunities presented at the meeting.

8. Performance Report

TD presented the Performance report and the following key points were noted: The position against National targets for this month’s year to date status was

reporting three ambers and no reds. It was noted that two of the amber targets related to finance; capital expenditure

and revenue surplus/deficit. The NHS Safety Thermometer measure for harm free care during December was

94.44% against a target of 95%. It was noted that the national average in December was 93.5%.

Performance monitored by the Trust against 26 Contractual indicators was reporting just under half red.

MR commented on the improvement during December relating to length of stay in community hospitals. TN said this related to winter pressures with improved response from the Local Authority regarding packages of care which had seen a significant drop in the system during December.

Work was still required on the underlying trends and also work was on-going on a range of metrics through contracting to identify important information on the whole performance management framework.

MS commented that there should always be year on year figures and to include annual totals.

JD commented on paragraph 1.6 as misleading. She would like to see a development in reporting of information by divisions so that there would be a confidence in managers receiving the right information for their service.

MR queried the increase in long term sickness. TN confirmed that there were robust management arrangements in place within the community teams. There was a significant problem with long term sickness and this had been fully discussed in the Operations Meetings with HR and work to drill down and identify the divisions was being undertaken.

MR queried the increase in the December position for medical and dental absence. It was noted that this related to a small team with one person on sick leave for a month.

MR queried the process for setting targets for the next financial year. TD replied there was a small contracting group meeting with commissioners where targets would be agreed and then monitored against the contracts.

It was noted that this Committee would focus on data quality; waiting times, activity and finance everything else would be discussed at the Quality and Safety Committee

MS would like to see activity levels delivered by the Trust and track the work through the contracting reports.

MR queried the I&E surplus margin rating from red ytd status to green forecast year end status on appendix 1. TD explained that because the Trust was

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forecasting a planned surplus but was currently reporting a year to date deficit the ratings changed to reflect this.

The Resource & Performance Committee noted the current performance in relation to key performance indicators as at the end of November 2013 (M8) and December 2013 (M9); the actions being taken where the performance requires improvement and discussed and questioned the report to ensure that appropriate assurance was in place.

9. Charitable Funds for the Quarter ending 31 December 2013

TD presented the Charitable Funds report for the quarter ended 31 December 2013. It was noted that a Charitable Funds Group was being established to bring increased focus on the management of funds. The Committee noted the movement of funds during the quarter from £507k to £502k a decrease of £5k which comprised of donations of £69k and expenditure of £74k. MR queried the £8.5k expenditure on the SCHNHST general fund. It was noted that this related to the staff awards event. The Resource & Performance Committee noted the current position on the fund balances for the quarter ended 31 December 2013

10. Business Development Proposals; Tenders; Service Developments

10.1 Tender Update

T&W Council intention to go out to tender for the School Nursing Service has been delayed until March

Second phase on Health Improvement – impact on residual services - work required on how we get back to cost neutral – SCC have approached the Trust to request a transition period until they have set up a provider – noted huge risk.

11. Review Terms of Reference for the Resource & Performance Committee

It was agreed to send an electronic copy of the updated terms of reference to MS for further amendment prior to circulation to the Committee for approval.

12. Information Management & Technology

12.1

IM&T Steering Group Minutes

The Committee noted the minutes of the IM&T Steering Group held on the 12 November 2013 which were approved at the IM&T Steering Group meeting held on 15 January 2014.

13. Authority of Single Source Arrangement for Goods and Services

There were no Single Source Agreements received by the Committee.

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14. Risk Assurance Update

Noting the concern around the delivery of £4/5m a year and the recommendation of this Committee that it may not be feasible from 1 April 2014 and the longer term Health Economy with recognition across the CCGs and other organisations.

15. Burdett Checklist

Completed, but needs to be reviewed.

16. Any Other Business

16.1 TD confirmed the context of the £1m Ludlow investment which related to a

report on the condition survey in which it was highlighted that an investment of just under £1m would be required for the 5 years. It was noted that NHS Property Services own the building and the Trust will be liaising with them on this matter.

18. Date and Time of Next Meeting

The next Resource & Performance Committee meeting will be held on Monday 3 March 2014 commencing at 8.30am in Room B, WFH Site.

………………………………. ……….………………. Chair – Mike Sommers Date

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Monday 3 March 2014

Present: Mike Sommers (Chair) (MS) Peter Phillips (PP) Jan Ditheridge (JD) Trish Donovan (TD) Tessa Norris (TN) Steve Gregory (SG)

In Attendance: Mike Ridley Julie Thornby (agenda items 8 & 9 only) Vic Middlemiss (agenda items 8 & 9 only)

(MR) (JT) (VM)


1. Apologies: Rolf Levesley (RL)



3. Minutes of the Meeting held on 27 January 2014

The minutes of the meeting held on 27 January 2014 were agreed as a correct record with the exception of the following:

Page 5 – 8th bullet point – to remove ‘the Trust’ and replace with “what we were seeing” was developing into a health economy problem. Transformational Board to be replaced with Transformation Board Page 3 – 5th bullet point to replace ‘prospectus’ with ‘perspective’ Page 3 – 6th bullet point – ‘Executive’ to be replaced with ‘Operations and Performance’ Page 5 last paragraph to reword Page 6 bullet points 4, 5 & 6 – Need to rephrase. Page 6 last bullet point item 6 - delete

The Committee noted and agreed the commentary reported on the Burdett checklist from the meeting held on 27 January 2014.

It was agreed that the Burdett checklist would be replaced in future with an agenda item entitled ‘Meeting Review’.

4. Matters Arising

4.1 Action Log

It was noted that the first Capital & Estates Strategy Implementation Group was held on 21 February 2014 and will report into the Transformation and CIP Board. MR queried the estates review relating to properties transferred from the PCT and asked when this work would be finalised. TD replied that work was on-going with the current review in line with the clinical strategy and forward plan and this work should be completed in the next couple of months. The Trust has a list of properties where services are

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accommodated, estates and operations are looking at these in line with the Trust’s forward strategy. It was noted that the estates strategy is a new piece of work and will be presented to the Committee at a future meeting.

MR queried to OH non-healthcare income. TD replied that OH would need a forward plan, business had been lost and the plan would be adjusted going forward. It was noted that OH’s approach is aspirational in obtaining new business and they are presently pursuing a business opportunity and if successful this would be reported to the Committee.

To liaise with information outside the meeting to see if the data could be ring-fenced – noted discussions on-going with the CCG – closed.

5. Financial Monitoring for 10 Months to 31 January 2014

TD presented the Financial Monitoring report for Month 10 to 31 January 2014 and the following key points were noted:

TD apologised to the Committee for the lateness of the M10 detailed financial information in support of the summary report already distributed.

The financial position was reported to be a surplus of £100k at month 10 against a planned surplus of £48k, which was a favourable variance from plan of £52k.

The previous month’s deficit was £116k in line with plan, but reflecting non-recurrent benefits.

The Trust is continuing to forecast that it will achieve its control total of £212k surplus based on the assumption that the remaining CIP requirement is fully delivered or replaced with other measures which is a significant financial risk.

CIP performance now demonstrates that the Trust is recording and monitoring all CIP schemes and there is increased recognition reflecting the validation process.

It was noted that the cash position remains strong. The revised capital programme is below planned levels to date and is expected

to remain underspent at year end. The two significant risks reported last month remain and discussions are on-

going to try and resolve prisons income and FP10’s. MR asked if the Trust had reported the risk to the TDA. TD confirmed that the

risks had been flagged to the TDA and they were aware of the issues. TD reported on work around data sharing regarding FP10s and it had been recognised that the Trust should not be left with the risk. TD confirmed that this had been escalated to the LAT which had resulted in data sharing but we need to pursue as funding is not just being held locally. It was noted that discussions are being held on year-end settlement with the CCGs and information on challenges had been shared.

ACTION: TD to follow up again this week with the LAT. JD asked if FP10s had been resolved for next year. TD replied that FP10s

should be a settlement of invoices and are outside the main contract. Agreed to pick up outside the meeting and TD to explore how this can be made contractual for 2014/15.

MR referred to appendix 3 and queried the contract position with Betsi Cadwaladr and Powys LHBs as contracts had not been signed. He asked if there was a risk that the settlement would be less than the activity provided. TD confirmed that this would be fully pursued. It was suggested investigating a joined up approach with other Providers and the Commissioners.

ACTION: TD to investigate a joined up approach with other Providers/Commissioners. Pay – MS queried the Operations Directorate month 10 pay position. TD

confirmed the tables show the correct position. Note: Error in narrative on page 6 of the report. Operations Directorate month 10 pay position was £305k overspent, which was an improvement of £54k compared to the month 9 overspend of £360k.

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MS noted the ongoing challenge to fill vacancies. MR referred to page 7 and queried spend being higher this month on agency,

bank and substantive than at the start of the financial year. TN explained that changes over the first three months should be averaged. It was noted that the trend from January was due to sickness.

It was noted that the establishment had gone up due to additional funding for winter schemes.

TD explained that it was difficult to bring together information from HR and finance systems to map into the position, however the information was available. It was noted that if this information could be produced at divisional level it would show clearly the reductions in bank and agency.

MR asked if monthly figures were available on the number of agency and bank hours used and if so how reliable would this information be over the last two years. TN confirmed that there was robust information from July on bank and agency in community hospitals, however there were some issues in trying to identify where agency was commissioned and be clear on business as usual and what was due to winter pressures.

JD commented that Executives are working this through. MS referred to non-pay - overspend is down to £970k from £1,030k a £60k

improvement, however queried changes across key areas including wheelchairs and equipment. TD said the team were reporting based on average usage levels.

It was noted that cost pressures around increased activity are being addressed through contract negations.

Centrally held budgets have been released in the M10 position to offset cost pressures reported in pay and non-pay.

It was noted that the non-recurrent transformational funding was subject to agreed business cases with the two main CCGs and is cost neutral.

It was noted that a significant amount of work has been undertaken in the finance department to ensure that CIP savings are being generated and reported within the financial position and the validation process has improved the CIP position reported.

MR referred to appendix 4 and queried contract variations. TD explained the process. Items listed were considered individually.

PP queried outstanding debt and the challenge in meeting the surplus and whether achieving balance was acceptable. TD £212k is the planned position which we are forecasting. The statutory duty is to achieve breakeven.

The Committee noted the financial position at 31 January: a surplus position of £100k against a planned surplus of £48k and the requirement to deliver a surplus of £212k at year end (after adjusting for donated assets, government grants and impairments); that achievement of the planned surplus is predicated upon successful delivery of the CIP, or other replacement measures; and resolution of the key risks relating to funding described above and that significant risk remains that this can be achieved by year-end.


TD tabled the summary of 2013/14 Risks and Opportunities which were fully discussed.



TD presented the Performance report and the following key points were noted:

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Performance against national targets shows one rated red and one rated amber. The red rating was against the complaints acknowledged within three working

days indicator. One complaint received in January 2014 was not acknowledged within 3 working days.

The amber rating relates to the January assessment against the NHS Safety Thermometer assessed at 93.3% against a target of 95%

It was noted that there a number of areas within contractual and local indicators where further improvement; the implementation of recovery plans and actions will be required.

MR referred to page 5 and commented on the number of registered nurses handing in their resignation. TN said this was normal turnover however Ludlow, Whitchurch and Bridgnorth Hospitals have been identified as difficult areas for recruitment and retention. Interviews are being held on a monthly basis to resolve the situation.

It was agreed to consider skill mix using the present vacancies to provide better quality staffing and patient care but be mindful of the safe staffing guidance. This would be discussed fully at Executive Team.

PP commented on page 15 of the report regarding red rated appraisal rates. JD referred to page 7 and the serious incident reported in January where medical

records were mislaid. The sentence where no breach of data protection or patient confidentiality occurred should read technically a breach in data protection was noted.

TD reported on the procurement of a performance management system which will reduce the manual process and allow for improved presentation. The software is due to be installed by the end of March for implementation in April.

MS asked if it was possible to look as the same month of the previous year, month on month to show seasonal trends.

The Resource & Performance Committee noted the current performance in relation to key performance indicators as at the end of December 2013 (M9) and January 2014 (M10); the actions being taken where the performance requires improvement and discussed and questioned the report to ensure that appropriate assurance was in place.

8. Update on Financial Planning & CIP (Annual Plan)

Julie Thornby joined the meeting and together with TD gave a presentation on Financial Planning; CIP and the Annual Plan which were discussed by the Committee

TD gave a brief summary on the 13 January submission which identified a deficit of £3.5m.

Feedback from a meeting with TDA held on the 26 February following the submission was noted as follows: - Closing cash balance of £1.5m driven by reporting deficit. - Capital Expenditure Plan £1.1m funded by internal generated funds and

existing cash balance. - TDA discussions included challenge in relation to the proposed 5 March

submission of a deficit of £600k driven by the CIP position. £2.9m represents 4% and indicates a closing cash balance of £4.4m.

We indicated for the April submission the Trust aspires to a breakeven plan which would require additional improvement.

The CIP plan identified £4.1m of opportunity of which £2.9m was indicated for 2014/15.

Clinical Innovation & Productivity would look to release clinical time by driving down travel time; reducing the number of handovers; improved referrals; etc. and achieve improved VFM from staff.

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SG said the leadership structures element would be driven by how operations are structured. We could be aligned with the main commissioning structures which might release £0.5m savings and includes reduced agency admin spend.

SG referred to conversations on service improvement techniques that would make a difference; e.g., pathways on how District Nurses and Inpatient staff work.

JD added that clinical and leadership re-design schemes are to be worked up in more detail and QIAs are to be completed for all items.

MS asked how you make District Nurses; Health Visitors; Community Hospitals more efficient.

JD replied that the Trust is developing its IT plan to support change which all links to the community hub model.

MS asked what procurement efficiencies are. TD explained that it was pushing for better pricing through the procurement function and improved use of contracts.

It was noted that back office functions are being reviewed. TN confirmed community equipment stores and wheelchair clinical assessment

are to be reviewed separately to understand the efficiencies to be made. MR queried whether this was all achievable outside “future fit”. It was noted that

future fit might represent growth and this does not assume any impact on future fit at the moment.

Community Bed Efficiency is the area most closely aligned to future fit. MR queried whether £800k improved use of community beds includes Whitchurch

empty wards. TD clarified that it doesn’t, this initiative is looking at 16 beds across the four community hospitals with options for consideration being set out in a paper.

MR asked where does the £800k saving come from and how many staff might be lost. TN replied that it depends on options; we are in the early stages of looking at what we would be able to deliver, however it was noted that there would be no redundancies due to the vacancies we cover via temporary staffing.

JD commented that we need to agree the most sensible options for us to then take to the commissioners for discussion.

The Plan in January was red rated however it was acknowledge that the Trust had made significant progress in the March submission. There were no firm plans at this stage for future fit but there was an acceptance that there will be a solution going forward. The TDA want to make sure that the Trust is still operating as a business however we do need a solution for the future. We need to demonstrate that we could breakeven without dependence on future fit.

TD referred to the future challenge on CIP, the March submission proposed a £2.9m improvement that would leave a gap of £600k still to be identified.

If the Trust moved to a balanced position in 2014/15 & 2015/16 the red rating would be removed. This would give a CIP target of £3.5m; cash would return to a healthy position and capital maintained at a similar level however it all depends on the level of CIP that can be identified.

MS questioned the £3.1m saving in 2015/16. TD confirmed that if there were any cost pressures locally they would be added to that figure.

PP referred to the proposed submission for 5 March and the summary CIP plan and said we had to ensure that we achieve the community bed efficiency of £0.8m and the Clinical Innovation and Productivity of £0.7m and acknowledged that there was still work around directorate efficiencies to achieve the £0.6m. TD confirmed that the Trust was not 100% but schemes were progressing.

TD referred to the balance currently unidentified on the summary CIP plan of £0.6m for 2014/15 and £1.9m for 2015/16 and recommended that we submit on 5 March with the aim of achieving a balanced position.

MR confirmed that he was happy with the submission however acknowledged the huge challenge ahead for a small Trust and gave his support on behalf of the Board.

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TD reiterated the challenge in terms of the CIP agenda but we still have a strong cash position to enable us to operate if we can deliver our plan and position we could run a deficit for a year.

JT talked through the narrative of the submission – putting more focus in making us deal with situation independently

It was noted that the first draft of clinical design work on future fit model will be released this week with potential for future growth around integrated community teams and community hub.

JT commented on the description in the narrative; small changes; growth in health visitors; anticipating what future fit will require; generic and special roles; specifics in appraisals; mandatory training; workforce transformation for future fit.

MS asked if we could be so specific in savings in community hospitals when we do not yet know how many or what sort of people we will require for “future fit”. JT commented that we would not be undermining our future ability. In order to achieve £800k we are taking out staffing commensurate with number of beds, but we are hoping we will get to a position when this does not actually happen.

JT commented on the short narrative and template and the initial work for the two year plan with the final submission due at the TDA on 4 April.

JD felt the Trust was well supported at the meeting with the TDA and positive comments were received.

The Resource & Performance Committee approved the initial version of the two year plan due for submission on 5 March 2014.


9.1 Business Developments – Proposal for Reporting to the R&P Committee

Vic Middlemiss joined the meeting to present the proposal for reporting to the Resource & Performance Committee and the following points were noted:

The proposal aims to ensure that reporting of business development issues is completed in a planned, systematic way and gives the Committee greater assurance around the work being undertaken.

A report would be received by the Resource & Performance Committee on a quarterly basis commencing from March 2014 in the form of service development proposals; tender updates; service transfers; decommissioning; updates from the Internal Planning & Investment Group and themed issues on organisational topics related to business development.

Whilst MS agreed with the idea of three monthly updates he felt that they must then be comprehensive (i.e. Including all developments which involve significant reallocation of resources, such as last year’s 'integrated teams’ approach), they must be demonstrably consistent with our future vision and be subject to some simple scoring method to demonstrate their priority for investment, e.g. They might have to tick the boxes of at least 3 of, say, 5 standard judgment criteria”.

The Resource and Performance Committee approved the proposal for quarterly updates for business develop/strategy issues, as a combination of standing items and themed topics.

9.2 Business Development Update

Vic Middlemiss presented the Business Development update and the following points were noted:

Shropshire CCG prioritisation bids – a proposal on six specific service

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developments was submitted to the CCG in November 2013. The prioritisation process was discussed at the CCGs February Board meeting however notification of the outcome has still not been received to date.

Nurse technology fund - an expression of interest is to be put forward by the Trust for the next bidding round which is part of the national fund to buy innovative technology to support nurses.

Tender update: – School Nursing T&W Council tender to be released this week. It was

noted that a project team has been established to respond to the tender.

– Drug and Alcohol Recovery Service to be tendered by T&W Council. Commissioners have issues a nine month extension of the current service until December 2014.

– Musculo-skeletal Service T&W CCG tender due to be released in the next 4/6 weeks. Notification of the contract end dates to the services is not known.

New Service Opportunities – Community Gynaecology Service T&W CCG – noted new service

development which will be fully assessed once advertised. It was noted that and audit had been undertaken of the Trust’s tendering

process and a draft audit report is due in April. H2Q Services Shropshire – Noted the extension of our contract for service

delivery for a period of 3 months with a possible extension of up to a maximum of 6 months accepted in principle.

MS said that when looking at new developments we need to demonstrate that they are in line with our strategic vision and consistent with “future fit”.

SG referred to the CAMHS business case. VM said that the business case required more work. SG suggested a proactive approach with agreed timescales to come back to this Committee.

The Resource & Performance Committee noted the content of the Business Development Update.

10. Communication from the TDA/DoH

Property:

The Committee noted the communication issued by the TDA, Department of Health and Monitor dated 27 January 2014 relating to surplus NHS land. It was noted that the Trust had not currently declared any surplus land.

The Committee noted a letter dated 12 February 2014 from the Department of Health addressed to all Trusts who had received land and buildings from former PCTs on 1 April 2013 reminding them of the conditions on transfer that were contained in all Health and Social Care Act 2012 property transfer schemes.

Procurement:

A letter dated 3 February 2014 from the Department of Health and TDA detailed a number of initiatives being taken forward nationally. It was noted that the Trust’s procurement strategy was being developed and would address these requirements.

It was agreed that Peter Philips would be the Trust’s NED representative to ensure appropriate Board level focus; with whom the procurement team would engage to share information and for Peter to attend a procurement summit in 2014.

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11. Mayfair Church Stretton

TD presented an update on discussions between the Community Trust and the Mayfair Trust to establish a Health & Wellbeing Centre in Church Stretton.

The Trust is proposing to offer a 20/25 year lease (on a peppercorn rent) to the Mayfair Trust in exchange for guarantees from the Mayfair Trust to fund the conversion of the existing Health Centre into an exemplar Health and Wellbeing Centre.

After discussion the Committee agreed to recommend to the Board that subject to the satisfactory conclusion of current discussions with the Mayfair Trust, issue a 20/25 year lease (at a peppercorn rent) in exchange for confirmation of investment (circa £750,000) to convert the existing Church Stretton Health Centre into a Health and Wellbeing Centre.

To sanction the increased capital charge element of £42,000 (from the current £18,000) per annum – this will not become payable for five years (i.e. 2019) when the District Valuer assess’s the increased value of the property.

The nomination of an individual to represent the Community Trust’s interests on the Church Stretton Health and Social Care Partnership would be agreed by the Operations Directorate outside the meeting.

12. Terms of Reference for the Resource & Performance Committee

The Draft Terms of Reference for the Resource & Performance Committee were agreed by the Committee. They will now be presented to the Trust Board for ratification.


13.1 IM&T Steering Group Minutes

The Committee noted the minutes of the IM&T Steering Group held on the 15 January 2014 which were approved at the IM&T Steering Group meeting held on 11 February 2014.

Apologies at director level were noted and it was suggested that a refresh of the IM&T Steering Group was required.


The following Single Source Agreements were noted by the Resource and Performance Committee:

14.1 Bridgnorth Hospital – Supply and install automatic oxygen manifold, control panel at a value of £5,800.00 excluding VAT supplied by HAC Technical Gas Services Ltd.

14.2 Children’s & Specialist Services – Sleep Systems at a value of £4,238.15 excluding VAT supplied by Symmetrikit.

14.3 Children’s & Specialist Services – Personal Child Health Record Books (Boys/Girls) at a value of £11,859.00 excluding VAT supplied by Harlow Printing.

14.4 Estates – Roofing and guttering repairs at Dental Matters, Castle Foregate, Shrewsbury at a value of £10,270 excluding VAT supplied by RG Hinds Roofing.

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15. Risk Assurance Update

There were no new risks reported at the meeting.

16. Burdett Checklist

It was agreed that the Burdett Checklist would be replaced on the agenda by ‘Meeting Review’.

Meeting Review 3 March 2014

Comments from today’s meeting were noted as follows:

TD noted the lateness of the detailed paper this month which resulted from resources in the finance directorate focussed on the financial plan and CIP analysis and staff shortages within the finance directorate due to sickness.

JD commented we are getting better and focussing down on where more information is needed.

PP commented on the need for more thought and strategy around the Trust’s bidding process - prioritisation issue.

MS queried community benchmarking best practice – JD confirmed that the Trust had just populated a range of groups through FTN (Foundation Trust Network) on benchmarking.


There was not any other business recorded at the meeting.


The next Resource & Performance Committee meeting will be held on Monday 31 March 2014 commencing at 9.30am in Room B, WFH Site.


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Monday 31 March 2014

Present: Mike Sommers (Chair) (MS) Rolf Levesley (RL) Peter Phillips (PP) Trish Donovan (TD) Tessa Norris (TN) Vic Middlemiss (VM)

In Attendance: Mike Ridley (MR)


1. Apologies: Jan Ditheridge (JD) Steve Gregory (SG)



3. Minutes of the Meeting held on 3 March 2014

The minutes of the meeting held on 3 March 2014 were agreed as a correct record.

4. Matters Arising

4.1 Action Log

FP10’s – payment expected detail included in the finance report – closed. Betsi Cadwaladr & Powys contract position - on–going – open.

5. Financial Monitoring for 11 Months to 28 February 2014

TD presented the Financial Monitoring report for Month 11 to 28 February 2014 and the following key points were noted:

The financial position was reported to be a surplus of £228k at month 11 against a planned surplus of £176k, which was a favourable variance from plan of £52k.

It was noted that to date £2,368k annual efficiencies had been identified against the CIP target of £2,504k.

The overall forecast remains to deliver the planned revenue surplus at year end. The Trust is forecasting £253k below its Capital Resource Limit. It was noted that the cash position remained strong. The level of risk around achieving year end had improved significantly. It was noted that table 10 was an addition to the monthly report and showed

graphically pay and agency in proportions of spend. MS queried why there was a budget reduction in February. TD confirmed that this was due to non-recurrent underspends transferred to the CIP Programme.

It was agreed to continue the trend graphs (table 8; year to date pay analysis by type) showing a year on year figure moving as a 13 month picture.

TN reported that the Trust was recruiting to substantive posts which were reflected in pay budgets total spend including fully funded commissioned agency.

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PP referred to centrally held budgets. TD explained that the budget had reduced by £1.4m due to the removal of transformational funding. There was an equivalent reduction in income.

MS queried operational budgets going forward and whether these would reflect spend levels. TD referred to the budget setting exercise at month six which aligned funding at the correct level, following a detailed review process, however also noted there will always be change in year, for example where there is additional funding for specific initiatives which may result in non-recurrent variances across income and spend compared to original budgets.

MS questioned vacancies recognised as CIPs resulting in a pay overspend offset by central budgets and asked why central reserves are not just put into CIPs. TD explained it was an operational decision to record some vacancies against CIP and these are areas of underspend e.g. children & families division, the overspends are in different areas and are driven by different things i.e., children’s where there have been non-recurrent savings in year they are recognised as non-recurrent CIP and you cannot take this underspend to offset cost pressures in other divisions e.g. community hospitals, central budgets are used to fund cost pressures whilst costs are expected to be managed down in the longer term.

MS queried where we are meeting CIPs with reductions in pay spends and questioned if people are not in post then why is it not recurrent. TN explained the approach was to deliver in year savings some of which are identified initially as non-recurrent that will transfer into recurrent CIPs as posts can be taken out of the system, reflecting service needs.

MR referred to page 4 and queried how the underperformance on contacts for non-PbR block activity impacts on the contract for 2014/15. TN replied this is across service lines and most have a tolerance level, contracts are likely to be based on outturn levels and there will be overs and unders, however she would look at this outside the meeting and report back.

ACTION: TN to confirm the totals. MR questioned agency and bank and asked if subjective budgets had been set

for next year. TD explained that we budget for the establishment not for agency because ideally we plan not to use it.

MR questioned the reduction in funded established WTE going forward as a result of CIP noting that it must be significant – this was confirmed later in the agenda under the financial plan item.

MR asked for clarity on the position with Betsi Cadwaladr. TD confirmed that payments had been received from Betsi Cadwaladr and the contract had recently been signed for 2013/14. Powys - we were initially looking at higher contract levels but they are paying for the activity received.

MS referred to page 3; payments ceased in January from Powys at £350k. TD confirmed that Powys had paid for activity delivered and the issues have been raised with the commissioner regarding the contractual position.

MS referred to non-pay expenditure and the timeframe of the wheelchair and community equipment review. VM agreed to report back to the Committee once the timeframe of the review had been agreed. ACTION: VM to inform the Committee of the timeframe of the review.

PP commented on the aged debt position including table 12, TD said she would expect some improvement as issues are resolved at year end e.g. prisons income which had been billed throughout the year totalling £386k which is now resolved.

PP referred to page 9; inventories increased by £112k due to an interim stocktake. TD confirmed that the counting had been verified however there had been some inconsistency on what had been previously counted in relation to consignment stocks and this is currently being validated for year-end.

RL referred to the capital underspend of £144k and asked if this would incur financial consequences for the Trust. It was noted that it was acceptable for

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spend to be under but not over the capital resource limit. It was noted that energy efficiency spend shown on appendix 7 had increased in

month 11 due to lighting in community hospitals. The Capital and Estates Strategy Implementation Group would be looking at

investment developments in the future. MR queried page 10 NHS England prisons funding at a full year value of £386k.

TD confirmed settlement had been agreed non-recurrently for 2013/14 which would be paid by NHSE through Shropshire CCG, in addition this is agreed and included non-recurrently in the 2014/15 contract with Shropshire CCG.

The Committee noted the financial position at 28 February and that the forecast year-end position remains on plan.


TD reported on the forecast year end position for risks and opportunities. It was noted that the vast majority of opportunities had been progressed, and risks mitigated - additional prison funding resolved; PbR income agreement reached; patient transport costs resolved; FP10 charges we are receiving payment from some commissioners and agreement has been reached with others; continence products resolved; AQP income agreed for 2013/14 and included in the contract. It was noted that HIMP redundancy costs funded by TWCCG/TW Council remained red rag status, as discussed a few months back but was included for completeness. Why weight/enhanced prescribing funding settlement agreed in part however it was noted that we need to review this for the future. ACTION: TN

It was noted that the risks and opportunities summary would continue to be reported at this Committee going forward into 2014/15.



TD presented the Performance report and the following key points were noted:

National indicators below target: - Complaints acknowledged within 3 working days RAG status red. This is an

annual target and will remain red until the end of the financial year. - Safety Thermometer RAG status amber with February’s patients considered to

be harm free at 94.06% against a target of 95%. The national average of all providers in February was 93.3% and this target will also remain amber until April. Work is on-going to clarify if this is a data issue or the trend is correct. It was noted that there had been a steady improvement over the year and the Trust was still above the national average.

PP referred to the pie chart summarising performance against contractual targets with an indicator rating of 8 red. Key targets need to be monitored and the organisational targets relate to agency usage and sickness absence and need to be driven down.

MS referred to falls and pressure ulcers and in one or two cases issues in June and July set the plan red for the year. TD explained that this related to a historic element of reporting that had not been changed however where it is not the national target discussions are now taking place around reporting and this will be reviewed in the New Year.

MS suggested benchmarking pressure ulcers and data entry 21 days with other similar Community Trusts to compare their reporting process. ACTION: Benchmark pressure ulcers and data entry 21 days

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TN commented on the work of community nurses and the tissue viability team who work to drive down this target but agreed it will always be red rated the way it is reported.

MR asked who was responsible for monitoring performance. TD explained that the TDA monitor national indicators and monthly meetings are held between the Trust and TDA. Commissioners monitor against indicators within the contract and two meetings are held monthly (performance and quality) to go through performance reports and sign off serious incidents. Commissioners have sight of root cause analysis and go through quality indicators in great detail.

MR asked who sets the target for agency 3%. TD explained the process between the Trust and CCG; local targets are discussed agreed and monitored through the contract. Whilst the financial schedule for the 14/15 contract had been signed performance indicators are being finalised. TN reported on on-going work in driving agency down, work had not started on reducing health care agency assistants some agency spend is in service areas that we are struggling to recruit to and this contributes to the position. It was also noted that schemes such as winter pressures are variable and involve agency usage.

MR referred to page 16 ‘bed occupancy’ and the £800k included in CIP plans. Paragraph 3 refers to prolonged length of stay due to complexity and patient dependency levels. It was noted that Julie Thornby was chairing a meeting with the CCG on behalf of Jan who had initiated conversations before her leave. The Trust’s plans are predicated on achieving 20 day length of stay based on the review by Finnamores indicating capacity release of around 16 beds. There are a variety of patients in acute and community hospitals who could be cared for in a different setting. Those beds could be released or re-commissioned which may require a different skill mxi. It was noted that the Acute Trust are looking at commissioning an organisation to undertake "hospital at home". We have ongoing dialogue with the CCG on bed utilisation and funding however the long term position may not be clear until the implementation of Future Fit. We may need a transitional arrangement.

MR was still concerned that length of stay would not be reduced sufficiently this year. TN reported that the Trust had achieved the target for 2 months; the criteria had been flexed and different processes had been introduced over the winter months.

Options to deliver the community bed efficiency were discussed in detail and the options noted. It was recognised that transitional arrangements may be needed given the work on Future Fit, however it was also noted that if beds are not decommissioned we will have some difficult decisions to consider in order to release efficiencies.

The Resource & Performance Committee noted the current performance in relation to key performance indicators as at the end of February 2014 (M11); the actions being taken where the performance requires improvement and discussed and questioned the report to ensure that appropriate assurance was in place.

8. 2014/15 Plan

8.1 Budget and Contracts

TD updated the meeting on budgets and contracts, noting that due to meeting timing, the opening budget has already been approved by the board, the following points were noted: It was noted that signed financial schedules for the Two CCGs and NHS

England are in place. Within the two CCG financial schedules some cost pressure funding has been negotiated.

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MR questioned how the Trust would monitor contract performance in 2014/15. TD explained that new information was being developed and a software package purchased to support reporting, and this would be reported through performance and finance.

MS said we need to agree the detail on how the Trust measures performance over and above the current need and the importance of tracking performance on key areas year on year.

8.2 Annual Plan

TD and VM presented the Annual Plan which was fully discussed by the Committee and the following points were noted: The meeting noted feedback from the TDA following previous submissions,

including the point that a Trust Strategy for delivery was required ahead of Future Fit.

The financial submission was noted, including the updated CIP position. It was agreed that from next month onward CIP would be added as a

separate agenda item to enable full discussion by the Committee. ACTION: To include CIP as a separate agenda item in future.

Work being undertaken by the Task & Finish Group on the vision and strategy for community services must be factored into the 5 year plan.

The Trust is exploring with the TDA the exact requirements around the IBP, given that we do not currently have an agreed timescale for a FT application.

It was noted that a 5 year LTFM is required. The committee agreed the approach should be to target financial balance or better for the 5 year plan and this will include an as yet unidentified CIP requirement based on national planning assumptions. It was noted that this may partly be delivered via growth as a result of service changes.

The Resource & Performance Committee approved the initial version of the final two year plan due for submission to the TDA on 4 April 2014.


9.1 Business Case and Tender Update

Vic Middlemiss presented the Business Case and Tender/Bid reporting update which will become an appendix to the monthly Transformation report in future.

MS referred to the scoping exercise by SaTH on healthcare at home. The Trust needs to build and deliver a broader spectrum of services around the community vision. We will need to see the scope of the recovery at home service to build the community strands and link them in with the overall clinical strategy. Our internal strategy must have examples to show how acute costs can be reduced by our strategic initiatives and to justify the allocation of resources. The Trust will submit its tender to Telford and Wrekin Council for the School Nursing Service on 3 April. £398k is the annual contract value. Our submission will be very close to the contract sum indicated. We assess direct, indirect and full costs and are looking at the level of contribution to overheads. The direct costs are less than £398k but with the addition of indirect costs and overheads this rises. If the Trust is not successful in securing this tender it would fragment the service from Shropshire which links closely to Health Visiting and handover from preschool to school. It was noted as part of the

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tender process there is a requirement to do a presentation in May with the successful bidder commencing the contract in September 2014. Staff have already been formally notified and it has been made very clear that the Trust would expect TUPE arrangements to be put in place if we are not successful.

MR referred to occupational health overspending. TD confirmed that part of the overspend was that the budget for income remained at the higher level however in 2014/15 the income target will be lower and back in balance. The Resource and Performance Committee noted the update on Business Cases and Tenders.

10. Transformation and CIP Programme Board – Minutes

The Committee noted the minutes of the Transformation and CIP Programme Board held on the 18 February 2014.

MS commented on NP5 and 6 alternative models of provision. VM confirmed that he was overseeing a review of community equipment and wheelchairs and would appraise the current service on finance and performance.

TD confirmed that Service Line Management was not currently being taken forward as a specific project however it would come back in line at an appropriate time in the future.


11.1

IM&T Steering Group Minutes

The Committee noted that the Information Management & Technology Steering Group meeting scheduled for the 11 March 2014 had been cancelled.


The following Single Source Agreement was noted by the Resource and Performance Committee:

12.1 Finance & Informatics – Procurement of InPhase BMS Comm DW Tool Kit a bespoke software solution to link with the current data warehouse for the provision of performance reporting at a cost of £46,660 excluding VAT supplied by InPhase Limited.

13. Meeting Review including Changes in Risk Ratings

There were no new risks reported at the meeting.

The meeting was reassured on the achievability of this year’s financial position and the associated risks.

Agreed that business developments would inform the Transformational Development Board.

The Committee agreed that the meeting was productive.


There was no any other business recorded at the meeting.

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The next Resource & Performance Committee meeting will be held on Monday 28 April 2014 commencing at 9.30am in Room B, WFH Site.


Quality and Safety Committee – Shropshire Community Health NHS Trust

Quality and Safety Committee Minutes 30 January 14 Page 1 of 9

ENCLOSURE 1

MINUTES OF QUALITY AND SAFETY COMMITTEE

HELD ON 30 JANUARY 2014 SHROPSHIRE COMMUNITY HEALTH NHS TRUST

ATTENDEES: Angela Saganowska, Non-Executive Director (Chair) (AS) Mike Ridley, Trust Chair (MR) Steve Gregory, Director of Nursing (SG) Julie Thornby, Director of Governance and Strategy (JT) Dee Radford, Quality and Safety Facilitator (DR) Rolf Levesley, Non-Executive Director (RL) Dr Alastair Neale, Medical Director (AN) Trish Donovan, Director of Finance (TD) Mike Sommers, Non-Executive Director (MS) Sally Anne Obsorne, Deputy Director of Operations (SO)

ATTENDING TO PRESENT PAPERS: Rita O’Brien, Chief Pharmacist (RO) Peter Foord, Risk Manager (PF) Lynne Taylor, Deputy Director of HR (LT) Joy Tickle, Tissue Viability Nurse Specialist (JTK)

APOLOGIES: Jan Ditheridge, Chief Executive (JD) Tessa Norris, Director of Operations (TN) Andrew Coleman, Deputy Director of Nursing & Quality (AC)

MINUTES: Sharon Turley, PA to Director of Nursing (ST)

Welcome AS welcomed Steve Gregory and Mike Sommers to the meeting.

1.0 Apologies Apologies were received on behalf of the committee members listed above.

2.0 Declaration of Interest

There were no declarations of interest from those present at the meeting.

3.0 Minutes of the meeting held on 28 November 2013

The minutes of the meeting held on 28 November 2013 were agreed as a true and accurate record.

4.0 Matters Arising

Action Log See also completed action log:

31.1.13/11 – AN confirmed that he has yet to meet with AC and will report back to next meeting.

26.9.13/4 – Some information obtained from Worcester. No other data available that would be useful. Completed.

26.9.13/05 – TD reported that the IT Strategy was under development and she has been liaising with TN. Data collection will be addressed. This is early stages. TD would like to include data quality confidence levels on future reports to flag areas where we have made progress or not. The main work is through operations and reporting into R & P Meeting. Deadline deferred to March 2014.

31.10.13/07 – More detail regarding medical study leave to be provided by AN who is awaiting confirmation on budget working with Sara Vale and Sonia Orr. Policy has been written and is going through approval processes at present. Completed.

31.10.13/09 – SG/DR/AC meeting re Quality Strategy.



28.11.13/01 – Divisional Manager for Community Hospitals is undertaking a review of the SLA at present and a paper will be prepared and discussed at the Executives Meeting.

28.11.13/07 – Data reflected in Quality Report. Completed. Work Plan

DR stated that the Patient Experience and Public Engagement update were deferred to the February meeting. With regards to the Quality Governance Assurance Framework AN will review this first and so this is also deferred. There was no Trust Board visits feedback as there were no formal visits in December. Burdett Trust Review The Burdett Trust Review was agreed to be an accurate record of the last meeting. The top clinical risks are given to the Board. Audit process of risks identified on Burdett checklist AS stated that it was important to ensure that issues flagged up are followed through. JT has produced a paper and explained that the risks are given to Peter Foord at which time they are reviewed to make sure they are captured within the risk system or if they are new a decision made as to where they need to be managed. A discussion ensued regarding the assurance of risks and reporting to the board. Action: JT to discuss with Execs the reporting of risks/assurances to the Board and report back to the Committee. Whitchurch Whistleblowing Report and Action Plan The above report was taken as read and SO gave updated highlights from the report and action plan. Recruitment was on track with two sisters recruited on wards who were now providing support to Ward Managers. A meeting has been arranged with HR to look at staff rosters and developing standard operative procedures to get a better mix of staff on nights and weekends. HR are also assisting with workload management looking at clustering training in localities. This also feeds into rostering to give staff time to go for training. SO confirmed that with regard to HCAs administering medicines which had previously been rated as amber, assurance was given that HCAs only give medication under instruction and supervision of a registered nurse. A rolling programme is in place for recruiting bank staff. The team have met to look at a process to develop sharing information. Therapists do go on ward rounds in the mornings and have input into documentation and health records. 1:1’s are scheduled and the CSM is providing support to the Team Leader and Ward Manager and systems and processes are being developed to make sure the workload is manageable and flows through the whole workforce. The CSM will be attending ward meetings to ensure information is cascaded down and up. They are looking to improve handovers and are exploring the productive ward model to



ensure effective and right information is handed over. Staff have been reminded to open emails every day and that this will be monitored. There is good access to computers so this should not be an issue. SO confirmed that this should be scheduled into the day but not during visitors time when staff should be around and visible. With regards to the work needed on the MIU entrance door this issue is being escalated. SG suggested numbering the actions following them through. He stated that national staff rota management gave the biggest savings and this was an urgent issue to do. There was a professional code regarding behaviours, and this did not appear in the action plan. SG had spoken to some of the CSMs and there were important issues not just pertinent to Whitchurch and as a Committee we need to assure ourselves that big issues are covered elsewhere also. SO, TN and SG are catching up to progress these issues including professional code, expectations from all staff and governance around action plans which is critical. A discussion ensued regarding the development of competencies and providing the right care for people with complex needs. RL asked for assurance regarding the quality of agency staff as this had been talked about during the Ludlow exercise. SO confirmed that prior to a nurse’s shift we would be assured that they are competent and registered. They will be observed in their shift and informed as to processes in place on the ward and expectations. SG stated it was important to pick up any issues actually at the time. A discussion ensued regarding having an update at the next meeting regarding outstanding actions rather than the whole action plan. Action: Update on outstanding actions for Whitchurch following the whistleblowing to be brought to next meeting. TD confirmed that the performance team are developing a document regarding proposals on monitoring and processing action plans, this is currently being drafted. SO informed MR that there were plans in place to recruit substantive staff and the bank has been increasing. From 1 April 2014 staffing levels will be reported. SO stated that if patients with dementia needed closer support HCAs give additional support when required.

5.0 Quality Report including: Performance/Serious Incidents/Nursing Issues/QRP With the paper taken as read AN stated that this report was becoming increasingly

easier to read with more helpful narrative contained within it and being more analytical. Appraisal rates to be discussed later in the meeting with LT. A short discussion ensued regarding the wish for improved use of ESR and staff being competent to ensure completed appraisals are recorded on the system. JT stated that there are a series of sessions taking place to support Managers targeting and there is a targeting of areas which show lowest appraisal rates. SG suggested that when complaints and Sis are being reviewed, that appraisal and training compliance to be noted and to reinforce the importance. JT explained that due to the changes in the national pay and conditions system during the next year training and appraisals will need to be completed to get through to the next salary increment. SG explained to MR how the average length of stay was worked out and stated that



some organisations report the median as opposed to the mean. District Nurse response times are going down but it is thought this is a data issue. RL thought we should perhaps have a higher target reference new birth visits which was noted. MR spoke about data quality and improved access to computers to help. Encouragement was being made to get all staff to check their computer each day although SO said it was a matter of mind set with patients coming first but there was a need to protect some scheduled time for this. Quality Risk Profile – DR stated that there had been no change from the last profile, there was a small amount of data but the risk had not changed. With regards to the Inspection Report for Oswestry Health Centre congratulations to the staff involved were noted, with full compliance of all standard being achieved. The key issue was the building. SO confirmed that the CSM is progressing these issues. AN commented that staff should perhaps have raised these issues appropriately and they could have been dealt with.

6.0 Terms of Reference – for review and approval of amendment AS stated that the function of the Committee would be reviewed and so there may be

further changes to the Terms of Reference. Page 5 still refers to PCTs and so will need to be amended and page 6 – further requirement that members should not be absent for more than 2 meetings without approval of the Chair. These amendments were agreed. Action: DR to ensure amendments made as agreed to Terms of Reference

7.0 Pressure Ulcer Peer Review Report JTK was welcomed to the meeting and introductions made with all members present.

The report and appendices were taken as read. AS explained that the Committee wanted to look at Community Hospitals and teams and the peer review would look at where good practice was and what we can do to improve. This was a comprehensive set of reports and JTK presented the key findings. Community Hospitals – positive actions included the profile information above patients’ beds and the management and information on wards. There was a valuable contribution of the Pressure Ulcer Prevention Team. Nutrition and Hydration considered along with comfort rounds. All pressure ulcers had RCA and were datixed with tissue viability links. There was some improvement in care planning on all new patients on admission as this wasn’t regularly updated and this was raised. JTK spoke of the consideration of repositioning of patients that actually could get up and about and equipment provision was not consistent at all hospitals. There was no regular audit of the SSKIN document which was maintained. Community Teams – good practice was recognised with regular team meetings particularly about pressure ulcers. Pressure Ulcer mandatory training was good. Patient leaflets were in use. Equipment was in staff cars and so was readily available with satellite stores. There were workload pressures in certain teams. The SSKIN was not always completed on the first visit and assessment and treatment plans did not always reflect



the patients complex needs. There was also concern regarding accessing pressure ulcer equipment urgently. Actions had been drawn up from the review. An audit of the SSKIN documentation is now on-going and will take place regularly. There is increased engagement in involvement of patients and the Lead Nurse has been visiting Community Hospitals. With regards to documentation and care planning there is new nursing documentation being implemented; JTK and two other leads are looking at new pressure ulcer documentation for inpatients with Birmingham sharing information which will assist greatly. The Community Hospital leads were looking at standardised equipment for community hospitals. Meeting had been taking place with community leads regarding end of life, looking for improvements. Safety thermometer – having own safety thermometer boards and benchmarking against this. JTK stated she was working with Birmingham and the Tissue Interest Group for West Midlands looking at a grading tool. Our pressure ulcer prevalence is lower compared to some counties although we report all pressure ulcer damage where as some counties do not. Quality visits have helped keep momentum. JT stated that this review had been a good experience and one which we would welcome again with external people. DR confirmed that there had been some positive feedback. It was agreed that we should always strive for the zero target. DR stated that she visits each of the community hospitals once a month and looks at 5 patients and their journey. Discussions continued regarding the community teams domiciliary care, training and education for carers for which patient leaflets shows images and explains what to look out for. A proposal had been put in to increase resources for specialist support. JTK assured AS that with regards to community equipment they were aspiring for more robust processes. JTK explained the SSKIN 5 key points for MS. SO stated that they were looking at this and what has to be completed on the first visit. It was agreed that if there were complex needs that the process would take longer and that this should be best practice. AS said that prevention was crucial and asked if there was anything the Committee could do regarding resources in domiciliary care. SG asked if this gets picked up at Shropshire Partners In Care and JTK confirmed it was. Karen George collects data at the care homes as there was a high proportion of referrals from them and doing a lot of education. A discussion ensued regarding the training in care homes and the fact that some counties pay for this training and support. RL thanks JTK for her good work and it was agreed to have an update in 6 months’



time. Action: Pressure Ulcer Update to be provided in 6 months’ time (July meeting)

8.0 Inquest Report PF was thanked for his Inquest Report and went through the key features within it. The

coroner had directed two judgements which did not read well for our organisation. The Health and Safety Executive had been involved in this incident as it was an accident at work and we await a decision as to whether this is being taken further. Discussions ensued regarding possible outcomes. If it was believed there was a material breach costs can be recovered. An improvement notice could also be given. It may take many months for a decision to be reached. RL asked about possible learning around the bed alarm and PF stated that existing systems tested better, however some with this type of alarm have failed and some organisations have stopped using them. Investigations are still taking place as to what we may do. There is a three year limitation from the date of the incident. PF stated that we have a lot of falls in hospitals and we have looked at the work being done in Birmingham with DR and we compare well, in fact remarkably low. PF stated that we have a death in custody outstanding inquest which although was due to be held has now been postponed to October. He confirmed for AS where our responsibilities lay in that we provided primary medical health care. It will be a 2 week inquest and there will be gruelling questioning. PF confirmed for SG that there had been some shared learning from this case and improvements made. Action: PF to meet with SG to discuss the Inquest Hearing in October.

9.0 Francis Inquiry Action Plan Update AN stated that progress on the action plan was noted and for information of the

Committee members. We will be aiming to try and made this a bit more succinct and look at the overarching culture. MR asked about the recent publicity of having a named nurse and named doctor for each patient but AN explained that this was mostly about consultants in acute hospitals although Dr Clowes will be looking at this for us DR on her quality visits. There was a discussion about the role of Clinical Leads. Andrew Coleman is bringing the review to a conclusion. SG added that there had been some differences in the roles and bandings and a need for a different culture. With reference to monitoring and future assurance for the Committee of changes in culture this can be picked up when reviewing the role of the Quality and Safety Committee.

10.0 QUARTERLY/SIX MONTHLY/ANNUAL UPDATES

10.1 – Medicines Management Quarterly Report RO was thanked for her report which was taken as read. With regards to the Prison action plan it showed what needs to take place although progress had been slow. There had been some negotiations with the Commissioner on short term increased capacity although to be effective the prison also needs to assist. There are some security level issues. There had been a couple of incidents in prison of overdosing on personal medication. There had been a prison meeting a couple of days ago to move on with some issues. A good HCA works at the prison and has pharmacist support.



Concern was expressed of our staff being exposed to potential danger. RO confirmed that security staff had decreased over the last year and this had caused limitations for the health care staff leaving a degree of risk. RO stated that this was discussed at a recent meeting and it was agreed to review the timings and gave her the opportunity to discuss the risks. There was further discussion about how to flag these risks to the LAT Commissioner in writing to express concerns of these unacceptable risks. It was agreed that this needs to be formalised. SO gave assurance that these issues had been discussed within Operations but had received feedback that this matter was resolved, different messages being received, and so it was agreed that this was now a high priority. Action: SO/RO to draft a letter from the Chief Executive to be sent to the Prison stating we required a written response to our concerns/risks at the Prison and ensure this is on our risk register. RO went on to explain that there had been a big focus on CQUINS audits with a final audit in February to be completed. RO spoke about the issue of prison waste. With regards to nursing incidents there had been a few procedural things slipped in December and so spot checks were being done to address issues and share with the wider community. Training regarding non-medical prescribing had been well received. RO gave thanks for the Committee’s support for the prison issues. 10.2 - Quality and Safety Operational Group Quarterly Report AN reported good membership and attendance at the Quality & Safety Operational Group meetings. The majority of papers reviewed follow to this meeting. Risks are identified in a similar way to be passed on to this meeting. Divisional Managers provide interesting reports from their areas, there are usually two verbal and one formal update from them which provides informative and gives a greater understanding of the risks in more depth. This meeting will be reviewed in line with this Committee and if necessary a revised Terms of Reference will be submitted. 10.3 – OD and Workforce Quarterly Report With those present having read the above report LT confirmed that it focussed on key hotspots as previously requested by the Committee such as; sickness absence, appraisal rates, mandatory training and flu vaccination update. Sickness - The sickness level from October – December had been quite static at 4.68%. The HR Team are working with managers to give support through sickness absences and assisting with how to manage any hotspots. A discussion ensued regarding recognising stress. LT stated three part time advisors had been taken on with Transformation Funding who will support Divisions regarding sickness absence and will be working with Occupational Health. LT confirmed that NED’s sickness was not recorded. A discussion ensued regarding workforce planning for maternity absences. RL asked what the new staff would be



doing differently to assist. LT said that they would be giving more dedicated time in their support to managers looking at health and wellbeing with a planned website and dedicated 1:1 support. The staff are fixed term for 12 months and whilst they were performing this role it would obviously free up other staff for other duties. Action: LT to include update on work being done by the 3 new HR Advisors in the next 6 monthly report. Appraisals – The latest update for appraisals was 52% completed. An appraisal support plan was being pulled together to get an understanding about what is happening. Two members of the Workforce Team are going out to all areas to support managers with inputting onto the computer record and new appraisal system training is also being undertaken including using ESR. Managers were being targeted for those appraisals not completed. LT stated that as from 1 April this year staff would be unable to go through the next pay point if they had not met their objectives, completed all necessary mandatory training and had their appraisal. This would hopefully see an upturn in figures. A discussion continued about the numbers some managers have to appraise and the need to ensure there is still a quality appraisal. AN suggested an item in Inform about appraisals. Action: LT to ensure item in Inform regarding how appraisals affect people and include a link to Agenda to Change. MS asked about bank only contracts and TD explained the current situation. Flu Vaccination – The flu vaccination figure was currently 54% and there had been a big push to improve with a payslip questionnaire and an email to staff. Vaccinations were being offered at the MIU to encourage staff to have it done in their work location and on 7.2.14 they will, be offered at the HV Conference. It was hoped to plan more in advance for next year. Other possible gatherings were being targeted and thee was a need to sell the positive benefits. Volunteers to become Flu Champions next year have been asked for. 10.4 – Equality and Delivery Standards Report The above report was taken as read and JT went through the key highlights. The paper attempts to get meaningful feedback from our services. Questionnaires have limited gain. Mark Donovan had his first meeting of the Patient Council which had a good mix of people present and he was keen to grow the diversity of this rather than rely on questionnaires for feedback. The Trust has introduced an equalities impact assessment as part of the quality impact assessment carried out on every proposed cost improvement before it can be agreed to go ahead. The Equality Delivery System is a way of assessing against key headings on equality and diversity and the report details a new refreshed system. A discussion ensued regarding the two original outcomes which have now been dropped referring to staff with protected characteristics. JT spoke about disabilities and recognising people with particular needs.



11.0 Policies for Notification: From Organisational Development and Workforce Meeting, 23.12.13:

Uniform Policy

The above policy was noted. 12.0 Burdett Checklist for completion including identification of key risks:

See also completed Burdett Checklist: Preparation – Medical Director met with the Chair of the Committee prior to the

meeting to agree the agenda. Nothing new since papers had been circulated Nothing missing from the meeting CQC report reflects good patient experience in MIU Oswestry. Pressure ulcer peer review gives assurance relating to practice around pressure

ulcers. Prison staff experience reflected in Medicines Management report. Appraisal rate and the actions being taken to address. No walkabouts reported upon. Dashboard - still duplication of reporting – actions required. All discussions at meeting related to quality. Medicines Management in the Prison and security of Trust staff due to changes

in practice in the Prison. Upcoming inquest relating to death in custody in terms of staff experience and

also potential damage to Trust reputation. Checklist to be reviewed to ensure good feedback to Board. Good discussion around a range of topics regarding quality. Assurance – Medicines management in prison and the implications for our staff

– negative. Pressure ulcer peer review – positive.

13.0 Any Other Business There was no other business.

Date and Time of next meeting AS and RL were unable to make the next planned meeting on 27.2.14 and so it was

agreed to look and see if it was possible to move the date to the following week or consider cancellation.


Quality and Safety Committee Meeting March 14 Page 1 of 6

MINUTES OF QUALITY AND SAFETY COMMITTEE

HELD ON 27 MARCH 2014 SHROPSHIRE COMMUNITY HEALTH NHS TRUST

ATTENDEES: Angela Saganowska, Non-Executive Director (Chair) (AS) Mike Ridley, Trust Chair (MR) Julie Thornby, Director of Governance and Strategy (JT) Rolf Levesley, Non-Executive Director (RL) Dr Alastair Neale, Medical Director (AN) Sally Anne Obsorne, Deputy Director of Operations (SO) Andrew Coleman, Deputy Director of Nursing & Quality (AC)

ATTENDING TO PRESENT PAPERS: Mark Crisp (MC)/Soma Moulik (SM)

APOLOGIES: Jan Ditheridge, Chief Executive (JD) Steve Gregory, Director of Nursing (SG) Tessa Norris, Director of Operations (TN) Trish Donovan, Director of Finance (TD) Dee Radford, Lead Nurse for Quality (DR)

MINUTES: Sharon Turley, PA to Director of Nursing (ST)

Welcome

AS welcomed those present to the meeting.

1.0 Apologies Apologies were received on behalf of the committee members listed above.

2.0 Declaration of Interest

There were no declarations of interest from those present at the meeting.

3.0 Minutes of the meeting held on 30 January 2014

The minutes of the meeting held on 30 January 2014 were agreed as a true and accurate record.

4.0 Matters Arising

Action Log See also completed action log:

31.1.13/11 – AN had met with AC and then DR/Michelle Bramble to look at a different style of meeting than the Clinical Advisory Panel. Consideration was being given for a twice yearly meeting interested in audit and improving practice and quality outcomes. The first meeting may possibly be in September. AC has the Terms of Reference from the CCG and will alter it for our use. He will also go to the RJAH to observe one of their meetings. Completed A discussion ensued regarding sharing good practice Trust wide and a link in with the Community Trust Leadership Group. AS asked about the audit programme and mechanisms to get an overview of audits being targeted. AC confirmed that his team does this and then links to the Audit Committee. As agreed Terms of Reference for this Group will come to this meeting.

28.11.13/5 – Performance Framework – JT updated that there were new aspects including reviews of each operational division which will then move on to corporate departments. Completed

28.11.13/12 – AN had received the report this week and needs to look in more



detail but confirmed that relevant pathways were followed and the Liverpool Pathway was in place. There were some learning points taken from this and they will be included in Dr Ganesh’s Mortality Review. AC explained that the End of Life Care Policy was being ratified through the Clinical Policies Group and when approved would come to this meeting. Completed.

30.1.14/1 - JT had looked at the use of the Burdett Checklist and the risks coming out of it. Peter Foord picks up these issues from meetings and tracks them through to ensure that they have gone on the correct register or board assurance framework. After discussions regarding the checklist it was proposed that formally each Committee would be asked to report risks and assurances and PF would pick these up. JT asked if there was a preference for this Committee to use the checklist at every meeting and/or do we look in 6 months’ time to evaluate. It was agreed to review the list and adapt it to be simpler format and also to propose to the Board and other Committees to evaluate meetings 6 monthly or annually. Completed

30.1.14/6 – SAO updated that a letter did not go from the Chief Executive to the Governor of the Prison as the following day there had been a Prison Partnership Board Meeting where the issues were raised and discussed. Actions were undertaken by the following week around the safety of staff being escorted when involved in the wings and when receiving medication from the gate. Subsequently there had been various meetings with Managers of the wings and an Area Team visit and inspection the report from which had been received earlier this week. The Local Area Team had said that alterations had to be made to the clinic rooms as they were not acceptable or fit for purpose and the Governor had given clear instruction that their response was to put this right. SG had met with the lead and will pick up this urgent requirement for changes. Assurance was given that the safety of staff issue had been executed and it was helpful that the visit had made it clear that the alterations were the prison’s responsibility. AN confirmed that there are some actions for us and this will go to Quality & Safety Operational Group and then to this meeting. This part of the action was Completed.

Work Plan

Patient Experience and public engagement had been deferred to the next meeting. Burdett Trust Review The Burdett Trust Review was agreed to be an accurate record of the last meeting. The top clinical risks are given to the Board. Infection Prevention and Control Group amended Terms of Reference for approval AC confirmed that the Terms of Reference had been amended to give a more equal balance and highlighted the changes. MR suggested the first bullet point in the introduction should reflect infection and control and SAO that the membership authors of amendments be amended. These amendments were agreed.

5.0 Quality Report including: Performance/Serious Incidents/Nursing Issues/QRP AC reported that the key element was complaints, there had been a slight issue about

when a complaint is received it not being pushed to the Complaints Manager as quickly as possible and Managers had been reminded to be more timely. The Safety Thermometer continues with no variations. Pressure Ulcers – we have developed on-going CQUINS for next year with the CCGs and pressure ulcers are still included, looking at reporting Level 2’s.



SAO confirmed for MR that the Influenza outbreak at Ludlow had meant isolating patients and there had been different strains of Influenza. This was well managed and patients and staff recovered quickly. RL asked about the extra resources in the HR Team and JT stated that there were 3 part time staff for 6 months specifically tasked to look at sickness absence and ensure compliance with the policy. They would establish relationships with Managers and Team Leaders looking at reasons for sickness. An update will be given in the next report from HR. AC explained the pressure ulcer details on page 8 for MR and will email him with details of the Grade 4. MR pointed out the figures at the bottom of page 10 where 65 and 25 should be in red. Action: AC to ensure Help 2 Quit figures and Length of Stay tables are coloured correctly. RL asked about the child immunisations and issues with the second dose of MMR, was it a system issue. Action: SAO to check on issues relating to the second dose of MMR. AS asked about the new birth visits, not hitting the target and the data being collected to look at why this was the case. SAO stated that there were a number of incidents where either incorrect contact details were given or given late but she is tracking these to understand the process. It is an important issue due to safeguarding issues. Action: SAO will get more detail regarding new birth visits processes and update at next meeting. SAO explained work taking place around DNA rates and the high complaints rates for Podiatry. They have been investigating ways of booking through GPs and reminding patients of their appointment through phone or SMS. Action: SAO to report back in 2 months regarding Podiatry complaints and DNA rates. West Midlands Quality Review Service did a review of Frail and elderly Patients on 5/6 March and AC reported that immediate feedback had no surprises with a formal report in due and an action plan. AC reminded those present to encourage people to attend the Safe Care Shropshire Event which will take place on 2 April. There are up to 170 applicants so far. The report detailed the key risks from the Quality & Safety Operational Group.

6.0 Trust Board Clinical Quality Visits Feedback AC stated that the feedback sheets were based on using the 6 C’s questions. DR has

asked if anyone has any requests for places they wish to visit, could they please let her know. Discussion ensued regarding thinking about different ways of doing visits with ‘back to the floor’ working in different roles being one valuable suggestion as well as visiting at different times of the day. AS asked about things learnt and RL about feeding back to those visited. AC thought it was important to give instant feedback and it was suggested to look at doing a ‘you said…. We did ….’ type sheet.



Action: AC/DR to look at ‘you said… we did…’ type of information regarding Board Visits.

7.0 QUARTERLY/SIX MONTHLY/ANNUAL UPDATES

7.1 Complaints and PALS Quarterly Report AS thanked MC and SM for their report which was taken as read. Complaints – MC reported 58 complaints, 17 during the last quarter. The top three service areas with most complaints were; the Shropshire Wheelchair and Posture Services (4), Dental Services (3), Speech and Language Therapy (2) and Podiatry (2). The top three complaints categories were; Communication/manner/attitude (8), Quality of care/treatment (8) and other (1). Response performance – out of 20 complaints, 18 had been responded to within the timescales making 90% rate. Acknowledgements were 100% within 3 working days. The report detailed Parliamentary and Health Service Ombudsman cases updates and MC answered an questions with AC giving assurance that learning is cascaded as necessary. Compliments – 166 compliments had been received and the report details the areas they were received in. PALS – SM ran through the key areas of the PALS section of the report. There had been 68 PALS contacts for the quarter in question. The highest number of enquires was about the Community Hospitals and Outpatients Services received the most. Top three areas by service were: Oswestry MIU (13), Podiatry (11) and Ludlow Hospital (7). Section 3.6 of the report details changes/improvements and learning. The report then compares PALS and Complaints data with the top three service areas of each by both service and subject. The Committee thought the learning element of the report was good. SM agreed to include a section on parking issues. SM confirmed that signage was being improved. SAO asked about capturing compliments if they were by text and it was agreed that these could be logged. Action Plan for Clywd Hart Report – the recommendations were discussed. MC stated that an overview would be done at the Quality & Safety Operational Group to drive monitoring of the actions within and then there will be an update back at this meeting. With reference to p26, top action, MR asked about necessary skills for Trust Chief Executives and Board members and AC is speaking with OD about what is available from the Leadership Academy. Action: MC to bring Clywd Hart Report Action Plan back in 3 / 4 months’ time to ensure progress. 7.2 Safeguarding Group Six Monthly Report



AC explained that he was the joint lead for Safeguarding for both adults and children. MR commented that this was a helpful report. AC stated that with regards to training we were still way above other Trusts when looking at benchmarking. One issue to note was the growing numbers of Looked After Children. AN confirmed that we have a lot of out of county fostered in our area. A new Designated Doctor is due to start during March. With regards to Prevent training we are also way above our partners too and SaTH has asked us to do Prevent training which would be good income generation. The report details 3 Serious Case Reviews of child deaths. We are up to date with the action plan from Brent and are awaiting a report from the MAPPA Gold Meeting which will be out shortly. RL asked what was the split regarding fostered and residential numbers. Action: AC to let RL have details of fostering/residential numbers AC confirmed the robust system in place and gave reassurance with regards to alerts and how they are dealt with. Good partnership work takes place within safeguarding.

8.0 Policies for Notification: The below policies were noted:

Employment Break Policy Over/Underpayment of Salary, Allowances and Benefits Lease car

9.0 Burdett Checklist for completion including identification of key risks:

See also completed Burdett Checklist: Nothing new that was not covered in the papers. Areas of concern – New Birth Visits – RL would like discussion regarding these

targets. AC also providing breakdown of fostering/residential figures for RL. Speech and language therapy capacity. Nothing missing. Issues regarding patient or staff experiences – looking at visits/culture. Talked about walk rounds and will hope to do more. Top risks/assurances: received a lot of assurance regarding safeguarding and

the role of district nurses. Ambition had been demonstrated.

There was a discussion regarding the Terms of Reference and having this meeting bi-monthly. For the meetings in between we would look at having more service review style meetings with discussion and fewer papers. It was queried whether an April meeting was required but it was agreed that this needed to be ratified and that an amended Terms of Reference go to the May Board Meeting. Action: An amended Terms of Reference to indicate the bi-monthly meeting to go the May Board Meeting. AC stated that they were looking to review the Quality Strategy which could be done at this meeting. AS confirmed that there would be a major presentation on patient



experience also in April’s meeting. There were no new risks.

10.0 Any Other Business There was no other business. Date and Time of next meeting 24 April 2014 from 1000 – 1300 hours in Room K2, William Farr House

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AUDIT COMMITTEE

Minutes of meeting held at 14:00pm on Tuesday 7th January 2014 in room K2, William Farr House

Present: Peter Phillips (Chairman) Non Executive Director Mike Sommers Non Executive Director Rolf Levesley Non Executive Director Angela Saganowska Non Executive Director Alex Hire Client Manager, Baker Tilly Peter Foord Corporate Risk Adviser Trish Donovan Director of Finance Andrew Coleman Deputy Director of Nursing and Quality,

attending on behalf of Maggie Bayley Julie Thornby Director of Governance and Strategy Terry Feltus Lead Local Counter Fraud Specialist Grant Patterson Director, Grant Thornton Allison Rhodes Manager, Grant Thornton In attendance: Anita Bishop Minutes Secretary

ITEMS ACTIONS1.0

APOLOGIES: Apologies were received from Maggie Bayley. All those present introduced themselves and welcomed the new Chairman.

2.0 DECLARATIONS OF INTEREST There were none.

3.0 MINUTES OF MEETING HELD ON 1st October 2013 Enc 1 The minutes were approved as being a true and accurate record of the meeting, and would be signed and approved by Mike Sommers, as Chris Bird had now left the Trust and today was Peter Phillips’ first meeting.

4.0 MATTERS ARISING FROM AUDIT COMMITTEE MEETING Enc 2 OF 1st October 2014

4.1 Clinical Audit Report – J Thornby, P Foord Verbal Options for closer links between the Clinical Audit Programme and Internal Audit Reports.

Julie advised that the previous Chairman had intended to have further discussions on this matter, however, the task had not been completed before his departure from the Trust. It was agreed that a meeting would be set up with Dee Radford, Angela Saganowska and the Chairman to discuss and review the processes outside the Audit Committee meeting. An update on discussions would be brought to the next committee meeting in April.

A Saganows

-ka

Chairman

4.2 Emergency Planning – J Thornby Enc 3 Julie introduced the Emergency Planning reports, which showed actions completed and those still to be undertaken to meet national emergency planning core standards. A discussion took place regarding the emergency planning rehearsal scenarios and training for Trust staff. Julie advised that on 17th September 2013 Trust staff took part in a multi-agency emergency planning training exercise, chaired by the Police.

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Additionally Pete Old had held a workshop for the Trust’s directors and senior managers on 10th December 2013, to take them through three main scenarios of different events to talk through procedures and improve staff knowledge and skills base. Further emergency planning events would be scheduled in the future. The content of the report was noted by those present, and the comprehensive plans provided assurance that the Trust had actions in hand to be compliant with emergency planning standards. It was noted that a full report on this had been received by the Trust Board in November 2013.

4.3 Update on progress against CQUIN scheme – A Coleman Verbal Andrew advised that the Trust was hitting national targets or is above the target. There were two targets that were proving more difficult to achieve and these related to VTE (venous thromboembolism), which was a GP- led assessment in community hospitals, and Patient Discharge. The Trust would hit the VTE target this month as Ludlow had hit 100%, Whitchurch was lower and therefore more work was required to make improvements. For the Patient Discharge CQUIN, work was in progress and a review of the previous work relating to the ATOS project was taking place, and a review would be conducted on 6th March 2014. The Chairman enquired if the Trust would be financially penalised if it did not achieve the CQUIN targets. Andrew advised that penalties would be levied if the targets were not achieved, however, currently the Trust was doing well. It was noted that CQUINS were closely monitored at the meeting of the Quality & Safety Committee to ensure compliance.

4.4 Discussion about the review of the draft Accounts – T Donovan Verbal before the start of the Accounts Audit The Audit Committee Handbook suggests that the Audit Committee could request to review the draft Accounts before the start of the Account Audit if they wished. A discussion took place regarding the tight accounts timescale, and it was agreed that the draft accounts could be made available to the NED’s, however, they would not be generally circulated unless specifically requested. It was agreed that External Auditors would notify member of any issues found as they occurred

4.5 Terms of Reference – P Foord Verbal Minor amendments would be made to the Terms Of Reference: a) Committee Membership would be reviewed on an annual basis. b) Members should not be absent from two or more meetings without the

agreement of the Chairman.

The above amendments were agreed by all present.

The Audit Committee Handbook suggested that the Committee would need five meetings per year. As the committee does already meet 5 times a year (including the extra-ordinary meeting to approve the accounts) the committee felt this was sufficient.

4.6 Governance Processes in Major Investments – T Donovan Verbal Trish advised that the governance process for major capital investment projects would be documented, and was being developed with the capital monitoring group.

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5.0 NEW ITEMS

5.1 Directorate Risk Register – T Donovan, P Foord Enc 4 Finance, Contracting and Performance A considerable amount of work had been completed to bring the directorate risk register up-to-date, however, the work had now moved on and further amendments would need to be made. Peter advised that it was important that staff gave achievable due dates for the completion of actions.

Risk ID: 1591 Oracle System Failure – Trish confirmed that if the Oracle system failed, then the system back-up would ensure that the Trust should only lose 1 working day of input.

Trish advised that all the current risks were rated as Medium to Low.

The committee members thanked Trish for the Directorate Risk Register, and noted the contents of the report.

5.2 Review system for ensuring compliance with – A Coleman Enc 5 CQC Essential Standards Andrew advised that the CQC Standards had been notified to the appropriate divisional service leads. A meeting would be held to establish how the standards would be applied to the business plan. Papers were being compiled in the event of CQC inspection of Community Services. Star Chambers were being held to review the evidence held within the Trust. The committee highlighted that the star chamber model could be used to monitor or investigate other processes.

5.3 Clinical Audit Report – A Coleman Enc 6 Andrew highlighted the main points of the report and advised that plans were being drawn up for next years’ Clinical Audit Programme. Clinical audit training had been well attended by staff, and had been over-subscribed, therefore further training dates would be scheduled in the future. The committee noted the content of the report.

5.4 Review effectiveness of Internal Audit Function – T Donovan Verbal This item was considered at the last meeting, and discussions had taken place on how to demonstrate a review of internal audit. It was agreed that Trish and Alex would bring a proposal to the next meeting.

T DonovanA Hire

5.5 Counter Fraud Policies – T Feltus Enc 7 a) Local Counterfraud Specialist and Internal Audit Protocol

Terry advised that minor changes had been made to the policy with regards to terminology and procedural processes. The Committee approved the changes to the protocol.

b) Local Counterfraud Specialist and Local Security Enc 8 Management Specialist Terry advised that minor changes had been made to bring the document up-to-date. The Committee approved the changes to the amended protocol document.

c) Community Trust NHS Prescription Payment / Enc 9 Exemption Declaration form Policy It was noted that the document, which formalised arrangements for the issue of NHS prescription payments/exemption declaration forms for patients, had been reviewed and approved by the Trust Medicines Management Group in November 2013. Terry advised that the policy

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introduced a system whereby any patient receiving medication and being liable to pay the appropriate NHS prescription charge fee would sign a promissory note at the time of dispensing which would result in an invoice being raised by the Trust and sent to the patient to recover the charge. The policy also introduced procedures for the collection of NHS prescription charges, and if appropriate Penalty Charges, from patients claiming to be exempt from paying those charges, where subsequent checks on their forms indicated they were not. Trish mentioned that consideration would be given in the future to including a section on the form where the patient could give their debit/credit card details for payments to be made, thereby eliminating the need to raise invoices and as a consequence reducing the costs of administering the process. The Committee noted the content of the policy.

5.6 Internal Audit Recommendation Analysis – P Foord, A Hire Enc 10 Peter advised that an analysis of the outstanding audit recommendations had been carried out. The data had been provided by Internal Audit on 5th December 2013, therefore the data was now a little out of date. Of the 12 actions outstanding at the time the report was generated 8 have been completed, leaving 4 still outstanding. Peter advised that it was important to remind staff of the importance of setting realistic dates for the time required to complete tasks. Internal Audit would supply a simple user guide to help managers in completing audit recommendations. A follow up review would be carried out in six months. The committee noted the content of the report.

A Hire P Foord

6.0 STANDING ITEMS 6.1 Workplan – P Foord Enc 11

The committee acknowledged that workplan was up-to-date.

6.2 Board Assurance Framework – P Foord Enc 12 The committee considered the report on the Board Assurance Framework (BAF) and the risk themes identified at informal Board in detail. Following discussions the committee resolved to recommend to the Board that existing risks should be amended to include new themes, and new risks added to the Board Assurance Framework, so that in total it included risks for:

- Clinical Quality - Transformation – Local and National Contexts - Transformation – Systems - Transformation – Staffing - Trust sustainability recognising the Trust’s small size and commissioning

and contracting impacts - Meeting Financial Targets - Changing Culture

Plus continuation of current BAF risks: risks for Ludlow Hospital and Data Quality to remain on the BAF as they are and; risks for RTT waiting time targets and Failure to develop business skills for staff to be moved from the BAF to the Corporate Risk Register.

6.3 Corporate Risk Register – J Thornby, P Foord Enc 13 Lead directors had reviewed their entries and provided updates. The Chairman enquired about the entry for Community Links and Reputation.

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Julie advised that a Patient Council had recently been formed which will look to expand feedback on patient experience, and develop relationships. The Trust’s capacity in this area has been improved by the appointment of the Patient Experience and Engagement Lead. Two risks had been added to the register:

Entry 1716 - Quality issues from medical staffing for Community Hospitals.

Entry 1717 - Achieving adequate completion levels of staff appraisals. The Committee noted the content of the report.

6.4 Regulatory and External Body Report – A Coleman Enc 14 Andrew highlighted the main points of the report. With regards to the Inquest Report about the death of a young person in contact with the CAMHs service, a narrative verdict had been given which identified four opportunities for a mental health assessment to be carried out, two of these opportunities related to other agencies making referrals to CAMHS. Andrew noted that he was awaiting further feedback as to whether there was further learning for staff. The Committee noted the content of the report.

6.5 Risks from Other Committees – P Foord Enc 15 The Committee noted the content of the report.

6.6 Suspension/Waivers to Standing Orders None to report.

6.7 Losses and Compensations Report None to report.

7.0 AUDIT ITEMS

EXTERNAL AUDIT

7.1 Audit Progress Report - G Patterson, A Rhodes Enc 16 Grant advised that the majority of their work would be taking place from the next month going forward. The Auditors agreed to ensure that any issues identified within the annual accounts and value for money conclusion would be communicated to the committee when identified. The Chairman noted that the Audit Committee needed to consider the Emerging Issues detailed at the back of the report. A checklist would be drawn up and consideration would be given to the items and how to tackle them. Grant advised that he could offer guidance and comments on them and would bring the details to the next meeting. Health and Social Care Integration Transformation Fund (ITF) – The members noted that the work on this was led by commissioners and the Trust was not yet aware in any detail of intentions for the locality, although it was noted this was being discussed in the Chief Officers’ meeting. Grant advised that he was involved in the local discussions and would try to arrange a meeting for all parties to ‘get round the table’ to discuss the future plans.

G Patterson A Rhodes

G Patterson

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7.2 Audit Plan 2013/14 - G Patterson, A Rhodes Enc 17 Allison highlighted the main points of the report and would bring an update to the next meeting. The fee remained the same as last year, and was fixed for 5 years. Trish advised that the accounts were as expected. A discussion took place about there being no revenue support this year from the SHA. Grant advised that he would give advice on achieving the best outcome.

INTERNAL AUDIT

7.3 Progress Report – A Hire Enc 18 Alex advised that Internal Audit were confident that they would deliver the scheduled plan, and she highlighted the main points of the report. It was agreed that for the future, the full internal audit reports would be circulated by e-mail to committee members as soon as they were finalised. The full reports would not be included in the meeting pack, but would be represented as a summary in the progress report.

7.4 Audit - Enc 19 Governance – Board Committees Composition & Business – A Hire This was an advisory report, with no assurance rating. A number of recommendations had been identified, to strengthen processes being followed by the Board and the Committees.

7.5 Audit - Payroll and Expenses – A Hire Enc 20 An Amber/Green opinion rating had been given, which indicated reasonable assurance that good controls were in place. Four recommendations were made.

7.6 Audit - Assurance Framework – A Hire Enc 21 This was an Advisory report with no assurance rating. Two actions had been identified, including the Board BAF review. Both actions had been implemented.

7.7 Audit - Key Financial Systems – A Hire Enc 22 An opinion of ‘Substantial Assurance’ had been given for this report, and the Chairman congratulated the finance team for receiving a ‘green’ rating for all the key controls in relation to the Trust’s financial systems.

7.8 Audit - General Ledger and Budgetary Reporting – A Hire Enc 23 An opinion of ‘Substantial Assurance’ had been given for this report, and two actions had been recommended.

7.9 Audit – Data Quality – A Hire Tabled The Data Quality audit was an advisory review. Alex highlighted the main points and questions were asked about how the five areas of area activity were identified. Mike and Angela advised that although there had been considerable work involved in the current audit, the work had not included the aspects of Data Quality that they had expected. The NEDs requested further work following on from the previous Lorenzo based audit, particularly with regards to data capture systems. It was agreed that further work would be undertaken. Alex confirmed that a Data Quality review, also considering the performance indicators, would be included within the Audit for 2014/15. The committee noted the content of the report, and that the recommendations should be implemented.

A Hire T Donovan

8.0 Risks identified to be reported to the Board – P Phillips There were none.

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9.0 Items for Information Enc 24

Quality & Safety Committee Minutes & Action Plan – for information The content of the minutes were noted.

10.0 Burdett Checklist It was agreed that all areas covered by the Burdett Checklist had been followed; the Chairman would complete the form and Anita would circulate so others could comment.

Chairman A Bishop

11.0 Any other Business Grant advised that there were some seminars in the near future that the NED’s may be interested in attending. The events may be useful as networking forums, and provide an opportunity to share ideas and debate subjects of common interest. It was agreed that Allison would e-mail the information to those NED’s who were interested.

A Rhodes

12.0

Date of next meeting Tuesday 1st April 2014 at 09:30 in room K2, William Farr House.

2014 Meeting Dates: Tuesday 1st April 2014 09:30 – 12:30 in K2, WFH Wednesday 2nd July 2014 14:30 – 17:00 in Room B, WFH Tuesday 7th October 2014 09:30 – 12:30 in K2, WFH Approved by: ……………………………………………………………… Date: ……………………………

Peter Phillips, Chairman

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\\xscpcttwpct.nhs.uk\sctw-dfs\WFH Governance & Strategy Directorate\Corporate\corporate governance\Board meetings\2014\Part 1\5. MAY\FINAL\MINUTES\IG Committee - Minutes 11-03-14 v1 0 Final.doc

Shropshire Community Health NHS Trust

Information Governance Committee Minutes of a meeting on Tuesday 11th March 2014

At 9.30 am – 10.40 am In Room A, William Farr House

Present: Rolf Levesley, Non-Executive Director (RL) Sara Vale, Divisional Manager (SV) Gill Richards, Project Manager – Information Services (GR) Dr Alastair Neale, Medical Director (AN) Andrew Crookes, Head of Informatics (AC) Louisa Statham, Business Administration Manager (LS)

Chair Minutes

Apologies: Julie Thornby - Director of Governance & Strategy (JT) Trish Donovan, Director of Finance (TD)

In attendance:

Copy for Information:Gilda Thornton, Lisa Mansell, Louise Tompson, Jan Cox

Item No. Topic Action 1 Apologies As recorded above. 2 Declaration of Interests There were no declarations of interest. 3 Minutes of the Previous Meeting – 14-01-14 The minutes of the meeting held on 14th January 2014 were agreed

as a correct record.

4 IG Committee checklist – Completed version for January Meeting 4.1 The Committee noted and agreed the commentary reported on the

Burdett Checklist from the meeting held on 14th January 2014.

5 Terms of Reference – for information GR reported that all of the amendments have been made.

The Committee received the final document for information.

6 Matters Arising from the Action Log (not on the agenda) 6.1 All items from the Action Log were on the agenda. 7 IG Toolkit Assurance Report and Sign Off 7.1 GR assured the Group that all requirements for the Information

Governance Toolkit have been met in readiness for the 2013-2014 submission on the 31 March 2014.

The Group reviewed the IG Toolkit Tracker Document and GR confirmed that all of the elements that are currently amber, will be completed before the end of the month.

The Summary to the SIRO has been sent to Trish Donovan, and she has been asked to approve this today as this will be one of the few outstanding items ready for the submission.

GR has also responded to Baker Tilley (auditors) regarding the audit recommendations and they have acknowledged her response.

The Committee noted that Level 2 is the minimum standard and agreed that next year, we should be looking to see if we can achieve Level 3 for some of the requirements, if it is appropriate and advantageous to the Trust.

Action: The group accepted the assurance from GR that the Information Governance Toolkit evidence is now at a state of readiness for the 2013-14 submission at Level 2 Compliance. The group approved the evidence and asked GR to submit and publish the Toolkit on behalf of the Trust. GR agreed to review the IG Toolkit for 2014/15 and identify any Level 3 requirements that the Trust would fine useful/helpful to implement

G. Richards 31.03.14 G. Richards 22/07/14

7.2 IG Training – Current completion rate GR reported that the Information Governance Training completion

rate now stands at 97.2% against the target of 95% of all staff

Approved by the IG Committee at a meeting held on 13th May 2014.

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having completed their training. RL congratulated GR and everyone who has been involved in

achieving the target. There are approximately 45 staff left to complete the training and

they have been written to directly. The Committee recognised the huge level of input that GR has

given to this project and acknowledged that she will be unable to sustain this for future years.

GR notified the group that she had identified a number of staff that had never completed IG Training or any other mandatory training.

The Committee were concerned about this issue and noted that it is the managers responsibility to ensure that staff complete mandatory training. GR explained that some of these issues will be picked up as part of the work being carried out by the IT Training Manager who is reviewing how mandatory training is delivered across the Trust.

7.2.1 Training for Trust staff based with another organisation e.g. Macmillan Nurses

GR reported that this group of staff are employed by the Trust but are line managed by Severn Hospice.

GR and a trainer from OD and Workforce delivered the ‘Danny’s Day’ training to these staff.

Subsequently, GR has spoken with the Director of Nursing at Severn Hospice, who has confirmed that they will deliver this training for future years and will ensure that the Trust is informed of all the mandatory training completed by this group of staff so that the Electronic Staff Record can be updated.

SV confirmed that she has raised this issue with Karen Taylor, Community Services Manager, in order to try and identify any other staff groups that are employed by the Trust but line managed by another organisation as part of the Service Level Agreement

8 IG Incident – CAMHS – update and lessons learned Following a meeting between GR, AN and Alan Ferguson, AN took

three actions as a result of the lessons learned. 1. An article is going to be published in Inform to highlight near

misses and lessons learnt. 2. AN has contacted the Keele University co-ordinator to

highlight issues relating to IG training compliance for trainees. AN to keep the group updated.

3. Review the process regarding the supervision and monitoring of trainee doctors and the methods used by the relevant mentoring consultants when raising awareness of topics such as confidentiality and IG to ensure that they understand the key policies and the risks around the work that they are undertaking.

The group agreed that the Trust must ensure that bank, agency, trainee and locum staff receive adequate and appropriate induction and mandatory training. The group also agreed that line managers and mentors must ensure that these groups of staff are recruited, managed and supported in the same way as permanent members of staff.

The group noted that it is difficult to include Bank staff in the IG Training figures as this changes each month depending on whether their role is ‘active’ or ‘inactive’ in ESR. However, managers must still ensure that they comply with mandatory training.

The group noted that as the majority of Trust staff will have completed the IG training, the risk for the Trust is more likely to come from Bank, Agency, Trainees and Locum staff.

Action:

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GR agreed to raise this issue with the IG Operational Group in order to produce some recommendations regarding the training of these groups of staff.

G. Richards 10/04/14

9 Datix Reporting 9.1 High Level Incident Report

The group reviewed the High Level Incident Report and noted that the number of incidents reported in the Children and Mental Health Services (CAMHS) had significantly reduced during the period January 2013 to December 2013. The report showed a high point of 27 during April to June compared to only 3 incidents during October to December.

There is some work that the IG Operational Group can do by following up the lessons learned and GR has spoken to Peter Foord, Risk Advisor regarding this.

GR stated that she is hoping to set up some site visits to a number of services and attend team meetings to raise awareness of Data Protection. Case studies will be used as part of these sessions, including Trust incidents. It is hoped that staff will identify what their concerns and issues are within their service area.

10 Consideration List for commissioning/decommissioning a service 10.1 The group discussed the Information Governance issues that have

been highlighted around the decommissioning and commissioning of services, following a serious incident during the transfer of the Sexual Health Service to a new provider.

The group agreed that the current process needs to be more robust to ensure that the Trust not only complies with Information Governance, but also that all other elements of decommissioning and commissioning are dealt with effectively and appropriately.

GR confirmed that following the last meeting, she has discussed this issue with Trish Donovan. GR said that TD had explained that this process probably fits in the contract award/withdrawal process and would ask for it to be discussed at the Deputy Directors Forum.

The Committee agreed that this issue should now be picked up by TD and GR, however, agreed that the lack of a process is a significant IG risk for the Trust.

The Committee stated that they need to be assured that whatever process is agreed, that it has been set up correctly and robustly.

Action: GR to raise this issue with Trish Donovan and agreed to update the Committee on any future developments.

G. Richards asap

11 Information Sharing 11.1 Information Sharing Agreements (ISA) submissions for notification

The Committee were notified that the following ISA is in process: - The National Child Measurement Programme – Telford &

Wrekin.

11.2 New Child Health Programme The Committee were made aware of a new Child Health

programme regarding information sharing around child protection issues within health and social care organisations.

The project is being led by Andrew Coleman, Deputy Director of Nursing and Quality.

AC stated one of the options for implementing this is to use the Summary Care Record as it has an Enhanced Record feature.

The data items that are required are demographics and patient identifier information.

The suggestion is to link systems to systems however, the clinical systems will not be able to interface with the local authorities so the flag would be in the clinical system but noted in SCR.

12 IG Risks and Issues

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12.1 Risks Identified by the IG Operational Group Nothing to report.

12.2 New risks identified by the IG Committee Mandatory training for Bank, Agency, Trainee and Locum staff The commissioning and decommissioning process.

13 Any Other Business 13.1 Information Asset Register Review

The Committee noted the report. GR reported that this document has been sent to TD for sign-off as

part of the IG Toolkit submission.

13.2 Complaint from the ICO GR informed the group that the Trust has received a letter from the

Information Commissioner’s Office (ICO) regarding a complaint. The complaint concerns the Trust’s response to a subject access

request and in order for the ICO to make an assessment and decide whether further action is appropriate they have requested further information from the Trust. The Trust is required to provide a response within 28 days.

13.3 Certifications AC reported that discussions are taking place around making

certification easier for software applications that are created in the USA so that they can have automatic certification in the UK.

14 Date of the next meeting Tuesday 13th May 2014, 9.30am – 10.30am, Room K2, WFH

Documents

Meeting Date: 22 May 2014 SUMMARY REPORT Agenda Item ... · Strategic Priorities this report relates to: To exceed expectations in the quality of care delivered To transform our services