1. society
2. welfare
3. healthcare
4. hospital

BOARD OF DIRECTORS
PUBLIC
DATE:
3rd October 2013
TIME:
09.00 am
VENUE:
Room 2, Level 0, Training & Education Centre
DISTRIBUTION:
CHAIR OF MEETING:
Sean Lyons
Chairman
Stuart Grasar
David Leah
Non-Executive Director
Non-Executive Director
Ray Dawson
Peter John Marks
Claire Ward
Gerry McSorley
Non-Executive Director
Non-Executive Director
Non-Executive Director
Non-Executive Director
Paul O’Connor
Nabeel Ali
Susan Bowler
Karen Fisher
Fran Steele
Chief Executive
Executive Medical Director
Executive Director Nursing & Quality
Executive Director of Human Resources
Chief Financial Officer
IN ATTENDANCE:
Jacqui Tuffnell
Craig Day
Kerry Rogers
Yolanda Martin
Lisa Bratby
Ian Greenwood
Director of Operations
Lead Governor
Director of Corporate Services
Head of Communications
Minutes
Interim Director of Strategic Planning &
Commercial Development
OBSERVERS:
Jane Stubbings
APOLOGIES:
Ray Dawson
Mark Chivers
For information:
Tim Reddish
Mark Chivers
Board of Directors cover sheet for 03.10.2013
Non-Executive Director
Non-Executive Director
Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
These Minutes may be made available to the public and persons outside Sherwood Forest Hospitals NHS
Foundation Trust in compliance with the Freedom of Information Act 2000
Unconfirmed MINUTES of a Public meeting of the Board of Directors held at 9.30am
on Thursday 5th September 2013 in the Holy Trinity Centre, Boundary Road, Newark,
Nottinghamshire
Present:
Sean Lyons
David Leah
Stuart Grasar
Ray Dawson
Claire Ward
Dr Gerry McSorley
Paul O’Connor
Dr Nabeel Ali
Susan Bowler
Fran Steele
Karen Fisher
Chairman
Non-Executive Director (Senior)
Non-Executive Director
Non-Executive Director
Non-Executive Director
Non-Executive Director
Chief Executive Officer
Executive Medical Director
Executive Director of Nursing & Quality
Chief Financial Officer
Executive Director of Human Resources
SL
DL
SG
RD
CW
GMc
PO
NA
SB
FS
KF
In Attendance:
Kerry Rogers
Director of Corporate Services /Company
Secretary
Director of Operations
Head of Communications
Head of Programme Management (Enc D
only)
Interim Director of Strategic Planning &
Commercial Development
Lead Governor
Minutes
Non-Executive Director- Designate
Non-Executive Director -Designate
Health and Safety Manager (Health & Safety
Report only)
KR
Ward Leader, Ward 52
Consultant Geriatrician
AB
ALS
Practice Development matron – Dementia
AH
Jacqui Tuffnell
Yolanda Martin
Shirley Clarke
Ian Greenwood
Craig Day
Lisa Bratby
Tim Reddish
Mark Chivers
Robert Dabbs
Observers
Adele Bonsall
Dr Anne-Louise
Schokker
Adam Haywood
JT
YM
SC
IG
CD
LB
TR
MC
RDa
Action
13/77
Date
CHAIRS WELCOME AND INTRODUCTION
The meeting being quorate, SL declared the meeting open at 9.30 hrs
and confirmed that the meeting had been convened in accordance with
the Trust’s Standing Orders.
SL welcomed KR to the meeting. KR had recently been appointed as the
Director of Corporate Services /Company Secretary.
PATIENT STORY
13/78
SB delivered an update regarding the patient story presented to the
August Board of Director’s meeting reminding Directors that this patient
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story was not a complaint but was about how improvements could be
made in terms of compassionate care and putting ourselves “in the
patient’s shoes”.
SB advised that following the August Board meeting SL, GMc, SB, the
Ward sister, the Head of Nursing for the ward area and the divisional
matron all met to review the story and ascertain what actions could be
taken to ensure that things could be done better moving forward.
SL also met with the ward staff who were involved in the story and they
were quite upset by the lady’s perception of her care and were keen to
contribute to any changes that could be made.
Subsequently the operational policy for the ward area has been updated
and will be re-launched on 9 September 2013 and further improvements
are expected now that the ward has commenced comfort rounding.
Improvements have also been made in regarding communicating with
patients and relatives with the introduction of information leaflets,
posters displaying the ward purpose and ethos and the rehabilitation
focus of the ward.
AH introduced a new patient story that involved a patient who linked to
the work of the National Dementia Strategy. AH explained that the aim
of the Strategy is to ensure that significant improvements are made to
dementia services across three key areas: improved awareness, earlier
diagnosis and intervention, and a higher quality of care. The Strategy
identifies 17 key objectives which, when implemented, largely at a local
level, should result in significant improvements in the quality of services
provided to people with dementia and should promote a greater
understanding of the causes and consequences of dementia. This
Strategy should be a catalyst for a change in the way that people with
dementia are viewed and cared for in England.’
AH added that a key element of this strategy is a focus on “This is Me”
where important information to help in the understanding of the patient’s
needs is identified.
The other key priorities are
Patient & carer involvement & information
Pilot of reducing harms team
Enhanced observation tool
Geriatric team at front door
Training and development
Inside out of mind
Practice Development Dementia Nurse
AH presented a new story which involved a 60 year old gentleman who
was living in a care home and had advanced dementia which caused
him to be confused and aggressive and as a consequence was subject
to a deprivation of liberty (D.O.L) order.
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This gentleman presented with a swollen leg and the most probable
diagnosis was a DVT. However, due to his aggressive tendencies it was
realised that it would not be possible to deliver an ultrasound scan under
normal conditions as his symptoms dictated that he required intensive
supervision so a CT scan under general anaesthetic (GA) was
considered. It was identified, during the initial admission process, that
this gentleman had a previous history of risk associated with sedatives
so a decision was made to delay the GA until his notes were obtained
from NUH. This caused a further delay which added to an eventual 13
day stay in hospital.
During this gentleman’s care ALS was contacted and an ultrasound was
eventually carried out under sedation which showed a negative result for
DVT. A review of this gentleman’s analgesia was also undertaken and
resulted in improved pain management.
The learning points from this gentleman’s story were
Specialist intervention may have prevented admission if this was
implemented earlier
No patient history profiling used and the use of “This is Me needs
to be embedded
An extended length of stay was caused due to difficulties in
clinical decision making and also the fact that the care home
where this gentleman resided were not happy to accept him back
into their care immediately
The excellence in practice points were
The gentleman was afforded excellent nursing care throughout
his stay
The management of aggression and personal care was well
planned
A pain assessment was undertaken which led to a review of his
analgesia and improvements being made.
No harms were sustained by the patient or staff
The communication was good at all times.
Following the completion of the presentation of the patient story ALS
confirmed that the geriatric team are firmly embedded in the EAU team
and stated that education is already underway to clarify the best use of
the team at the “front door”. Work is also being undertaken to improve
communication between GPs and geriatricians to encourage GPs to
refer patients directly to geriatric services rather than via emergency
care routes.
PO suggested that the option of implementing the “This is me” concept
be developed earlier in the patient’s pathway, i.e. in the care home
setting which will make the handover process more streamlined and
informative. JT added that a new pathway is now in place within the
Sherwood Forest Hospitals NHS Foundation Trust
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Trust discharge team which will improve the patient discharge pathway
to a care home setting.
Board members requested that thanks be passed to all staff involved in
this gentleman’s care and stated that it is clear to see that the Trust’s
business evidences compassionate caring for patients.
SL encouraged any members of the Board to contact ALS if they think
they can support the implemented changes in line with the National ALL
Dementia Strategy
13/79
APOLOGIES FOR ABSENCE / CHANGES IN MEMBERSHIP
It was CONFIRMED that apologies were received from Dr Peter Marks.
13/80
DECLARATION OF DIRECTORS INTERESTS
It was CONFIRMED that there were no new declarations of interest.
13/81
OCT
2013
MINUTES OF THE MEETING HELD ON 1 AUGUST 2013
Following review of the minutes of the public meeting held on 1 August
2013 the following amendments were proposed;
Page 3 – 13/54 – Mortality – para 4 – “PO added that during the recent
Keogh report the team only recommended that a review of mortality be
undertaken at Newark Hospital only. The terms of reference for this
review have been agreed”
be changed to read
“PO added that during the recent Keogh report the team
recommended that a review of the mortality of Newark residents
that attend Newark Hospital be undertaken separately”
Page 3 – CQUIN - para 6 – “CW questioned why the smoking at the
time of delivery CQUIN was not achievable in Q3 and Q4. SB clarified
that this CQUIN is difficult to measure as not all patients go full term to
delivery” change to
“CW questioned why the smoking at the time of delivery CQUIN
was not achievable in Q3 and Q4. SB clarified that this CQUIN is
difficult to measure as not all patients go full term to delivery at
SFH. ”
Page 4 – Complaints – para 1 – “Following a question from TR it was
clarified that the 3 outstanding complaints do not include complaints that
are still in the system and currently within the stated timescales for
response of which we are achieving 100% response within 72 hours”
Change to read acknowledging 100% of complaints within 72 hours.
Subject to these amendments the minutes were APPROVED as a true
and accurate record
13/82
MATTERS ARISING / ACTION LOG TRACKER
The Board REVIEWED the matters arising / action tracker document in
detail. The following updates were AGREED
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Action 18 – Transforming Pathology Services – It was noted that the
date of the Pathology Alliance presentation has been updated to
November 2013.
Action 17 – Chief Executives Report - CIP – This action remains
ongoing. Engagement with clinicians to bring forward more savings
incentives continues.
Action 22 – ODP NED involvement – It was acknowledged that the
development of the Trust ODP continues and any NED involvement is
welcomed.
Action 34 – Patient story – Acknowledgement was given that an
update was given earlier in this meeting. The action is now
COMPLETED.
Action 35 & 36 & 37 – Quality & Safety – Complaints / Review of
end of life care / MRSA - Confirmation was given that a further update
on all issues will be given in the Quality and Safety report to the October
Board of Directors meeting.
Action 38 – Quality & Safety – Friends & Family test – It was updated
that trend analysis will be provided quarterly. This action is now
COMPLETED.
Action 39 – Mortality Monitoring - Confirmation was given that the
mortality presentation has been issued to all new NED’s. This action is
now COMPLETED.
Action 43- Performance Appraisal- KF updated that the appraisal rate
in HR is currently up to 82% and further measures will be undertaken to
achieve the 100% target.
Action 45 – Exit interviews - It was noted that it is not necessary for an
exiting member of staff’s line manager to undertake the exit interview
and a more flexible method of interview with varied members of staff is
available . This action is now COMPLETED
Action 46 – Mandatory training – It was confirmed that this issue had
been referred back to the Clinical Governance and Quality Committee
and a further update will be given at the October Board meeting.
Directors discussed the importance of this issue being addressed
urgently and the impact of what will happen from an individual and also
an organisational perspective if training is not undertaken. The specific
importance of training pertaining to fire safety and resus training was
identified.
Action 47 – Governance Programme - It was noted that the
Governance framework was due to be discussed as an item on today’s
agenda. Therefore this action is COMPLETED.
CHAIRMAN’S REPORT
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13/83
SL presented the Chairman’s report giving an update on progress, plans
and regulatory developments.
Monitor
The Trust undertook the monthly progress meeting via teleconference
on 30th August 2013. Further details of this call will be given in the Chief
Executives report later in this meeting.
Governor meeting
A very lively Council of Governors meeting was held on 15th August
2013. During the meeting a number of ideas were put forward to
improve and build on the relationship between the Board and Governors
including how the Governors can become more involved in the Board
sub committee meetings and how their training needs can be met.
It was identified that in the past Governors received an update following
each Board meeting but this has not been forthcoming during the last
few months. KR responded that consideration will be given to this as all KR
Board papers are now available on the Trust website.
Oct 2013
MP’s meetings
SL updated that he had met with Gloria DePiero and PO to discuss
various complaints and feedback was given by Gloria that her
constituency office had seen a marked improvement in the turnaround in
responses to complaints being received.
FT Chair’s meeting
A meeting of all the Chairmen in the East Midlands area was held in
Derby on 3rd September 2013. This meeting was a very helpful forum to
share views and ideas for improvement.
Government Support for A&E departments
Directors discussed the recent information that had been released
pertaining to government support for A & E department “in need”. PO
added that a clearer understanding needed to be gained of what
determined whether a Trust was “in need” and highlighted that any
support would be non-recurrent.
SL concluded his report by encouraging all Directors to get out and
about across the Trust as often as busy schedules allowed so that the
hard work and dedication that is taking place by our staff can be
witnessed first hand.
Directors NOTED the Chairman’s report
13/84
CHIEF EXECUTIVE’S REPORT
PO presented the Chief Executive’s Report and apologised for the late
distribution of this paper. The following points were brought forward
CIP
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Foundation Trust in compliance with the Freedom of Information Act 2000
SC advised that at 15th August 2013 the ‘opportunity’ for in year savings
of schemes identified a total of £14,155,000, exceeding the target of
£13,301,000 by £853,000.
The value of schemes currently in the developed or implemented
gateways totals £11,605,000 i.e. 87% of the in-year target. These
schemes achieve £9,376,000 recurrent savings, with a full year effect of
£13,506,000.
Initiated schemes which do not yet have fully developed plans total
£2,549,000. Work is progressing with the divisions to move these
schemes through the gateways as quickly as possible in order to
optimise the savings potential identified.
All CIP schemes have been RAG rated to reflect risk adjusted CIP
delivery using the agreed criteria:
•
Green 100% CIP delivery
•
Amber 70% CIP delivery
•
Red
30% CIP delivery
This gives a total risk adjusted in year delivery CIP total of £11,245,000.
MC requested more clarity regarding how the full year effect and the in
year savings totals are achieved. SC agreed to discuss this with MC SC
outside this meeting.
Discussions were held regarding the need for the CIP update to be
included in the Finance report, as a fuller review of the CIP position will
have been undertaken in advance of the Board meeting by the Finance
& performance sub committee. This question will be considered and PO/FS
feedback given at the next meeting
Oct 2013
Oct 2013
SL questioned whether the international recruitment initiative is proving
to be beneficial. SB responded that the international recruitment drive is
underway and added that 41 staff members were recruited from the
local clearing house which is the highest level achieved to date.
GM reported that a large part of the agenda of the next Finance &
Performance meeting has been dedicated to CIP and a detailed report GM/FS
and contextual view will be given to the Board in October
Oct 2013
Progress Review meeting with Monitor
PO updated that on 30 August 2013 a teleconference was held with
Monitor to undertake the Trust’s Progress Review Meeting (PRM).
Discussions included the formal agreement to extend to 31st October
2013 the date by which the Trust (in accordance with Discretionary
Requirements) will deliver the Board and Quality Governance and
Financial Governance Action Plans and achieve a sustained recovery of
quality governance (i.e. a score of less than 4 on the Quality
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Governance Framework).
A formal record of the PRM is awaited from Monitor.
APR 2013/14 Reporting Executive Summary
On 7 August the Trust received news from Monitor that it had completed
its review of 2013/14 Annual Plan submissions from NHS Foundation
Trusts and was publishing the results of its annual plan monitoring
exercise to individual FTs. Following Monitors review of the Trust’s selfassessment the outcome was :
•
•
Financial Risk Rating: 1
Governance Rating: Amber/Green
The ratings are now published on Monitor’s website and Monitor will
continue to assess the risks to the Trust’s compliance with its licence
conditions through the returns provided by the Trust as part of the
monthly monitoring process. In its outcome of APR, Monitor has
confirmed that the Trust remains subject to enforcement action as a
result of breaches of its licence conditions.
Cancellation of Potential Industrial Action
As advised at the Board meeting on 1 August 2013 the potential for
industrial action on 27th August 2013 called by the GMB Union was
highlighted. Following extensive negotiation between the Trust and
GMB, the union informed the Trust that it would withdraw its proposal for
the industrial action that had been planned for the 27th August and no
further industrial action is anticipated on this matter.
Learning from the Keogh Rapid Responsiveness Review
PL updated that a formal statement from the Secretary for Health
pertaining to the actions required for Trusts to come out of special
measures is still awaited. The delivery of the Keogh action plan will be
assessed by the CQC review team which is expected between January
– July 2014.
Healthwatch
On 8 August PO and YM attended a very useful meeting with Derbyshire
Healthwatch and Nottinghamshire Healthwatch. Last year’s Health &
Social Care Act created a role for Healthwatch in representing the
interests of local communities and we encouraged both the Derbyshire
and Nottinghamshire Healthwatch organisations to participate alongside
the Trust in helping to develop our strategic ideas. YM is working with
both Healthwatch organisations to facilitate this.
Audiology Accreditation
TR conveyed his congratulations to the Trust for becoming the first
within the Midlands region to receive accreditation against new national
standards for its Audiology service. To date only 3 other NHS Trusts in
the country have received this accreditation standard.
Directors NOTED the Chief Executive Report and the specific
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Sherwood Forest Hospitals NHS Foundation Trust
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recommendations given.
13/85
QUALITY
MONTHLY QUALITY AND SAFETY REPORT
SB presented the monthly Quality and Safety Report and requested that
Board members NOTE the contents of the report and the progress /
position to date.
Mortality
NA tabled a report detailing graphs pertaining to HSMR All deaths by
Quarter, HSMR by Acute Trust in the East Midlands and Residual codes
by Acute Trust- June 2013. Each graph indicates a further improvement
in terms of the Trusts HSMR and if the Trust remains on the trajectory
planned further improvement will be forthcoming. The reasons for these
improvements include more staff awareness, Trust wide improvement
projects and improved coding.
CW highlighted the importance of getting the improved headlines
communicated to all areas in the run up to the Dr Foster release in YM
November 2013.
Infection Control
DL stated that following the report of a second case of Trust acquired
MRSA bacteraemia in July 2013 assurance needs to be gained
confirming that the Trust’s levels of infection control are still being
maintained. SB responded that assurance detailing the measures that
SB
are being taken will be given at the next Board meeting.
NA added that the c.difficile infection rates did rise periodically but have
now started to get back on track following the relaunch of the hand
hygiene campaign and the reinforcement of the key principles around
cannulae care.
Oct 2013
Oct 2013
Friends and family
GM requested that consideration be given to the level and type of
information that is given pertaining to the friends and family test results.
Following a discussion TR proposed that for the purpose of the Board
report high level information is presented and if further details and
statistics are required this information could be provided separately
outside the meeting.
Never Event
SL expressed his concerns regarding the 2 month timeframe that is
detailed to deal with the medication never event that occurred in July.
SB clarified that this timeframe is the timeframe for response to
commissioners in terms of the Root Cause Analysis investigation. The
actual incident was resolve in a timely manner and had been presented
to CG&QC.
GMc added that it was agreed at the Clinical Governance & Quality
Committee (CG&QC) in August that the Board members will be informed
of any never events that occur.
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
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Foundation Trust in compliance with the Freedom of Information Act 2000
Complaints
RD expressed his disappointment that the slight lapse in complaints
handling was associated to the level of annual leave that has been
taken. SB responded that the response rates are on target and the
mention of slight delay due to staff annual leave was an honest
comment. PO added that the majority of the complaints that he signs are
exceptionally detailed and required multiple discipline input to get an
accurate and thorough response. If staff are not available a slight delay
is unavoidable.
CRB checks update
KF reported that at the CG&QC meeting which was held on 23 August
2013 the Committee were informed that there were 26 individuals whose
posts required CRB checks that were still outstanding as they were
recruited prior to CRB checks being a mandatory requirement.
GMc expressed his concerns that although the number of affected staff
had reduced from 36 to 26 this action is not being undertaken quickly
and this delay is exposing the Trust to potential liability
PPC workforce change
Directors noted that the recent PPC workforce change will be reviewed JT
in 3 months to check the effectiveness and benefits.
KR proposed that the Trust Board needs to concentrate in the coming All
weeks on determining a clear focus on the key themes in Quality and
Safety in preparation for the quarterly report to Monitor which is due in
October 2013, especially important being triangulation of emerging
themes and trends.
Dec 2013
Oct 2013
Directors NOTED all points and the progress to date.
13/86
INPATIENT CAPACITY AND DEMAND REVIEW OF KINGS MILL
HOSPITAL
JT advised that the Inpatient Capacity and Demand review paper was
presented for noting and assurance only.
This paper summarises the Kings Mill bed capacity and demand
analysis completed to date. It describes the methodology undertaken as
well as the status of recommendations made within report.
These recommendations support planning for the emergency care
pathway across the Trust as well as acting as supporting evidence for
winter planning. JT assured Directors that all recommendations are on
track
GMc expressed his concern that the recommendation affordability
detailed in section 5 states that there is £2m in reserves to support this
work but the plan equates to £2.254m.
GMc questioned whether the staff that are required to incorporate this
plan are embedded in the recruitment plan. JT confirmed that the staff
are embedded in the recruitment plan but they are not in place yet.
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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13/87
Directors NOTED the recommendations in the report
ELECTIVE ACCESS POLICY
JT advised Directors that the Elective Access policy paper had
previously been considered by the Executive Team on 2 September
2013.
The Trust is required to have an Elective Access Policy detailing how we
manage patients on a pathway of elective care that is signed off locally
by the Trust and Commissioners with clinical and patient consultation.
This policy is required to be published on the Trust’s internet site.
This proposed policy has been subject to three weeks internal
consultation at SFH through Divisional Management teams of which
comments that were received and have been incorporated. The policy
has also been presented to the Executive Committee of Mansfield &
Ashfield CCG and the Clinical Executive Committee of Newark &
Sherwood CCG.
An implementation plan is being developed to support the roll out of the
revised arrangements to clinical, administrative and management teams
that will be supported by monitoring arrangements which are set out
within the policy. A programme of training is being developed to support
roll out.
NA questioned whether the department were confident that the required
administration support would be in place prior to the implementation of
the policy. JT confirmed that a full implementation plan, including a
training schedule for all staff involved, is in place and will be adhered to.
During discussions JT advised that as this policy is quite heavy in terms
of detail it will be refreshed yearly and reviewed in detail every 3 years.
CW questioned whether the Trust experiences issues obtaining
interpreters for overseas visitors. SB responded that no issues have
been encountered obtaining appropriate access to interpreters
TR suggested that the option of forming a database of Trust staff that
speak more than one language be arranged to be used in emergency
situations. KF identified that this database had been created previously.
However, the requirements had been too onerous and therefore the
arrangements now in place were adopted
Directors APPROVED the sign off of the proposed Elective Access
Policy
The meeting broke at this point (11.40am) and reconvened at 11.55am
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Unconfirmed Board of Directors – 5 September 2013
Page 11 of 18
Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
13/88
FINANCE AND PERFORMANCE
INTEGRATED PERFORMANCE REPORT – EXCEPTION SUMMARY
REPORT
JT presented the Integrated Performance (Exception) Report giving an
update on the performance summary for July 2013. The following points
were brought forward
ASI rates
RD questioned why the ASI rates are still variable. JT confirmed that the
Trust does have planned capacity and demand data but whilst
improvements have been made we are still experiencing issues with
higher than predicted demands. Work is in place to change working
practice to even out the variables and provide a better response.
Sickness absence
MC questioned what actions have been put in place to address the
Trust’s high level of sickness absence. KF confirmed that the Trust have
recently introduced an additional data set which allows managers to
easily identify when an employee has had 3 periods of sickness in a
given time period and are therefore required to attend a review meeting.
To support managers JT and KF are holding meetings monthly with all
managers with high levels of sickness absence to discuss and address
any issues. JT is also holding meetings to pick up the operational
consequences separately.
KF added that during the review meetings it has been identified that
back to work meetings are being undertaken but not always in a timely
manner, i.e. not within 72 hours of return. This issue is being addressed.
MC questioned whether the current sickness policy that is in place is
enough to drive down sickness levels to an acceptable level. KF
responded that she was confident that the policy will enable the Trust to
get to the 3.5% target but is not confident it will enable the Trust to
reduce the sickness levels beyond this level.
MC proposed that the Trust investigate the option of changing the way
that sickness pay is given to discourage staff from repeatedly being
absent i.e. 3 paid episodes in a given period and then a significant drop.
This option has had a large impact in the private sector.
PO stated that he would address this issue at the next team brief and PO
give staff a clear message pertaining to the “real” financial effect that
increasing sickness absence has on the Trust financial status.
SEPT
2013
62 day cancer risk
CW noted that the 62 day cancer target is flagged as a potential risk with
the projected Q2 performance as at 23 August 2013 deteriorating to
86.9% and questioned what exactly the risk is. JT responded that the
risks are associated with CT colons and endoscopy capacity issues.
This issue is improving with only 3 patients currently outside the target
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Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
These Minutes may be made available to the public and persons outside Sherwood Forest Hospitals NHS
Foundation Trust in compliance with the Freedom of Information Act 2000
and a request for an additional CT scanner is being considered by the
Capital Management Group to further reduce waiting lists.
Appraisal rates
It was noted that the Trust are working hard to achieve 79% appraisal
rate by the end of September 2013.
13/89
FINANCE PERFORMANCE REPORT
FS presented the financial performance report giving key headlines
arising at the month 4 position. The following points were brought
forward during the presentation;
We recorded a positive Q1 EBITDA of £0.75m against a planned
EBITDA of £0.05m. Whilst ahead of plan our EBITDA margin was still
just 0.8% (against a Foundation Trust acute sector average of 5.8%),
however adjusted for the impact of the PFI premium our Q1 EBITDA
margin would have been 8.0%. FS added that an external firm have now
been appointed to assess the impact of the Trust PFI debt and are due
to commence work on 16 September 2013. A further update will be
given at the September Finance & performance meeting and the next
Board of Directors meeting
Our cash balance at the end of July was £27.62m which was £3.60m
better than plan. However, after adjusting for cash payments received in
advance our cash balance would be negative £8.95m. The latest yearend forecast cash position is for a shortfall of £25.99m, with a cash
negative position being reached in February 2014.
Director’s attention was drawn to table 5 on page 8 of the report which
detailed the sanctions that are currently in place against the Trust.
Further information on the probability of these sanctions being
reinvested back in the Trust and the likely financial loss at Trust entity FS
level will be reported at the next meeting following discussion with
commissioners on Qtr 1 performance during August and September.
Divisions will continue to incur sanction where performance has not
been met irrespective of any financial agreement between
Commissioners and the Trust.
Oct 2013
SL referred to table 4 on page 7 of the report and questioned why the
cumulative variance was 4.91%. FS explained that this variance has
occurred whilst the implementation of the Clinical Decision Unit (CDU) is
being worked through.
IG advised that following initial concerns that the Capital programme
was slipping, some intensive spending has resulted in a pleasing report
that the programme currently stands at 86% on target which is within
Monitor’s tolerance levels.
FS reported that to assist with the further streamlining of financial
matters Keith Turner, the newly appointed Head of Estates and
Facilities, is looking at the non-pay elements of the PFI and Colin
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
McLean, Interim Strategic Head of Procurement, is investigating
procurement improvements.
CW advised that at the Finance & Performance meeting on 22nd August
2013 the large increase in drug spend that is identified on page 13 of the
report was discussed and a timeline for this matter to be resolved was
requested. FS clarified that some of these additional costs were pass
through costs and further clarity of the reasons behind this increase FS
would be provided
Oct 2013
Directors NOTED and the key areas of concern and the actions being
taken.
13/90
GOVERNANCE AND RISK
MONITOR IMPROVEMENT PLAN
IG tabled an update regarding the Monitor Improvement plan.
IG presented the information highlighting that the approach that needs to
be taken and the associated planning cycle moving forward into
2014/15. IG identified that more details of what is required to be included
in this planning cycle will be undertaken in a separate strategy session
that is scheduled to take place later in today’s meeting.
Directors noted that work that is being undertaken within the Newark
Strategy Group and the associated workstreams as well as the Mid
Notts Review work will also feed into the planning cycle for 2014/15.
During the presentation IG advised that it is hoped that external
assurance will not be required ahead of October submission but this
remains a possibility. This extra resource will need to be procured and
will have a further financial impact.
Directors NOTED the updated regarding the Monitor Improvement Plan
13/91
GOVERNANCE PROGRAMME TASK AND FINISH GROUP
PO updated that the Governance Programme task and finish group
continue to meet on a weekly basis and he encourages any NEDs to
attend the meeting, for information and assurance, as often as possible. NEDs
The role of the group is to provide assurance by means of collecting all
relevant evidence and ensuring improvements are taking place.
OCT
2013
PO reminded Directors that the purpose of the task and finish group is to
draw together all the action points identified by KPMG, PwC, CQC and
Sir Bruce Keogh. Good progress has been reported with the KPMG and
PwC reports/ action plans but matters relating to relevant training for the
new NEDs remains outstanding.
Response to the Sir Bruce Keogh report remains on track for completion
by 31 October 2013.
With regards to the CQC visit the Trust have received an initial draft
report but an official report is still awaited. Actions were to be
progressed by 31 October 2013 concerning the CQC warning notice.
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
Directors noted that it is not likely that the Sir Bruce Keogh team will
return to revisit the Trust but the CQC team will revisit to review the
Trust against their actions again.
PO identified that demonstrable progress needs to be made to allow the
special measures that are currently in place to be lifted.
It was acknowledged that a debate took place at the August Board of
Directors meeting and it was agreed that it is likely to be July 2014
before demonstrable progress would be evident. SB questioned whether
this date had changed.
PO responded that this had now changed as it is anticipated that we are
likely to be re-inspected between January – June 2014.
KR added that she would arrange a confirm and challenge panel, with
the NEDs, so that the Trust can undertake independent scrutiny and KR
gain assurance that progress is being made.
RD advised that he had met with the Trust’s internal audit team and DL
to look at the Internal Audit plan as a result of the Keogh
recommendations. It was agreed that the internal audit team will look at
7 specific areas which will be incorporated into the 2013/14 audit plan. RD
Further feedback will be given later in the year.
Oct / Nov
2013
Nov/Dec
2013
PO advised that the Trust was viewing its self-assessment with the
same scrutiny as if in the application process required to become a
Foundation Trust. The self-assessment undertaken has resulted in a
score of 13. Actions taken have progressed this score to 6 but for the
Trust to demonstrate to Monitor that adequate arrangements exist for
ensuring safe , effective and high quality care at all times the score
needs to be below 4 and further work would include the Board in order
that all members are confident in the Trusts stated position
KR tabled 3 documents and drew Directors attention to the timeline
contained in the document titled “Board visions, values and culture”.
This timeline identifies the work that will be required to ensure that
adequate self-assessment is undertaken to identify any gaps prior to the
submission of the assessment to Monitor on 31st October 2013.
The Board NOTED the work that is being undertaken by the
Governance Task and Finish Group and AGREED that further
involvement is required to ensure that all actions are being addressed.
13/92
HEALTH AND SAFETY ANNUAL REPORT
RDa presented the Health and Safety Annual Report bringing the
following points forward;
Directors were advised that the annual report highlights the work
undertaken by the Trust’s health and safety function during 2012/13 to
protect staff, visitors and contractors from those risks created by the
work that the Trust undertakes.
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
The main points in this report include:
•
•
•
•
•
•
The Trust’s management of work related violence and
aggression. There has been a 22% reduction in incidence of
violence, 172 incidents compared to 219 incidents in the
previous year.
Slips, trips and falls.
The prevention of sharps injuries. The reported incidents remain
largely unchanged with 144 incidents.
the main risks and the controls that are in place or are in the
process of being put in place, to mitigate these main risks.
comprehensive data on the health and safety performance of the
Trust together with an analysis of current successes and areas
for future work.
how the health and safety function works in partnership with staff
and the staff side unions to mitigate and control health and safety
risks.
The report also contains a list of the risks and issues considered by the
Trust’s Health and Safety Committee during the year and the actions
that have been taken to manage those risks.
RDa advised that the number of staff accidents reported to the Health
and Safety Executive (HSE) under the Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations (RIDDOR) 1995 decreased
from 17 to 15. This decrease was mainly due to changes made in April
2012 to the reporting requirements for RIDDOR. Of the 15 incidents only
3 were related to patient RIDDOR which is an all-time low.
TR noted that within the various tables included in the report a nonoccurrence is sometimes noted as “0” and sometimes “-“. A more RDa
consistent approach is required moving forward.
SEPT
2014
TR questioned if there is an escalation policy in place for injuries in the
workplace. RDa confirmed that all serious incidents are escalated to
Trust Board level.
CW questioned what measures are in place for employees that sustain
stress type lifting injuries in the work place and if there is a policy in
place to support these measures. RDa responded that there is a policy
in place and staff have access to moving and handling training and
access to physiotherapy services.
MC questioned whether RDa was the Trust accountable officer for
health and Safety and if other staff are also accountable are they aware
of this requirement. RDa confirmed that he was the accountable Officer
for Health and Safety as well as the Trust Chief Executive. RDa also
confirmed that there are accountable officers for fire and asbestos and
these staff members are aware of their responsibilities.
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
MC requested that the next report includes a contractor safety report RDa
and also a report relating to road safety and car parking
SEPT
2014
GMc asked for the date of the last HSE visit. RDa responded that the
last visit was in March 2013 following a RIDDOR incident involving a
doctor. RDa added that the HSE appear to be reactive in terms of
visiting and routine visits are not undertaken
DL drew attention to the statement in the report relating to the significant
risk outstanding regarding the provision of visual skin checks for all staff
frequently washing their hands.
DL questioned how high the risk of staff contracting dermatitis is, due to
frequent hand washing. RDa replied that it is difficult to measure this risk
as lots of staff hide this issue as they do not want their hand hygiene to
be scrutinised.
Directors NOTED the Health and Safety Annual Report for 2012/13 and
approve the plan of work for 2013/14.
SUMMARY REPORTS OF THE BOARD SUB-COMMITTEES
13/93
Risk Assurance Committee
RD explained that the Risk Assurance Committee meeting that was held
on 29 August 2013 was not as productive as planned and there were
issues in terms of communication. Documents were also presented that
had not been updated or were still in draft form. SL added that he
anticipated that the next meeting that was scheduled to take place on
11th September would be more structured and better attended.
Finance and Performance Committee
GMc advised that the Vitalpak was re-presented to the Finance and
Performance Committee meeting on 22 August for further scrutiny
regarding the financial elements of the business case. The Committee
carried out a thorough check and RECOMMENDED that the Board of
Directors approve this business case.
Following a discussion Directors APPROVED the Vitalpak business
case which had also been debated in detail at a previous Board
meeting.
Clinical Governance and Quality Committee
GMc advised that a full summary of the Clinical Governance and Quality
Committee was detailed in the Quality and Safety report.
Directors NOTED all summaries of the Board sub Committees and
recognised that a review of the effectiveness needed to be undertaken
now all Board positions were appointed to.
ANNUAL MEMBERS MEETING - UPDATE
13/94
YM advised Directors that the upcoming Annual Members Meeting
(AMM) that is scheduled to take place on 19th September 2013 will be
used to showcase the range of services that are available at our
hospitals including an opportunity to see a marketplace of stands and
interactive displays. There will also be 2 separate presentations
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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Sherwood Forest Hospitals NHS Foundation Trust
(‘SFHFT’, ‘the Trust’ or ‘the Board’)
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Foundation Trust in compliance with the Freedom of Information Act 2000
following the meeting relating to thyroid conditions and how to maintain
a healthy heart.
All members will be provided with a summary version of the annual
report.
KR recommended that the external auditor attend in order to present
their opinion to Members on the Annual Report & Accounts. It was
agreed that for the future, an early invite to attend would be extended to
the Auditors.
GMc encouraged Directors to prepare anticipated questions and ALL
answers prior to the event
MONITOR FT BULLETIN
13/95
13/96
13/97
13/98
18
Sept
2013
The Board NOTED the Monitor FT bulletin (28 August 2013 issue 72)
ANY OTHER BUSINESS
There was no other business to discuss
POINTS OF REFLECTION
The following points of reflection were brought forward
• The meeting was short on decision making with too many papers
“to note”
• Directors expected to receive all Board papers in a more timely
manner.
• Clarity needs to be gained regarding delegated authority. This
clarity will be achieved as part of the review of the Standing
Orders
• Highlighting issues that are due to be considered and
encouraging Directors to think ahead was very helpful.
• There was a lot of insight during the meeting but not sufficient
foresight. The Board need to be more forward looking in the
future in order that it is more proactive
DATE AND TIME OF NEXT MEETING
It was CONFIRMED that the next meeting of the Board of Directors
would be held on Thursday 3rd October 2013 at 9.30am in Room 2,
Level 0, Education Centre, King’s Mill Hospital.
There being no further business the Chairman declared the meeting
closed at 13.30hrs
Signed by the Chair as a true record of the meeting, subject to any
amendments duly minuted.
……………………
[Name of Chairman]
Chairman
………………………..
Date
Sherwood Forest Hospitals NHS Foundation Trust
Unconfirmed Board of Directors – 5 September 2013
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