80thMeeting of the Board of Directors
Thursday 7 November 2013
Room 4, Memorial Hospital
Board of Directors
Dave MellishChair
Archie HerronVice Chair and Non-Executive Director
Anne TaylorNon-Executive Director
Paul WardNon-Executive Director
James KellockNon-Executive Director
Steve JamesNon-Executive Director
Stephen FirnChief Executive
Helen SmithDeputy Chief Executive and Director of Service Delivery
IfyOkochaMedical Director
WilfBardsleyDirector of Nursing and Governance
Ben TravisDirector of Finance
Simon HartDirector of HR and Organisational Development
In attendance
Ann RozierTrust Secretary and Head of Governance
Susan Owen Risk Manager (Minutes)
Members of the Council of Governors in attendance
Richard DimentPublic Governor, London Borough of Bexley
Malcolm WoodVoluntary Partnership Governor (Learning Disability), Bromley Mencap
Action1 / Apologies for absence
Seyi Clement, Non-executive Director / Noted
2 / Minutes of the Board of Directors meeting 5 September 2013 and the Board of Directors meeting 3 October 2013
5 September 2013
- Page 1 – SF had sent apologies to the meeting, so his name to be removed from list of attendees.
- Page 3 – Amend Paediatric Assessment Unit to Paediatric Ambulatory Unit.
- Page 6 – Add a statement that no children came to harm as a result of the BCG vaccination incident.
3 October 2013
The minutes of the meeting on 3 October 2013 were approved as an accurate record. / Approved
3 / Matters arising
5 September 2013
- Page 1 – Michael Witney will bring a report on Referral to Treatment Times for psychological therapies to the next Board of Directors.
- Page 4 – A report on Board Visits will be a standing item at each Board meeting under the Quality and Governance section. This will be a verbal item from NEDs.
- Page 1 - The purchase of 1-6 Carlton Parade will complete on 25 March 2014.
MW
4 / Key Performance Indicator report – September 2013
The Trust continues to perform well against Monitor targets. For patients having a CPA review within 12 months, we are performing above the target Trustwide, but the Adult Learning Disability service has dropped below target. This relates to a small number of patients (3 breaches) and the reasons are being explored. The Urgent Care Centre continues to perform well. The service continues to receives a substantial number of contacts and performs well within target. Monitor have stated that they will not be collecting the new indicators proposed in the consultation Risk Assessment Framework from April 2014, but may do so later in the year. The Trust will keep a focus on these. Referral to Treatment for Psychological Therapies is not a Monitor target but the Trust has a focus on meeting the internal target of 95% of patients to be seen within 18 weeks. This runs alongside reviewing job plans for psychological therapists. We are currently performing at 88% and expect to reach 95% soon. There is some way to go to meet the target for patients on an incomplete pathway for psychological therapies.
DM – Are we satisfied that 18 weeks is an appropriate waiting time?
HS – Many would think that this is too long to wait. Some teams are aiming for 13 weeks.
PW – It would be a judicious use of money to invest in reducing waiting times.
HS – We can invest more resources or look at different ways of working.
AH – We need to see a profile of waiting times by treatment type so we can understand the detail.
HS – The Psychological Therapies Executive receives this. It can be brought to the Board.
In-patient occupancy in adult acute services remains high, but the Trust has not used a private bed for some weeks. The Older Peoples Directorate is performing at 75% to 80% occupancy and this appears to be a settled trend.
JK – When do occupancy levels become dangerous?
IO – Clinicians know when to use private beds. We work hard on discharge planning to better manage occupancy levels.
PW – How many out of area placements do we have?
SF – As of last night, we are not using any private beds, but nine patients were slept over on other wards. Staff undertake a risk assessment to make a judgement on sleepovers.
HS – We are opening a mixed age ward (45 – 70 years old) in Oxleas House. We do have some patients on working age adult wards who are physically frail and this will enable us to improve how we care for this group.
DM – There has been national criticism of reducing beds in the NHS. Oxleas has not reduced the bed base for working age adult services.
Adult Community Health Services are struggling with recording ethnicity and outcoming appointments. For new birth visits in Bexley, the target of 95% is to be reached by Quarter 4 and the current position against this trajectory is 86.6%. In Greenwich, the Trust is performing at 90.7% against a monthly target of 95%.
AH – How is the Trust performing with regard to delayed discharges?
HS – We are focused on this through joint working with our partners.
SJ – Is learning disability occupancy settled?
HS – Due to refurbishment and the admission of some acutely unwell patients, the bed base was reduced so the service could continue to deliver good care. There are some outstanding issues to resolve. / Noted
HS
5 / Director of Service Delivery Report
The Trust has been shortlisted for the Health Service Journal (HSJ) Provider of the Year award and the Staff Engagement Award. We should know the outcome on 19 November 2013. Our Advanced Dementia Service has been shortlisted for a NHS Innovation award.
The team at HMP Maidstone has won the top prize in the respiratory nursing section of the Nursing Times awards for their work in improving the health of prisoners through pulmonary rehabilitation. The Trust has submitted a bid to become a pioneer for the delivery of integrated services in Greenwich. A CPN is working with community health teams to explore whether closer working has benefits. This is part of a “Promise Programme” which will initially focus on winter pressures.
PW – What progress is being made on innovation and integration?
HS – We are using technology to improve patient experience and quality. This includes taking a proactive approach to the management of long term conditions by encouraging self-care. We are also supporting staff to remotely access patient records.
SF – We have a three year ICT plan. We are currently in year 2 (implementation). Year 3 will focus on embedding.
DM – Alison Furzer will be invited to attend the Board in the New Year to report on progress.
6 / Service Delivery Strategy – Quarter 2 progress report
The SDS identifies four overall priorities that the Trust needs to focus on over the next three years. This includes the development of a community estates strategy in conjunction with Greenwich CCG.
JK – What productivity priorities will be achieved by March 2014?
HS – The productivity report will pull indicators together in iFox. There are still some data quality issues to resolve, but the results of this will be brought to the Board in a meaningful way. Phase 1 will be to produce a rank ordering of indicators and phase 2 will produce more comprehensive reports.
IO – We have appointed a senior nurse to focus on care planning, initially to focus on community health services. We will use existing resources to work on mental health.
WB – Heads of Nursing will also have a role on focusing on care planning across all services.
7 / Quality Report
QSIP
Transition CPA for 17 year olds transferring to Adult MH services is reported quarterly. In Quarter 2, there were 55 17 year olds who turned 18. Of these, six required a CPA review. Four had the review on time, one after they had turned 18 and one did not have a CPA review. Four out of 27 targets are below target by more than 10%. The red indicators are:
- PE1.2 MH - The offer of a carer’s assessment to all registered carers of patients subject to CPA. Much work is being undertaken in this area.
- PE1.1 CH – Care plans on RiO for community teams.
- CE1.2 CH - Patients with COPD referred for pulmonary rehabiltation to be screened for anxiety and depression
- PS1.3CH – Number of grade 2 pressure ulcers. The number of new cases reported in month six has increased.
- PS1.2 MH –Follow up after a self-harm/suicide attempt within 48 hours of discharge from hospital. Follow-up will be undertaken face to face by the Home Treatment Teams rather than a telephone contact. This newapproach will be piloted in Greenwich.
- PE2.3MH – Patients on CPA to have received a CPA review within 6 months. This is under target by 0.8%.
- CE3.1MH – Detained patients provided with information under S132 of the MHA.
- CE1.3CH –Babies discharged from hospital to have received a new birth visit within 14 days.
Smoking cessation is an area of focus. Although teams state that they have referred patients, there is not always evidence of this in RiO. Further awareness of recording appropriately on RiO and dissemination of patient information has taken place.
JK – Why is the 48 hour follow-up being piloted in Greenwich?
IO – We want to make sure it does not unduly increase caseload before implementing Trustwide.
SJ – This is a very clear indicator. The next set of results should tell us if this is successful.
IO - Some of the breaches were because teams were unable to make telephone contact. This is why we have moved to face to face contact.
SJ – Do we have a sense of why reporting of grade 2 pressure ulcers has increased?
IO – It is good that reporting has increased. We have a robust system for undertaking RCAs and if there are safeguarding implications, these are flagged with the LA. We have appointed a nurse to take forward embedding learning.
Patient Safety Group sub-group report
The Patient Safety Group meets every month and alternates between the embedding learning meeting and the business meeting. The embedding learning meeting is attended by each CCG. The following standing agenda items are discussed in each business meeting: serious incidents and trend analysis, infection prevention and control, safeguarding adults, safeguarding children, falls prevention, medical devices, pressure ulcersand Harm Free Care.
AH – Have the problems with the medical devices contract been addressed?
WB – There is now one supplier for medical devices maintenance.
AT – Is equipment standardised?
WB – Defibrillators have been standardised for some years and syringe drivers have recently beenstandardised. We are now looking to standardise ECG machines.
DM – When this is next reported to the Board, the report should focus on the key issues and the action taken. / Noted
WB
8 / Safeguarding Children Annual Report
The report sets out how the Trust is meeting its Section 11 obligations and our priorities going forward. The Trust has made excellent progress with training and named doctors are in post. Positive feedback has been received from inspections.
JK – The report is well complied and shows that improvement has been made.
DM – Who are the external customers?
WB – The Local Safeguarding Children’s Board and our commissioners. / Noted
9 / Compliance report
CQC compliance visits
The CQC conducted compliance visits to six Trust sites from 25 September to 2 October 2013. Atlas House, Ivy Willis, Bracton Centre, and Hazelwood and Greenwood were fully compliant. One moderate and two minor concerns were identified at Oaktree Lodge and two minor concerns were identified at Oxleas House.
DM legal claim
The inquest into the death of DM recorded a verdict of misadventure. The internal inquiry found that 15 minute observations were appropriate. The NHSLA obtained two expert opinions, both of which reached the conclusion that DM should have been on 1:1 observation. The NHSLA advised that the Trust would be unsuccessful if we attempted to defend the claim and advised us to settle. There has been publicity which implies that we admitted liability.
AT – DM spoke and behaved in a way that suggested she was safe on the ward. The incidents cited in the press took place outside the ward.
SJ – Have we made representation to our insurers about how this has been interpreted in the press?
DM – This matter will be discussed at the Council of Governors.
Service improvement
The taskforce at the Bevan Unit is overseeing improvements fortnightly. A new interim manager is in post and a robust performance management process is in place. IO said that the Trust is considering the appointment of a resident doctor, rather than using GP cover. BT said that financial resources will be available to support this.
MHA commissioner visits
There have been two positive MHA Commissioner visits at Scadbury Ward and Shrewsbury Ward.
Ofsted full inspection at Bluebell House
An Ofsted full inspection was undertaken at Bluebell House on 23 July 2013. This was a very positive visit and the unit achieved an outcome of “outstanding” in the final report.
Infection prevention and control
In order to be eligible to receive a portion of winter pressures funding in future years, Trusts need to vaccinate 75% of the staff against flu this year. There is currently a programme to encourage uptake.
SLHT claims
The Trust has inherited 22 legal claims from SLHT but is working towards reducing these.
Complaints
Two fifths of complaints are upheld or partly upheld. Michael Witney is leading work on action planning.
JK – Why are the numbers of complaints increasing?
WB – We are a changing organisation. The same types of issues are frequently raised.
AH – Who decides whether a complaint should be upheld?
SF – There is a investigation which is signed off by myself. Complainants can appeal the outcome or refer the matter to the Ombudsman. / Noted
10 / Oaktree Lodge CQC visit
One moderate and two minor concerns were identified following the CQC inspection at Oaktree Lodge. The moderate concern related to a number of small issues for Outcome 4 (care and treatment). One of the minor concerns related to staffing. The Trust could evidence that staffing levels are safe, but the CQC were obliged to report staff feedback in relation to this. No other concerns have been raised about staffing and levels are within RCN guidance. As part of the Nursing Strategy implementation, the use of the Telford model will be prioritised at Oaktree Lodge.
IO – Staff need to get use of the Modified Early Warning System (MEWS) right. Our response is satisfactory.
JK – How do we capture weaknesses?
WB – I meet with IO and BT to ensure that CREs do not impact on quality. We review incident reports of short staffing and monitor vacancy, sickness and turnover levels.
IO – We will use productivity data to give a view on what is acceptable.
SH – The HR teams are supporting this.
AR – The CQC have approved our action plan and will expect a progress report in six weeks. / Noted
11 / Staff uniforms
The Trust has a wide range of services, but no consistent style. Benefits of uniforms include improving public confidence, easier identification of staff, projecting a professional image and supporting infection control measures. The proposal has been discussed within directorates and staffside and a formal consultation process is in progress.The cost of implementation is £162,500 and ongoing revenue costs will be in the region of £76k. BT confirmed that providing uniforms would not be treated as benefit in kind. The Board approved the Uniforms and Workwear proposal. / Approved
12 / Governance Board update
The following changes have been made to the Corporate Risk Register.
KP1.3.4: Care plans that demonstrate service user involvement are not always evident in the case record. This means that services users may not engage with care and treatment, resulting in poor patient outcomes and experience. As this was an area of concern raised by the CQC, the Governance Board considered if the risk rating should be increased. It was agreed that a rating of MODERATE (9) was appropriate. Consequence = 3, likelihood = 3, risk rating = MODERATE (9)
KP7.3.1: Although relationships with key GPs are largely good there is a risk that commissioning strategies and priorities will change as CCGs develop. It is unclear as to how the changes in specialist commissioning arrangements will impact on CCG budgets.
Risk to remain at consequence = 4, likelihood = 2, risk rating = MODERATE (8).
KP8.2.1: The enhanced role for local authorities in Health and Wellbeing Boards may lead to changes in local commissioning patterns. If the Trust does not develop effective working relationships with local Health and Wellbeing Boards, this may result in loss of income. The position has not changed since the last review. Consequence = 3, likelihood = 2, risk rating = MODERATE (6).
QM1: An undetermined amount of transitional costs may need to be met by local CCGs, which would impact on exiting services in future contract negotiations. Some issues relating to the transitional funding remain unresolved but a contingency plan is in place. This risk had been reduced from a SIGNIFICANT (16) to a MODERATE (8) risk by the QMH Project Board. The consequence remained at 4 and the likelihood was reduced from 4 to 2. / Noted
13 / Business Committee update
SARD
SARD has won three major contracts with Guys and St Thomas’, Kings College Hospital and Oxford University Hospitals. The organisation is becoming self-sufficient and is in a position to benefit from nurse validation and GP validation. Payback is expected within three years.
Contracts
Bexley CCG are proposing contract reductions of £1.4m in 2014/15. SF has met with Sarah Blow, the CEO of Bexley CCG. GP expectations of district nurses differ from ours and this may impact on decisions around care pathways. The CCG is supportive of our plans for the QMH Sidcup site.
14 / Council of Governors update
The Council of Governors approved the appointment of AH as a Non-executive Director for a further term of three years. Nine new governors will attend an induction session on 11 November. The dates for focus groups in February 2014 have been circulated. The next meeting of the Council of Governors is on 12 December 2013.
15 / Board visits
DM said that feedback from Board visits will be a standing item at each Formal Board meeting. This will be verbal feedback led by NEDs.
DM – A very positive visit to the Tarn.
AH – Visited The Older Persons Service (TOPS) with BT. We were satisfied that service users get a high level of care. There were some environmental issues which have been fed back to the Estates and Facilities directorate.