WEST LONDON MENTAL HEALTH NHS TRUST
OPERATIONS BOARD MEETING
Minutes Tuesday 5th January 2010 (draft)
Present: Peter Cubbon, Chief Executive (Chair)
Mr Ian Kent, Deputy Chief Executive
Mrs Barbara Byrne, Director of Finance & Information
Mr Steve Trenchard, Director of Nursing and Patient Experience
Ms Lesley Stephen, Director of Strategy & Performance
Ms Carol Scott, Acting Director of Nursing
Mr Andy Weir, West London Forensic SDU Director
Dr Nick Broughton, West London Forensic SDU Clinical Director
Dr Kevin Murray, High Secure Services SDU Clinical Director
Ms Bridget Ledbury, Ealing SDU Director
Dr Jonathan Scott, Ealing SDU Clinical Director
Ms Helen Mangan, H&F (incl Gender Identity) SDU Director
Mrs Nicky Holdaway, Hounslow (incl Cassel Hospital) SDU Director
Dr Alice Parshall, Hounslow (incl Cassel Hospital) SDU Clinical Director
Ms Gemma Stanion, Programme Director for the CQC Action Plan
Also present: Dr Tim Bullock, Deputy Medical Director
Miss Abby Fadina, Board Secretary (minutes)
In attendance: Mrs Jo Smith, Deputy Director of Finance
Mr Alan Wishart, Deputy Director of Human Resources
Mr Michael Patrick, Information Governance Manager (item 4 only)
Mr David Stone and Ms Susan Thomas – Apira Ltd Consultants (item 4 only)
1 APOLOGIES FOR ABSENCE
1.1
Dr Elizabeth Fellow-Smith, Medical Director
Ms Linda Dyson, Acting Director of Workforce & Organisational Development
Dr Michael Phelan, H&F (incl Gender Identity) SDU Clinical Director
Ms Angela Dolan, High Secure Services SDU Director (Acting)
2 MINUTES OF THE LAST MEETING
2.1 Subject to the following addition the minutes of the meeting held on the 17th December 2009 were agreed as a correct record:
(para 7) New Policy P18 - Preceptorship Policy
7.4 - The Operations board agreed that the new policy would be circulated as a working document on the Exchange with an 8 week consultation period.
3 MATTERS ARISING
3.1 (para 4.4)IM&T Strategy and presentation of the Exchange / Knowledge Management of IT
Mrs Byrne said she would raise the issue regarding the number of incident alerts on the Exchange to SDU leads with Mr Andy Burton, Intranet Systems Manager.
Action: Mrs Byrne
3.2 (para 4.6)IM&T Strategy and presentation of the Exchange / Knowledge Management of IT
Dr Murray confirmed he now had access to the drill down levels and statistics relating to the Performance / Corporate Objectives. Mrs Byrne agreed to ask Mr Burton to send out guidelines to the board members on how to access this area.
Action: Mrs Byrne
3.3 (para 9) Trust Governance Committee Structure – members of ISSG
Members noted that the ISSG terms of reference would be issued in due course.
3.4 (12.2) Policy ICP14 – Decontamination. Discussions regarding role of the Head of Nursing
Mr Trenchard said he and Mr Weir had exchanged e-mails and met to discuss this.
3.5 (14.4) Disciplinary Policy and Procedure Review
Mr Wishart said that the issues raised with regards to the policy not reflecting the SDU structures would be raised first in a paper to SMTs to review.
Action: Ms Dyson
3.6 (para 3.2) Matters Arising: Feedback from KPMG re further development of financial way forward
Mrs Byrne said that the earlier meeting, Clinical Engagement & Leadership Forum, focussing on the leadership challenge for the next two years at the Trust had formed part of the feedback.
4 INFORMATION GOVERNANCE AGENDA
4.1 Mr Cubbon welcomed the Information Governance (IG) Project Team; David Stone and Susan Thomas from Apira Limited and Michael Patrick, Trust Information Governance Manager, to the board meeting to present their role to support the Trust to achieve evidence level 2 compliance in the 25 core requirements of the Information Governance Toolkit by the 31st March 2010.
4.2 The Operations board agreed that they would be the Trust’s Accountable Asset Owners (IAOs); their role would be to address risks to the information assets (any paper or electronic information which is stored by the Trust) that they ‘own’ and provide assurance to the Senior Information Risk Officer (SIRO), Dr Fellow-Smith, on the security and use of the assets. The Operations board agreed to invite the IG Project Team to provide appropriate training to the SDU leads and to the Executive Directors.
4.3 The IAOs in turn would then be required to identify and designate responsible Information Asset Administrators (IAAs); their role would be to ensure that policies and procedures are followed, recognise actual or potential security incidents, consult their IAO on incident management and ensure that information asset registers are accurate and up to date. The board noted that the IAAs would also receive appropriate training.
5 UPDATE ON MORI
5.1 Mr Kent’s report provided the board with an update on the progress made on the MORI Poll Action Plan over the last year. It identified the additional priorities and actions being taken forward locally; and included the 3 SDU Primary Care Interface Improvement Plans which had all been updated to detail progress made to date.
5.2 Mr Kent agreed to feedback the 3 SDU Primary Care Interface Improvement Plans to the GPs and to work with Lucy McGee, Director of Communications, with regards to the most appropriate way to do this.
Action: Mr Kent
6 POLICY M5 – SAFER MOVING AND HANDLING POLICY (revised)
6.1 The board discussed the contents of the revised policy and concerns were raised with regards to its length, the link with the Trust’s Health & Safety Policy, its possible conflict with the contents of the Trust’s current PMVA policies (V2 - Violence Reduction and Management) and whether or not all the appendices would be completed appropriately by front line staff. Mr Trenchard suggested that the content of the policy could be improved by the highlighting of issues specific to clinical and non-clinical staff.
6.2 Mr Cubbon asked the Policy Review Group to consider designing front end summaries for each policy and for the Policy Review Group to review the number of policies that the Trust currently has; establishing which could be combined and which are necessary for NHSLA assessment.
Action: Ms Scott, Mr Kent
6.3 The revised Policy was approved, to be placed on the Exchange, for the benefit of NHSLA assessment compliance but should be reviewed with regards to the concerns raised by the board.
7 FOLLOW UP FROM CLINICAL ENGAGEMENT & LEADERSHIP FORUM MEETING - 5TH
JANUARY 2010
7.1 Mr Cubbon’s presentation at the Forum had focused on the Trust’s leadership challenge for the next three years. Forum members had split into six groups to discuss:
§ What are the quick wins to get this moving?
§ What are the transformational changes that will deliver this and can we front load these rather than back end load to ease the pressure?
Feedback from the groups would be circulated to board members to discuss at the Operations board meeting in February.
Action: Miss Fadina
7.2 Mr Cubbon agreed to circulate his presentation to the SDU Leads so that a single presentation could be used to cascade the message to the SDU Senior Management Teams and ward staff. The presentation would also be used at the Trust’s staff forums.
Action: Mr Cubbon
7.3 The board agreed that the Forum had been a useful session. Mr Cubbon referred the board to the Operating Framework for further information.
7.4 The board received the “Review of West London Mental Health Trust Governance Arrangements” report compiled by Ursula Martin, Consultant in Governance and Risk Management. Mr Cubbon asked SDU Leads to discuss the contents of the report within their SDUs.
Action: SDU Directors, SDU Clinical Directors
7.5 The board noted that the NHSLA assessment review would be taking place in February 2010.
7.6 The board reviewed the revised Trust governance committee structure and agreed that the SDU SMT minutes would be received at the Operations board. The board made amendments to the structure and agreed that subject to the changes the structure would be presented to the January 2010 Board for approval. Mr Cubbon stressed that outside of the approved committee structure task & finish groups would exist to conduct complex work as appropriately designated and additional Groups or Committees could not be added to the approved structure.
7.7 The board noted that the next steps would be for terms of references to be updated or developed for the meetings within the new structure.
Action: Chairs of meetings, Board Secretary
7.8 Mrs Smith introduced the Audit Commission report titled ‘ Mental Health Benchmarking Club’ and highlighted that the output from the Club was available to assist the Trust to benchmark its services against that of other mental health trusts. The board suggested it would be useful to identify the other London mental health trusts for comparison. Mr Cubbon advised that the Trust should look at best practice nationally.
Action: Mrs Smith
7.9 Dr Bullock highlighted the data resource analysis shortfall in the Trust and he described the current work he is doing to address this. The board agreed that Dr Bullock would meet with the 3 local SDUs (H&F. Hounslow and Ealing) to discuss and agree their data analysis needs. Dr Bullock agreed to make his preliminary analysis of data available.
Action: Dr Bullock
Mr Cubbon left the meeting for another engagement
Mr Kent Chaired the remainder of the meeting
8 CQC ACTION PLAN UPDATE
8.1 Mr Kent informed the board that the CQC had informed the Trust and the SHA that they would no longer be attending the quarterly action plan program meetings.
8.2 Mr Trenchard said that the Trust was facing another inspection relating to hygiene and cleaning and the action plan for it was being tasked to the Heads of Nursing. He agreed to send an e-mail to the SDU Directors with more information.
Action: Mr Trenchard
9 CIP ANALYSIS AND NEXT STEPS
9.1 Mrs Byrne tabled a paper detailing the efficiency savings that had been identified as at 4th January 2010. Each SDU described their progress towards achieving their CIPs.
10 COMPLAINTS TRACKER
10.1 This item was deferred until the next meeting due to insufficient time.
11 TERMS OF REFERENCE OF EALING SITE INTERFACE STEERING MEETING.
11.1 The board approved the terms of reference. Dr Broughton said that the meeting had been
Up and running for 8 moths and was proving effective in improving the relationship between the 2 SDUs based on the Ealing Hospital site and Ealing General NHS Trust.
12 CQC REGISTRATION
12.1 Mr Trenchard agreed to circulate appropriate literature outside of the meeting. He informed the board that the Trust had registered under 6 locations.
Action: Mr Trenchard
13 NEW POLICY M12 - MANDATORY TRAINING
13.1 The new policy aims to formalise the Trust’s current mandatory training guidelines. The board agreed that the policy is circulated for an 8 week consultation period.
Action: Board Secretary
14 POLICY D3 – EQUALITY & DIVERSITY (revised)
15 Policy R5 – Criminal records bureau (crb) (revised)
16 POLICY R6 - RECRUITMENT & RETENTION (REVISED) (revised)
17 POLICY S26 – SUPERVISION (revised)
The board approved the above policies, in line with NHSLA requirements, to be cascaded to staff and placed on the Exchange.
Action: Board Secretary
18 ADMISSIONS OF UNDER 18s
18.1 The board agreed that the following wards would be designated to admit under 18s where no private beds are available:
Campion ward (male) in Ealing
Kingfisher ward (female) in Hounslow
18.2 Mr Kent agreed to circulate the AIMS relating to the admission of adolescents from the Royal College to SDU Directors.
Action: Mr Kent
19 ANY OTHER BUSINESS
19.1 Date of Next Meeting
19.1.1 The next meeting would be held on Tuesday 2nd February 2010.
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