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TRUST BOARD OF DIRECTORS (PUBLIC)

Minutes of the Public Meeting held on Tuesday, 4 August 2020 at 10.00 am

Via Video Conference

For the purpose of transacting the business set out below

Present: Mr Terry Moran CB Chair Dr Peter Reading Chief Executive Mr Jim Hayburn Interim Director of Finance Mrs Ellie Monkhouse Chief Nurse Mr Shaun Stacey Chief Operating Officer Dr Kate Wood Medical Director Mr Antony Bramley Non-Executive Director Mr Neil Gammon Non-Executive Director Mrs Sandra Hills Non-Executive Director Mr Michael Whitworth Non-Executive Director In Attendance: Mr Ade Beddow Associate Director of Communications Mrs Elaine Criddle Deputy Improvement Director Mr Jeremy Daws Head of Quality Assurance (for item 3.1) Mr Stuart Hall Associate Non-Executive Director Mrs Helen Harris Trust Secretary Mrs Elizabeth Houchin Freedom to Speak Up Guardian (for item 8.4) Mrs Alison Hurley Membership Manager & Assistant Trust Secretary Mr Jug Johal Director of Estates & Facilities & Interim Director of Digital Services Mrs Jo Loughborough Senior Nurse, Patient Experience (for item 1.1) Mr Ivan Mcconnell Director of Strategic Development Mrs Shauna McMahon NHS South, Central & West Mr Ian Reekie Public Governor Mrs Sarah Meggitt Personal Assistant to the Chair, Vice Chair & Trust Secretary

(for the minutes) Cumulative Record of Board Director’s Attendance (2020/21) Name Possible Actual Name Possible Actual Mr Terry Moran 3 3 Mrs Sandra Hills 3 3 Dr Peter Reading 3 2 Mrs Linda Jackson 3 2 Mrs Jayne Adamson 1 0 Mr Jug Johal 3 3 Mrs Wendy Booth 1 1 Mrs Claire Low 3 2 Mr Antony Bramley 3 3 Mr Ivan Mcconnell 3 3 Mr Neil Gammon 3 3 Mrs Ellie Monkhouse 3 3 Mr Stuart Hall 3 2 Mr Jeff Ramseyer 1 0 Mr Marcus Hassall 3 0 Mr Shaun Stacey 3 3 Mrs Helen Harris 2 2 Mr Michael Whitworth 3 3 Mr Jim Hayburn 3 3 Dr Kate Wood 3 3

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1. Patients’ Stories

Terry Moran welcomed Jo Loughborough, Senior Nurse for Patient Experience to the meeting. Jo Loughborough shared the Patient Story “what does it feel like not being able to see the person you love? Stories during COVID” with Board members and explained how vital communication had been during the restrictive pandemic periods between patients and their families. The positive impact the IT tablets had made during this period was highlighted. Reference was made to a particular story about ‘Anna’, a patient who had been in hospital for some time pre-COVID-19 who had then tested positive at the start of the lockdown period and her family had become concerned for her welfare due to difficulties for her speaking with them on the telephone. The Patient Experience team had managed to get an IT tablet for Anna to use to enable her to speak and audibly interact with her family, which had also offered support to her parents through this method. This had, therefore, been a positive experience for them all. Unfortunately Anna’s health deteriorated and she was moved to the intensive care unit (ITU). During this time the team kept in contact with her family, read their messages to Anna and the family also provided music for Anna. Sadly Anna passed away but the family had said how they had appreciated being able to stay in contact with her during that time due to the efforts of the Patient Experience team. Other positive stories during this period included a gentleman who had been away from his wife as she was an inpatient. When he attended the hospital to bring her some belongings, the Patient Experience team arranged for him to speak to her whilst on site by using an IT tablet in the reception area of the hospital, which was very gratefully received by them both. Jo Loughborough advised the positive feedback from patients and their families had given the team pride and passion for the work they undertook during the difficult time of the pandemic. Terry Moran thanked Jo Loughborough and her team for the work undertaken during this time, and the positive impact it had had on patients and their families. Ellie Monkhouse concurred, explaining the team had gone above and beyond what was expected of them to support patients and their families. The Patient Experience Report within the items for information section of the meeting was referenced, and Board members’ attention was drawn to pages 9, 12 and 13 which highlighted the major activity undertaken during this time. Jug Johal and his team were also thanked for their support in enabling wards to receive the IT tablets in a timely manner. Neil Gammon sought approval to share the slides with the Health Tree Foundation (HTF) to allow feedback of the positive impact of the IT tablets with the organisations who had donated money which funded IT tablets. Terry Moran agreed they should be shared, and Neil Gammon agreed to liaise with the Charity. Terry Moran informed Board members that he had recently received confirmation from Claire Low that the application submitted by HTF to the NHS Charities Together Grants had been accepted and £50,000 would now be received by them. This would now support the Black, Asian and Minority Ethnic (BAME) Project, and Trustees’ were thanked for supporting this.

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2. Business Items

2.1 Chair’s Opening Remarks Terry Moran declared the meeting open at 10.00 am and provided a warm welcome to Shauna McMahon who would join the Trust in October as the Chief Information Officer. Ian Reekie, a Public Governor for the Trust and Paul Bunyan, Head of Recruitment & Employment Services attending the meeting on behalf of Claire Low, were all welcomed to the meeting. He then again thanked staff for their commitment during the current circumstances on behalf of the Trust Board. Recent publications shared in the last week were referred to, being the NHS People Plan along with a letter which detailed the Phase 3 Planning from Simon Stevens, NHS Chief Executive, which would be discussed further during the private part of the meeting.

2.2 Apologies for Absence Apologies for absence were received from Linda Jackson, Claire Low (represented by Paul Bunyan) and Kathryn Helley.

2.3 Declarations for Interest Terry Moran requested any declarations of interest in relation to the business to be transacted. No declarations of interest were declared at this point.

2.4 To approve the minutes of the Public Meeting held o n Tuesday, 7 July 2020 – NLG(20)154 The minutes of the meeting held on Tuesday, 7 July 2020 were approved as a true and accurate record of the meeting and would be duly signed by the Chair following the amendments detailed below:

• On page 5, the final sentence in the first paragraph required rewording to enable greater clarification and to state it had been noted;

• On page 9, in the second paragraph of section 2.5.1, additional details were required to state that Terry Moran had previously seen a piece of work undertaken by Bradford Teaching Hospitals which had specifically captured data relating to BAME patients, and a link to the document had been shared with Neil Gammon;

• On page 13 it was agreed to add a paragraph at the end of section 3.4 to state that the Trust Board had agreed with the decision to support the establishment of the midwifery team following the piece of work undertaken, and the report would be provided to the Trust Board if financial issues required further resolution.

2.5 Urgent Matters Arising Terry Moran invited Board members to raise any urgent matters which required discussion which were not captured on the agenda. Kate Wood referred to the query raised by Neil Gammon at the previous meeting in respect of whether the Care Quality Commission (CQC) Ambassadors would be based at each site, and confirmed they were in place across all areas of the Trust

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which included Community Services. Shaun Stacey referred to the action for Tony Bramley and himself regarding the associated minute 2.2 of the meeting held on Tuesday, 7 July which related to the lack of an update on the mental health report in the Quality and Safety Committee (Q&SC) highlights report. A meeting had not been held since, but it was confirmed that the Trust Board minutes did confirm that mental health was important and it was discussed within the meeting.

2.6 Trust Board Action Log – Public by exception NLG(20)155 Terry Moran invited Board members to raise any further updates by exception in relation to the Trust Board Action Log, and requested that future actions should include a review date if a completion date was unable to be provided. Sandra Hills referred to item 2.2.2 from the meeting held on the 7 July, related to Ophthalmology. The Q&SC has kept a watching brief on Ophthalmology and requested periodic deep dives but not with specific timescales. It was agreed to incorporate such updates within the Q&SC highlight report in future and to remove this item from the action log. Dr Kate Wood clarified that the information was also included within the Board Assurance Framework (BAF).

2.7 Chief Exec utive’s Briefing Dr Peter Reading thanked staff who continued to perform exceptionally well during this extra-ordinary time, advising that staff who had been shielding at home had returned to work this week. Particularly staff who are required to wear personal protective equipment (PPE), senior managers, and in particular Kathryn Helley and her team in respect of the Phase 3 Recovery Planning which had been a complex piece of work. This had now been reviewed together with work to establish and address the activity gap. Work had been undertaken during the pandemic in respect of the Interim Clinical Plan (ICP) and the Humber Acute Services (HAS) programmes along with the allocation of capital. A HAS meeting was due to take place the following day, Wednesday, 6 August 2020 to consider and aim to establish current and future requirements. Further updates and discussions would be held in respect of the People Plan and Phase 3 Recovery plan at the Public Trust Board meeting in October 2020.

3. Board Assurance

3.1 Board Assurance Framework – NLG(20)156 Terry Moran explained this item related to the ‘Deep Dive’ of strategic objective one and referred to the presentation shared with Board members. Jeremy Daws, Head of Quality Assurance was welcomed to the meeting in support of this item. Dr Kate Wood advised the slides explained the assurance processes in respect of the BAF within each triumvirate and how risks were mitigated. This was the first deep dive which had been shared via this method and the objectives for discussion included those for Diabetes Management, Mortality & End of Life, Waiting Lists – Gynaecology, Ophthalmology and Complaints.

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Three strategic risks were linked to the non-achievement of strategic objective 1: ‘to give great care’. These were performance and the focus of achievement of constitutional standards with a risk rating currently of 20, quality was also rated 20 with a focus on six agreed quality priorities, and external events impacting on business continuity which currently sat at a risk rating of 16 with a focus on COVID-19 incident management and Brexit. The session focussed on performance and quality of the highest rated risks and their impact on achievement of strategic objective 1. The full summary was included in the BAF for each element which included the risks, actions and mitigations. Dr Kate Wood advised she would deliver the Diabetes Management and Mortality & End of Life aspects of the presentation. In respect of Diabetes, this had improved over recent months’ with the recruitment of the Divisional Clinical Director in Medicine, which had led to increased monitoring and oversight in place. Training for diabetes management had recently changed and a more successful training package had been implemented. Previous incidents which had occurred in Accident & Emergency departments in respect of blood glucose measurements were referenced, and it was confirmed that these remain a focus. Attention was drawn to the Mortality and End of Life care and the new key performance indicators (KPIs) established to address the required reduction in the Summary Hospital-level Mortality Indicator (SHMI) score for the Trust. The current SHMI score reported being 113.32 which was marginally outside the expected range of 113.25, although it was noted that recent un-validated data was now showing 111 which was within the expected range. This evidenced slow but steady improvement was being made. The End of Life slide required further work from an organisational perspective as well as system-wide. Positive changes within the Trust were evident in respect of a change in leadership. Robust audit plans were now in place and progressing. Due to COVID-19, a national decision had been reached to not undertake national audits for End of Life care in 2020; however, the Trust had requested that the team continue with this approach in-house. NHS England / Improvement (NHSE/I) supported the system-wide work being undertaken to ensure patients receive care without boundaries and the first strategic meeting took place the previous week. Shaun Stacey presented the Waiting List elements of the presentation and drew attention to Gynaecology and Ophthalmology. Expectations had been established for delivery and outcomes to the end of March 2021, and activity levels had been within this trajectory until the pandemic had commenced earlier in the year. The Trust would not reduce the overall position of the waiting lists which had increased over recent months, but in order to endeavour to address this growth more none face-to-face appointments were planned to take place. Gynaecology illustrated a decline in appointment performance due to COVID-19 as of April 2020, which had since improved and very good progress was again being made. The need to reduce the overdue follow-up waiting list to fewer than 9,000 by 31 March 2021 was re-iterated, with the need to also ensure there were no 52 week waits for patients. In relation to ophthalmology serious harm, increased scrutiny continued with oversight at the Q&SC and although the waiting list was significant, it was in a better position for Trust compared to other Trusts in the system. There was a marked improvement in the ophthalmology service since 2017 and a reduced number of Serious Incidents (SIs).

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Ellie Monkhouse presented the update in respect of complaints, where some culture changes had taken place in respect of the management of complaints leading to major changes in respect of communication. The learning from complaints had also now been embedded into other processes at the Trust which included the 15 steps process. All of these elements had now been triangulated into incidents, claims and SIs. NHSE/I had supported Ellie Monkhouse and the complaints team with an improvement programme which was due to be implemented for senior managers to support them in how to write a good complaints response. The key remit was that divisional staff had increased communication with complainants to establish the main elements of the complaint received, along with what resolution the complainant wanted, and this included face to face meetings if required. Terry Moran sought any comments or queries in relation to the information shared in respect of diabetes. Terry Moran invited Dr Kate Wood to share her own assessment of the diabetes service. Dr Kate Wood explained there was a more positive understanding of patients that required care within the organisation and she was pleased with the definite improvements. Close scrutiny and oversight was still being maintained. Terry Moran asked Board members for any comments or queries in relation to Mortality and End of Life care and queried with Dr Kate Wood whether the SHMI figure may change once it had been validated. Dr Kate Wood advised the data did tend to track very closely with the national data and advised this did not include COVID-19 deaths. Tony Bramley advised he was a member of the Mortality Improvement Group and although improvements had been made over recent months it was felt that greater Trust Board support was required in respect of the progressing the required changes identified. Improvement was needed for End of Life care requirements due to the previous issues raised by CQC. Dr Kate Wood explained the Trust needed to focus more on the process for patients entering the organisation in respect of them and their families. The Trust continued to drive the care for end of life patients across the divisions, which meant that patients would not particularly need an end of life specialist nurse as all nurses should be able to provide the care required with support from the end of life team. In terms of the system, NHSE/I had established system-wide working groups to review and establish the specific requirements. Terry Moran thanked Dr Kate Wood for her update and advised he would welcome future updates at this meeting. Dr Peter Reading acknowledged the substantial progress made by Dr Kate Wood, Jenny Hinchliffe and their teams in respect of end of life care, which had made a significant difference, although further embedding is required across the Trust. Terry Moran asked for comments and queries in respect of the Waiting List update. Neil Gammon asked for clarification of the risk stratification, in respect of gynaecology, as 358 patients had been risk stratified, however, the number of patients on the graph were in excess of 1000, therefore, was the process undertaken with certain patients. Shaun Stacey explained the table was in relation to the inpatient component part and the total patient tracking. This did not show the entire patient treatment list, and only referred to the inpatient list. Neil Gammon thanked Shaun Stacey for the clarification and noted the work that went into this process.

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Stuart Hall felt the Trust needed to focus on outpatient issues which were controllable, such as theatre productivity, early staff starts and late finishes. The Trust also needed to look at ethical considerations in terms of 52 week waiters, with reviews of the treatment required and validation of the waiting lists. Was the Trust adopting a strategy on ‘patients know best’ and were they involving patients to take an active part in their own follow-up appointments. Shaun Stacey supported this very important point and felt it was challenging when a patient had waited more than a year for a definitive treatment, explaining this was why the risk stratification was taking place. The Trust needed to recognise the partners involved in the patient care to ensure they were also engaged. During COVID-19 this process had been utilised to work closely with patients and to seek their views on whether they wanted to come into the hospital or not, and whether their symptoms had changed during this time. This meant they may be removed from the waiting list if they wished to, but they could also request a follow-up with a clinician during the next 12 month period if it was required without going back through their own General Practitioner (GP). Dr Kate Wood referred to Stuart Hall’s query in respect of the ethical side and advised she was a member of a Regional Senior Professional Leaders Group which was established to help ensure consistency of care across the region. These issues had been discussed at a recent meeting of the group, and a Task & Finish Group meeting had taken place previously where a set of principles had been established to endeavour to cover the ethical considerations. Terry Moran sought assurance on the credibility of the waiting lists. Shaun Stacey explained that 18 months ago the Trust developed and strengthened the Trust’s validation team from four to 15 staff, who validated the waiting list data on a daily basis. An external audit had also been undertaken which demonstrated the robustness of the validation process. Historically the Trust had not reliably delivered on waiting lists and had not been able to provide the CQC with the assurance they had required. Terry Moran sought comments or queries in respect of the Ophthalmology update. There had been a positive increase in telephony activity for appointments; however, this had now started to decline as activity changed. Terry Moran asked for comments or queries in respect of the Complaints / Patient Advice and Liaison Service (PALS) update. Stuart Hall queried how the Trust utilised data to support the complaints process, and questioned if it was used for tracking through the complaints process. Neil Gammon noted progress over the last 18 months in respect of complaints had been outstanding; recognising this included greater clinical engagement. Ellie Monkhouse thanked Neil Gammon for his positive feedback and agreed to inform her team. The data was managed manually which did cause some problems, although an Analyst had now been appointed to the nursing team which would improve future processes. Terry Moran asked Board members to state in the on-line chat function of the meeting whether they were now fully assured in respect of the update that had been provided, partially assured or not assured at all. Following the feedback provided members mostly felt partially assured. Members who were not assured were asked to discuss this with individual colleagues outside of the meeting. It was agreed members would provide Helen Harris with feedback in respect of why they were not fully assured, to enable collation of the feedback. Action: All / Helen Harris

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Terry Moran asked Board members if they had felt the deep dive session of the BAF had been beneficial. Board members felt the update and discussions had been very useful.

4.1 Finance & Performance Committee

4.1.1 Finance & Performance Committee Highlight Report – (F&PC) NLG(20)157 Neil Gammon presented the Finance & Performance Committee Highlight (F&PC) Report and sought any comments or questions. None were received.

4.2 Supporting Papers

4.2.1 Finance 2020/21 – Month 03 – NLG(20)158 Jim Hayburn presented the report and advised that the Trust had a balanced financial position due to the top up provided from NHSE/I, and confirmation had now been received stating it would be agreed. COVID-19 expenditure continued to be greater than the top up payment received. Agreement had been provided by the Executive Team to proceed with some weekend and evening additional working to address some of the issues that had been highlighted earlier in the meeting by Shaun Stacey to take up the underspend. With reference to the letter from Simon Stevens, a critical issue was that the Trust had only received confirmation that funding arrangements in place would continue through to September 2020, but no clarification had been provided following this period except that block payments would remain but not the associated funding levels, making planning difficult for the remainder of the year. Terry Moran sought any comments or queries in respect of the finance position. Stuart Hall queried if there would be any lenience from a system perspective for Trusts to make surplus or deficits depending on agreement within the organisation. Jim Hayburn advised there had been no formal recognition provided, although there was an agreement that some Trusts may be able to make surplus or deficits but this related to whether they had specific issues raised with NHSE/I. Jim Hayburn referred to the midwifery establishment and advised the Trust had included this as part of the bid to NHSE/I. Terry Moran noted this, but agreed the Trust would continue with recruitment.

5. Quality & Safety Committee

5.1 Quality & Safety Committee Highlight Report and Boa rd Challenge – July 2020 – NLG(20)159 Sandra Hills presented the report and drew the Board’s attention to the detail regarding the Clinical Negligence Scheme for Trusts (CNST). Safety action four illustrated where trainee doctors’ felt they had missed out on educational / training opportunities due to gaps in the rota. Terry Moran thanked Sandra Hills for the report and sought any comments or questions. None were received.

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5.2 Supportin g Papers

5.2.1 Nursing Assurance Report – NLG(20)160 Ellie Monkhouse shared the report and drew the Board members’ attention to the positivity of the implementation of Safe Care Live. This enabled the Trust to have live data in respect of the safety of patients along with safer staffing levels. Visiting of patients continued to be reviewed on a weekly basis and changes were put in place to ensure the Trust was not an outlier by adhering to the guidance. The Directorate had now recruited a Complaints Manager and following the report the number of complaints had reduced. The Q&SC had received the 15 Steps Annual Report at their last meeting and Version two had been launched the previous day, being 3 August 2020. This incorporated end of life care, increased infection control and more discussions with the multi-disciplinary teams. Ellie Monkhouse advised the team had embedded the vulnerability walk round which

commenced the initial phase of the COVID-19 pandemic. The biggest risk on the risk register still continued to be the number of nursing vacancies which was now the highest it had been over recent months. This had been offset due to the reduced bed base in respect of social distancing. If this had not been the case, some areas may have required closure. Additional support had been provided by third year students working as aspiring nurses at the Trust and this now included the support of second year students. Sickness levels remain quite high although COVID-19 sickness was separate to the number provided. Issues around sourcing data remained a concern, as the data provided within the report included caveats due to the manual collection. It was noted that some data would not be available for benchmarking due to the reconfiguration of wards. In respect of community services, a trend may become evident in relation to the affects COVID-19 had on the team having restricted access to enter care homes to validate pressure ulcers. However, further work would now be undertaken in respect of finding a resolution.

Sandra Hills referred to the nurse vacancies and noted that over 50% of them were within the medicine group, and whether this caused a skill set issue. The number of Clostridium Difficile (C Diff) infections appeared high, and asked for clarity in respect of a target. Ellie Monkhouse advised that in respect of the C Diff numbers the previous year, the trajectory was 36 cases so the Trust was still within the normal trajectory of infections. However, the team were reviewing this as infections do not usually occur at this time of the year. Ellie Monkhouse advised that staff vacancies had traditionally been higher within this area but due to the reconfiguration of ward areas, staff had been moved around to provide support where it was required, ensuring the skill mix had been maintained. Tony Bramley queried if this insightful report would be presented to Q&SC for review in greater detail at committee level, then key points could be shared with the Board through the committee highlight report. Sandra Hills confirmed it would. The Board supported this proposal going forward. Ellie Monkhouse noted the comments made but advised she had wanted to share greater detail due to the report not being

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shared at Board meetings during the initial COVID-19 period. Stuart Hall raised a concern about the reliance on manually collected data and the need for this to be addressed. Terry Moran queried whether Ellie Monkhouse felt she was in a position to ensure the Board would be assured going forward and that the right processes could be put in place. She confirmed that the analyst would be looking to re-establish the nursing dashboard to demonstrate the progress being achieved.

5.2.2 Guardian of Safe Working Hours Annual Report – NLG(20)161 Terry Moran welcomed Bryony Simpson to the meeting. Bryony Simpson presented the Guardian of Safe Working Hours Annual Report. In terms of COVID-19, some changes had led to improved rotas being designed during this time and the British Medical Associated (BMA) had complemented the Trust on the process implemented. Fill rates had increased from 178 last year to 220 this year. The report summary highlighted the Fatigue and Facilities fund work had been delayed due to COVID-19, which was now back on track. Two fines had been imposed during the year in respect of a breach of the Junior Doctor Contract, both related to a breach of 72 hours worked within 168 hours. There had been some negative behaviours in the completion of Exception Reports which were now being investigated, and meetings had been undertaken with NHS Education England to consider suitable resolution. Terry Moran queried whether there were any items to be raised which had not been included in the report and Bryony Simpson confirmed there was nothing to add. Dr Kate Wood thanked Bryony Simpson for the report and the work undertaken during her four years’ in her current role, especially as she was due to leave the role at the end of the year. The rotas had been very complex work supported by many individuals which had proven to be very positive and was evident in the comparison with other Trusts. Suggestions from junior doctors for the allocation of the Fatigue and Facilities funding had been slow and followed by further delays due to COVID-19, so further tendering had been required. In respect of the Education Supervisors, Mr Silas Gimba had presented a report at Trust Management Board (TMB) on 3 August by, to address this issue. Stuart Hall recognised the complex work undertaken, but was concerned that supervisors were receiving pay and not taking time off in lieu for additional hours worked and also junior doctors not logging exceptions to work patterns. Bryony Simpson advised this related to a small number of Exception Reports and although the Trust would prefer to give time off in lieu for additional hours worked, it was not always possible due to rota pressures, although junior doctors and consultants were offered the option to have time of in lieu to support a healthy work-life balance. It was confirmed that exceptions were raised for work patterns if they were significant. Stuart Hall added that although the Trust had been successful in attracting junior doctors, there was a concern that this would change if the issues were not addressed. Neil Gammon queried whether it would be helpful to have the number of Exception Reports shared to determine the exact numbers. Bryony Simpson agreed to note

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this for her successor for future reports. Terry Moran suggested it may be helpful to periodically raise the profile of this report for future Trust Board meetings. Terry Moran thanked Bryony Simpson for attending and sharing the report.

5.2.3 Serious Incident Update – NLG(20)162 Dr Kate Wood presented the paper, and explained it was the first time the paper had been shared as part of the public Trust Board meeting. Terry Moran confirmed that future reports would not include any dates to ensure individuals could not be identified. Dr Kate Wood informed members that the number of open Serious Incidents (SIs) was currently 40, with 10 being granted an extension. Two of these were due to complex investigations with police involvement and the Trust were not permitted to investigate until completion of the police investigation. Work continued with the Clinical Commissioning Groups (CCGs) in order to establish the implementation of KPIs. Terry Moran queried whether SIs were reviewed at the Q&SC due to the extensions and Dr Kate Wood confirmed they were. Tony Bramley confirmed the CCG lead was very complimentary at the last Q&SC meeting about the SI process undertaken by the Trust and the quality of the reports. Terry Moran thanked Tony Bramley for raising that point as it was excellent to hear this feedback from the CCG.

5.3 CQC

5.3.1 CQC Progress – NLG(20)163 Lucy Kent presented the CQC Improvement Plan Progress paper with Board members advising that CQC representatives had now attended all divisional meetings within the Trust and provided positive feedback. The CQC ambassador network was now developing adequately. The financial update sits alongside this paper, and divisions had been requested to consider what could be delivered if the requested funding was not received. A paper had been shared at the Trust Management Board (TMB) meeting on 3 August 2020, which now required additional details prior to submission to NHSE/I. The most significant challenge identified was to be able to evidence the mitigation actions being undertaken to provide robust assurance. Work was underway to complete the Integrated Performance Report (IPR) by the end of August. Terry Moran stated that although preparing for the inspection was important, effective patient care remained the key focus. He thanked everyone for their commitment and particularly Lucy Kent for the work she had undertaken, and sought any comments or queries. Neil Gammon queried how fully assured the Trust could be in respect of finances at present. Terry Moran agreed with Neil Gammon’s point as there were a number of red rated actions unless associated funds were secured.

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Lucy Kent added that the financial paper in respect of funding for CQC actions had been complex and timely to complete but the Trust were now in a position to prioritise funding allocations, and this paper would be submitted to the next TMB for consideration. The red/amber/green (RAG) ratings had been determined by the divisions with a remit to be transparent when rating the actions in terms of mitigations. Dr Kate Wood confirmed further mitigation would be required if the funding was not received. Jim Hayburn stated that there was a requirement for the system to take some ownership in respect of this funding. Ellie Monkhouse concurred and re-iterated the need to raise awareness of the lack of education for post graduate provision to help address this area of weakness in the Trust. Dr Kate Wood referred to the difficulties for the Trust in endeavouring to deliver the same services on two acute hospital sites, which would not be sustainable and required reconfiguration with potentially different commissioning arrangements. Terry Moran reminded the Board that a further session in respect of CQC progress was scheduled for 1 September 2020 where the Divisions would present their updates, and CQC representatives would be invited to attend.

5.3.2 CQC – Infection Prevention & Control Assessment – NLG(20)175 Ellie Monkhouse presented the report and advised this had resulted from discussions about the Infection Control element of the BAF report at the July Board meeting. The CQC had been informed that the Trust had been assured in all 10 domain areas, which included 12 areas of outstanding practice. The CQC had fedback that the Trust had been very open and transparent in respect of the buildings and how services were delivered in those areas. Jug Johal had supported the assessment and provided an update to the CQC on the capital bids. Jug Johal felt this was very positive feedback to communicate with the workforce.

6 Leadership, OD & Culture

6.1 Workforce Committee Highlight Report & Board Challe nge – NLG(20)164 Michael Whitworth presented the report and noted the risks raised around safe staffing in respect of COVID-19, and the organisational development work undertaken in relation to culture and health and wellbeing. Freedom to Speak Up and improved staff responses in terms of raising concerns had been discussed at the committee, and benchmarking for this would be investigated.

6.2 Supporting Papers:

6.2.1 Monthly Staffin g Report – NLG(20)165 Paul Bunyan presented the Monthly Staffing Report and drew the Board’s attention to the slight increase in turnover and vacancies, along with changes in sickness rates. The current vacancy position had increased again in month from 8.80% (548.91 whole time equivalent (wte)) to 9.18% (573.16 wte) and the budgeted establishment had also increased by 7.34 wte. Nursing in particular had increased to 12.77% which equated to 213.28 wte. 80 wte third year nursing students were expected to join the Trust which would help to address this, and it was noted that

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July typically holds the highest vacancy levels. In terms of international recruitment, the Trust was working with Health Education England to address delays due to COVID-19. Medical workforce vacancies, this decreased slightly to 13.37% which remained within the Trust target. The vacancy position was equivalent to 96.69 wte vacancies. This was a significant improvement in fill rates. Resource re-allocation was being investigated, and work with the flu campaign was in progress. Terry Moran thanked Paul Bunyan for the report and reminded members of the scope and opportunity for the Trust and Hull University Teaching Hospital NHS Trust (HUTH) to ensure greater collaborative working and support for each other. He sought any comments or queries regarding the paper shared. Sandra Hills queried the number of staff on the apprenticeship scheme, and whether those withdrawn had been included within the original figures or were in addition to them. This will be discussed further at the Workforce Committee due to concerns about the amount of staff that had dropped out. Paul Bunyan agreed to provide an update at the next Workforce Committee meeting. Action: Paul Bunyan

7. Audit, Risk & Governance Committee

7.1 Outcome of the Review & Refocus of the Audit, Risk & Governance Committee – NLG(20)166 Tony Bramley drew the Board members’ attention the Terms of Reference, item 3.2 which included the addition of the Associate Non-Executive Director (NED) role on the committee as part of the membership. A recommendation is made to other sub-committees to consider adopting the same approach. Item 3.2.2 had been amended to allow the committee to adopt temporary changes should another major disruption to services occur. It was recommended that this be adopted for all sub-committee terms of reference. Terry Moran sought any comments or queries and questioned whether Board members felt the Associate NED role should be adopted for other committees. Board members agreed with the proposal. The Trust Board agreed to approve the amendments to the Audit, Risk & Governance Committee (ARGC) Terms of Reference.

7.2 Audit, Risk & Governance Committee Highlight Report & Board Challenge – July 2020 – NLG(20)167 Tony Bramley presented the report and highlighted the delays with the Scheme of Delegation which would be introduced in September 2020 following discussion at the committee meeting. The Trust’s current compliance for the Information Governance training was now at 91%, which demonstrated an improvement. Discussions had taken place in respect of the WebV investigation and this work continued. A Counter Fraud collaborative arrangement was being expanded to now also include two other Lincolnshire Trusts as of September 2020.

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Terry Moran sought any comments or queries. None were received.

8. Items for Approval

8.1 Workforce Race Equality Standard Report - NLG(20)168 Paul Bunyan presented the report and referred to the focus around band eight and nine staff in post which had remained fairly static. In terms of the overall workforce, Black and Minority Ethnic (BAME) staff had increased slightly in 2020 and was currently at 10.38%. It was clarified that the matrix was based on NHS England reporting, and anything below one was positive for the demographic, over one was a positive towards the comparator and one was positive towards the white demographic. The Trust’s previous indicator was 1.5, being greater towards the white demographic in terms of the likelihood of them being appointed; however, this was now 0.8% which now meant BAME staff were more likely to be appointed to those of a white demographic. Dr Kate Wood sought clarification for section 4.1 in respect of the narrative of the 406 BAME consultants. Paul Bunyan advised this number included specialty doctors and those that were currently in training. Clarification would be sought on the information and discussed with Dr Kate Wood outside of the meeting. Terry Moran requested the breakdown of the figures be shared with all Board members. Action: Paul Bunyan Paul Bunyan referred to item 4.3 and the likelihood of BAME staff entering into a formal disciplinary process against the likelihood of white staff, which was noted as 1.62 times more likely than white staff. The final indicator related to the likelihood of staff accessing non-mandatory training and continued professional development (CPD) compared to white staff, which was slightly higher than 1 at 1.01 times greater. Paul Bunyan referred to the staff survey results and highlighted the bullying and harassment item which demonstrated the Trust was an outlier in this area due to the significant difference from BAME to white staff. In summary, the recommendations for all three reports shared at the meeting would be very similar. It was noted that staff group feedback was not included at this time.

8.2 Workforce Disability Equality Report – NLG(20)169 Paul Bunyan presented the report and explained. The report illustrated that staff remained less likely to share whether they had a disability with their employer. The report detailed the likelihood of disabled staff being appointed from shortlisting compared to non-disabled staff was just above the marker of one, and meant staff with a disability were slightly less likely to be appointed. The likelihood of staff to enter into a disciplinary hearing was 0, which related to a lack of data available in this area. The final section of the staff survey related to staff feeling pressured to come to work if they felt unwell to perform their duties, which showed a significant gap between disabled which was 38.8% and non-disabled staff being 24.9%. In terms of benchmarking, the Trust was higher in this area than the average benchmark data.

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8.3 Annual Equality & Diversity Report – NLG(20)170 Paul Bunyan presented the Annual Equality & Diversity Annual Report which detailed four key priorities. Following the previous year’s report, the equality and diversity agenda and programme had been internally audited and had received significant assurance. This related to the implementation of a legally required quality framework and the training and reporting elements. The ARGC had recommended the understanding of local communities required improvement. Improvements and plans for staffing were to be relaunched and implemented in respect of undertaking a review of access to services, following a delay due to COVID-19. An update was provided on recent celebration events which had taken place at the Trust. Terry Moran suggested the three reports be addressed at a separate Board Development session where a wider audience could be invited. Dr Kate Wood advised that these reports were shared at Board committees prior to the Trust Board and queried whether attendance at those committees should be considered. Terry Moran confirmed this could be a helpful approach but felt the whole Board were interested in these reports and required the opportunity to fully discuss these reports. ACTION: Karl Portz / Helen Harris Dr Peter Reading requested his congratulations be passed on to Karl Portz for the very useful reports. The challenge was for the Trust to determine the next steps to make positive progression to address risk areas. The recent situation with COVID-19 had recognised such issues that needed to be raised in terms of BAME staff. In terms of the Workforce Disability Equality Standard Report, it was agreed that this required greater discussion in respect of minority groups. Terry Moran concurred, adding that some staff felt less valued which needed to be addressed. Terry Moran sought Michael Whitworth’s comments on the reports as Chair of the Workforce Committee. Michael Whitworth advised the reports had been endorsed by the committee and agreed that further discussion on the reports would be helpful with ongoing oversight of the issues raised. Neil Gammon requested that an executive summary be included within the report to highlight key areas. Through the Health Tree Foundation, he queried whether the funding could be utilised to invite someone from a national level to deliver a Trust Board session. Sandra Hills referred to the Workforce Disability Equality Standard Report due to concerns that staff were still not identifying themselves as having a disability. It was noted that some disabilities were also not visible, such as mental health and learning disabilities. Terry Moran suggested that other Trusts be contacted to establish what they had in place for these areas. Further clarification was required in respect of information provided within the Workforce Race Equality Standard Report. ACTION: Karl Portz Trust Board members agreed to approve the three reports.

8.4 Freedom to Spe ak Up Annual Report – NLG(20)171 Terry Moran welcomed Liz Houchin to the meeting.

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Liz Houchin presented the report and highlighted key issues that had not been included within the report due to the time it was distributed. The index score had reduced by 0.4% to a score of 73.3% taking the Trust to the bottom half of the league table. The national average comparators of the staff survey questions identified some areas of concern around staff confidence in being treated fairly if they were involved in an error or near miss. This included being able to raise concerns in relation to unsafe clinical practices. The final point was in respect of staff not being provided with feedback following incidents which they raised. Due to the COVID-19 pandemic there had been a delay in the introduction of a training package from Health Education England and no confirmed release date had been provided to date. NHSE/I had agreed to continue to support the role until September and advised they would be keen to deliver a Board Development session for the Trust. The Trust were recruiting Freedom to Speak Up champions to enable appropriate signposting ahead of October which will be “speaking up month”, and Board members were asked if they would be willing to take part by providing a ‘speaking up’ pledge. Thanks were given to colleagues on the Human Resources Helpdesk for signposting concerns raised along with the dedicated Hub site. Concerns currently being raised were back to pre-COVID-19 levels and related to behaviours, bullying and harassment. Terry Moran asked if there was anything else to add which was not included in the report. Liz Houchin confirmed there was nothing else to add. Dr Kate Wood thanked Liz Houchin for the report and explained the Board needed to provide greater support for staff speaking up. She queried what the Board development session would include. Liz Houchin advised Rachel Clarke could deliver a training session for Board members to ensure a full understanding of requirements. Terry Moran requested clarification be provided for the training course overview outside of the meeting for consideration. Neil Gammon enquired whether it was possible to provide a breakdown for any concerns raised from BAME staff along with staff with disabilities. Liz Houchin agreed to explore this going forward and added that she planned to work with the divisions to develop the process further and to support Karl Portz on the Equality and Diversity networks. Dr Peter Reading thanked Liz Houchin and Kay Farquharson for positively transforming the process and referred to recent changes to the agenda and the need for increase grip and oversight. He supported inviting Rachel Clarke from NHSE/I to undertake a workshop for Board members and expressed concern at the bullying and harassment issues being raised despite the impact of the Pride and Respect programme. The Trust Board approved the Freedom to Speak Up Guardian Annual Report.

8.5 Annual Fire Report – NLG(20)172 Jug Johal referred to the Annual Fire Report for the period 1 April 2019 to the 31 March 2020, and explained that it had been approved at the ARGC. The action plan and deep dive is monitored by the F&PC. He drew the Board’s attention to the estates risk assessments and advised they were underpinned by a fire action plan

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which was regularly shared with the Humberside Fire & Rescue Service. The capital allocation for backlog maintenance was a small amount and fire was an issue that needed to be addressed within this allocation. The Trust were awaiting formal confirmation from the Region on a major capital infrastructure bid for around £3.6 million which would be spent on a new fire alarm systems at all three hospital sites, which would address this risk. Terry Moran endorsed this approach and queried whether the risk levels could be detailed in sections eight and nine for future reports. Tony Bramley requested that the report detail the risk assessment in each section as requested and agreed at the ARGC. Action: Jug Johal The Trust Board approved the Annual Fire Report for 2019/20 and it was agreed appropriate signatures would be added.

8.6 Emergency Preparedness & Resilience Annual Report – NLG(20)151 This item was deferred to the October 2020 meeting.

8.7 Revalidation of Do ctors Annual Report – NLG(20)174 Dr Kate Wood presented the Revalidation of Doctors Annual Report and confirmed the need to share it at the Trust Board for approval, to allow Dr Peter Reading to provide a formal signature. The Trust had previously been under scrutiny from the General Medical Council (GMC), NHSE/I and NHS Education England around appliance of appraisals for medical staff. This had entailed providing regular updates to the GMC and NHSE/I to demonstrate Trust performance levels including updates on the action plan, and targets and milestones to be met. The Trust was currently achieving these now as expected. There was an action from the previous year that staff did not go into category three for not undergoing an appraisal. The importance of understanding why appraisals were not undertaken to enable any issues to be addressed was noted by Board members. The Trust had achieved against this category in the current year, good justification had been provided for any appraisals not undertaken and this demonstrated a greater understanding by the Trust. Tony Bramley referred to section 6, Medical Governance which detailed the recommendation from NHSE/I that once the systems were where they should be, the Trust should be encouraged to assess medical governance arrangements against the GMC handbook “Effective Clinical Governance for the medical profession: A handbook for organisations employing, contracting or overseeing the practice of doctors”. Tony Bramley queried if there was a timescale for when this would happen. Dr Kate Wood advised the information was within the action plan and would provide this detail outside of the meeting and include this within future reports. Action: Dr Kate Wood The Trust Board approved the Annual Revalidation Report 2020.

8.8 Staff Governor Election s & Terms of Office – NLG(20)176 Alison Hurley presented the Staff Governor Elections & Terms of Office paper. Due

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to the COVID-19 pandemic, engagement with members and the public had not been permitted to allow the planned July 2020 Governor elections to take place. Approval was being sought in respect of the extension of the existing staff Governor’s term of office until the October 2020 elections conclude. This had been approved by the Council of Governors with agreement provided for 15 out of the current 19 Governors. Terry Moran commended Alison Hurley for her short and clear paper and update. The Trust Board agreed to the extension of the term of office.

9. Communications Round Up Adrian Beddow explained the Trust had continued to send out staff emails to provide updates in respect of issues around COVID-19 arrangements. He referred to the “Ask Peter” questions raised and advised they had received approximately 400 queries over the previous three months. During the pandemic there had been an introduction of a staff Facebook page which now had around 3,000 staff, and feedback had been very positive. Work had continued with television and newspaper enquiries and they had worked well with the Health Tree Foundation in respect of coverage for donations received. Media enquiries had increased over the last three months with 153 being received against the usual average of 90 to 100 per year.

10. Items for Information: To raise any urgent concern s or questions by ex ception

Terry Moran sought any issues or comments from Board members. No comments or queries were received.

11. Any Other Urgent Business

Terry Moran queried whether there was any other urgent business that needed to be raised. Ellie Monkhouse referred to the Emergency Support Framework in relation to Infection Prevention and Control. CQC had provided full assurance in all ten domains and areas of significance which had been able to display multi-disciplinary approaches. Jug Johal confirmed this was fantastic news to take back to staff due to the significant achievement. Terry Moran concurred and referred to the potential and capability of staff and the strength and depth of what they had made possible.

12. Board Performance & Reflection Terry Moran sought support from Board members in completing a questionnaire in respect of Board performance and reflection for the meeting, which would then be formally fed back at the October 2020 meeting as an item on the agenda. He requested Board members specific feedback on the ‘deep dive’ of the BAF.

Action: All Terry Moran referred to the discussions on papers and noted that although committees had discussions about staff issues, he felt they should also be discussed at the Board so they could have ownership.

Terry Moran sought Shauna McMahon’s comments and feedback in respect of the

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Board meeting. Shauna McMahon explained she had been overwhelmed with the enthusiasm of Board members and the good work being undertaken. The Digital Strategy that is being refreshed showed there was a need for better access to data to enhance decision making and ensure better quality decisions for safer care. She was excited to join the team and the Trust.

13. Date and Time of the next meeting:

Trust Board Development Session – Quality Improveme nt Tuesday, 11 August 2020 Time: 10:30 am – 5.00 pm Via video conference

Trust Board Development Session – CQC Tuesday, 1 September 2020 Time: 1:00 pm – 5.00 pm Via video conference

Formal Trust Board Meeting Tuesday, 1 October 2020 Time: TBC Via video conference

Private Trust Board meeting to follow at 15.00 hours via video conference

Terry Moran closed the meeting at 14.50 hours.