title minutes of performance committee – 25 may 2012 · 1. purpose • what is the key reason and...

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Title Minutes of Performance Committee – 25th May 2012

1. Purpose

• What is the key reason and context for this paper from the Board’s perspective? The attached minutes are from the Performance Committee for the Trust, held 25th May

2012.

2. Key Issues

• What are the key issues that the Board needs to consider regarding this matter? The work programme of the new Performance Committee continues to be developed,

alongside the development of the Performance Management Framework. The Committee reviewed the performance scorecard, and cross-checked this with the responsibilities of the respective Board sub-Committees. The Committee reviewed the arrangements for developing performance indicators and agreed a programme of ‘deep dive reviews’ for the next five months.

3. Action required by the Board /

Discussion & Decision Approval Assurance √ To note (Information purposes only) 4. Committee Approval

Committee Chair Date reviewed

Assurance Further information for Board

Performance Committee

Mark McJennett (Chair)

10.6.12 This Committee provides oversight and assurance around the finance of the Trust.

5. Source Executive Director Jonathan Reid, Director of Finance and Estates Executive Director sign

off date 10.6.12

Author of Report Jonathan Reid, Director of Finance and Estates Lead manager Jonathan Reid, Director of Finance and Estates

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Reference information 6. Strategic Objective(s) to which this paper relates /

• Develop flexible and innovative care based on patient-centred design • Improve patient experience and raise the quality of care √ • Sustain and improve our financial strength √ • Become a thriving Foundation Trust supported by excellent staff and public

Engagement

7. CQC Registration – Impact assessment

Outcome Standard (s)

Location(s) affected

a) Not applicable

8. Patient Safety impact

This is considered in each of PC decisions, and is a specific focus of the scorecard.

9. Equality & Diversity impact

This is considered in each of PC decisions. 10. NHS Constitution Values Y

Meeting: Performance Committee Date: Monday 25th June 2012 Chair: Mark McJennett (MM) Non-Executive Director Present: Sue Bucknell (SB) Non-Executive Director

Niki Baier (NB) Interim Head of Performance Development

Richard Curtin (RC) Director of Operations

Jenny Harding (JH) HR Business Partner

Jonathan Reid (JR) Director of Finance & Estates

Tim Blatt (TB) Head of Financial Management

In attendance: Karen Kilshaw (KJK) PA to Director & Deputy Director of Finance

MINUTES

Action

1. Apologies for absence

Apologies were received from Nicky Sullivan.

2. Minutes of the Meeting 25 May 2012 The Chair welcomed the Group and the minutes of the last Committee were agreed with some clarifications.

3. Actions from the 25 May 2012 Meeting These were accepted.

4. Review of Monthly Scorecard – Month 1 The new scorecard was discussed and commented upon.

5. Operational Performance Management Review RC reported on the Performance Management review process that had commenced. He reported that the first meeting with CHRW had been held the previous Friday and that it had been useful. MM commented that he was very encouraged by this.

6.

Deep-Dive Review – Sickness JH presented three papers to the Performance Committee. MM commented that the papers were comprehensive and useful. MM commented that there were some very high levels of localised sickness that were unacceptable and require further investigation He brought the committees attention to; 150 Adult Brighton Community (Ser) where the sickness level was 6.12% amongst a workforce of 164. JH explained that there had been no significant change in sickness rates and that Sussex Community Trust was broadly in line with the rest of the South East Coast. JH noted that the highest cause for absence was from Mental Health. SB commented that she thought that where managers are personal friends it can make managing staff challenging. MM noted that it is the Manager’s responsibility to manage sickness and that sickness levels can be noted on their appraisals. MM asked how we obtain evidence of absentees and sickness and he requested that JH produce a written paper on this. ACTION: JH produce a written paper - evidence of absentees and sickness KJK was asked to ensure that the graphics were included in the Board papers. ACTION: KJK

JH

KJK

7. QIPP Update

TB presented the QIPP update and talked through the paper which included the KPMG findings. This paper was discussed in depth. MM expressed his concern with regard to the timeliness and deliverability of all the QIPPs and asked for this to be formally recorded.

8. AOB NB discussed a proposal with the committee to provide formal assurance on the implementation of the Performance Management Framework. The committee agreed that this was a sensible proposal. NB to provide a highlight report for all future committees. ACTION: KJK - note to be included in all papers NB to provide a highlight report for all future committees.

KJK NB

9. Date of next meeting – 23 July 2012 08.30am – 10.30am Venue - Jonathan Reid’s office 2nd Floor, Arundel Building, BGH

The table below has been produced as per the new ESR structure which reflects the current service structure. The table shows a breakdown of the percentage of available workforce and the percentage of total sickness days for each service and how the services contribute to the overall days lost through sickness.

Service Headcount Calendar Days Sick Sick % % Avail Workforce % Total Sick Days

150 Adult Coastal MDT (Ser) 622 1103 5.91% 14.32% 19.67% 150 Adult North Community (Ser) 250 440 5.87% 5.75% 7.85% 150 Adult North MDT (Ser) 275 423 5.13% 6.33% 7.54% 150 Healthy Child Programme (Ser) 301 401 4.44% 6.93% 7.15% 150 Section 75 BHCFS (Ser) 290 388 4.46% 6.67% 6.92% 150 Facilities Services (Ser) 302 348 3.84% 6.95% 6.21% 150 Adult Brighton Community (Ser) 164 301 6.12% 3.77% 5.37% 150 Adult Brighton MDT (Ser) 166 216 4.34% 3.82% 3.85% 150 MSK & Outpatient (Ser) 209 185 2.95% 4.81% 3.30% 150 Time to Talk (Ser) 166 180 3.61% 3.82% 3.21% 150 Adult Coastal Community (Ser) 198 161 2.71% 4.56% 2.87% 150 Adult Brighton Trust Wide (Ser) 103 144 4.66% 2.37% 2.57% 150 Dental Services (Ser) 87 131 5.02% 2.00% 2.34% 150 Comm Child Dev & Therap (Ser) 190 125 2.19% 4.37% 2.23% 150 CWRI Management (Ser) 42 125 9.92% 0.97% 2.23% 150 Chailey Services (Ser) 155 123 2.65% 3.57% 2.19% 150 Reablement (Ser) 67 99 4.93% 1.54% 1.77% 150 Comm Child Nursing (Ser) 69 97 4.69% 1.59% 1.73% 150 Wellbeing (Ser) 127 93 2.44% 2.92% 1.66% 150 Estates Services (Ser) 41 80 6.50% 0.94% 1.43% 150 Clinical Serv Trust Wide (Ser) 38 57 5.00% 0.87% 1.02% 150 Strategy & New Business (Ser) 29 53 6.09% 0.67% 0.95% 150 Human Resources (Ser) 100 51 1.70% 2.30% 0.91% 150 Dental EDS (Ser) 34 40 3.92% 0.78% 0.71% 150 Adult North Trust Wide (Ser) 10 38 12.67% 0.23% 0.68% 150 Estates & Facilities Mgmt (Ser) 5 30 20.00% 0.12% 0.53% 150 Safeguarding Adults (Ser) 7 30 14.29% 0.16% 0.53% 150 MD Management (Ser) 23 24 3.48% 0.53% 0.43% 150 Occupational Health (Ser) 21 24 3.81% 0.48% 0.43% 150 South Coast Audit (Ser) 71 23 1.08% 1.63% 0.41% 150 Research & Development (Ser) 12 20 5.56% 0.28% 0.36% 150 Professional Development (Ser) 34 15 1.47% 0.78% 0.27% 150 Comm Partnership Team (Ser) 12 14 3.89% 0.28% 0.25% 150 Chief Executive Offices (Ser) 13 8 2.05% 0.30% 0.14% 150 Child Health Improvement (Ser) 22 6 0.91% 0.51% 0.11% 150 Adult Coastal Trust Wide (Ser) 20 4 0.67% 0.46% 0.07% 150 Adult Services Management (Ser) 24 4 0.56% 0.55% 0.07% 150 Infection Control (Ser) 5 3 2.00% 0.12% 0.05% 150 Pharmacy (Ser) 8 1 0.42% 0.18% 0.02% 150 Accounting (Ser) 18 0 0.00% 0.41% 0.00% 150 Foundation Trust Prog (Ser) 1 0 0.00% 0.02% 0.00% 150 HIS Services (Ser) 1 0 0.00% 0.02% 0.00% 150 MD Governance (Ser) 6 0 0.00% 0.14% 0.00% 150 Ops Admin & Management (Ser) 2 0 0.00% 0.05% 0.00% 150 Procurement (Ser) 5 0 0.00% 0.12% 0.00% Grand Total 4345 5608 4.30% 100.00% 100.00%

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Title Minutes of Audit Committee – 7th June 2012

1. Purpose

• What is the key reason and context for this paper from the Board’s perspective? The attached minutes are from the Audit Committee for the Trust, held 7th June 2012.

2. Key Issues

• What are the key issues that the Board needs to consider regarding this matter? The Trust Audit Committee reviewed the progress against workplans for internal audit

and local counter-fraud services, ensuring that reports are being considered by EDMT and recommendations agreed, and acted on in a timely way. The Committee received and discussed the Annual Governance Report from the Audit Commission, noting the issues identified during the year end audit process. The Committee also reviewed and approved the Annual Report and Accounts, including the Remuneration Report and the Annual Governance Statement, on behalf of the Trust Board.





Audit Committee

Colvin Rae (Chair)

7.6.12 This Committee provides oversight and assurance around the governance arrangements for the Trust.

5. Source Executive Director Jonathan Reid (Director of Finance and Estates) Executive Director sign

off date 12.6.12

Author of Report Jonathan Reid (Director of Finance and Estates) Lead manager Jonathan Reid (Director of Finance and Estates)

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Engagement




a) Not applicable – considered in reports


This is considered in each of AC decisions.


This is considered in each of AC decisions. 10. NHS Constitution Values Y

[T:\SECRETAR\1KJK Folders January 2012\2012 Audit Committee\5July 2012\POST MEET] 1

Meeting: Minutes of the Audit Committee Meeting Date: Thursday 5 July 2012, 14.30 – 16.30, J1 Boardroom BGH Present: Colvin Rae Chair Sue Johnson Non Executive Director In Attendance: Jonathan Reid

Mike Townsend Graham Nice Tracey Paton Kevin Maloney John Butler Karen Kilshaw

Director of Finance and Estates Head of Internal Audit, SCA Director of Nursing Interim Deputy Director of Finance Client Audit Manager SCA Local Counter Fraud Service Specialist SCA Exec PA to Director of Finance (minutes)

MINUTES

Item No

Item Information and Action Action/ Owner/ Due Date

Item 1 Apologies Apologies were received from, Mark McJennett, Richard Curtin and Sue Giddings Item 2

Minutes of the meeting of 7 June 2012

The minutes of the 7 June 2012 were received and approved as an accurate record.

Item 3 Actions from previous meeting held on 7 June 2012 The Action Schedule was reviewed; all items due were either completed by due

date or included on the agenda with the exception of: Item 3(ii) – Overpayments Protocol – report on agenda does not give assurance, defer to August meeting. Item 8 – Sample sizes ACTION: The appropriateness of sample size to be discussed at August meeting Item 11 – KPMG update – recommendations will now be part of the HDD process

All

Item 4 Business Schedule It was reported that the Board Assurance Framework had been to the Board.

JCR felt it should first come to the Audit Committee prior to Board to be challenged. ACTION: JR to bring it to August meeting. Controls assurance papers on agenda to be carried forward to August as did not currently give assurance ACTIONS:

JR

JR / KJK

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JR/ KJK to produce a new up to date schedule for next meeting July Move all of August schedules to October, KJK - private CEO meeting to be made 15 minutes prior to next Audit Committee.

Item 5

SCA Internal Audit & Counter Fraud Progress Report MT explained the Progress Report consisted of four pieces of work produced and finalised two HIS pieces of work HIS audits both give limited assurance MT noted since last progress report further audit had been completed to a final report stage, JCR thanked MT for a comprehensive report and commented on the 2011/12 Assurance Framework & Risk Management outcome being only adequate. JB presented his paper on counter fraud. JB reported that phone calls were still regular coming in from people in the community regarding suspected fraud activity. SJ commented that the report was very clear. JCR noted that more information was required regarding the allegations that an electric wheelchair that had been provided by the Trust had been sold. MT replied that he was waiting for future information from the manager following the allegations. JCR asked about on controls on Bank and Agency expenditure. TP outlined the work that was being done under QIPP around Temporary staff expenditure which JCR suggested was reported to the Performance Committee as a ‘Deep Dive’.

Item 6 Draft Audit Committee Annual Report April 2011- March 2012 JCR commented that it was a good report and was rolling out practice of producing an Annual Report to the Finance Committee. ACTION Reword para 9 to say with regard to audits with limited assurance ‘All agreed remedial actions agreed with management (with appropriate timescales) to be followed up with Internal Audit and the report needed to state that the counter fraud session had been reinstated on the staff Induction programme.

KJK

Item 7 LCFS Annual Report JB informed the committee that cases which involved a criminal conviction were not routinely published in the local press only on the Trust Website (Pulse) and on the Fraud Focus Website ACTION: GN and JB to look at policy on communication of counter fraud activity

GN / JB

Item 8 Trust Finance Report Month 2 May 2012 JR presented this report in the new format; SJ commented that this was an excellent report.

Item 9 Scorecard JCR noted it was consistently showing a little slippage and to keep an eye on this.

Item 10 KPMG Recommendations Implementation Update JR updated the committee on this and it was noted.

Item 11 SCA Business Case Update JR noted that there is a Business Plan which will be presented. An update will be sent to the Chair of the Consortium Board who will then bring it to the SCT Audit Committee.

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Items 12,13, 14,16, 17 & 18

Controls Assurance Reports JCR noted that these items did not have an authors name on it and commented that they did not give the assurance required. It was agreed that the reports would lay out clearly the controls in place for the next committee.

Item 15

Historic Due Diligence process JR presented an overview of the HDD process which was duly noted.

Item 19 Any Other Business There was no AOB.

Next Meeting: Thursday 2nd August 2012

Time: 14.30- 16.30 Venue: J1 Boardroom, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW

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Title Minutes of Finance Committee – 7th June 2012

1. Purpose

• What is the key reason and context for this paper from the Board’s perspective? The attached approved minutes are from the Finance Committee for the Trust, held 7th

June 2012.

2. Key Issues

• What are the key issues that the Board needs to consider regarding this matter? The Trust Finance Committee reviewed the new format of the Trust Board Finance

Report, and the details of financial performance in Month 1, including cash flow and capital expenditure. The Committee noted the need for continued improvement in forecasting, including improved engagement with budget-holders. The Committee also noted progress on Service Line Reporting, and the ongoing work to develop a robust and sustainable QIPP programme.





Finance Committee

Colvin Rae (Chair)

7.6.12 This Committee provides oversight and assurance around the finance of the Trust.

5. Source Executive Director Jonathan Reid, Director of Finance and Estates Executive Director sign

off date 10.6.12

Author of Report Jonathan Reid, Director of Finance and Estates Lead manager Jonathan Reid, Director of Finance and Estates

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Engagement




a) Not applicable


This is considered in each of FC decisions.


This is considered in each of FC decisions. 10. NHS Constitution Values Y

Item: 1 Enc: A

[T:\SECRETAR\1KJK Folders January 2012\2012 Finance Committee\POST MEETING\Minutes\7 July]

1

Meeting: Finance Committee Meeting Date: Thursday 5 July 2012, 0800-0945, J1 Boardroom, SCT Chair: Colvin Rae Non Executive Director, SCT Present: Richard Curtin

Jonathan Reid Gillian Wieck Tracey Paton Sue Sjuve John Forrester

Director of Operations Director of Finance & Estates Assistant Director of Operations Deputy Director of Finance & Estates SCT Chairman Dental Manager

In attendance: Karen Kilshaw

Exec PA to Director of Finance (minutes)

MINUTES

Action

The Chair welcomed Sue Sjuve and Tracey Paton to their first meeting. JCR asked it to be noted that, as there was only one NED present the meeting was not quorate and CJR asked JR to check minutes before being presented to the Board

1. Apologies Apologies were received from Carl Radcliffe, Mark McJennett, Sue Giddings,

Nicky Sullivan and Graham Nice. .

2. Minutes of the meeting of Thursday 7 June 2012 The minutes were approved as an accurate record of the meeting. 3. Matters arising from the meeting of Thursday 7 June 2012 not mentioned

elsewhere on the agenda 3.1 Action Schedule

4.2 RC confirmed that Performance Meetings were in place

8.0 JR confirmed that they hoped to have the QIPP 12/13 update in place by

next month (August)

3.2

4.1 GW presented the CES Business Action Plan – GW explained that they had a ‘Roadshow’ which started yesterday, GW noted they had a robust action in place and did not think they could do any more than they were doing now. JCR thanked GW for a comprehensive report. RC noted we do not have the control of the budget for Acute, which represented between 15% and 20% of the budget.

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It was also noted that £250k is spent on equipment which goes into care homes RC noted that this is a complex situation and that he would be looking at the contract. ACTION JR+RC JCR said that more Manager Training on CES needed to be undertaken.

3.2 Other Matters Arising None to report 4. SCT Income and Expenditure Financial Position and Forecast 4.1 Page 2

Key Performance Indicators – it was noted that more trends were required and it was agreed to include these in future months. Page 7 Twelve month rolling cash flow – asked why the trends were fluctuating. JR responded that it was based on Phil Fenwick’s methodology which he agreed to share at future meetings. Page 8 Capital Expenditure - JR commented that, at this early stage in the year, it is very difficult to estimate the progress of many of the projects so expenditure was accrued to budget Page 9 Divisional Contribution Analysis - SS asked why the shortfall in contributions were showing as negative and JR confirmed that this was correct. Page 10. Indicators of Forward Financial Risk JR noted that No.2 ‘The Quarterly self-certification by Trust that the financial risk rating (FRR) may be less than 3 in the next 12 months’ was the most important JR suggested that they needed to do a ‘dry run’ at 3 months. He also noted that the self certification came from the SHA, - a ‘dry run’ would be good possibly to come firstly to the Finance committee for challenging, but work should be done by the Executive Leadership Team.

4.2 Finance Commentary Enc C(ii)

Adult Services RC indicated that he hoped to have more detailed and better QIPP plan for Adults for the next committee. JCR noted that triangulated evidence was required. TP stated that she was looking at high spend areas and it needed to be systematic JR noted that the possibility of further roll out NHSP needed to be investigated. Children, Health, Reablement & Wellbeing Services JCR asked GW to indicate how much of the recovery plan might be delivered. She indicated that 90% of best case will need to be delivered and that this was a challenging task. GW indicated that £1.4k of the recovery plans were robust. JR noted that there is an opportunity, by bringing in extra support to QIPP is risky but we are trying to define the precise nature of it. It was noted that many of these issues had been discussed in depth at the Divisional Performance Reviews and JCR indicated that he was very encouraged by the feedback from these meetings.


Dentistry JF noted he was not convinced that the QIPP target was realistic and would discuss the JR in their next weeks meeting. JF stated that they had £80k of additional business coming in from October 2012 JF had produced a paper which JCR suggested was circulated ACTION JF to send paper over to RC

5 Cash, Debtors and Creditors Debtors

JR confirmed he has meetings planned with BSUH, NHSWS & SPT to discuss outstanding invoices SS suggested that if these disputes still remained unresolved that the NHS Commissioning Board could be approached JR noted that much of the historical debt has been resolved and commended the finance team for this.

5.1 Cash Flow Report was reviewed and noted 5.2 Rolling Cash Flow Report was reviewed and noted 5.3 Trade and other receivables Report was reviewed and noted. 5.4 Analysis of Chailey and SCA debts Report was reviewed and noted 5.5 Analysis of debts > 6 months Report was reviewed and noted. 6.0 Capital Expenditure JCR queried whether we could be assured that the delay in the Community and

Child Health project would have an adverse impact of patient safety, outcomes and experience. JR indicated that we could not but that the delay was outside of our control. JCR said the Quality and Safety Committee should look at it JCR queried why there has been no expenditure in Estates in April. JR noted that overall capital expenditure was on plan, and explained that the estates plans have been going through the Capital Review Group business case process.

6.1 Phased capital programme Report was reviewed and noted 6.2 Capital programme Report was reviewed and noted 7 Balance sheet Report was reviewed and noted


8 QIPP 2012-13 Update JCR noted that there was a high risk to the delivery of the QIPP programme.

JR stated that in order to develop the QIPP plans, to deliver service transformation and the corporate QIPPS an invitation to tender had been sent out. Bids are due in next Monday.

9 Service Line Reporting Update This update was noted and JCR stated they needed to see some milestones.

10 Any Other Business

There was a short discussion about a briefing paper on South Coast Audit. JR noted that SCA pay us £90k hosting fee, they had requested a cost decrease to £30k which JR had refused. JCR requested clarification.

11 Next Meeting Thursday 2 August 2012, 0800, J1 Boardroom BGH

Public Board Meeting: 16.8.12

Item: 174.12

Enc: Q

Title Quality and Safety Committee Minutes of 25th June 2012

1. Purpose

• What is the key reason and context for this paper from the Board’s perspective? • To provide the Trust Board with an update from the Quality and Safety Committee

meeting of 25th June 2012.

2. Key Issues

• What are the key issues that the Board needs to consider regarding this matter? The Quality and Safety Committee is a Non-Executive chaired meeting which reviews

quality, safety and governance processes for the Trust.


Discussion & Decision Approval Information and Assurance To note (Information purposes only) 4. Committee Approval



n/a

5. Source Executive Director n/a Executive Director sign

off date n/a

Author of Report n/a Lead manager Ceri Davies, Assistant Director of Governance Date of Meeting EDMT date approved Link to further reading

Public Board Meeting: 16.8.12

Item: 174.12

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• Develop flexible and innovative care based on patient-centred design • Improve patient experience and raise the quality of care • Sustain and improve our financial strength • Become a thriving Foundation Trust supported by excellent staff and public

engagement




a) Assurance of ongoing compliance All All b) New Registration requirement - - c) Amendment to existing Registration - - d) De- registration required - - e) Breach in registration - - f) Not applicable - - 8. Patient Safety impact This report promotes the 7 steps in the Patient Safety Assurance Framework. 9. Equality & Diversity impact The Quality and Safety Committee contributes to enabling the Trust to identify where patients, relatives and staff may not have been treated in accordance with equality law and good practice, and take action to prevent recurrence. 10. NHS Constitution Values This report supports the 6 NHS Values of; respect and dignity, commitment to quality of care, compassion, improving lives, working together for patients, everyone counts

Y

Item No: 110.07.12

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Quality & Safety Committee Meeting Minutes from Monday 25th June 2012

Present: Caroline Becher, Non Executive Director & Chair (CB)

Sue Bucknall, Non Executive Director (SB) Sue Giddings, Deputy Director of Nursing (SG) Ceri Davies, Assistant Director of Governance (CD)

In attendance: Ray Sawyer, Risk Manager – for item 090.06.12 (RS) Philip Tremewan, Safeguarding Adults Lead – for item 100.06.12 (PT) Pauline Lambert, Head of Children's Services – for item 101.06.12 (PL) Georgina Forrester, Clinical Services Manager (Bank) – for item 102.06.12

(GF) Annie Elliot, Community Matron – for item 102.06.12 (AE) Mary O’Keeffe, Lead Assurance Facilitator – for item 104.06.12 (MO) Note taker: Rachael Allen, Assurance Facilitator (RA) Item No. Item Description Action 087.06.12 Apologies for non attendance Sue Sjuve, Trust Chairman (SS)

Bob Dean/Clodagh Ward, Chief Executive (BD/CW) Mark McJennett, Non Executive Director (MMcJ) Dr Richard Quirk (RQ) Graham Nice, Executive Director of Nursing (GN) Richard Curtin, Executive Director of Operations (RC)

089.06.12 Minutes from 17th May 2012 The minutes were noted and approved as an accurate record, aside

from the following errors to be corrected by RA: • 063.02.12 line 2 – replace ‘QUIP’ with ‘QUIPP’ • 063.02.12 line 3 – insert ‘draft’ before ‘Lifelong Learning

Policy’ • 080.05.12 paragraph 2 line 6 – remove the word ‘it’ from after

‘responded that’ • 082.05.12 line 5 – replace ‘me’ with ‘be’ • 086.05.12 paragraph 2 line 5 – insert ‘of’ between ‘list’ and

‘staff’.

RA

089.06.12 Action Record The action record was reviewed and updated and the following

actions noted: 062.02.12 Quality Account The Chair reported that the Trust’s Quality Account for 2011/12 had been well received by the Trust Board at their meeting on the 21st of

Item No: 110.07.12

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that were being

icked up by existing workstreams within the Trust.

re-

his een escalated to the Executive Director of Nursing for

solution.

g

ject plan to is Committee in August. RA to add to the workplan.

ollowed up through e Quality Team. This action is now complete.

ccessful. The team is ow embedding the new ways of working.

CD

RA

June. A letter is being drafted by CD to send to the external reviewers, thanking them for their responses and assuring them the Board feel confident that any suggestions made p 063.02.12 MAST Training element of IG Toolkit There are still capacity issues surrounding the project plan for thedesign and implementation of MAST training. The Project Team have agreed to help with the planning aspect but would withdrawtheir assistance once this was completed. There is no capacity within the Education and Training Team to complete the project. Tissue has bre SG is looking at the options of buying the MAST training in or buyinin trainers to carry out specific sections of the MAST training. The model is currently being reviewed, however the scoping and financesare yet to be finalised and agreed. This should be completed by theend of August. SG was asked to bring the finalised proth 067.02.12 GP Complaints SG has had discussions with the Trust’s Quality Head, KarenThorburn, and it has been agreed that complaints from “soft intelligence” e.g. GPs, will now be reported and fth 080.05.12 Risk Management Update (OR20 Burgess Hill) The recruitment of clinical staff has been sun

SG

102.06.12 Nutrition – Update on improvement actions following re-visit to Crawley Community Nursing Service

s

ts of health records carried out by the Deputy Chief Nurse, such

f the

1:2:1 nducting health records audits and carrying out

The paper was discussed and AE and GF provided further information on the topic of inadequate nutrition, which exacerbatedamage to patients caused by immobility, and the improvement actions that have been put in place in their service following the audias:

• Training sessions on the Waterlow, Falls Assessment and MUST audit tool are being run twice a month with all onursing staff, particularly capturing new nursing staff

• Audits are now carried out on a rolling monthly basis • AE & GF are going out into the community with staff on a

basis, cotraining

Item No: 110.07.12

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eceptorship (enhanced support) for the first or

ir team • Existing staff have mentors and 1:2:1s to provide extra

G noted that re-assessment documentation needed to be built into forward.

AE & GF

ce\Board\2012 Board\August 16th 2012\Public\Q\Q&S-CommMinutes 2

• Band 5s are now starting to take responsibility for carrying outhealth records audits

• New staff have pryear, mentorship with trained nurses, and a buddy/mentwithin the

support. Sthe audit process. AE and GF agreed to take this

100.06.12 Safeguarding Adults Revised Annual Report to this

ommittee for endorsement prior to being submitted to the Trust

oard:

Abbreviations should be listed in full the first time they are

e was

In order to remedy this he is looking at developing eographical areas for the service and working on rolling out MAST

the

isk. CB asked that progress against the action lan be reported back to this committee in six months time. RA to

PT

RA

This is the first annual Safeguarding Adults report, submittedcBoard in July. This is a strategic action plan for the service. This is a well written report. PT was asked to make the following amendments to the report before it went to the B

• The ‘No Secrets’ document should be referenced throughoutthe report, particularly in the introduction

• The guidance booklets mentioned on page 7 have not beenpublished yet, this should be reflected in the report

•used. The addition of a glossary would be useful.

PT said that although he felt comfortable that they could provide assurance to the Care Quality Commission on their statistics hnot sure all of the low level alert activity across the Trust was being captured.gtraining. The action plan contained within the report will be monitored by Safeguarding Committee meeting as a standing agenda item. CD requested more information on the action plan items relating to Governance and Rpadd to work plan.

PT

101.06.12 Safeguarding Children Annual Report his report has been submitted to this committee for endorsement

ed a comprehensive and well written report. PL was sked to make the following amendments to the report before it went

PL

Tprior to being submitted to the Trust Board in July. This was deemato the Board:

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n explanation for why Crawley has a much higher

page 5

used

was noted that a separate report is being written for Looked After report be submitted to this committee

PL

• Add an explanation for ‘final case discussions’ to the report• Add a

number of children subject to a CPP in the graph on• Abbreviations should be listed in full the first time they are

• Use job titles in the action plan, rather than initials • Add job titles to the named doctors at the end of the report.

ItChildren. CB asked that the prior to going to the Board.

090.06.12 Risk Management Update

s a risk

around staff not ttending training, which should be dealt with through Operations.

k transferred to Ops’

osures B noted that she was pleased to see that staff are attending SI

an increase in the number of open SIs

RS

The report was discussed. A query was raised as to why risk SO12 – Educated and trained workforce – had been downgraded to a 12 and removed from theBoard Assurance Framework (BAF). RS responded that it wadating from 2011/12 that is to be transferred for management withinthe risk register and revised to reflect the MAST training plan for 2012/13. SG added that part of the risk wasaCB asked that the table be amended to say ‘risrather than removed, as this is misleading. Verbal review of serious incident clCmeetings with the PCT to facilitate closure of open SIs by providing on the spot answers to PCT queries. RS mentioned that there was due to outbreaks of Norovirus causing closure of Community Beds.

104.06.12 2012/13 Clinical Audit Plan been

SG added that the new process is very good and most taff will engage with it. The focus must now be on embedding

pdates on progress are to be brought back to this committee on a

RA

The paper was discussed, with CD noting that the system had revised and tightened up to ensure that mandatory audits were completed and reported on. The paper will go to the Clinical Governance & Patient Safety Committee on the 2nd of July for approval. sclinical audit into everyday practice so it is not just seen as a tick boxexercise. Usix monthly basis. RA to add to work plan.

Item No: 110.07.12

Enc: A Pages: 6


105.06.12 Quality Governance Self Assessment/Action Plan nt

ittee agreed that this it.

The self assessment has been updated following a receteleconference with Board members. The commwas an honest and good assessment and were happy to approve Sue Bucknall left the meeting at this point (12:40 pm).

103.06.12 Venous Thromoboembolism (VTE) Pathway

essments within the rust and that this duty would be included within their job descriptions

y were also working on refining the

SG discussed the process map with the committee and informed them that the VTE policy had been drafted and would be going to the next VTE Steering Group for approval. It has been decided that medical staff would be undertaking VTE assTand contracts. SG added that theVTE risk assessment tool released by the Department of Health so that it was tailored for use within the Trust.

106.06.12 Quality Improvement Strategy he Quality Improvement Strategy had not been completed in time to

sted that it be submitted GN/SG T

be discussed at this meeting. CB requevirtually to committee members for approval prior to its submission to the July Board.

107.06.12 Meeting Schedule and Next Agenda CB asked that all committee members review the latest version of the

y believe it to be realistic and ALL

workplan and confirm whether or not theachievable.

108.06.12 AOB

Board, uld be taking place tomorrow. The topic of

ervice Governance Groups would be on the agenda for discussion e

s roughout the Trust.

the October meeting. RA to add to workplan.

ctors in the

dressing:

RA

CB

Internal Audit Report on CQC at SCT The report found significant assurance on the Trust’s Care Quality Commission (CQC) process. CD noted that the first action was to reinstate the Executive Leadership Team as the CQC Projectand the first meeting woSat that meeting. Following successful recruitment to the AssurancTeam the focus will now be on embedding the CQC procesth The Committee accepted this report and requested an update on progress at CB added that the involvement of Non-Executive Direunannounced mock CQC assurance reviews provided a great deal of assurance. Items raised at the previous Trust Board meeting Two items were raised at the last Public Board that need ad

Item No: 110.07.12

Enc: A Pages: 6


CB will share a deep dive

complaints submitted to the Q&SC in March to GN).

rence for this Committee of reference to the July meeting for

at issues around what constitutes quorum.

CB

• Temporary staffing in clinical areas (on recruitment provided to her by Sally Storey)

• Clinical complaints (CD will forward the report on clinical

Terms of RefeCB will bring the Q&SC terms review, specifically to look

CD

Date of Next Meeting

Monday 23rd July 2012 10:30 – 12:30 Governance Meeting Room Ground Floor, B Block Brighton General Hospital

These minutes are not exempt from the requirements of the Freedom of Information Act and will therefore may be released to the public if requested under the Freedom of Information Act.

title minutes of performance committee – 25 may 2012 · 1. purpose • what is the key reason and...

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