Board of Directors Agenda and Meeting papers 23 May 2017

221 Pages·2017·7.39 MB·English

Board of Directors
Public AGENDA
(held in public)
Date: Tuesday 23 May 2017
Time: 0830hrs – 1100hrs
Venue: Boardroom, Executive Corridor, Level D, Rotherham Hospital
Required
Time Item no. Page Lead
Actions
Chairman’s welcome and For Martin Havenhand,
0830 164/17 Verbal -
apologies for absence noting Chairman
Quality and Safety
For
Conrad Wareham,
165/17 Patient Story Verbal - informati
Medical Director
on
Procedural Items
Declaration of conflicts of For Martin Havenhand,
166/17 Verbal -
interest noting Chairman
Minutes of the previous For Martin Havenhand,
0845 167/17 Enc.
meeting held on 25 April 2017 approval Chairman
Matters arising from the
For Martin Havenhand,
168/17 previous minutes (not covered Verbal -
noting Chairman
elsewhere on the agenda)
For Martin Havenhand,
0850 169/17 Action Log Enc.
approval Chairman
Strategy and Strategic Planning
For Martin Havenhand,
0900 170/17 Report from the Chairman Enc.
noting Chairman
Report from the Chief For Louise Barnett,
0910 171/17 Enc.
Executive noting Chief Executive
Five Year Strategy and Two For Louise Barnett,
0920 172/17 Enc.
Year Operational Plan approval Chief Executive
Operational Performance
For Louise Barnett,
0935 173/17 Integrated Performance Report Enc.
noting Chief Executive
173/17 For Conrad Wareham,
0940 Quality Report Enc.
(a) noting Medical Director
Presented by Sally
173/17 Operational Performance For Kilgariff, General
0945 .
(b) Report noting Manager, Division of
Medicine
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173/17 For Cheryl Clements,
0950 Workforce Report Enc.
(c) noting Director of Workforce
173/17 For Simon Sheppard,
0955 Finance Report M1 Enc.
(d) noting Director of Finance
Assurance Framework
Anna Milanec,
For Director of Corporate
1010 174/17 Governance Report Enc.
noting Affairs/ Company
Secretary
Quality Improvement Plan For Ellie Monkhouse,
1015 175/17 Enc.
2017/18 approval Acting Chief Nurse
Anna Milanec,
Board Assurance Committees:
For Director of Corporate
1025 176/17 Revised Committee Enc.
approval Affairs/ Company
Membership Secretary
Anna Milanec,
2016/17 Board Assurance For Director of Corporate
1030 177/17 Enc.
Framework approval Affairs/ Company
Secretary
Regulatory and Statutory Reporting
Complaints Annual Report For Ellie Monkhouse,
1035 178/17 Enc.
2016/17 approval Acting Chief Nurse
Anna Milanec,
Director of Corporate
Annual Report & Accounts For Affairs/ Company
1045 179/17 Enc.
2017 (including Quality Report) approval Secretary,
Simon Sheppard,
Director of Finance
Anna Milanec,
Audit Committee Annual For Director of Corporate
1055 180/17 Enc.
Report approval Affairs/ Company
Secretary
Board Governance Planning (Governance)
Review of Annual Board For Martin Havenhand,
1100 181/17 Enc.
Planner approval Chairman
For Martin Havenhand,
182/17 Any other business
approval Chairman
Date of next meeting: For Martin Havenhand,
183/17 - -
Tuesday 26 June 2017 noting Chairman
To ensure smooth transaction of business, the Chairman will invite questions from the public at the
end of the meeting only.
In accordance with §152(4) of the Health and Social Care Act, 2012, a copy of this agenda has been
provided to Governors prior to the Board Meeting
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MINUTES OF THE PUBLIC BOARD OF DIRECTORS MEETING HELD ON TUESDAY 25
APRIL2017 IN THE BOARDROOM, LEVEL D

Present: Mr M Havenhand, Chairman
Mrs L Barnett, Chief Executive
Mrs G Atmarow, Non-Executive Director
Mr J Barnes, Non-Executive Director
Mrs C Clements, Director of Workforce
Mrs H Craven, Non-Executive Director
Mr M Edgell, Non-Executive Director
Ms L Hagger, Non-Executive Director
Mr C Holt, Director of Strategy and Transformation
Mr B Mellor, Non-Executive Director
Mrs E Monkhouse, Acting Chief Nurse
Mr S Sheppard, Director of Finance
Dr P Smith, Non-Executive Director
Dr C Wareham, Medical Director

In attendance: Mr J Beeston, Director of Clinical Services, Diagnostics and Support
Mr J Cartwright, Director of Estates and Facilities (minute 132/17(d) &
133/17)
Mrs M Dennis, Director of Operations
Ms A Milanec, Director of Corporate Affairs / Company Secretary
Dr J Miles, Director of Clinical Services for Integrated Medicine
Miss D Patel, Director of Clinical Services for Family Health
Mr J Rawlinson, Director of Health Informatics (minute 132/17(a))
Miss D Stewart, Corporate Governance Manager (minutes)

Apologies: Mr J Garner, interim Director of Clinical Services, Surgery

Observers: Members of staff x4
Public Governors x2
Members of the Public x0

123/17 CHAIRMAN’S WELCOME AND APOLOGIES FOR ABSENCE

Mr Havenhand welcomed those present to the meeting with any apologies
having been RECEIVED and NOTED.

At the invitation of the Chairman, Ms Milanec took the opportunity to introduce
to the Board Mrs Leanne Murphy, who had commenced in post as Committees
Secretary/Office Manager. Mrs Murphy was observing the meeting with regard
to her remit of supporting the effectiveness of the Board assurance
committees.
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Mr Havenhand, thanked members for accommodating the decision to hold the
public Board meeting before any private session. This decision had been taken
based upon feedback on the effectiveness of the meetings.

Unfortunately, despite agreement at the previous meeting with regard to the
timetable for production of board papers which formed an appendix to the
Board Governance Framework, a number of reports had been circulated
separately to the board papers. Mr Havenhand indicated that he anticipated
that this would be rectified for the next meeting.

QUALITY AND SAFETY

124/17 PATIENT STORY

The Acting Chief Nurse shared two patient stories with the Board.

One story highlighted the effectiveness of timely and face to face meetings,
which, following comments received, had resulted in a positive experience and
great confidence in the on-going treatment for one patient.

The second story related to the experience of a patient whose relative had
raised some concerns regarding aspects of care due to the patient’s visual
impairment. These concerns had been positively addressed, with some
actions being relevant to a number of wards. This case had also highlighted
additional support provided by the Royal National Institute for the Blind which
was not widely known within the Trust.

PROCEDURAL ITEMS

125/17 DECLARATIONS OF CONFLICTS OF INTERESTS

There were no declarations of any conflict of interest. Should any become
apparent during discussion, it was agreed that they would be declared.

126/17 MINUTES OF THE PREVIOUS MEETING

The minutes of the previous meeting held on 28 March 2017 were AGREED
as correct record, subject to the following amendment.

i. Workforce Report (minute 116/17(c))
Final sentence to read:

The Board was informed that during the transition period of the new
requirements, there may be some risks to the organisation regarding the
implementation of IR35 and the NHSI requirements.

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127/17 MATTERS ARISING FROM THE PREVIOUS MEETING

There were no matters arising from the previous meeting which were not either
covered by the agenda or action log.

128/17 ACTION LOG

The Board of Directors CONSIDERED and DISCUSSED the Board action log,
with a number agreed to be formally closed or those which would continue to
be monitored.

STRATEGY AND STRATEGIC PLANNING

129/17 REPORT FROM THE CHAIRMAN

The Board of Directors RECEIVED and NOTED the report from the Chairman.

Mr Havenhand highlighted a number of sections including the Rotherham
Together Partnership, the Acute Care Collaboration Vanguard (Working
Together Partnership – Providers), progress with the Chair and Non-Executive
Directors appraisals and two new nominated Partner Governors from RMBC
and Barnsley and Rotherham Chamber of Commerce.

With regard to The Rotherham Plan launched by the Rotherham Together
Partnership on 29 March 2017, it was agreed by the Board that there should
be cohesion between the milestones for the Rotherham Plan and those for the
Trust.

The Board NOTED the Chairman’s report.

130/17 REPORT FROM THE CHIEF EXECUTIVE

The Board of Directors RECEIVED a verbal update from the Chief Executive
in relation to strategic issues, financial, quality and operational matters and
stakeholder engagement.

Reflecting upon the 2016/17 financial year, Mrs Barnett commented that the
financial outturn was of significant concern, particularly the fact that the revised
financial plan had not been achieved.

The Board echoed their concerns regarding financial performance and agreed
that it would be imperative that the 2017/18 targets were delivered. As such,
Mrs Barnett confirmed that work had already commenced with Divisional and
Corporate areas to strengthen the management of budgets and performance.

Despite the financial position, Mrs Barnett indicated that the Integrated
Performance Report reflected areas of exemplar and good performance which
was improving patient outcomes and their experience of services.

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However, there remained some areas, most notably the 4 hour access target,
which continued to face challenges. Whilst, the Trust still had some way to go
to achieve and sustain 95%, there were signs of improvement.

Workforce costs, including bank and agency, had had a significant impact on
the financial position. Therefore, it would be important to shape the workforce
and culture to support delivery of the operational and strategic plans, with
effective communication being a key enabler.

Mrs Barnett indicated her continued commitment to work with partners to
ensure sustainable and resilient services within the organisation and across
the wider South Yorkshire and Bassetlaw area.

The Board NOTED the update from the Chief Executive.

131/17 ROTHERHAM PLACE PLAN

The Board of Directors RECEIVED and NOTED the Rotherham Integrated
Health and Social Care Place Plan.

Mr Holt explained that the plan had previously been presented to the Board as
a draft, underpinned the Trust’s own plans and would support the Five Year
Strategy.

Mrs Clements would pursue outside the meeting the networks or work streams
to join in order to ensure colleagues had the appropriate skills to deliver the
plan.
ACTION – CC

With regard to the expected benefits and investment section, Mr Holt clarified
that any investment requirements would form part of the Sustainability and
Transformation Plan. Should it become apparent that investment would be
required from the Trust, appropriate business cases would be developed for
consideration.

The Board of Directors SUPPORTED the Rotherham Integrated Health and
Social Care Place Plan.

132/17 REVISED PLANS TO SUPPORT FIVE YEAR STRATEGY

The Board of Directors RECEIVED the following Plans which were enablers
to support delivery of the Five Year Strategy.

a. Digital Plan
The Board of Directors RECEIVED the revised and refreshed Health
Informatics Digital Strategy and supporting presentation provided by the
Director of Health Informatics.

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The Strategy which had been developed with third party support detailed a five
year nine point action plan which would require funding of circa £3m per
annum. Any investment whether from within the trust or against national or
regional funding would require development of appropriate business cases
and discussion at the relevant Committees.

The Board proceeded to discuss a number of aspects of the Strategy,
including barriers to delivery, challenges, current and future IT systems,
software and replacement of current hardware.

The Board of Directors APPROVED the Digital Plan.

b. Risk Management Plan
The Board of Directors RECEIVED the Risk Management Strategy 2015 –
2020.

With regard to the version presented, Mr Barnes proposed that the
Accountabilities, Responsibilities and Governance section (section 5) could be
further strengthened by documenting the role of the Board Assurance
Committees in reviewing the Board Assurance Framework and Risk Register,
which should be carried out on a quarterly basis.

On a similar note, on clarifying that outcomes 4.1 and 4.9 were different in the
Our Risk Management Strategic Outcomes (section 4), it was suggested by
Mr Edgell that 4.1 should be reworded to something similar to "Ensuring risk
management is fully embedded into the culture of the Trust and its everyday
processes."

The Board of Directors APPROVED the Risk Management Strategy 2015 -
2020 subject to the additional areas for inclusion as suggested by members.
ACTION - EM

c. Communications Plan
The Board of Directors RECEIVED and NOTED the Communications Plan,
which would develop improved communications and engagement
opportunities both with colleagues and externally with patients and partner
organisations.

It was suggested that the plan should make reference to the Rotherham Story,
further embrace the promotion of excellence within the organisation and
develop performance metrics which could be monitored by the Strategic
Workforce Committee.
ACTION - CC
The Board of Directors APPROVED the Communications Plan.

d. Estates Plan
The Board of Directors RECEIVED the Estates Strategy and Capital
Programme 2017 – 2022.

Mr Cartwright explained that the strategy had been developed in conjunction
with Clinical Directors, Executive Directors and service managers and aimed
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to address current priorities and backlog maintenance. Due to the changing
NHS climate and investment available it would need to be a dynamic plan, with
current focus being on years one and two.

Mrs Craven confirmed that the plan had been considered, but not approved,
by the Finance and Performance Committee with a requirement for additional
discussion and redrafting of some matters which had yet to be undertaken.

The Board AGREED that they would NOTE current progress on the Estates
Plan. Further consideration would be undertaken with a view that it be
resubmitted to the May Board meeting.
ACTION – CH

133/17 SUSTAINABLE DEVELOPMENT MANAGEMENT PLAN

The Board of Directors RECEIVED and NOTED the Sustainable Development
Management (SDM) Plan.

Mr Cartwright indicated that there was a legislative requirement to have a SDM
Plan which would support the Trust in delivering resource efficiency,
sustainability and resilience to a changing climate.

It was confirmed that the SDM Plan had been through the appropriate
governance framework, including the Trust Management Committee to ensure
that it was aligned to the objectives and priorities of the organisation.

In outlining some of the achievements to date and areas for the future
consideration, it was suggested that further consideration should be given as
to how these were positively celebrated and promoted both within and external
to the organisation.
ACTION - JC
There remained a requirement as part of the SDM Plan to appoint an
Executive Lead for Sustainability, accountable to the Board. This would be
considered by the Chief Executive and informed to the members.
ACTION - LB
The Board of Directors APPROVED the Sustainable Development
Management Plan.

134/17 DRAFT QUALITY IMPROVEMENT PLAN

The Board of Directors RECEIVED and NOTED the draft Quality Improvement
Plan (QIP) 2017/18 presented by the Acting Chief Nurse.

Mrs Monkhouse explained that the QIP would incorporate the priorities from
the Quality Account, any regulatory matters and actions from the Care Quality
Commission (CQC) inspection and in due course would be updated to
incorporate information from the CQC State of Care report published in March
2017.

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A new Quality Improvement Board would discuss the approach to be taken to
monitor progress, with Mr Edgell adding that the Quality Assurance Committee
would additionally have a role in monitoring progress against the measurable
metrics and priorities once finalised.

As delivery of the QIP would be critical to the organisation in order to improve
the quality of services and the patient experience, clarity was sought as to
whether there was sufficient resources, capacity and capability within the
organisation to achieve the targets and priorities.

The Executive Directors explained that whilst there were some risks and a
requirement to change organisational culture, there currently was alignment to
the operational objectives which would support delivery. In terms of staffing, it
would be necessary to re-prioritise resources as necessary to deliver
operational plans and objectives. It was also suggested that a project
management office arrangement may support delivery of the plan.

The Board NOTED the draft Quality Improvement Plan, with the final version
to be submitted to the 23 May 2017 meeting.

OPERATIONAL PERFORMANCE

135/17 MONTHLY INTEGRATED PERFORMANCE REPORT

The Board of Directors RECEIVED and NOTED the monthly Integrated
Performance Report (IPR).

Mrs Barnett provided a summary overview before the Board considered the
detailed reports from Executive Director colleagues.

The most outstanding achievement had been the February cancer targets
which had placed the Trust nationally in the top 25% across all metrics. This
was a tremendous achievement for the organisation and a testament to the
hard work of all the teams involved in the process.

Another area of significant achievement had been the improvements seen in
theatre utilisation which had risen to 98%. Mrs Barnett indicated that his
improvement had been as a result of completion of phase one of the theatre
efficiency project. This review had also highlighted that the Trust was
performing well against a number national metrics. Another area of
improvement in month had been the reduction in DNA (Did Not Attend) rates,
which were as a result of enhanced communication with patients.

However, the key concerns remained the financial position and the 4 hour
access target, which would be considered later in the meeting.

The most deteriorated area had been the percentage of patients receiving
dementia assessments. Mrs Barnett commented that upon investigation this
had highlighted the significant reliance upon one member of staff, as a result
mitigating actions would be implemented to increase resilience in this area.
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Another area of deterioration had been an increase in patients experiencing
delayed transfer of care, with Mrs Barnett reporting that a specific piece of
work was underway in this area.

The Board NOTED the Integrated Performance Report.

135/17(a) QUALITY REPORT

The Board of Directors RECEIVED and NOTED the Quality Report presented
by the Acting Chief Nurse and Medical Director.

With regard to healthcare associated infections, Dr Wareham confirmed that
at year-end there had been 19 cases of Clostridium Difficile against the
trajectory of 26. Whilst this was a strong position, the organisation was not
complacent with regard to its performance going into 2017/18, as the target
was again 26. Disappointingly, there had been the one MRSA bacteraemia
case against the zero target. The Board were informed that there was now
also increased mandatory surveillance and reporting of E.coli bacteraemia.

Mortality in terms of the HSMR (Hospital Standardised Mortality Rate) had
seen a modest improvement to 107. However, SHMI (Summary Hospital
Mortality Indicator) had, as anticipated, risen. Although it was disappointing
that the position had deteriorated, Dr Wareham confirmed that the systems
and processes which had been established, continued to be appropriately
utilised. Transition to CHKS rather than Dr Foster for the data source was
taking longer than anticipated.

The Board NOTED the impact of the new tax legislation in relation to IR35,
with a number of locums withdrawing from shifts. Although it had been
possible to staff shifts due to the goodwill and cooperation of colleagues,
concerns on sustaining the position had been escalated to both NHS
Improvement and NHS England. Whilst there was no evidence of any
deterioration in the quality of care provided, should the position change it
would be escalated to the Board by either Dr Wareham or Mrs Monkhouse.
ACTION – CW/EM

On the matter of staffing across the medical wards and Acute Medical Unit,
details on the working group established to review staffing across these areas
would be provided outside the meeting.
ACTION - CW
The Board of Directors NOTED the Quality Report and areas for further action
and improvement.

135/17(b) OPERATIONAL PERFORMANCE REPORT

The Board of Directors RECEIVED and NOTED the Operational Performance
Report, which had been circulated separately to the Board papers, and was
presented by the Director of Operations.

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