Trust Board Monday, 26 September 2016 at 1.00pm Lecture Theatre, St Ann's Hospital, St Ann's ...

220 Pages·2016·5.25 MB·English

by  Barry Ray

Trust Board
Monday, 26 September 2016 at 1.00pm
Lecture Theatre, St Ann’s Hospital,
St Ann’s Road, London, N15 3TH
A G E N D A
(Meeting of the Trust Board held in public)
Time Item Agenda Item Page Lead
Number Number
1. General Business
1.00 1.1 Chairman’s welcome Verbal Michael
Fox
1.02 1.2 Apologies for Absence Verbal Michael
Fox
1.04 1.3 Declarations of Interest and of any Conflicts of Interest Verbal Michael
Fox
To review the attached Summary of Board Members’
declarations of interest and to declare at the meeting any
conflicts.
1.05 1.4 Minutes of the Board Meeting held on 18 July 2016 Page Michael
1 Fox
To confirm the minutes of the last meeting as a true record.
1.08 1.5 Matters arising from the Minutes Page Michael
15 Fox
To review progress set out in the attached written report and
to discuss any other matters raised by Board Members.
1.10 1.6 Patient Focus – Project Future Verbal / Mary
Page Sexton
17
1.40 1.7 Chairman’s Report Verbal Michael
Fox
To receive the Chairman’s verbal report.
1.45 1.8 Chief Executive’s Report Page Maria
19 Kane
To receive an update on Trust matters.
Time Item Agenda Item Page Lead
Number Number

2.00 1.9 Chief Operating Officer / Executive Director of Patient Page Andy
Services’ Report 27 Graham

To receive an update on Operational matters.

2. Risk and Performance

2.10 2.1 Board Assurance Framework Page Barry
35 Ray
To consider the Board Assurance Framework.

2.20 2.2 Integrated Quality and Performance Report Page Andy
71 Graham
To review the Integrated Quality and Performance.

2.30 2.3 Financial Performance: Month 5 (August 2016) Page Simon
79 Goodwin
To receive an update on recent financial performance.

3. Quality and Safety

2.40 3.1 Clinical, Quality and Safety Report Page Mary
93 Sexton
To receive an update on Clinical, Quality and Safety
matters.

2.50 3.2 Safe Staffing Levels Page Mary
107 Sexton
To note the Safe Staffing Levels report and the actions
being taken.

4. Governance and Assurance

3.00 4.1 Freedom to Speak Up - Changes to Arrangements in Page Mark
Raising and Handling Staff Concerns 129 Vaughan /
Mary
To approve the revised arrangements for staff to raise Sexton
concerns.

3.10 4.2 Medical Director’s Report Page Jonathan
137 Bindman
To receive an update on Medical matters.

3.20 4.3 Medical Revalidation Annual Report Page Jonathan
141 Bindman
To note the Medical Revalidation Annual Report.

3.30 4.4 Pharmacy Annual Report Page Jonathan
195 Bindman
To note the Pharmacy Annual Report.
Time Item Agenda Item Page Lead
Number Number

3.40 4.5 Freedom of Information Annual Report Page Barry
205 Ray
To note the Freedom of Information Annual Report.

3.45 4.6 Information Governance Mid-Year Toolkit Review Page Angus
211 Walker
To note the Information Governance Mid-Year Toolkit
review and endorse the action management plans.

3.50 5. Other Items

5.1 Any Other Urgent Business

The Chairman will be asked to consider any other urgent
business which he has been previously notified of in
advance of the meeting, but which has not been provided
for on the agenda.

5.2 Date and Time of Next Meeting

Monday, 30 November 2016 at 1.00 pm
Lecture Theatre, St Ann's Hospital

Reports scheduled for consideration at the next meeting, include:
• Chairman’s Report
• Chief Executive’s Report
• Chief Operating Officer’s Report
• Integrated Performance Dashboard
• Board Assurance Framework
• Financial Performance
• Clinical, Quality and Safety Report
• Safe Staffing Report
• Nursing Skill Mix Six Month Review
• Medical Director’s Report
• Trust and Charitable Funds Annual Report and Accounts
• Annual Workforce Report
• Standing Orders Review

6. Exclusion of the Press and the Public

To resolve that representatives of the press and other
members of the public be excluded from the remainder of
the meeting having regard to the confidential nature of the
business to be transacted, publicity on which would be
prejudicial to the public interest (Section 1(2) Public Bodies
(Admission to Meetings) Act 1960).

Michael Fox
Trust Chairman
BOARD OF DIRECTORS’ REGISTER OF INTERESTS

Board Member: Interest Declared:

Michael Fox • None.
Trust Chairman

Jonathan Bindman • Married to a GP currently working in Newham Community Services,
Medical Director managed by East London Foundation Trust and undertaking locum work
in Tower Hamlets.
• Unpaid adviser to Raphael, a Jewish counselling service based in Barnet.

Frank Devoy • Director and shareholder of Building Change Ltd, a strategic real estate
Non Executive Director consultancy (no previous or expected work with the NHS).
• Director and shareholder of Waverley Investments Ltd, a property
developer.
• Wife is a Community Pharmacist.

Paul Farrimond • Director of P.F. Consultancy Ltd.
Non-Executive Director • Trustee of Together (a mental health charity).
• Specialist Advisor on Mental Health for NHS Providers
• Member of the Care Quality Commission’s (CQC) Mental Health Act
External Advisory Group.
• Member of the CQC’s Deprivation of Liberty Safeguards Advisory Group.
• Member of the CQC’s review of how NHS Trusts investigate and learn
from deaths expert advisory group.

Simon Goodwin • Married to a senior manager at East London NHS Foundation Trust.
Chief Finance and
Investment Officer

Andy Graham • Partner is a Director at InHealth, which provides diagnostic services to the
Executive Director of NHS.
Patient Services

Cathy Hamlyn • Executive Associate Director in Nudge Associates (provision of
Non-Executive Director consultancy services to the NHS and local authorities in relation to sexual
health; HIV and in addressing sexual violence).
• Chair of MEDFASH (Medical Foundation for AIDS and Sexual Health).
• Member of the Labour Party.

Rebecca Harrington • Sole owner of Rebecca Harrington Ltd (intended provision of services to
Non-Executive Director the NHS – none at present).
• Chair at The Maya Centre, providing free psychological support for
women.
• Chair of the NICE Guideline Development Group for Transitions between
Inpatient Mental Health Care and Residential and Community Placements.
• Partner is Consultant Psychiatrist at Camden & Islington NHS Foundation
Trust and Professor at University College London.
• Partner appointed to the Care Quality Commission as National Adviser on
Rehabilitation Psychiatry.
Board Member: Interest Declared:

Dr Christine Harvey • None.
Non-Executive Director

Catherine Jervis • Non Executive Director for First Community Health and Care, a not for
Non-Executive Director profit company providing community health services (primarily to the NHS)
in East Surrey.
• Trustee and Treasurer for First Community Trust (supporting the provision
of health and social care in Surrey).
• Advisor to CEO for Achievement for All, a national education charity
providing services to schools and other educational settings in
collaboration with partners from the health field (e.g. Place2Be and Young
Minds).

Maria Kane • Trustee (unremunerated) of Young Minds (a small national charity
Chief Executive supporting better mental wellbeing for children and young people).
• Member of Information Committee of Lullaby Trust.

Mary Sexton • Honorary Clinical Professor, Middlesex University.
Executive Director of • Clinical and Professional Advisor, CQC.
Nursing, Quality and
Governance

Mark Vaughan • None.
Executive Director of
Workforce

Charles Waddicor • Director / Owner of SAMRO health and social care solutions
Non-Executive Director • Trustee of The Primary Care Respiratory Society UK.
• Mental Health Clinical Advisor to the care Quality Commission.
• Small shareholding in Ventura Group.
• Chair of a Board, operated by Social Finance, overseeing projects running

in Haringey, Tower Hamlets, and Staffordshire, supporting people with
mental health problems into employment.
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BEH-MHT – Trust Board – 26.09.2016 1.4 – Minutes of the Board Meeting – 18 July 2016

Minutes of the Board Meeting held on Monday, 18 July 2016 in the Lecture Theatre,
St Ann’s Hospital, St Ann’s Road, London, N15 3TH

The meeting commenced at 1.00 pm and closed at 3.23 pm

Present:
Michael Fox Trust Chairman
Maria Kane Chief Executive
Jonathan Bindman Medical Director
Frank Devoy Non-Executive Director
Paul Farrimond Non-Executive Director
Simon Goodwin Chief Finance and Investment Officer
Andy Graham Executive Director of Patient Services
Cathy Hamlyn Non-Executive Director
Christine Harvey Non-Executive Director
Catherine Jervis Non-Executive Director
Mary Sexton Executive Director of Nursing, Quality and Governance
Meera Nair Deputy Director of Workforce (attending in place of Mark Vaughan)
Charles Waddicor Non-Executive Director

In attendance:
Barry Ray Trust Board Secretary
Gillian Kelly Deputy Director of Nursing (For Minute Item 1.6)
Mark Cubitt Unit Manager, Magnolia Unit (For Minute Item 1.6)

Item Minute Item Actions
No.

1. General Business

1.1 Chairman’s Welcome

Michael Fox welcomed everyone to the meeting.

1.2 Apologies for Absence

 Rebecca Harrington, Non-Executive Director
 Mark Vaughan, Executive Director of Workforce

1.3 Declarations of Interest and Declarations of any Conflicts of Interest

The Trust Board agreed to note that there were no conflicts of interest
declared in relation to items on the agenda.

1.4 Minutes of the Meeting held on 31 May 2016

The Board confirmed the minutes of the last meeting as a true record.

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BEH-MHT – Trust Board – 26.09.2016 1.4 – Minutes of the Board Meeting – 18 July 2016

1.5 Matters Arising from the Minutes of the Meeting held on 31 May 2016

The Board noted the written report on matters arising and accepted the
updates.

1.6 Patient Focus – Healthwatch Enter and View of the Magnolia Unit

Mary Sexton introduced Mark Cubitt, Unit Manager at the Magnolia Unit who
was in attendance to give a presentation on the recent HealthWatch Enter and
View visit of the Magnolia Unit. She advised that HealthWatch had statutory
powers to ‘Enter and View’ health and social care premises, which provided an
additional level of scrutiny of the services which are provided to patients. Whilst
the final report into the visit had not yet been published the Trust has already
produced an action plan in response to the issues identified.

Mark Cubitt informed the Board that the Magnolia Unit, located at St Michael’s
Primary Care Centre, provides inpatient care which aims to prevent avoidable
admissions to acute hospitals where a patient cannot be looked after safely at
home but who are clinically stable. The majority of patients were elderly.

Mark Cubitt’s presentation:

 Advised that the purpose of the visit was to observe and assess the nature
and quality of services and obtain the views of the service users and carers.

 Outlined areas of good practice identified, including well-structured and
user-friendly referral form and care planning documents, involvement of
patients to set their own goals on admission and are provided with a
personalised schedule of therapies, tailored to their individual needs.

 Provided examples of positive and negative comments made by service
users and carers.

 Outlined of the recommendations arising from the HealthWatch Enter and
View visit.

 Summarised the challenges faced by the Magnolia Unit, which included
increasing numbers of patents with complex needs against a growing
population of people with early dementia.

Maria Kane highlighted that on her last visit to the Magnolia Unit she had
observed staff having to deal with some service users with challenging
behaviour and / or personality disorders. She asked if the staff at the Magnolia
Unit felt they were adequately supported by colleagues from other parts of the
Trust. Mark Cubitt confirmed that advice on dealing with service users was
readily available and commented that such service users took up a far greater
amount of staff time.

In response to a question from Jonathon Bindman, Mark Cubitt outlined the
existing arrangements for the provision of GP medical cover at the Magnolia
Unit which was being provided by Barndoc Healthcare.

The Trust Board agreed to note the Patient Focus on the Healthwatch
Enter and View of the Magnolia Unit.

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BEH-MHT – Trust Board – 26.09.2016 1.4 – Minutes of the Board Meeting – 18 July 2016

1.7 Chairman’s Report

Michael Fox informed that he had attended a number of national events which
focussed on the long term financial sustainability of the NHS. He highlighted
that there was a general feeling that politicians needed to engage in a debate
with the public about the level of service that can be expected for the level of
funding available.

Michael Fox advised that he had now completed a programme of visits to all
prisons that the Trust provides mental health services from. He highlighted that
that he was impressed by the staff that the Trust had who were working in very
difficult circumstances, including financial reductions in the Criminal Justice
system.

The Trust Board agreed to note the Chairman’s verbal report.

1.8 Chief Executive’s Report

Maria Kane presented her report on Trust Matters and highlighted the following:

 The North Central London (NCL) Sustainability and Transformation Plan
(STP) was submitted to NHS England on 30 June 2016. The STP
summarises the high level plans developed jointly across Barnet, Camden,
Enfield, Haringey and Islington to improve the health and wellbeing of local
residents and the care that they receive (further information is set out in
Minute Item 4.2 below).

 The Trust has appointed Mandy Stevens as Interim Improvement Director
from 20 July 2016, who will be working with Salford Royal NHS Foundation
Trust, who have been appointed as the Trust’s Improvement Partner, to
implement the ‘Haelo’ methodology for continuous improvement.

 A letter was sent to all staff from the Chief Executive on 6 July 2016 to
emphasise the serious financial challenges the organisation faces and
outline the steps the Trust is taking to address this, which include reducing
our reliance on bank and agency staff, supporting clinical teams in ensuring
their services are as cost effective as possible, and ensuring that all patient
activity is fully recorded, so that all activity is recognised by commissioners.

 The Trust submitted its Strategic Outline Case (SOC) for the redevelopment
of the St Ann’s Hospital site to NHS Improvement on 30 June 2016 for
review. The SOC focuses on the Trust’s redevelopment plans but allows for
flexibility to accommodate potential proposals for other NHS mental health
services to be provided from the St Ann’s site in the future.

 The Trust has undertaken a review of its Values, which involved consultation
with service users and nearly 500 members of staff. The responses
received produced a set of words that have been distilled into the following
agreed Values for the Trust:

o Respect
o Compassion
o Working Together
o Being Positive

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BEH-MHT – Trust Board – 26.09.2016 1.4 – Minutes of the Board Meeting – 18 July 2016

 The Chief Executive attended a student organised Mental Health
Conference, entitled ‘Stamp out Stigma’ on 13 July 2016, organised by
students at Hendon School.

Maria Kane also informed the Board that Dr Mehdi Veisi has been appointed as
the new Clinical Director for Specialist Services. Maria Kane placed on record
her thanks to Dr Katherine Bartlett for her excellent work as the Interim Clinical
Director.

In response to questions from Christine Harvey, Maria Kane informed that to
date she had received over 90 responses to the letter sent to all staff about the
serious financial challenges the organisation faces. The responses included
suggestions and examples of actions which will be reviewed and fed into the
Trust’s Financial Improvement Programme. A communications strategy will be
developed to assist in the delivery of the Trust’s Financial Improvement
Programme.

The Trust Board agreed to note the Chief Executive’s report.

1.9 Executive Director of Patient Services’ Report

Andy Graham presented the Executive Director of Patient Services’ report and
highlighted the following:

 The headline priorities for delivery by the Executive Director of Patient
Services, the Clinical Directors and their teams for 2016 / 2017 are:

o Delivery of the CIP programme and substantial progress towards a
monthly financial run rate that will deliver our control total
o Improving our recorded activity by at least 10%
o Transforming our services to meet the current and future needs of
patients, critically - delivering the ‘Enablement - Adult Mental Health
Pathway review’
o Implementation of the CQC action plan

 The Eating Disorders Service has undertaken a review of the community
pathways and is now developing a community based ‘hub and spoke’ model,
with satellite clinics and new pathways established. Acacia House is
planned to close in August with the five beds being relocated to Phoenix
Ward resulting in all of the Trust’s Eating Disorders beds being consolidated
on one site.

In response to a question from Michael Fox, Andy Graham advised that the
planned closure of Acacia House would result in some considerable disruption
over a period of 6-7 weeks but that he had not been aware of any adverse
comments about the planned relocation.

The Trust Board agreed to note the Executive Director of Patient Services’
report.

2. Risk and Performance

2.1 Board Assurance Framework

Barry Ray introduced a report which presented the Board Assurance Framework
(BAF), which identifies the highest risks faced by the Trust in meeting the Trust’s
objectives for 2016 / 2017.
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