Council of Governors

Transcription

1 Council Governors pm St Johns Hotel, Warwick Road, Solihull Interests Minutes s

2 Council Governors 1. Welcome s Interest (Enclosure) 4. Minutes meeting held on 20 January 2014 (Enclosure) man s, including: 6.1 Kennedy Review Task Force 7. Executive s, including: 7.1 Response to CQC concerns 7.2 CQC Pilot Ratings 7.3 Overseas patients - procedure & income Lord Philip Hunt Dr Mark Newbold Mr Aidan Quinn Mr Adrian Stokes (Enclosure) (Enclosure) (Enclosure) (Enclosure) (Oral) 10. Mr Simon Hackwell (Enclosure) 11. Ms R Blackburn (Oral) 12. Presentation prospective Mr Les Lawrence (Oral) 13. man s Mr Richard Hughes (Enclosure) 14. s : 14.1 Finance & Strategic ning Committee (10/03/14) 14.2 Finance & Strategic ning Committee Minutes (13/01/14) 14.3 Hospital Environment Committee Minutes (06/01/14) 14.4 Patient Experience Committee Minutes (12/02/14) 14.5 & Safety Committee Minutes (06/02/14) Date Next Meeting Mr Barry Orriss Mr Barry Orriss Mrs Elaine Coulthard Mr Mike Kelly Mrs Liz Steventon (Oral) (Enclosure) (Enclosure) (Enclosure) (Enclosure) 21 st May Harry Hollier Lecture Theatre, Partnership Learning Centre, Good Hope Hospital Refreshments will be available 3.30pm Kevin Smith Company Secretary 10.2 Interests Minutes s

3 Council Governors.3 Interests Minutes s

4 Council Governors s Interests.4 Interests Minutes s

5 Interests Council Governors COUNCIL OF GOVERNORS REGISTER OF INTERESTS NAME INTEREST DECLARED DATE DECLARED Cllr Mohammed Awaiting information Aikhlaq DATE CEASED Arshad Begum Nothing to declare 21 Nov 2011 Kath Bell Company Secretary - Succeed Services Ltd 21 Nov 2011 Barry MBE Clewer, 1. Sandwell & West Birmingham Hospital NHS Trust - Patient & Public Involvement (PPI) member 2. Sandwell & West Birmingham Hospital NHS Trust - Patient Led Assessment the Care Environment (PLACE) member. 3. Royal College Nursing - ACTION ON HEARING LOSS - Nursing Practice Steering Group member. 4. Birmingham Healthwatch - Enter & View Representative. 16 Sep Jan 2014 Elaine Coulthard Nothing to declare 21 Nov 2011 Dr Olivia Craig Carol Doyle Emma Hale No declaration received Awaiting information Awaiting information Ron Handsaker Shareholder Santander 2000 Albert Fletcher Richard Hughes Director - Aquarius (unpaid). A charity that specialises in helping and treating those with drink and/or drug issues. 1.man - Homestart (Tamworth) 2.man - Tamworth Credit Union Ltd 3.Director - The Pathway Project 4.Director - Tamworth Community Advice Network CIC 5.man - Tamworth Talking Newspaper Ltd 6.Trusteeman - The Rawlett Trust 7.Vice man - Standards Committee, Tamworth Borough Council 8.Divisional President - St John s Ambulance 9.Member - Appeal Committee, St Giles Hospice 10.Retired CEO & President Secretary, Tamworth Cooperative Society 11.Mr Hughes son holds a very senior managerial position with Barclays Bank 12.man - Tamworth Community Advice Network CIC 13. Independent Member - Tamworth 28 May Nov 2011 Amended 1 Sep 2013 Amended 23 Oct Feb Oct Oct Mar Oct Oct Oct Interests Minutes s

6 Interests Council Governors Borough Council Nominations Committee 14. Member - Conservation Advisory Committee, Tamworth Borough Council 15. President - Tamworth Male Voice Choir 16. Treasurer - St Andrew s Methodist Church, Tamworth 17. Shareholder - BP 18. Shareholder - Santander 23 Oct Oct Oct Oct Oct Oct Oct 2012 Michael Hutchby Nothing to declare 16 Aug 2013 Sue Hutchings Shareholder in Lloyds TSB 19 Sept 2013 Phillip Johnson Nothing to declare 21 Nov 2011 Michael Kelly Nothing to declare 21 Nov 2011 Attiqa Khan Nothing to declare 16 Aug 2013 Heidi Lane 1. Member Church - Renewal Christian 21 Nov 2011 Centre 2. Husband is an Elder the Church. 3. Trust uses Christian Renewal Centre for conferences & meetings Andrew Lydon Nothing to declare 16 Aug 2013 Anne McGeever Nothing to declare 17 Sep 2013 Margaret Meixner David O Leary Awaiting information Awaiting information Barry Orriss Nothing to declare 21 Nov 2011 Mark Pearson Nothing to declare 16 Aug 2013 Cllr Jim Ryan Archway Academy Ltd Owner/MD Archway Community College - Owner/MD Archway Brimstone Security Owner/MD 15 July 2013 Archway Renaissance LLP Owner/MD Robert Ryan Housing Investments - Owner /MD Liz Steventon Friends Solihull Hospital 21 Nov 2011 Joy Townsend Awaiting information David Treadwell Matthew Trotter 1. Shareholder - Lloyds TSB 2. Shareholder - STW 3. Shareholder - National Grid 1. HEFT Employee 2. Director - Specialist Health Partnership 21 Nov Sep 13.6 Interests Minutes s

7 Council Governors Minutes Meeting held on 20 January Interests Minutes s

8 Minutes meeting 20 January 2014 Council Governors COUNCIL OF GOVERNORS Minutes a meeting the Council Governors Heart England NHS Foundation Trust held in the Education Centre, Birmingham Heartlands Hospital on 20 January 2014 PRESENT: Lord Philip Hunt (man) Mrs Kath Bell Mr Barry Clewer, MBE Mrs Elaine Coulthard Dr Olivia Craig Mr Albert Fletcher Mrs Emma Hale Mr Richard Hughes Mr Michael Hutchby Mrs Sue Hutchings Mr Philip Johnson Mr Michael Kelly Ms Heidi Lane Mr Andrew Lydon Mr David O Leary Mr Barry Orriss Dr Mark Pearson Cllr Jim Ryan Mrs Elizabeth Steventon Mrs Joy Townsend Mr David Treadwell Mr Matthew Trotter In attendance Dr Clive Ryder Mr Les Lawrence Ms Alison Lord Dr Mark Newbold Mr Aidan Quinn Dr Jammi Rao Mr J Sellars Mr Adrian Stokes Mrs Lisa Thomson APOLOGIES Mrs Angie Hudson (Minutes) Dr Ann Keogh Mr Kevin Smith (Company Secretary) Members the Public for Governors had been received Ms Anne McGeever. for Directors had been received for Dr Cadigan, Mrs Foster, Ms Gunter, Mr Hackwell, Mr A Laverick, Mr Lock, Mrs Moore, Pr Peck, Pr Serrant-Green and Dr Woolley DECLARATION OF INTEREST The man referred to the Register Interests and asked that Governors with any new interests should notify the Company Secretary so that the Register could be updated accordingly MINUTES OF MEETING Recruitment man s Mr Smith advised that he had ed a revision to the second paragraph replacing the first sentence with Mr Lydon asked whether the Governors could be given more information (possibly anonymised) Interests Minutes s

9 Minutes meeting 20 January 2014 Council Governors on the applicants at the long list stage. The man stated that he could see no reason why the recommended candidate shouldn t meet the Governors prior to appointment Membership & Community Engagement Committee. The second sentence should read... The objective was to try to replace... Subject to these changes the minutes the meeting held on 18 th November 2013 were approved as a true record MATTERS ARISING Discussion on vendors at BHH main entrance vacant spaces and opening hours. Mr Sellars, Director Asset Management, advised that he had met with the landlord, Assura, to discuss the service issues; including opening hours and outstanding damages due to the Trust as a result the previous problems experienced with the escalators. The Trust had instructed its solicitors to write a formal letter requiring Assura to comply with the contractual terms opening hours. A meeting had taken place with Initial, which operated the service, to put in place an agreement to expand the opening hours. There was currently no demand for the vacant retail space. It was noted that a buy-out option Assura was likely to be expensive. Mr Sellars advised that plans were in place for the new public and patient restaurant at Good Hope Hospital (GHH) to be opened by Christmas In response to a question Mr Orriss, Mr Sellars advised that the Trust was currently looking at proposals for the multi storey car parks at GHH and should have a design specification within six months. Cllr Ryan asked when the Governors would receive a report on overseas patients the Trust and the arrangements for recovery associated costs. Mr Treadwell advised that he had also raised this matter with the Company Secretary. Dr Newbold advised that, as reported to the previous meeting, the Trust operated the same rules as other foundation trusts in relation to overseas patients and undertook to provide a report summarising the arrangements and income associated with this for HEFT CHAIRMAN S REPORT The man referred to his pre-circulated report and highlighted the following specific items: Sir Ian Kennedy s Review The report described the failings by the previous management team in handling the issues that arose the behaviour Mr Ian Paterson. The man had fered a full and unreserved apology to both patients and staff. The made a series recommendations that included changing the culture, practices and processes within the Trust in order to be fully aligned with the aims the Francis to ensure that the patients are at the heart every decision taken by the Trust. The Board had accepted these recommendations in full. An ambitious programme change had been implemented that would be overseen by a Task Force comprising various Directors and others supporting the actions, a Patient Member, a Governor and chaired by the man. The Board would report back to Sir Ian in the summer on progress in order to update and reassure him that the Trust had made meaningful changes in its processes. Pr Sir Muir Gray, Knowledge Officer to the NHS, has been engaged to work with the Trust to further develop an open and patient-centred culture..9 Interests Minutes s

10 Minutes meeting 20 January 2014 Council Governors The man asked for a volunteer the Governors to sit on the Task Force and received nominations Mr Kelly, Dr Pearson and Cllr Ryan. As there was more than one volunteer it was agreed that the Secretary would undertake a ballot by and advise the Governors the successful candidate. Mr O Leary asked how staff whistleblowers could be confident that they could raise concerns in anonymity and be safe in the knowledge that their jobs would not be affected. The man advised that the Trust was working with Public Concern at Work to develop a process that staff could be confident in. Mr Orriss and Dr Pearson asked how Governors could gain confidence that they would be made aware any future problems a similar nature. Dr Newbold advised that all new staff, as part the Trust induction, were given details on how to raise any concerns they may have and that this included making employees aware the status Staff Governors. Cllr Ryan was concerned that the Governors had received very little information on what had happened and their credibility could be damaged with members the public by this lack knowledge and that the Task Force should ensure that confidence could be restored in the Governors. He went on to question the qualifications senior managers and expressed the view that the skill set managers in the Trust needed to be addressed. Mr Trotter suggested that Governors undertake ward visits to gain a better understanding what was happening on the ground. Mrs Bell advised that the Consultative Health Council already undertook unannounced visits to wards and reported back to the Trust on its findings and that several the Governors participated in these inspections. In addition, it was noted that the new regime PLACE ward inspections would include Governors. The man commented that he and the Non-executive Directors (NEDs) also participated in regular Patient Safety ward visits. The man observed that the Governors were the external challengers on behalf the public and that he was confident that under the current structure any major matters concern would be brought to their attention and acted upon. The Task Force would consider how the role the Governors could be used to reinforce the initiatives that it was pursuing CHIEF EXECUTIVE S REPORT Dr Newbold referred to his pre-circulated report and noted that the key issues for the Trust in 2014 were:.10 Emergency pathway This was the single biggest issue for the Trust. Dr Newbold, together with the man and other Directors, had met with Monitor the previous Friday; when Monitor confirmed it was comfortable with the progress made by the Trust in recent weeks against its enforcement undertakings. The CQC inspection reports had been received and had highlighted, as expected, that Emergency pathway issues were the main areas concern. The CQC inspection had taken place in November during a time peak pressure on the Trust. Dr Newbold had been surprised that the Trust had been issued with a warning notice under Section 29 the Health and Social Care Act 2008 given that warning notices are normally issued immediately rather than several weeks after a visit. The notice related to GHH; most issues raised had already been addressed. The CQC report on Solihull Hospital (SoH) noted that clarity about the Interests Minutes s

11 Minutes meeting 20 January 2014 Council Governors scope services around A&E and critical care was required; this was being addressed as part the CCG led Urgent Care Review. Sir Ian Kennedy s Dr Newbold confirmed that he would be leading a work steam focused on delivering the cultural changes required to drive a change programme putting the patient at the centre everything the Trust does. Pr Sir Muir Gray would be working with the Trust to assist in this initiative. Re-configuration to meet the Trust s financial challenges The Trust continued to face significant financial challenges which could only be met through reconfiguration, which was currently being considered by the Executive Team and would be incorporated into the, the first stage which was due to be submitted to Monitor by the end March. Mr Hughes referred to the GHH warning notice and asked for assurance that the Trust would be compliant by the deadline 21 st February; Dr Newbold confirmed that it would. Mrs Foster was delivering executive leadership at GHH following Mrs Moore s departure, until an interim Managing Director took up post. The CQC would undertake an unannounced visit after the 21 st February to determine whether the recommendations had been addressed to its satisfaction. Mr Lydon noted the CQC recommendation that the Trust ensured that patients were cared for in the right area and asked what this meant and whether it was a problem. Dr Newbold believed the recommendation arose a comment taken a staff member about patients not always going to the correct speciality ward direct A&E. He added that following recent work, there were robust processes in place to avoid this. In response to a question Mr Orriss about recent negative local press coverage the man advised that the articles had been based on the press release the CQC and had highlighted the areas concern rather than focusing on the positive aspects the report. Dr Newbold added that the Trust was committed to be being open and honest; consequently there was a risk that it would be subject to negative press comment time to time. Further recent negative press comment in relation to GHH had questioned whether the hospital might be closed; work was being done to reassure local residents that GHH did have a future and would not be subject to closure. Mrs Thomson advised that a statement would also be posted on the Trust website to this effect. Cllr Ryan requested that the Trust shared its response to the concerns set out in the CQC reports with Governors. The man advised that a summary the CQC report along with the Trust s response and action plan would be made available to Governors. In response to a question Mr Treadwell regarding changes to senior management, Dr Newbold advised the Trust had a full complement 12 Executive Directors (voting and non-voting) and there would inevitably be changes time to time. The Trust had seen some recent movement but this was not outside the norm. He added that the Mr Richard Parker, interim MD at GHH, would be joining the Trust the beginning February and the new Medical Director, Dr Andrew Catto, would be joining the the beginning March FINANCE PERFORMANCE YEAR TO DATE Mr Quinn presented the Month 8 (October) Finance. The following items were noted:.11 Interests Minutes s

12 Minutes meeting 20 January 2014 Council Governors The Continuity Services Rating (COSR) was 4 at month 8. There was a 4.2m YTD surplus at the end October; 0.9m better than plan; this included one f income benefits. There was a 7.4m overspend against operational budgets. The year-end forecast 2m surplus was subject to winter costs, no unexpected income and provision reviews. The Cost Improvement (CIP) was for 22.2m; YTD date delivery was 10.3m (70% the YTD plan). The balance sheet remained strong. The Trust had missed its CDiff with a YTD figure 61 cases against 45. The Trust was expecting to miss its 18 week for quarter 4. The 62 day cancer wait had not been achieved. The Monitor plan was being developed, the would be a two phased submission with part one setting out a two year detailed financial plan and narrative detailing how it intended to deliver high quality and cost effective services submitted by 4 April 2014, followed by the second submission setting out the five years financial return and strategic plan submitted by 30 June The man noted the scale the challenge to deliver 24m CIP year on year. In response to a question Mr Lydon about the JMRA contract and the predicted 2m surplus, Mr Quinn and the man advised that the Trust had agreed the JMRA contract with commissioners instead a patient tariff to gain a level certainty and this arrangement included a 4m risk pool that could be adjusted either way. The Trust would have had a similar level income through the conventional tariff system. Mr Stokes noted that the JMRA contract rewarded the Trust for delivery outside the hospital setting. Mr Hughes referred to the 62 day cancer and asked for clarity about the figures set out in the paper. Mr Quinn advised that for October the Trust had achieved a 78% but this did not translate to a breach the year end figure. The Trust had seen an increase in the number urology referrals as a result the recent prostate cancer campaign. In response to a question Cllr Ryan, Mr Quinn confirmed that the submitted to Monitor would be supported with a high level detail for the first two years. Cllr Ryan postulated that the Trust should therefore have the detail he had requested on income overseas patients FLOW AND 4 HOUR TARGET Mr Stokes presented the report that was taken as read and noted:.12 In order to tackle the recent flow issues Mr Stokes had been re-assigned to lead a six month Emergency Care Pathway programme. To kick start the programme Gold Command had been implemented during December on the BHH and GHH sites. The actions put in place during that time had resulted in an improvement with the Trust delivering an improved A&E performance; however GHH continued to experience difficulties. The key to success was to sustain the improvements. GHH was to undertake a second Perfect Week supported by Mrs Foster and Mr Stokes. The Perfect Week concept was supported by additional resources e.g. ward liaison ficers on each ward and additional site fice staff to chase and solve delays in the system. Interests Minutes s

13 Minutes meeting 20 January 2014 Council Governors In response to a question Mr O Leary, Mr Stokes advised that each site tracked patient waiting times in A&E to ensure that patients did not breach the. Mr Orriss asked if the Trust was involving Social Services earlier to avoid delays when patients were ready to be discharged and whether minor injuries were being treated accordingly. Mr Stokes confirmed that the Trust was working with the various Social Services departments in respect discharges with differing levels success and confirmed that A&E units were using a number techniques, including rapid triage, GP care in A&E and focus on AMU/MAU and SAU practices. Mrs Steventon enquired what would happen to winter funding beyond March. Mr Stokes advised that the Urgent Care Board was away the problem and was due to meet in February; however, to date no decisions had been taken. In response to a question Mrs Coulthard, Dr Newbold explained that GHH had undertaken a huge amount work to improve discharges for elderly patients. Mr Stokes confirmed that patients should be being fed and watered whilst awaiting discharge. Mr Lydon noted the issues with the balance community provision between the East and West Birmingham and the complications created by moving patients further away their homes and asked if there were facilities in Solihull that could be utilised by BHH patients. Mr Stokes advised that the problem may be due to a lack resources overall. Mrs Townsend asked how GPs could be educated not to send frail elderly patients to A&E unnecessarily; Mr Stokes advised that there was a temptation to admit elderly patients when they present at A&E. In response to a question Mr Orriss, Mr Stokes advised that the Trust was working to improve actual discharge timescales including ensuring there were discharges before 1pm. The man and Mr Lawrence left the meeting at this point and Mr Hughes chaired the meeting for the following item business RECRUITMENT OF CHAIRMANS SUCCESSOR Mr Hughes reported that the man had fered to stay in post for some months in order to ensure that the work the Kennedy Review Task Force was diligently progressed. Mr Orriss suggested that it might be appropriate to Lord Hunt s brief on specific areas and allow the new to deal with other activities, Mr Hughes advised that this might depend on the preferred candidate s skills and availability to commence in post. After due discussion, Mr Fletcher proposed and Mr Orriss seconded the motion that Lord Hunt be invited to continue in post as man up to 31 July The motion was unanimously carried. Mr Hughes reported that the Trust had received 18 applications, a variety backgrounds, for the post man and that these had been shortlisted down to seven candidates for interview. All but one the shortlisted candidates had direct NHS experience and all were Midlands based or lived within a commutable distance. Interviews would take place on 13 th and 14 th February and candidates would be subject to psychometric testing before interview. The process allowed time for second interviews, if required. The Appointments Committee had agreed to invite the preferred candidate to the Governors Breakfast Meeting on 14 March and then to.13 Interests Minutes s

14 Minutes meeting 20 January 2014 Council Governors attend the Council Governors meeting on 17 March to make a brief presentation prior to Governors being asked to approve the recommendation the Appointments Committee. Mr Hughes advised that this particular approach had not been undertaken previously but felt it would give Governors the opportunity to meet the preferred candidate prior to a final decision. Mr Lydon asked how shortlisting had taken place and how many members the Committee had been in attendance; he added that he felt dissatisfied that the Governors as a whole had not received as much information on the candidates as he had expected. Mr Hughes advised that four Committee members out six had been in attendance and had taken into account the candidates full applications with any candidates being invited to interview if supported by one or more the members. Those candidates who had not been invited to interview were broadly perceived to be a lower standard than was required for the role. Mr Hughes reassured the meeting that the shortlisted candidates were all a high standard. Mrs Coulthard asked if there were any female shortlisted candidates, Mr Hughes advised there was one. Mr Fletcher, Mr Orriss and Mr Johnson were the view that Governors needed to support the Appointments Committee in progressing the recruitment process and making a recommendation to the full Council Governors. Mr Kelly added that the Committee members had considerable experience senior level appointments both within and outside the Trust. Mr Lydon noted that there was nothing in the job specification about how candidates were able to demonstrate that they had an ability to spot a problem or smell a rat or to avoid the appointment candidates for party political purposes. Mr Hughes took on board these comments and reassured the meeting that the interview panel would factor this into the interview questions. The man and Mr Lawrence re-joined the meeting COMMITTEE REPORTS Finance and Strategic ning Committee Mr Orriss advised that the Committee had met on 9 th December 2013 and 13 th January 2014 and the minutes 12 th November 2013 were taken as read. An additional meeting had been held in December to ensure that Governors were on board with the Corporate Strategy, and budget process. The Committee had noted concerns around the finances including that all additional income received during the year had been a one-f nature, however all expenditure tended to be a recurring nature. It was recognised that the forecast 2m surplus at year end was tight and financial controls up to the year end were crucial to ensure that the Trust achieved this surplus Hospital Environment Committee Mrs Coulthard advised that the committee had met on 6 th January The minutes the meeting on 7 th November 2013 were taken as read and the following items noted:.14 The January meeting had undertaken an interesting tour the catering facility at SoH. There had been an issue with non-attendance Committee members but this was in hand. Interests Minutes s

15 Minutes meeting 20 January 2014 Council Governors Refurbishment the renal wards at BHH was discussed; the need for the Trust to create flexibility to enable these wards to be vacated in order for the works to be carried out was noted. Mr Sellars advised that funding was available for the refurbishment and it would commence once a decant ward was available Membership & Community Engagement Committee Mr Fletcher advised that the committee had met on 29 th November 2013; the minutes were taken as read. Mr Fletcher advised that Mr Simon Jarvis had left the Trust and asked if a replacement had been appointed. Mrs Thomson advised that the vacancy had been filled and Mr Jamie Emery would be joining the Trust on 1 st. The Committee was looking to undertake a piece work around membership engagement in the Perry Barr constituency but would need budget approval for expenditure around 2k, which Mr Fletcher would pursue Patient Experience Committee As Mr Kelly advised that the committee had met on 29 th November 2013; the draft minutes were taken as read. Mrs Margaret Mitchell had attended the meeting and given an update on customer services and the complaints process. The meeting had also heard that there had been 90,000 DNAs last year costing the Trust approximately 2m. Mr Kelly requested Board intervention to reduce this number and suggested a visit to Lyndon Place to speak with staff in order to better understand the problem. The man asked Mr Lawrence if this could be picked up by the Board s Finance & Committee - Mr Lawrence agreed & Safety Committee Mrs Steventon advised that the Committee had met on 6 th December 2013; the draft minutes were taken as read. November and 4 th Following an informal meeting held on 10 th January, Dr Keogh had been tasked with a number requests for information to be bought back to the next meeting Remuneration Committee The draft minutes the meeting on 18 th November 2013 were taken as read the Transforming Patient Experience Conference Mrs Hutchings advised that she had attended a Kings Fund event in London and included a written report in the pre-circulated papers. The event had been very interesting and had considered how patient experiences could be used to improve services. The Patient Experience Committee had debated the topic and Mr Jarvis had advised that the Trust already used many the ideas presented to enhance staff training. Mrs Hutchings went on to reference the patient story set out in Mr Stokes paper on asked why, if the Trust knows that there is a problem, that it not addressing it. Mrs Thomson advised that the customer services department did capture all complaints information and work with individual teams to highlight areas for improvement and learning..15 Interests Minutes s

16 Minutes meeting 20 January 2014 Council Governors Mr Treadwell asked whether PALS (Patient Advice & Liaison Service) still existed and what impact it had in the complaints process. Mrs Thomson advised that the PALS Team had merged with the Customer Relations team in order to improve the complaints process. Customer Relations provided input to the Patient Experience Committee and the and Safety Committee. Mr Lydon asked about the number complaints per site noting that SoH and GHH appeared to receive more than BHH. Mrs Thomson advised that this was correct but noted that some specialities are managed through SoH, for example Diabetes and Ophthalmology, but span all sites which may, in part, explain this apparent anomaly. Mrs Thomson agreed to provide more detail on the breakdown the complaints statistics. Dr Pearson referenced Sir Ian Kennedy s report and the reporting patient complaints and questioned whether all complaints should report to and Safety Committee rather than Patient Experience Committee. It was noted that Dr Keogh was already liaising with Mrs Thomson in relation to complaints that included patient safety issues but not all complaints did. The man advised that this had been debated previously and it had been concluded that the present arrangement worked well. Mike Kelly advised that he attended both and confirmed that both dealt with complaints in an appropriate manner ANY OTHER BUSINESS Cedarwood Mrs Coulthard advised she had attended the ficial opening Cedarwood on Friday 17 th January. She advised that the ward was now operating at capacity and queried what plans the Trust had to ensure that patients were encouraged to return home. Dr Newbold advised that the planned length stay for a patient was up to 30 days; however the length stay was currently averaging seven days. Minutes Mr Lydon asked if minutes meetings could be circulated when they had been drafted rather than having to wait for the next meeting pack. The man undertook to discuss this with the Secretary. Parking Mrs Steventon questioned the Trust s recent decision to charge cancer patients attending BHH and SoH for Chemotherapy and Radiotherapy for car parking. Mr Sellars advised that those patients who needed to attend on a regular basis for treatment were able to get a reduced cost ticket at 20 for 20 days across the Trust. Governors Photo boards Mr Fletcher noted that these had not yet materialised. Mrs Thomson explained that an earlier proposal had become over complicated but she would action a simpler solution DATE OF NEXT MEETING The next meeting would be held on 17 th at St Johns Hotel, Warwick Road, Solihull..16 man Interests Minutes s

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18 Council Governors COUNCIL OF GOVERNORS SCHEDULE OF MATTERS BROUGHT FORWARD Date raised Minute No Detail Action by Due Status Completed 21 Nov Jul Nov Jan Governor podcast update Discussion on vendors at BHH main entrance vacant spaces and opening hours. Consider Governors training needs. on processes and income for overseas patients Response to CQC concerns Consider DNA (missed appointments) issue at Board F&PC Provide detailed breakdown complaint statistics by site and function Consider earlier distribution draft minutes. Organise Governor Photo boards Co Sec JS / CoSec MN MN LL LT / CoSec LT Mar 2014 Jan 2014 Mar 2014 Mar 2014 Mar 2014 Mar 2014 Mar 2014 Mar 2014 Mar 2014 item Jan 14 item 7 item 7.18 Interests Minutes s

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20 Council Governors CHAIRMAN S REPORT to the COUNCIL OF GOVERNORS MARCH 2014 Below is the report that I presented to the Board Directors meeting held on 4. CHAIRMAN S REPORT to the BOARD DIRECTORS MARCH 2014 Board to Board A Board to Board meeting in February with our CCG partners proved to be very productive. It looked at the challenges being faced and shared concerns across the health economy on delivery. It was agreed that further meetings would be held to ensure regular dialogue and I look forward to the formal feedback this meeting and the dates for forthcoming meetings. Monitor We are continuing to have regular meetings and dialogue with Monitor with regard to the Trust s performance and our progress on the Monitor undertaking. These meetings are challenging and continue to drive the importance delivery against the agreed plan. This is something which the Finance and Committee is focusing on and the Executive Management Board is monitoring and, where needed, taking corrective action. Kennedy Task Force We have held our first meeting the Task Force, formed to ensure the implementation the actions arising for the Sir Ian Kennedy Review. Over the next 5-6 months the group aims to establish key building blocks for continued development a safe and caring environment which enables patient centred safe care supported by an open, learning and accountable environment for our staff as part the recommendations the Sir Ian Kennedy Review. Due to the importance this work I have provided the Board in my report with a detailed overview. A programme work has been developed to support putting the recommendations into practice over the coming 5-6 months. This will be a piece ed and focused work to demonstrate innovation in each the 10 recommendations to establish an excellent basis for continued improvement which not only creates a safe and open culture for staff and patients but also one which places patients, families and carers at the heart decision making about patients care. As part the 10 recommendations the Board level lead will be supported by a senior operational lead to help develop and deliver each the respective work stream projects. Each work stream project lead will produce a detailed project initiation document detailing the overall approach, outcomes and measures they will use to ensure the effective development and delivery their particular project..20 Each work stream project must demonstrate how it will innovate and create a progressive and future thinking outcome. Integral to each the work stream projects is the need to ensure the use effective change management tools and with that being said it is vital that each project reflects on three dimensions: Interests Minutes s

21 Council Governors Workforce What does it mean for our staff? Process What does it mean for systems, policies and procedures? Patient/Service Users - What does it mean for our patients/service users? By articulating the impact, outcome and involvement each these groups we will ensure that all three are captured and included in the project to ensure a well-rounded outcome. Whilst the Kennedy Review recommendations have been specifically identified for action over the next 5-6 months, a great deal the work is recognised as part the overall Trust strategy to improve culture. Therefore a number the key works stream projects are already underway. Patient and service user involvement is integral to the overall approach that patients are involved in the development and, where appropriate, delivery the key recommendations. As part the original recall process a patient support group was developed and this group, which is chaired by Miss Ann Butler, will be given an overview all 10 work-stream projects. Alongside this, the support group will be asked to create sub groups to work alongside key work streams, which are: Further development a patient-centred approach Improving patient information and the patient environment Implementation values-based consultant recruitment Development a protocol for patient recall After a meeting held on the 12 th February, feedback the Support Group was that they felt that they needed to have an opportunity to review the Kennedy and to recommend their key actions/work-streams to sit alongside the Trust defined recommendations. A workshop was held on the 26 th February to carry out this work. The outcomes this will be fed back to the Task Force at its next meeting. A number the work streams wish to ensure that they are communicating and engaging with patients are service users, therefore we are developing a supporting engagement plan which will help with all work streams. This will be presented to the at the next Task Force meeting. It is essential that we involve and communicate with staff in relation to these entire work stream projects, as part the development the PIDs and the workshop held on the 7 th February the key internal communication messages were discussed as were the key staff groups who needed to be engaged with. A supporting staff communications and engagement plan is being developed to support all the work streams and this will be presented at the next meeting. A Governor representative has been elected to join the Task Force. Alongside this the Patient Experience Committee, which reports into the Council Governors, has received an update on the Kennedy Review and the work streams. The Task Force will take responsibility for ensuring the overall progress the 10 work streams and will meet monthly reporting progress to the Board. To date all the work stream project leads have been met with the Programme Lead to discuss the overall approach and expectations. Each work stream project has been clearly defined and.21 Interests Minutes s

22 Council Governors detailed in a Project Initiation Documents (PID). The Task Force has agreed an overarching communication message which can be published on the website alongside the Kennedy. It is intended that this message act as an overview to work underway with the Task Force agreeing a monthly highlight at each meeting which will then be used to update the website. Council Governors The man s Breakfast Seminars continue to prove to be very popular. Tania Carruthers, Clinical Director for Pharmacy came to the February meeting to talk and answer Governor questions on the work Pharmacy. The Trust, as you are aware, is in the process appointing a new following my decision not to stand for a second term fice as man and following requests the Governors I was asked to give my views on the qualities a good HEFT man. The Council s Appointments Committee will be concluding the process in March and putting their recommendation to the next formal Council Governors meeting on the 17 th. VISITS and MEETINGS Since the last Board Meeting I have continued to go out and about, internally and externally, and these visits have included: Patient Safety Visits I am pleased that the programme safety walk-rounds continues and I continue to be reassured by the feedback staff. We have seen high levels engagement in all areas the Trust in improving safety for our patients and I would continue to encourage all my Board colleagues to take part in the safety walk-rounds to support this vital agenda. Dying Conference I attended the recent National Council for Palliative Care (NCPC) and Dying Conference in London where I had the pleasure launching their new guidance Caring for Carers to improve the way that carers are involved and supported when the person they are caring for is nearing the end life. The NCPC has embarked on a compassionate care partnership with Heart England NHS Foundation Trust, working closely with Dr Dawn Chaplin, Head Bereavement, our nursing staff as well as involving carers to look at how we can involve and work with carers further in the acute hospital setting. As a result this work, a comprehensive guidance has been produced setting out the findings in order to help other organisations understand how better to work with carers going forward. A confidence building programme for nurses is also being evaluated and results have shown this is also having a positive impact..22 Lord Philip Hunt Kings Heath man Interests Minutes s

23 Council Governors 7.1 Response to CQC Concerns 7.2 CQC Pilot Ratings 7.3 Overseas Patients - Procedure and Income.23 Interests Minutes s

24 Council Governors CHIEF EXECUTIVE S REPORT to the COUNCIL GOVERNORS MARCH 2014 At the last meeting I undertook to share the Trust s response to the comments made by the CQC following the first new style inspection in November We have developed comprehensive action plans, which are enclosed with this report, to address each the comments made in the CQC s reports. Progress against these action plans is being monitored through the Executive Management Board. The CQC published the final pilot ratings for the Trust on 6 th March 2013; their letter advising us is enclosed. We have addressed the issues raised in the Good Hope Hospital warning notice and following a re-inspection last week, CQC has verbally confirmed that Good Hope Hospital has shown substantial improvements. We anticipate that the A&E rating will be amended accordingly in the near future. Also at the last meeting, I undertook to report on the processes that we operate and the income we receive for overseas patients; a report is attached on the processes and we will report on the income we receive at the meeting. Below is the report that I presented to the Board Directors meeting held on 4. CHIEF EXECUTIVE S REPORT to the BOARD DIRECTORS MARCH 2014 OVERVIEW We continue to focus all efforts on addressing the challenges I detailed in my previous report. In this report I will pick out some key themes and give an overview items which are covered in greater detail elsewhere in the Board papers. Care Commission (CQC) inspectors Visit Following on the Summit in January, and as a result the Improvement Notice served on Good Hope Hospital in relation to the Emergency Department, the Trust is expecting a follow-up inspection at any time after 21 February. The Good Hope team is prepared for this visit, which will be unannounced. A full and comprehensive action plan has been developed to address each the comments made in the CQC s reports and progress is being monitored through the Executive Management Board..24 As the Board will be aware, the Trust will be one the first three organisations to receive the pilot CQC ratings. A ratings grid which shows the Trust s overall rating, accompanied by ratings for each service at hospital level (including by each the five domain questions), as well as ratings for each the five domain questions at trust level will be provided. These ratings should be seen clearly as pilot ratings wave one the roll-out the CQC s new approach. Interests Minutes s

25 Council Governors The CQC will be publishing the three pilot ratings as part its report on the first 18 inspections and on its website on Thursday 6 March (it will be updated in our Trust s current inspection report). Winter and A&E 4 hour performance Overall, our performance during this winter has been considerably improved this year. Since the new measures taken in December, we have seen a marked improvement at Heartlands which has been sustained despite considerable pressure at times. At Good Hope the improvement has not sustained so well, and we have made some leadership changes on the site (see later in this report). We remain under close scrutiny Monitor via the Enforcement Undertaking, reporting to them twice weekly along with a monthly meeting. A key factor in the improvement this year has been the additional external capacity, both bedded capacity and home care. Some this has been provided or commissioned by us, and some by the commissioners using the winter monies. Work is now underway, through the Urgent Care Working Groups, to ensure we can sustain this once the winter monies finish at the end March. Our analysis suggests that there is a relative shortfall both intermediate care and mental health beds on this side the city, in comparison to the south. To achieve equity, we would need some 100 additional community beds, and mental health beds, and this is a key subject discussion with our commissioners as we plan for the 2014/15 financial year. 18 weeks The 18 week rectification plan is being implemented this quarter. Progress in reducing the number patients waiting longer than 18 weeks is slower than planned because continuing high numbers new referrals being added to the list, and partly because private sector capacity is less than expected. The private sector is very selective on which cases it will take, and in particular they are not taking gynaecology, urology or breast specialties, for reasons financial viability. Additionally, we are finding high numbers referrals are rejected (around 50%) and they are reporting challenges with theatre capacity. Following review at Executive Management Board, an action plan is in place to release a further 450 slots. We will keep this situation under very close review as the quarter proceeds. The financial challenge The Executive Team have taken additional actions to increase delivery Cost Improvement Programmes, including the implementation the Mutually Agreed Resignation Scheme (MARS). This has been agreed by Monitor and Staff side, and it has been launched with a close date the end April I will keep the Board informed progress on savings released as a result this scheme..25 Interests Minutes s

26 Council Governors The Monitor (first two years) is currently being finalised ready for submission at the end March. Following this, we will be completing the five year plan for submission in June. Forward planning is complex in the current climate, and bed capacity modelling is forming a key part our planning. Our experience during this winter suggests that external capacity is key to any reductions in ward capacity within the Trust, and this is a major focus the planning effort. Negotiations over next years contract with commissioners are continuing. Subject to a satisfactory conclusion, we are keen to maintain the Jointly Managed Risk Agreement, which delivers benefits for all parties. It is evident that the Solihull commissioners are experiencing particular financial pressures and these are impacting on our discussions. I will keep the Board updated as negotiations progress. Work on developing a patient-centred culture Work has commenced with Pressor Sir Muir Gray on the development a more patient-centred culture. An initial meeting the newly formed Steering Group was held on 31 January, and a short paper has been circulated to Board Directors for their input. This is a new approach for the NHS but one which is based on wide involvement staff and patient groups. It centres on practical behavioural changes and I am optimistic that our patients will benefit as the work progresses. Senior Leadership Update We look forward to welcoming Dr Andrew Catto as our new Medical Director in April. Dr Clive Ryder is doing an excellent job as Acting Medical Director and I thank him for his support. Richard Parker has commenced as Managing Director Good Hope Hospital, for an initial period six months. Dr Arne Rose has been appointed as Associate Medical Director Good Hope and takes up post in March. I will be seeking the support Remuneration Committee to extend Richard Parker s time with us to 12 months, to reflect the task he has undertaken. I will also be proposing that we go to formal advert for the Nurse and Managing Director Solihull posts. VISITS AND MEETINGS Reform Conference: A Strategy to fix Healthcare, Jan 22 Michael Porter was the main speaker at a short conference on the topic valuesbased healthcare. This is a concept that is likely to guide thinking on service change and integration in the coming years..26 HSJ Round Table Board assurance on staffing levels / patient safety Jan 23 A short debate on how staffing levels can be managed, and how Boards can be assured that safe levels are being maintained. Interests Minutes s

27 Council Governors Nuffield Trust: Francis One Year On, Feb 6 This half-day conference marked the release the NT research on this topic. In a panel discussion, Patrick Cadigan, Diane Eltringham, and Louise Wood represented an acute Trust perspective on this. We heard both Stephen Dorrell and Robert Francis during the morning. Board meeting with Governing Bodies Solihull and Cross City CCG s, Feb 7 It is likely that we will now have regular meetings at this level with our commissioners, to develop a broader and joint understanding both current challenges and future planning. At this initial meeting we did not have time to discuss future planning, but there was agreement that it is critical that we reach a jointlyshared understanding how we should move forward as a whole health economy. Dr Mark Newbold Executive.27 Interests Minutes s

28 CQC Action Council Governors Heart England NHS Foundation Trust CQC Inspection Action ISSUE 1: Solihull A&E reconfiguration Regulation 9 Care and welfare people who use services Progress to date Further actions identified Progress against actions - 14 th Feb 2014 Timescale Responsible Over the last few months HEFT has been working closely with Solihull CCG to determine the future urgent care in Solihull. A key part this has been the need to change the A&E name at Solihull Hospital, so that it accurately reflects the services available. This work involved detailed discussions with the clinical community and patients. The result has been a business case setting out the preferred option for change, namely the creation an Urgent Care Centre. This was presented to the Health and Well Being Committee and the Scrutiny Committee at Solihull MBC in January A formal consultation programme has been launched to invite the views the public on the proposed changes. Development detailed service specification for the Urgent Care Centre Completion formal public consultation Finalisation agreed changes Current feedback the public meetings and engagement programme is very positive. The CCG is encouraging as many local people as possible to share their views. These are being captured and are currently in support the proposals to rename and streamline the service. This is on to report back in. January April 2014 Commercial Director Please indicate which Committee / Group will monitor the implementation this action plan: Trust Board Action plan completed by: Simon Hackwell, Commercial Director Date: 17 th January 2014 Heart England NHS Foundation Trust January Interests Minutes s

29 CQC Action Council Governors Heart England NHS Foundation Trust CQC Inspection Action ISSUE 1: Clarification regarding mandatory training Regulation 23 Supporting Staff Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible HEFT has recently agreed our annual contract with the CCG s to include an 85% completion rate for mandatory training (MT). The overall completion rate at end Q2 was 63%, and Q3 was 65%. A Mandatory Training communications initiative, raising the prile Mandatory Training started in June and the Did Not Attend rate has shown some reduction A new Learner Management System is due to be piloted in January giving managers real time data about staff training who they are responsible for. Implementation an explicit link between incremental pay progression (AFC)and completion mandatory training A trajectory for 2014/15 is to be jointly agreed with the CCG to improve upon the % to meet the 85% by March 2015 Mandatory training data is to be spilt by subject to identify those areas training which are bringing the overall completion rates down Leaflet highlighting Mandatory training responsibilities for staff developed and attached to Feb payslips, poster campaign and comprehensive communications plan launched. Decision to procure Enterprize Systems as an LMS if pilot successful. Pilot due to start during February slight re alignment pilot date due to need to link Enterprize to Moodle (HEFT s e learning platform) Revised flow chart to demonstrate process to inform staff and managers if increment is not granted. Communication with CCG s to have further discussion about final. Training data split by subject to show individual completion rates ISSUE 2: Improving access to training for staff so they are able to complete it appropriately June 2013 January 2014 April 2014 March 2015 Feb 2014 Acting Faculty dean Acting Faculty dean Acting Faculty dean Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Paper to Executive Directors to consider charging areas for non attendance should be put in place (recommendation the Trust internal auditors) On line modules e.g. Equality and Diversity training, and other mandatory training topics to be developed, allowing staff to access these home or work, ad hoc, as and when required Options appraisals paper written On line modules developed, good uptake Equality and Diversity module launched in December. Currently at 1500 completions Complete Director Workforce Faculty Education.29 Interests Minutes s

30 CQC Action Council Governors Procurement 6 desktop computers to go into ward areas for the purposes education only. The 6 pc s are a pilot, are being placed at all sites and in medical and surgical areas, in quieter, non patient areas so staff could use them without interruption. Depending upon their use we may extend this to more pc s if the uptake is shown to be positive. Desk top computers on order, areas identified at each site for pilot Faculty Education ISSUE 3: Provision appropriate care for children and adolescents with mental health needs Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible We currently follow the NICE Guidelines CG26 Recent increase in referrals patients with physical and chemical deliberate self-harm. Significant increase in wait for final CAMHS Assessment and Placement - especially for those children requiring a Tier 4 placement. ISSUE 4: Dementia training Enhanced education staff who look after this group patients. No response received April 2014 Defined physical space to allow better use staff resources No response received April 2014 Consideration developing a facility for this patient group across the wider health economy. No response received September 2014 Head Children's Nurse Head Children's Nurse Associate Medical Director Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Baseline position for dementia education returned to LETB December 2013 to agree 3 year plan for improving dementia care 3 year plan to improve dementia care in development Initial scoping work streams undertaken by chief nurse and lead clinician focused on: Education Practice Environment Dementia and delirium pathways 3 year plan in development to be presented to Trust Board March / April year plan to include education stream lead by Claire Whittle No response received nurse and medical leads for dementia Associate faulty Dean.30 Interests Minutes s

31 CQC Action Council Governors ISSUE 5: Visibility senior managers within maternity service Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible There has been a 3 year strategy in place in midwifery since 2011 which has aimed to improve management interaction with midwifery staff. This has included: 1. Restructure midwifery management team to strengthen leadership. Matrons were put in place as site leads on BHH and GHH site and Delivery Suites to be the visible leader and the conduit information Head Midwifery and Deputy Head Midwifery to staff groups. 2. Standards practice were ten below the required standard this led to a number Clinical Governance investigations and HR investigations in 2012, this is one the reasons why staff may feel a disconnect with senior team 3. One member senior team has been on long term sick leave and further member has left leading to reduced visibility senior team due to increased workload 4. HoM has undertaken night visits in an effort to be visible to staff. Weekly meetings already in place with Head Midwifery and Deputy Head Midwifery and all Matron s Monthly meetings with other midwifery staff, alternate sites, with Head Midwifery and Deputy Head Midwifery. Rolling programme for midwives to shadow HoM and Deputy HoM in their role Meet midwives on induction programmes on commencing employment in trust Continue open reporting culture. Feedback to all Datix reporters. Replace Governance 8B post Reassess Matron structure/role for Solihull Community Team. held each Monday morning with deputy HOM, matrons and HOM held on alternate sites for Band 7s chaired by HOM Programme to be commenced in April 2014 for Band 7 to shadow HOM There is an open reporting culture, incidents reported and daily feedback given JD amended and updated EVAS submitted February for approval.will be advertised as soon as approval given. 8A for Matron for Safety and JD also in process being reviewed new JD has been submitted to panel for banding. EVAS will be submitted as soon as JD banded Matron in post for Solihull Birth Centre she is reviewing caseload in all community teams as there is shortfall staff in community setting. 90/10 skill mix being introduced to community setting and Cohort midwifery assistants to start in March Ongoing Ongoing February 2014 Head Midwifery Head Midwifery Head Midwifery.31 Interests Minutes s

32 CQC Action Council Governors 5. Midwifery strategy in place and actions for are to improve staff engagement Support organisational development to improve staff engagement and team building Deputy Head Midwifery to have more site presence at GHH Focus groups with staff to develop action plan together Develop a staff council Meeting arranged for 4 th with head OD Deputy HOM on GHH site 2 days a week Focus groups to be arranged for March 2014 Look at developing a staff council by June Ongoing Immediate June 2014 March 2104 Head Midwifery Establish and undertake a Pulse survey quarterly to test temperature to check if staff engagement improving ISSUE 6: Appropriate training for staff in Critical Care unit Solihull Meeting arranged with OD to improve staff engagement and establish a pulse survey Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible All critical care training is currently delivered locally. Faculty to review whether this is appropriate and discuss whether this needs to sit within the Faculty Coronary care staff attend critical care department training sessions Review ITU monitoring chart for level 2 patients which would be admitted to CCH/HDU, and associated staff training to be provided Review critical care competence documents sent to ensure that they are more appropriate for level 2 patients. A skills inventory for staff working in HDU has been developed A number cardiology staff were allocated Supernumary shifts with supervisors on HDU7 Faculty have reviewed the critical care programme content with the clinical educators and senior nursing staff both HDU Cardiology and this is satisfactory. Faculty will subsequently undertake a training needs analysis (in conjunction with Senior Sister HDU/Cardiology) staff skills and competencies to then develop further ed training based on need. No response received February 2014 Ongoing No response received No response received Complete Complete Acting Faculty Dean Pressional development nurse Critical care Pressional development nurse Critical care Pressional development nurse Critical care Pressional development nurse Critical care Please indicate which Committee / Group will monitor the implementation this action plan: Executive Management Board Heart England NHS Foundation Trust January Interests Minutes s

33 CQC Action Council Governors Heart England NHS Foundation Trust CQC Inspection Action Regulation 22 Staffing Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Assurance given to Trust Board that planned staffing levels meet case mix patients Investment trajectory on track for recruitment midwifery staffing Staffing dashboard reviewed monthly at performance meeting chaired by Nurse and Director Finance Refine workforce dashboard to ensure accuracy planned vs. actual staffing position Ensure that Trust Board are informed staffing breach position and mitigation plans Continue to facilitate bi-monthly nursing and Midwifery workforce review summit ISSUE 2: Reduction in the use bank and agency staff Dashboard is under review. Further meeting with senior nurses scheduled for 6 March to ensure requirements are being met. The Trust has implemented a new system to record planned vs actual staffing levels to ensure that the breach report also demonstrates the mitigation delivered. A pilot report is being trialled with a view to going to and Risk committee (Board subcommittee). Last summit held 4 th Feb continuing bi monthly March 2014 March 2014 Ongoing Director Workforce and Nurse Nurse Director Workforce and Nurse Progress to date Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible November and December Nurse bank requests have fallen by circa 500 requests per month, representing a c5% reduction compared to previous month. Recruitment activity to substantive vacancies is ongoing with further recruitment events planned throughout the year which is anticipated to positively impact the Bank usage position. Operational HR continues to support line managers in the managing sickness absence which will directly impact the number Bank requests required to cover sickness. Continued reporting bank usage to Head Nurses and senior stakeholders to increase awareness and ensure local actions plan are agreed to address high usage areas. Nursing Recruitment plan 2014 agreed with site recruitment events planned. Ongoing and specific project on HCA sickness reduction now commenced. Monthly reporting ongoing, usage remains high. Ongoing recruitment to substantive vacancies. On-going On-going On-going Deputy director workforce Operational Head HR & information Deputy director workforce Please indicate which Committee / Group will monitor the implementation this action plan: Executive Management Board Action plan completed by: Nurse and deputy director workforce Date: 17th January 2014 Heart England NHS Foundation Trust January Interests Minutes s

34 CQC Action Council Governors Heart England NHS Foundation Trust CQC Inspection Action Additional issues ISSUE 1: BIRMINGHAM HEARTLANDS Ensure patients are cared for in the most appropriate place Progress to date The Site have introduced the SAFER Flow bundle in the middle December to support releasing capacity early enough in the day to ensure right patient right bed Collaborated and agreed SAFER standards with clinical teams Rolled out bundle across all inpatient areas during breaking the cycle week Achieved compliance SAFE which is all patients have daily consultant review Establish SAFER bundles for assessment areas Established a programme Breaking the Cycle weeks across specialist pathways AEC now accommodated in AMU enabling extension to operating hours and access to senior decision making across the acute medical assessment floor up till 10am Early signs improved LOS times in A+E Further actions identified Working with CDs/Senior Sisters/AHPS to ensure consistent practice across all general adult inpatient areas Have included RAPID ASSESSMENT Triage as part ED SAFER Bundle standard Scheduled PDSA breaking the cycle week to improve flow Launched a work-stream across the site to ensure capacity earlier enough in the day so that clinical teams can pull right patients assessment areas Incentivized safe, timely and early discharge practice and working with wards adopting good areas practice to enable shared learning and embed in every day practice Devise electronic SAFER monitoring tool integrated with e-jonah to enable wards to monitor and improve performance Formalise plans for utilisation CDU during high activity peaks in A+E Progress against actions 14 th Feb 2014 No response received No response received No response received No response received Timescale Responsible Monitoring On-going Commenced PDSA week 20 th Jan Commences 20 th Jan as part breaking cycle week Commence Dec 2013 Senior Hospital Team (Director Operations HON Associate Medical Director) CD/GM/Matron ED CD/GM/Matron for ED, SAU,AMU Senior Hospital Team supported by clinical directorate No response received As above As above No response received Feb 2014 No response received Feb 2014 Head Nursing /Associate Med. Director BHH Site Board ISSUE 2: BIRMINGHAM HEARTLANDS Signage Progress to date In 2004 group established to look at signage supported by Way-Finder strategy group identified at that time 25 frequently used languages therefore unanimous decision made not to use other language signage however a colour strategy system was developed to help guide patients around the site. Due to changes to demographics over the last ten years has resulted in around 52 languages been commonly used. Therefore following CQC visit the site team is scoping the feasibility icon signs to support not only patient with language barriers, but those with sensory or condition such as dementia where language signs present a difficulty Further actions identified Scoping meeting is to be arranged to look at the feasibility a visual system signage Progress against actions 14 th Feb 2014 No response received February 2014 Timescale Responsible Monitoring Head Nurse/Estates/Diversity manager BHH Site Board.34 Interests Minutes s

35 CQC Action Council Governors ISSUE 3: MATERNITY Communication and cascade information relating to learning incidents etc Progress against actions Progress to date Further actions identified 14 th Feb 2014 Communications Strategy - Project Pelican News letter to all staff Monthly Women's Governance Team meetings PNMM Safety Briefs on handovers to all staff Labour ward Forums Timescale Responsible Women s & Children s All actions in place and ongoing Ongoing Head Midwifery ISSUE 4: MATERNITY Staff not feeling they could suggest new ideas and raise issues (particularly at SH) Progress against actions Progress to date Further actions identified 14 th Timescale Responsible Feb 2014 Internal safety walkabouts have shown that staff have no reservations in challenging or raising concerns. Recently reminded staff how to take ideas forward, this can be through their ward manager, team leader or matron. Staff on "Leading the Front Programme" to present their work and how to take project forward at staff meetings Staff regularly report through the Datix system Open door policy for all managers with staff Extraordinary meeting to be held with Solihull Team HOM meeting weekly with staff in February whilst reviewing the model the birth centre. Message reinforced to staff how to take ideas forward through their line managers Band 7 s allocated to present their projects the Leading fro m the front course. February 2014 Head Midwifery site and Safety meeting Women s and Children s site and Safety meeting.35 Interests Minutes s

36 CQC Action Council Governors ISSUE 5: MATERNITY Signage (particularly BHH) Progress to date Further actions identified Review this in line with trust strategy as numerous languages on BHH site. There needs to be a consistent approach. Progress against actions 14 th Feb 2014 Site lead matron allocated to review this Timescale Responsible Monitoring April 2014 Head Midwifery Women s & Children s site and Safety meeting ISSUE 6: SOLIHULL Communications to staff Progress to date Further actions identified Progress against actions 14 th Feb 2014 A series HR forums and drop in sessions are already being Staff been provided with up provided. In addition, a monthly dated information To be included in site based induction staff forum is in place and each Leaflet in production area has responsibility for cascading information to their wards and departments. ISSUE 7: SOLIHULL documentation in medical notes Progress to date Staff been provided with up dated information Leaflet in production Further actions identified To be included in site based induction Progress against actions 14 th Feb 2014 Timescale Responsible Monitoring To be included in site based communication quarterly as a reminder Awaiting confirmation whether To be included in all clinical site based training this action has been misallocated to the Solihull site April 2014 Selected audit to take place on a quarterly basis to inform training Frieza Mahmood Solihull Site Board Timescale Responsible Monitoring April 2014 Frieza Mahmood Frieza Mahmood Vanessa Clarke/Rex Polson Martin Sandler Solihull Site Board ISSUE 8: CLINICAL SUPPORT SERVICES Efficient running operating lists (specifically BHH) Progress to date Reinforce current policy to send for first patient irrespective bed capacity. ENT patient admissions have been relocated to another admissions lounge within the Trust which is in closer proximity to ENT theatres which will improve patient flow and improve start times theatre lists. case currently being written to improve the current admissions area which will have the added benefit improving start times theatre lists Improved bed availability has improved flow within theatre as there are fewer delays due to blocked recovery Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Monitoring Ongoing work to improve theatre list scheduling No response received 6 months Stuart Dale.36 Interests Minutes s

37 CQC Action Council Governors ISSUE 9: CLINICAL SUPPORT SERVICES Critical care consultant staffing cover (BHH) Progress to date There are 2 consultant staff covering ITU & HDU in the morning followed by a handover to the ICU consultant on call. HDU is further supported by 2 junior doctors and in ITU by 1 CCP along with 2-3 junior doctors. Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Monitoring We feel that the cover is adequate due to the intensity the patients in HDU and their turnover. We have enough support the medical team to carry out tasks. Average length stay is 1.5 days and represents a fast turnover area with patients awaiting optimisation their critical illness or escalation to ITU so currently does not require more consultant input. Nil, but will continue to review No response received Ongoing Raghuraman Govindan CSS Board ISSUE 10: CLINICAL SUPPORT SERVICES critical care overnight visitors room (BHH) Progress against actions Progress to date Further actions identified 14 th Timescale Responsible Monitoring Feb 2014 No progress on relocation the visitor s room. Will look to Trust Funds to provide improvements to the current environment. case currently being written regarding a new ITU / HDU which will include co-located visitor accommodation No response received Stuart Dale CSS Board ISSUE 11: CLINICAL SUPPORT SERVICES Confusion for visitors regarding clinics in main outpatients and those in MIDRU Progress to date The patient appointment letters are very clear in terms venue, however patients can tend to go directly to a central outpatient service for an outpatient appointment. Signage is clear around the Trust. Further actions identified Review outpatient clinic letters to confirm there is no room for confusion in the terminology. When patients receive their verbal call reminder 2 weeks before their appointment the co-ordinator will reiterate that MIDRU is the outpatient venue for this particular clinic Progress against actions 14 th Feb 2014 No response received No response received Timescale Responsible Monitoring End January 2014 Immediately Karen Roberts, Centre Manager Karen Roberts, Centre Manager CSS Board ISSUE 12: CLINICAL SUPPORT SERVICES Surgery (SH) query delay in running operating lists due to availability interpreters Progress to date Interpreters are requested and booked at the time the patient is listed for surgery. We are reliant on external interpreters attending on the day surgery. Further actions identified Work to increase pool available interpreters Review current booking and reminder process Progress against actions 14 th Feb 2014 Timescale Responsible Monitoring No response received 3 months Sarah Hollingshead CSS Board.37 Interests Minutes s

38 CQC Action Council Governors ISSUE 13: CLINICAL SUPPORT SERVICES Critical care (SH) query relating to feedback mechanism to staff re complaints / incidents Progress to date The unit is now managed through the joint CCU / HDU model by cardiology. Further actions identified Progress against actions 14 th Feb 2014 Timescale Responsible Monitoring Staff raise issues through the Cardiology matron who will then involve appropriate key medical or management colleagues Improve staff communication to ensure staff are aware and follow all escalation processes No response received February 2014 Sarah Quinton / Theresa Ashton CSS Board Incidents raised formally through the Trusts DATIX system and investigated as appropriate ISSUE 14: CLINICAL SUPPORT SERVICES Outpatients (SH) patient feedback re delays due to block booking system Progress to date We do not operate a block booking system all patients are given individual time slots except in occasional circumstances when clinics are overbooked to make sure patients are seen within the appropriate timescale. Further actions identified Review level overbooking to ensure duplicate appointment times are kept to a minimum Complaints to be monitored and feedback to Outpatients or the relevant Progress against actions 14 th Feb 2014 No response received January 2014 No response received Timescale Responsible Monitoring Immediately Karen Roberts, Centre Manager Helen Evans, Ops Manager, OPD Karen Kirby, Senior Sister OPD CSS Board ISSUE 15: CLINICAL SUPPORT SERVICES Outpatients (SH) staff perception regarding over reliance on them to work long hours Progress against actions Progress to date Further actions identified 14 th Timescale Responsible Monitoring Feb 2014 OPD clinics can run over as Directorates add additional new or urgent follow up patients into clinics This can result in the OPD staff receiving very short lunches or working late. Escalation process in place between Senior Sister and Operations Manager to highlight concerns regarding overbooked clinics. To review all outpatient clinics with Senior Sister to identify maximum patient load per clinic, before it is identified that clinics will run over. Identify clinics who have historically run over weekly and if this is to continue (due to capacity gaps) agree with Directorates that extended clinics are required substantively, fund and resource appropriately. Escalate to nursing team in advance any clinics where urgent patient review is required over and above agreed allocation to confirm nursing staff is available to cover additional patient need. Capacity and Demand work required for outpatient services as well as inpatient services. ECIST are meeting with General Managers to support this initiative. No response received In place now Karen Kirby/Helen Evans No response received No response received No response received No response received End February 2014 End February 2014 End January 2014 in January with ECIST. D&C work timeline TBC Karen Kirby/Helen Evans/Karen Roberts Karen Kirby/Theresa Price Karen Kirby/Karen Roberts David Booth ECIST/General Managers CSS Board Heart England NHS Foundation Trust January Interests Minutes s

39 Response to CQC Concerns Council Governors Heart England NHS Foundation Trust The Care Commission-The Health and Social Care Act 2008 Warning Notice CQC Inspection Action November 2013 ISSUE 1: Appropriate Pressional and expert advice on arrival at the Accident & Emergency department. Streaming in A&E Review current triage process for all groups patients. Update existing Standard Operating Procedure for rapid assessment process. Reception streaming guidance for all administrative staff. Progress to date Rag Status Further actions identified Timescale Responsible How will this be monitored? RAG Status Action completed Compliance check -Triage position statement completed and in place.(ar). Escalation triggers to be added (AH 11 Feb 2014). Escalation actions to be developed for Matrons/night sisters and circulated (AMR 11 Feb 2014) Review Current Processes: a) Adopt Rapid Assessment Triage (RAT) approach for 24 hr period across all areas the Accident & Emergency department. a)14 Feb 2014 A. Rose/ A. Howell Weekly observational audits AE/Site team audit timescales for all groups patients.(ah) -Site team visit scheduled for w/c 17/02 /14 (SH/CS) -Reception streaming document in place and communicated/training given to all administrative staff.(rbp) Action completed. b) Adopt Clinical Emergency Medicine (CEM) algorithms. b) 14Feb 2014 A.Rose -External Peer review visit scheduled for 10/02/14 (MC) Compliance check -Staffing numbers established for all triage areas including minors.(ah) Rapid Assessment triage model in place. Action completed ISSUE 2: Checking Emergency Resuscitation Equipment. Progress to date Action completed c) Update existing Directorate Standard Operating Procedure for Good Hope Hospital Accident &Emergency department. c) 14 Feb 2014 A.Rose - Staffing breaches recorded daily by nurse coordinator.(ah) -Training records for all non-registered healthcare workers to have basic training in red flag presentations.(rbp) Further actions identified Timescale Responsible How will this be monitored? Compliance check Compliance check -Daily checks by Matron/AE Coordinator - Audit all resuscitation equipment to be undertaken by Corporate Nursing/ Resuscitation team w/c 3/02/14 Develop equipment checking protocol and establish daily checks all equipment/trolleys/oxygen cylinders a) 30 Jan 2014 A Howell -Current daily monitoring captured in equipment checking log. - Memo sent to all staff w/c 20/1/14 individual responsibility for checking Emergency Resuscitation equipment. a) 30 Jan 2014 A Howell -Monthly Emergency department metrics will capture equipment checks/compliance. (GHH currently at 90%) (BHH currently at 100%).39 Interests Minutes s

40 Response to CQC Concerns ISSUE 3: Long waits on Clinical Decisions Unit. Progress to date Action completed Council Governors Further actions identified Timescale Responsible How will this be monitored? Compliance check -Clinical Decisions Unit protocol reviewed and completed(ar) - CDU removed emergency cascade CDU exit flow chart to be developed Update existing directorate SOP s: a) Clinical Decisions Unit protocol to be reviewed reinforcing patient criteria/timescales.(am/ar) b) Capacity/ flow exceptions to be agreed (AR/AM/ RBP) a) 14 Feb 2014 b)14 Feb 2014 Carol Scott/Ann Marie Riley/A. Rose Right patient, Right bed Site team review at Site Capacity meeting four times a day (CS/AMR) -Jonah Board to be erected in CDU to capture time logs for CDU patients/monitored by Site Capacity Lead (AMR). ISSUE 4: Clinical Intentional rounding Progress to date Short term arrangement - observation tool captures technical/comfort elements patient care in place. Long term - Development tool that captures routine observations/comfort elements patient care pressure area care/toileting/food/drinks/appropriate equipment/beds. Action completed Further actions identified Timescale Responsible How will this be monitored? Update existing directorate SOP s: a) Separate spot audit process for when department drops into crisis. a)14 Feb 2014 A. Howell/ Hilary Clemson /A,Rose Audit w/c by Site team. Operationally managed at every site/capacity meeting by reviewing activity in ED major s area. - Decision made to escalate or not depending on staffing levels. Additional staffing resource sought at this point. Compliance check -Electronic prescribing list Senior Staff competent in skill held at department level. Audit w/c agreement to take this f reviewed action. a) Needs to be closely linked to operational policy and escalation processes. AH to develop flow chart key actions expected for a pt at 6 hrs which includes printing f paper drug chart. To be placed in every cubicle b) Identification Senior Nursing staff that have appropriate skill set specific prescribing processes. (HC/AH) b) 14 Feb 2014 c) Feb 14 AM/AR AH -To be added to ED Nursing Metrics collated monthly c) Dr to print f EP chart in line with 6 hour SOP AR/AH Short term funding agreed by site team for role Housekeeper in AE. d) Develop a business case for role substantive Housekeeper at GHH Emergency department. d) 30 Mar 2014 RBP - Temporary Housekeeper role to commence w/c17/02/14 for 3 month period.40 Interests Minutes s

41 Response to CQC Concerns Council Governors ISSUE 6: Managing the risk. Ward 20 Temporary flex ward at time visit. Ward 20 now a substantive ward. Ward 12 is currently flexible capacity area. Progress to date Action completed Further actions identified Timescale Responsible How will this be monitored? Compliance check -Temporary ward is supported by standard operational procedure that details patient group and workforce requirements. Revised SOP in place -Daily risk assessments undertaken and reviewed Head Nurse/Medical lead to ensure all risks is mitigated. -Daily risk assessment undertaken to ensure short term mitigations plans are in place to support risks/identify equipment shortages. Patient Equipment In place for 20 patients. -Currently checking appropriate storage Medical records (trollies) a) Robust operational processes in place to support the opening and closing flex capacity. b) Detailed risk assessments in place with mitigation to ensure safe opening flexible ward area. c) Sufficient equipment in place to support patient use in flexible capacity area. a) 14Feb 2014 b)14 Feb 2014 c) 14Feb 2014 AMR/EH AMR/EH AMR/EH -Review daily risk assessments by Senior nursing team/operational team. -Twice weekly metric undertaken to capture quality indicators/patient experience indicators. ISSUE 7: Concerns re nurse staffing in A&E. Progress to date Action completed Further actions identified Timescale Responsible How will this be monitored? Compliance check AR to assign Dr to minors via allocation list (11Feb 2014) ENP/ Nursing Recruitment: a) Robust Nursing recruitment plan. b) Additional Nursing resources available at point escalation (in response to increased activity). a) 14 Feb 2014 AMR/AH -Monthly review nursing establishment/vacancies. -Validated nursing rosters in place set against recommended staffing levels. -Robust Nurse Staffing escalation process monitored at Capacity team meetings. ISSUE 8: A&E lack risk assessments Progress to date Action completed Further actions identified Timescale Responsible How will this be monitored? Compliance check -Matrons to develop ED metrics/ quality markers which provide assurance supporting a regular process across the directorate (AH/HC) Develop risk assessment approach a) Falls Risk assessment undertaken/recorded in AE. b) Tissue Viability (Intentional rounding) c) Nutrition a) Feb 14 AH/AMR -Falls risk captured on MSS system (Go Live 3/2/14) -Transfer document identifies Falls risk to receiving ward/department. ED metrics agreed and live Feb Interests Minutes s

42 Response to CQC Concerns Council Governors ISSUE 9 : Training dementia training required for security staff ten called to deal with dementia patients who become aggressive (p10) The security ficers when attending a patient take their instructions the nursing staff. All Security ficers have completed a conflict management course as part their SIA training. This forms part the mandatory training, the ficer must complete and pass this training in order to obtain a licence. The ficers have also completed additional training a Maybo programme in SAFER work,physical intervention Disengagement & holding. This is a non pain compliant physical intervention due to the environment we work in. All ficer that attend Good Hope on a regularly basis are trained apart 3 relief ficers who are due to be trained within the next 2 months. From a portering perspective, they are not required to assist with security duties at GHH, therefore have not had specific training regarding dementia patients. Conflict resolution training/mental Health Training provided to Security staff. a) Review ED management specific patients (AM/RAID). b) 100% Security SAI staff trained. c) 8 security staff are required daily to run GHH site those a max 1 member staff may be a relief member staff and may not have received Maybo training if a relief security person is required on site. This will obviously not be an issue when the 3 trust relief staff have received their training. Ann Marie Riley -Security staff training requirements/logs -The Prevention and Management Violence & Aggression Policy is referred to in the case an aggressive patient - G4S and portering communication to be circulated making it clear on which staff can assist in the management aggressive patients Please indicate which Committee / Group will monitor the implementation this action plan: Good Hope Site & Safety committee reporting up to Trust Clinical Group Please give details any additional support / resources which are required to address these actions: Action plan completed by: Date: Heart England NHS Foundation Trust February 2014 RAG RATINGS Action f trajectory/ poor compliance Action on trajectory/ work needed to improve compliance Action completed/ fully compliant.42 Interests Minutes s

43 CEO - Pilot Ratings Council Governors Care Commission Finsbury Tower Bunhill Row London EC1Y 8TG Telephone: Fax: CQC ratings to go live on the website on Thursday 6 March Heart England NHS Foundation Trust Dear Mark, As we recently discussed, as part the process for developing ratings and testing our approach, your trust will be one the first three to receive pilot ratings. We have previously discussed your draft ratings. I am now pleased to attach the final versions these grids at the end this letter. In particular, please note that caring in A&E has been changed inadequate to requires improvement and the format is a little different. On Thursday 6 March these ratings will go live on our public website, on the pages locations that we have inspected. We will be careful to present them as pilot ratings, which were undertaken for the participating trusts in order to assist us in confirming our ability to rate at different levels an organisation. Please see the screenshots attached to this letter for an example how your page will look once the ratings are live on the site Thursday 6 March. The screenshots show how the shadow ratings for your trust and associated locations inspected recently will look online. As you can see, ratings appear in the following places: at hospital level, ratings appear against the core services at trust level, ratings appear against the five key questions we asked at trust level, ratings appear for the trust overall There are also ratings for each the five questions for each service these are presented in the pdf report. To get to the pdf report, users click on the concertinas (for the services / key questions / overall summary), which open to reveal a summary for the relevant area taken directly the pdf report, plus a link to the pdf report to read more. Extensive usability testing was undertaken with the public to test this approach to presenting ratings, and findings indicate that they understand the ratings and can navigate easily through to the pdf for more detailed information. man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG.43 Interests Minutes s

44 CEO - Pilot Ratings Council Governors As previously confirmed, if we undertake a follow up inspection at any time, which results in a change to your ratings at any level, we will update the information on our website to reflect the amended ratings. I would again like to emphasise our thanks to you for agreeing to be a pilot ratings site. I hope that you have learnt the experience and found it at useful as we have. Yours sincerely Pressor Sir Mike Richards Inspector Hospitals Care Commission.44 Interests Minutes s

45 CEO - Pilot Ratings Council Governors Ratings Grid Heart England NHS Foundation Trust Commentary on Heart England that will appear in our Wave 1 overview report, also being published on 6 March: The Heart England NHS Foundation Trust is one the largest hospital trusts in England. It provides general and specialist hospital and community care for the people East Birmingham, Solihull, Sutton Coldfield, Tamworth and South Staffordshire. The trust comprises three main locations: Birmingham Heartlands Hospital, Solihull Hospital, Good Hope Hospital and has more than 1,500 beds. We found that most people described their care as good, telling our inspection teams that staff were caring, despite being busy. However, while most services were delivered safely at the trust, the safety patients in all the A&E sites, the acute medical unit at Good Hope Hospital and the Critical Care Unit at Solihull needed to be improved. We were concerned about staffing levels in some parts the trust. However, the trust had an active recruitment programme and could demonstrate that significant numbers staff were due to start work in early Given the seriousness the concerns that we uncovered, we have formally warned the trust it must improve. We will continue to monitor the service closely and our inspectors will be returning unannounced to check on whether improvements have been made and standards are being met. We issued a Warning Notice to the trust with regard to the quality care in A&E at Good Hope Hospital. Ratings Grid Trust Overall provider Safe Effective Caring Responsive Well-led Overall RI G RI RI RI RI Ratings Grid Heartlands Heartlands Safe Effective Caring Responsive Well-led Overall Accident & Emergency RI NSE RI RI G RI Medical care G RI G RI G RI Surgery G G G RI G G Intensive/critical care G G G G G G Maternity & family planning RI G G G RI RI Children's care G G G G G G End Life G G G G G G Outpatients RI NSE G RI G RI man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG.45 Interests Minutes s

46 CEO - Pilot Ratings Council Governors Ratings Grid Good Hope Good Hope Safe Effective Caring Responsive Well-led Overall Accident & Emergency I NSE RI I RI I Medical care RI RI RI RI RI RI Surgery G G G G G G Intensive/critical care G G G G G G Maternity & family planning RI G G RI RI RI Children's care RI G G G RI RI End Life G G G G G G Outpatients G NSE G G G G Ratings Grid - Solihull Solihull Safe Effective Caring Responsive Well-led Overall Accident & Emergency NSE* NSE G RI G RI Medical care RI RI G G G RI Surgery G G G RI G G Intensive/critical care RI RI G RI G RI Maternity & family planning G G G G RI G Children's care NA NA NA NA NA NA End Life NA NA NA NA NA NA Outpatients G NSE G RI RI G * Safety the A&E department at Solihull has not been rated. This service is signed as an A&E, but is in fact a minor injuries unit. We are concerned that members the public, including children, could come to this site expecting a full A&E, but then require urgent transfer to Birmingham Heartlands..46 man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG Interests Minutes s

47 CEO - Pilot Ratings Council Governors Example screenshots Trust level man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG.47 Interests Minutes s

48 CEO - Pilot Ratings Council Governors Example screenshots Location level Heartlands.48 man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG Interests Minutes s

49 CEO - Pilot Ratings Council Governors Example screenshots Location level Good Hope man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG.49 Interests Minutes s

50 CEO - Pilot Ratings Council Governors Example screenshots Location level - Solihull.50 man: David Prior Executive: David Behan CBE Registered fice: Finsbury Tower, Bunhill Row, London EC1Y 8TG Interests Minutes s

51 CEO - Overseas Patients Council Governors Governors Council: 17 - Briefing note on Overseas Patients In response to a question about overseas patients attending our Emergency Departments, please find the response the Finance Department: * * * We do not have detailed information as there are no private patients in A&E, and overseas charging only applies after A&E. Overseas Patients The NHS rules state that everyone is entitled to free emergency department care (human rights). If overseas patients present at A&E and are treated within the ED and are discharged we have no right to charge them. As a result at the moment we do not keep a log who is and isn t entitled to free care in A&E department. Once patients are given treatment outside A&E i.e. admitted or given an outpatient referral then if they are not eligible for free treatment we should be charging them. We have an overseas patient policy that details the process for doing this. We are particularly tight on the BHH site as the ficer has many years experience in this. She has good links with the outpatient booking team so they query potentially chargeable patients seeking and outpatient appointments (both GP referrals and internal referrals) with her and we seek documentation before allowing them to book an appointment. Since the Panorama case the radiology teams have also tightened up their processes, especially in relation to direct access. The harder to reach areas are the emergency areas and if patients are admitted out hours or weekends the ward clerks are ten not there to spot overseas patients. However following the recent ombudsman case we have had a discussion with the ED owners about changing the IT system so there are a number questions that can be asked when a patient presents at ED to clarify if they are eligible for free treatment, which can be used if they need to be admitted. This may take a while to implement but in the meantime we have agreed to do an education/ briefing to the staff in the relevant directorates. At Solihull there is a smaller incidence overseas visitors but again there are reasonably well applied procedures. At Good Hope the procedures have been historically less rigorously applied. Recent staff changes have resulted in an improvement in application. Private Patients Private Patients tends to come via the elective route rather than emergency route, mostly because patients want to have treatment quicker than the NHS waiting time, although this can sometimes apply where a patient has been admitted as an emergency and then need follow up care. Again there is an agreed policy and the known consultants are mostly very helpful in letting the finance ficers have the details so money can be charged up front. There are known regular users private patient policy (cancers, maternity and dermatology). * * *.51 Interests Minutes s

52 CEO - Overseas Patients Council Governors I hope this is helpful. I have asked Aidan Quinn to come to the meeting with information on how much income is earned via overseas patients, and what he estimates any shortfall might be. Mark Newbold CEO.52 Interests Minutes s

53 Council Governors Year to Date.53 Interests Minutes s

54 Council Governors Council Governors Finance and Update Month Interests Minutes s

55 Year to Date Council Governors Current and forecast financial performance Continuity Services Rating (COSR) 4 at month m YTD surplus at the end January (month 10). 2.8m adverse variance to plan. 7.6m overspend against operational budgets. Medical and nursing staffing overspends. CIP slippage and slow delivery against rectification reports. One f benefits in position include; HPA contribution 4m BCC resolution 2m. Forecast 2m subject to; Winter costs No unexpected income Provisions reviews (revaluations, asbestos).55 Interests Minutes s

56 Year to Date Council Governors CIP is for 22.2m CIP. YTD delivery is 13.0m,71%. Forecast CIP remains at 15.9m, 72%. Focus on Pay control and CIP delivery Level 5 Level 4 Level 3 Level 2 and below Delivered ned with expected delivery ned with likely delivery Delivery less certain Continued focus on pay control and CIP delivery. Escalation meetings are being held on non-delivery. Early implementation for next year key to mitigating risk..56 Interests Minutes s

57 Year to Date Council Governors Balance sheet Strong balance sheet. Cash balance 109m, 5.4m above Debtors remain below 15m but with a persistent 1m over 1 year old. Capital Capital progressing in line with revised forecast 29.6m submitted to DOH in January Capital underspends due to money not allocated to schemes and delays in site strategy schemes. Full Year budget m Month 10 YTD m Operational Capex Large Schemes Cross site strategy Schemes Total Small revaluation required in year for new build schemes progressing with valuation company to include GHH CHP, Solihull generator, Yardley Green car park, Chest Clinic refurbishment, pathology refurbishment, Cederwood refurbishment and energy sustainability)..57 Interests Minutes s

58 Year to Date Council Governors Overseas Income overseas and private patient over last 3 years, 0.1% total income. 2011/ / /14 Actual Actual Month 10 YTD '000 '000 '000 Private Patient Income Overseas Income Total Income Overseas bad debt written f Overseas Patient Policy. This policy is based on Department Health guidance; Everyone is entitled to free primary care and free emergency care in the A&E department. Once overseas patient is admitted they are chargeable (even if to HDU/ITU type care) for the portion their treatment after A&E. Where possible the Trust charges in advance Treatment. The Trust works with the Borders Agency to improve collection rates. Recent case taken to Ombudsman and found in Trust s favour..58 Interests Minutes s

59 Year to Date Council Governors Monitor Standards Jan 2014 Information KPI Month Target In Month position YTD YTD position A&E 4 hour wait 95% 95.28% 95% 93.29% C Difficile weeks admitted 90% 84.33% 90% 90.97% 18 weeks nonadmitted 95% 95.84% 95% 96.43% 18 weeks incomplete pathway 92% 93.43% 92% 94.14%.59 Interests Minutes s

60 Year to Date Council Governors A&E The failure to meet the so far in Q4 relates to 2,658 breaches out a total 42,609 patients attending the Trust A&E departments (including Solihull Walk-In Centre).60 Interests Minutes s

61 Year to Date Council Governors A&E The table above shows the number breaches in Quarter 4 (up to 24 th Feb) by reason delay..61 Interests Minutes s

62 Year to Date Council Governors Monitor Standards Cancer Information January 2014 position reported one month in arrears KPI MTH Dec-13 YTD Target position YTD position Cancer 2 week wait 2 week waitbreast symptoms > 93% 93.08% > 93% 93.58% > 93% 95.78% > 93% 94.87% Cancer 31 day > 96% 98.12% > 96% 98.17% Cancer 31 day - surgery Cancer 31 day drug treatment Cancer 62 day - GP referral > 94% % > 94% 98.30% > 98% % > 98% % > 85% 86.51% > 85% 86.93% Cancer 62 day - national screening service > 90% 100% > 90% 97.85%.62 Interests Minutes s

63 Council Governors (Oral).63 Interests Minutes s

64 Council Governors.64 Interests Minutes s

65 Council Governors Monitor Council Governors.65 Interests Minutes s

66 Council Governors Monitor Requirements Required by the Monitor Risk Assessment Framework (RAF). The main aim the Monitor assessment under RAF is to show when there is: A significant risk to the financial sustainability a provider Key NHS services which endangers the continuity those services; and/or Poor governance at an NHS Foundation Trust. Key Changes & Rationale: Monitor s main goals is to ensure that they have greater visibility over the extent the short and longer term challenges facing the sector, to ensure that there is robust planning across local health economies and that there are credible plans to deliver high quality services for patients on a sustainable basis. Foundation Trusts will be required to submit financial plans covering 5 years for the first time. Therefore this has led to the splitting the APR process into 2 Phases using the standard templates issued by Monitor: 1. Review the foundations trusts operational plans including a review the supporting two year s financial projections to 2015/16 due by 4 th April A review the foundations trusts strategic plans and commentary to ensure sustainability high quality care for patients, including a review the supporting 5 years financial projections, corporate governance statement and governor development and membership report submitted by 30 th June Interests Minutes s

67 Council Governors Monitor Requirements Strategy Trust visions, mission, objectives Workforce and human resources development Commissioning intentions intentions Governance by the Board on corporate governance and effectiveness on ability to hit performance s Finance Surplus, cash and capital Activity and income CIP K PI s (eg LOS, theatre utilisation, capacity) Assumptions Strategic Overview slides and Draft Strategic Document See Corporate Governance Statement that needs to be signed f by trust Board Corporate Governance Statement, Avalibility Resources Statement Financial Overview Slides and Finance Return.67 Interests Minutes s

68 Council Governors Governance.68 Interests Minutes s

69 Council Governors The Corporate Governance Statements are no longer submitted as part the APR Template, Foundation Trusts are required to make a number further statements to Monitor following their Financial Year End. These will consist : 1. Corporate Governance Statement Confirming compliance with condition FT (4) the provider licence. 2. Availability Resources Statement as required by condition CoS 7 the provider licence. 3. Certification regarding systems for compliance with the license as required by condition G6 the provider licence. 4. Certification AHSCs and governance - as required by appendix E the Risk Assessment Framework. 5. Training Governors Statement - as required by s.151(5) the 2012 Act. Following the 13/14 year end these statements will be consolidated into a template and distributed by Monitor..69 Interests Minutes s

70 Council Governors CORPORATE GOVERNANCE STATEMENT.70 Interests Minutes s

71 Council Governors.71 Interests Minutes s

72 Council Governors Targets The Trust will need to assess whether it can meet its performance s over the next 12 months..72 Interests Minutes s

73 Council Governors Strategy.73 Interests Minutes s

74 Council Governors.74 Interests Minutes s