Minutes from the Trust Executive Committee Meeting date 12 th February 2016 Lead director

Meeting title Trust Board Report title Minutes from the Trust Executive Committee Meeting date 12 th February 2016 Lead director Daniel Elkeles, Chief Executive. Report author Phil Ireland, Trust Secretary FOI status Disclosable Report summary Purpose Recommendation Minutes of the Trust Executive Committee meetings held on 18 th November and 16 th December 2015. Information The Trust Board is asked to note these minutes. Corporate objective links CQC standard Identified risks and risk management actions Resource implications Legal implications Equality impact assessment Safe and effective care, positive patient experience, responsive care, financial sustainability and working in partnership. Safe, effective, caring, responsive and well-led. Risks and mitigations are identified on the individual reports to the Committee and summarised on the trust Risk Register and Board Assurance Framework. None identified. None. Equality Impact assessments have been completed for all new trust policies, any service changes and for all business cases. Report history Considered by other committees Appendices N/A Minutes are approved at the appropriate meeting. N/A Great care to every patient, every day 1

EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST TRUST EXECUTIVE COMMITTEE Minutes of the Meeting held on Wednesday 18 th November 2015 Conference Room 1, Postgraduate Centre, 2 nd Floor, Wells Wing, Epsom Hospital Chair: Daniel Elkeles, Chief Executive Present: Peter Andrews, Clinical Director, Renal Services Clive Charig, Clinical Director, Surgery, Critical Care and Anaesthetics Ruth Charlton, Joint Medical Director and Deputy Chief Executive (part) John Clark, Director of Medical Education Andrew Cobb, Clinical Director for Transformation & Integration Kevin Croft, Director of People and Organisational Development Shaktijit Dave, Lead Doctor for Infection Prevention and Control Peter Davies, Director of Strategy, Corporate Affairs and ICT Deborah Frodsham, Deputy Chief Operating Officer Ramesh Ganapathy, Clinical Director, Obstetrics Charlotte Hall, Chief Nurse and Director of Infection Prevention and Control (part) Tim Hamilton, Director of Communications Amir Hassan, Clinical Director, A&E Steve Hyer, Joint Clinical Director, Medicine (St Helier) Lydia Jones, Clinical Director, Outpatients and Medical Records Arun Kundu, Clinical Director, Paediatrics Gabrielle Lamb, Clinical Director for Transformation and Integration Guan Lim, Joint Clinical Director, Medicine (Epsom) James Marsh, Joint Medical Director Martine Meyer, Clinical Director for Transformation and Innovation Shanthi Paramothayan, Associate Medical Director, Medical Education Rakesh Patel, Chief Financial Officer Anna Perkins, Director for Transformation and Integration Hassan Shehata, Joint Clinical Director (Epsom), Women s and Children s Andrea Sott, Clinical Director, Trauma and Orthopaedics Martin Stockwell, Associate Medical Director and Responsible Officer Rebecca Suckling, Joint Associate Medical Director, Quality Jackie Sullivan, Chief Operating Officer Pauline Swift, Associate Medical Director, R&D and Innovation Steve Thomas, Director, South West London Elective Orthopaedic Centre (SWLEOC) Carole Webster, Deputy Chief Nurse. Hervey Wilcox, Clinical Director, Clinical Services Tim Wilkins, Deputy Director of Estates In Attendance: Phil Ireland, Trust Secretary Apologies: Carolyn Croucher, Joint Clinical Director (St Helier), Women s and Children s Anne Davies, Chief Pharmacist Jill Down, Associate Director of Quality Page 2 of 12

Trevor Fitzgerald, Director of Estates, Facilities and Capital Projects David Male, Clinical Director, Critical Care Pat Ogungbesan, Programme Director for Patient First Jim Stephenson, Joint Associate Medical Director, Quality TB 015/16 MEETING MINUTES 1. INTRODUCTION 1.1 Chair s Welcome and Introduction 1.1.1 Daniel Elkeles welcomed everyone to the meeting. 1.2 Apologies for absence 1.2.1 Apologies were notes as above. 1.3 Sharing in our Successes 1.3.1 Clive Charig reported on the appointment of a new Resident Medical Officer (RMO) for Northey Ward who he felt would be a real asset on the private patient ward. 1.3.2 Steve Hyer reported that the trusts cardiology service had just received reaccreditation by British Society of Echocardiography (BSE). 1.3.3 Peter Andrews reported that the new satellite dialysis unit at Farnborough would be opening the following day. 1.3.4 Daniel Elkeles stated that most of the findings by the CQC had been positive. 1.4 Declarations of Interest 1.4.1 The Trust Secretary reported that changes to the declarations had been made by Hassan Shehata and Anna Perkins. It was agreed that declarations from all new Clinical Directors would be reported to TEC next month. Phil Ireland 2. General Business Issues 2.1 Minutes of the previous meeting 2.1.1 The minutes of the Trust Executive Committee meeting held on 21 st October 2015 were approved as an accurate record of the meeting. 2.2 Matters Arising 2.2.1 All items on this report had been discharged. 2.3 Actions Log 2.3.1 Tim Wilkins reported that the appointment to the post of Sustainability Officer had been made effective from January 2016 and this would enable 6- monthly reports to be provided in 2016. 3. Our People 3.1 Nursing and Midwifery Staffing Compliance Report Page 3 of 12

3.2.1 Carole Webster reported on planned staffing levels compared with actual staffing levels for October. One general adult area fell below the 80% actual nursing hours provided which was on CCU at Epsom. Two wards were over 130% of actual nursing hours which were ward A3 and C6, both for HCA night duty. 3.2.2 Ward Management Supervisory days showed that 88% of the Ward Managers were supervisory for 50% or more of their time on duty and that only 12% of wards managers were supervisory for less than 50%. It was agreed that the graph in section 9 of the report would be changed to reflect this position before submission to the Board. Carole Webster 3.2.3 Daniel Elkeles noted the report highlighted nurse vacancies in ED. Carole Webster stated this was an area difficult to recruit to and a number of recruitment media had been identified to address these vacancies. 3.2.4 Hassan Shehata asked that band 7 cover for midwifery posts also be included in future reports as this had been raised by the CQC in their inspection. Carole Webster 4. Delivering safe and effective care 4.1 Infection Prevention and Control Monthly Report 4.1.1 John Clark reported no trust apportioned cases of MRSA in October with the year to date position at 2 cases against a target of zero, and compared to 4 cases for the same period last year. There had been 1 trust apportioned case of C.difficile in October. The internal trajectory for C.difficile was at 16/21. The trend for C.difficile cases continued downwards. 4.1.2 Greater frequency of infection control audits was planned, moving towards monthly auditing to identify areas of poor practice. 4.1.3 Antimicrobial prescribing audits showed that compliance with indications written on the drug chart had remained relatively consistent, with a review of antibiotics remaining poor at 58% for Epsom and 68% for St Helier overall. James Marsh stated that the board had identified a lack of grip in undertaking antibiotic reviews and was concerned that progress was not being made. John Clark reported that -E-prescribing was being rolled out into other areas of the Trust following successful implementation in the renal unit. 4.1.4 Two cases of Norovirus had occurred on C4 ward and AMU. Both outbreaks had been declared closed shortly afterwards. Martine Meyer asked whether other trusts had Norovirus and it was noted that some schools and nursing homes in Croydon had been affected. Early recognition of the signs was vital. 4.1.5 Peter Andrews thanked John Clark on behalf of Renal for all his support and wished him well in his new role as Director of Medical Education. Page 4 of 12

John Clark introduced his successor, Dr Shaktijit Dave who would be taking over as Director of Infection Prevention and Control from 1 st December 2015. 4.2 Infection Prevention and Control Annual Report 2014/15 4.2.1 The Committee approved the Annual Report for submission to the Trust Board. 4.3 Consent Policy new Consent Forms 4.3.1 Martin Stockwell presented the four updated Consent Forms which formed part of the trusts Consent Policy. Form 4 Lack of Capacity to Consent - had been updated to take account of changes to legislation in order to be compliant with the Mental Capacity Act 2015. The other three Consent Forms had minor changes. 4.3.2 Jackie Sullivan asked how it was intended to communicate these changes and to withdraw and destroy all old versions of the forms in circulation to be replaced by this latest version. Daniel Elkeles stated the CQC had identified these forms were out of date and therefore all old forms needed to be replaced immediately with the updated versions. 4.3.3 Tim Hamilton agreed to instruct Medical Illustration to ensure all stocks of old forms were destroyed, ensure all out of date forms located on wards were replaced with new forms and the change was communicated across the trust. Martin Stockwell would support this initiative. 4.3.4 Charlotte Hall stated there needed to be a consultant group for Consent and this had been discussed at the Clinical Quality Assurance Committee (CQAC). Rebecca Suckling agreed to reinstate and chair the Consent Group and Arun Kundu stated the group would need a paediatrician included on it. Rebecca Suckling 5. Creating a Positive Experience 5.1 Naming of the Cardiology Day Unit at Epsom Hospital 5.1.1 The committee approved the proposal to name the Cardiac Catheterisation Laboratory (Cath Lab) Service on the Epsom site the Cardiology Day Unit. 6. Providing Responsive Care 6.1 Performance Report Month 7 6.1.1 Jackie Sullivan reported on a number of key performance standards for October. 6.1.2 RTT within 18 weeks for incomplete pathways was still subject to validation but was expected to just exceed the target of 92.0%. Specialties not expected to be achieved were T&O and urology. Paediatric dentistry was expected to improve and ENT had suffered due to staff shortages. 6.1.3 Cancer 62 day waits was expected to be achieved for the first time since Page 5 of 12

December 2014 and Jackie Sullivan congratulated everyone for making this possible. 6.1.4 James Marsh stated that VTE performance was slipping at 94.1% in October against the standard of over 95% and he asked TEC members to continue to focus on this measure. 6.1.5 Jackie Sullivan reported that the A&E 4-hour wait target had not been achieved in September or October at 94.5% and 94.2% respectively. It was important to recover the position in November. 6.1.6 Daniel Elkeles stated it was essential to improve on the performance and asked TEC members to maintain focus in this area. 7. Being Financially Sustainable 7.1 Finance Report Month 7 7.1.1 Rakesh Patel stated the trust had posted a deficit of 14.2m which was 15.6m adverse against the plan submitted to the TDA. He stated the trust had forecast a 17.5m deficit at year end, before fixed asset impairments, and at the end of month 7 was 2.6m adverse against this forecast. He had reviewed the assumptions for the 17.5m deficit plan and apart from one element, these assumptions were robust. 7.1.2 Jackie Sullivan challenged directorates about knowing what they were spending, and to discuss this in their DMTs so there were no surprises at the end of the month. Solutions needed to be found for shortfalls. 7.2 Award of a Contract for the Supply of Stationery 7.2.1 The committee approved the award of a managed service contract to Clares Stationery for three years to go to the board for Board approval. 7.3 Outsourced Transcription Services 7.3.1 The Committee approved the award of a contract to Dictate IT for outsourced transcription services for three years. 8. Working in Partnership N/A 9. Minutes from sub-committees N/A 10. Any Other Business 10.1 Hassan Shehata asked about the planned industrial action by junior doctors. It was agreed to carry this item forward to the Part 2 Discussion for wider input into this discussion. 11. Date of the Next Meeting 11.1. 1 The next meeting of the Committee would be held on Wednesday 16 th December 2015 in the Conference Room 1, Postgraduate Centre, Epsom Hospital from 9:00am to 12:30pm. Page 6 of 12

EPSOM AND ST HELIER UNIVERSITY HOSPITALS NHS TRUST TRUST EXECUTIVE COMMITTEE SUB- COMMITTEE Minutes of the Meeting held on Wednesday 16 th December 2015 Conference Room 1, Postgraduate Centre, 2 nd Floor, Wells Wing, Epsom Hospital Chair: Present: Daniel Elkeles, Chief Executive Peter Andrews, Clinical Director, Renal Services Clive Charig, Clinical Director, Surgery, Critical Care and Anaesthetics Ruth Charlton, Joint Medical Director and Deputy Chief Executive Andrew Cobb, Clinical Director for Transformation & Integration Kevin Croft, Director of People and Organisational Development Carolyn Croucher, Clinical Director, Gynaecology Peter Davies, Director of Strategy, Corporate Affairs and ICT Trevor Fitzgerald, Director of Estates, Facilities and Capital Projects Charlotte Hall, Chief Nurse and Director of Infection Prevention and Control Tim Hamilton, Director of Communications Steve Hyer, Joint Clinical Director, Medicine Gabrielle Lamb, Clinical Director for Transformation and Integration David Male, Clinical Director, Critical Care Martine Meyer, Clinical Director for Transformation and Innovation Rakesh Patel, Chief Financial Officer Andrea Sott, Clinical Director, Trauma and Orthopaedics Rebecca Suckling, Joint Associate Medical Director, Quality Jackie Sullivan, Chief Operating Officer Steve Thomas, Director, South West London Elective Orthopaedic Centre (SWLEOC) Hervey Wilcox, Clinical Director, Clinical Services In Attendance: Phil Ireland, Trust Secretary Apologies: Ramesh Ganapathy, Clinical Director, Obstetrics Amir Hassan, Clinical Director, A&E Lydia Jones, Clinical Director, Outpatients and Medical Records Arun Kundu, Clinical Director, Paediatrics Guan Lim, Joint Clinical Director, Medicine James Marsh, Joint Medical Director Hassan Shehata, Joint Clinical Director (Epsom), Women s and Children s Jim Stephenson, Joint Associate Medical Director, Quality Martin Stockwell, Associate Medical Director and Responsible Officer Page 7 of 12

MEETING MINUTES 1. INTRODUCTION 1.1 Chair s Welcome and Introduction 1.1.1 Daniel Elkeles welcomed everyone to the first of this new format of meeting. The purpose of this meeting was to provide assurances that clinical and operational scrutiny was properly discharged and that all reports submitted to the board had been fully discussed and approved. Items that required further consideration would not progress to the board but would be referred to the wider membership group of the Trust Executive Committee (Big TEC). 1.2 Apologies for absence 1.2.1 Apologies were noted as above. 2. General Business Issues 2.1 Minutes of the previous meeting 2.1.1 The minutes of the Trust Executive Committee meeting held on 18 th November 2015 were approved as an accurate record of the meeting. 2.2 Matters Arising 2.2.1 Both items on this report had been discharged. 2.3 Actions Log 2.3.1 A date would be fixed for the R&D review. 3. Our People 3.1 Nursing and Midwifery Staffing Compliance Report 3.1.1 Charlotte Hall reported on an improved position with no general adult areas which fell below the level of 80% of actual nursing hours provided. There were three wards recorded with over 130% actual nursing hours, which were A3 (orthopaedics), C3 (stroke) and Casey (paediatrics Epsom). 3.1.2 Ward Manager supervisory days had increased with an upward trend in the number of ward managers who spent 50% or more of their time supervising practice. 3.1.3 Newly started in November were 53 registered nurses and 3 midwives, of which 24 were from overseas recruitment. The post of Lead Nurse for Retention and Progression had now been appointed. There was currently just one vacancy for band 7 nurse, and all band 7 midwifery posts were now fully filled. 3.1.4 The number of falls had remained fairly static over the last 12 months per 1000 occupied bed days, but the variation in the rate of harm between same specialities across sites was being investigated by the falls team. Page 8 of 12

There had been an improvement in how nurses were monitoring patient s vital signs. Overall the trust had moved from 28% down to 12% of breached or late observations. Carolyn Croucher noted that the 12% figure had levelled out. Charlotte Hall stated that the VitalPAC Group had been reopened to monitor progress. 3.1.5 It was agreed the include graphs for nurse recruitment net gains and nurse retention for the next report. Charlotte Hall 3.1.6 Carolyn Croucher asked why the figures for monthly planned hours to be worked was much higher than actual hours worked. It was noted the difference related to nurse vacancies. Peter Davies asked that all reports identified the outliers so that the board could have greater visibility of these. 4. Delivering safe and effective care 4.1 Infection Prevention and Control Monthly Report 4.1.1 Charlotte Hall reported there had been one trust apportioned case of MRSA in November which had been referred to arbitration. The year to date position was 2 cases against a target of zero, and compared to 4 cases for the same period last year. There had been 3 trust apportioned cases of C.difficile in November. The internal trajectory for C.difficile at this stage of the year was 19/24. The trend for C.difficile cases continued downwards. 4.1.2 Following the CQC inspection concerns that were raised about infection control practice and it was agreed to undertake an external review of all aspects of infection control trust wide will be undertaken. 4.2 Quality Report for Q2 4.2.1 Ruth Charlton noted there was a slide deck summary report and a more detailed report and TEC members should look at these in detail in their own time. Summary points were: - the trust was in the top quartile for reporting of incidents nationally - the trust had participated in 100% of the relevant national audits - presentation of audit findings received are presented to the Clinical Audit and Effectiveness Committee - there had been a 9% decrease in PALS enquiries in Q2 compared to Q1 - the key for reducing clinical negligence was to improve the sharing of learning from claims - the risk register needed to be improved to reflect issues of known concern. The Care Quality Commission had not produced an Intelligent Monitoring Report since May 2015. The hospital inspection had been undertaken in November, but the trust continued to provide evidence to the CQC. The CQC report was expected in February 2016. 4.2.2 Daniel Elkeles stated that the St Helier A&E Friends and Family Test Page 9 of 12

recommended results had declined to 89% since the Urgent Care Centre figures had been taken out and if replaced would put the trust back at Epsom levels of 96%. 4.2.3 Kevin Croft would discuss separately outside of this meeting how Patient First could link to Patient Experience. 4.2.4 Ruth Charlton asked TEC members to share the findings of the report with their teams. 4.3 Slips, Trips and Falls (Patients) Policy 4.3.1 This policy had come to the Committee as revisions had been made to include the management of suspected head injury following an unwitnessed fall in a patient on anticoagulation therapy. Amendments had also been made to reflect management of additional anticoagulation therapies. These revisions had been recommended by the Falls Prevention Steering Group. 4.3.2 The committee approved the revisions to this policy. 4.4 Safer Nursing and Midwifery Staffing Levels Policy 4.4.1 This policy had been brought to the committee for approval following changes to the policy for the risk assessment tool used to calculate required staffing establishments and clarity on the triggers required for immediate actions to be taken to ensure safe care continued to be provided. 4.4.2 Daniel Elkeles stated that the policy needed to be written so that it was more specific about the use of professional judgement used in conjunction with the Safer Nursing Care Tool (SNCT). 4.4.3 The Policy could not be approved until these changes were incorporated in the policy. 4.5 Chemical, Biological, Radiological and Nuclear (CBRN) Assurance Results 2015 and Emergency Planning, Resilience and Response (EPRR) Assurance Results 4.5.1 These reports were presented to the committee The committee was asked to support the identified actions and priorities in these reports and to approve the Declaration of the level of compliance achieved. 4.5.2 Daniel Elkeles questioned how he could be assured that senior managers knew what actions to take in the event of serious CBRN or EPRR event. 4.5.3 Ruth Charlton proposed complementing the assurances stated in the reports with a mock exercise and Jackie Sullivan stated that the trusts EPLO could provide training for staff. It was noted the last chemical training exercise was 12-18 months ago. 4.5.4 It was agreed to take assurance from the achievements to date, to support the identified actions and priorities for the next 12 months and ask Taryn Trevor Fitzgerald Page 10 of 12

Milton to organise a training event in Q1 of 2016/17 in conjunction with the trusts local CCGs. 5. Creating a Positive Experience 5.1 Naming of the Assisted Conception Unit 5.1.1 The committee approved the proposal to name the new Assisted Conception Unit Beginnings having followed due process in reaching this recommendation. Trevor Fitzgerald stated that signposting in the trust would direct patients initially to the Assisted Conception Unit and then it would be called Beginnings. 6. Providing Responsive Care 6.1 Performance Report and Draft Integrated Performance for Month 8 6.1.1 Peter Davies asked TEC members if they were satisfied that the actions articulated in the report against underperforming areas gave them sufficient assurance so that the board could take assurance from them. 6.1.2 Jackie Sullivan asked for feedback on the work that Peter Davies had coordinated on the new format integrated performance report. 6.1.3 Daniel Elkeles asked about the recent reduction in performance against the A&E target which for November was 94.4% against the target of 95.0%. Jackie Sullivan reported that despite milder weather there had been greater acuity and increased admissions even with Business Continuity in place. Both sites had been very challenged in November and December. Greater clinical engagement was required to provide the clinical input into the patient information held on the wards, e.g. packages of care needed for medically fit patients, reasons for delayed discharges etc. 7. Being Financially Sustainable 7.1 Finance Report Month 8 7.1.1 Rakesh Patel stated he would go through more detail in the next meeting (Big TEC) but headlines for Month 8 were that the trust had posted a deficit of 17.0m and was 18.4m adverse against the Trust s plan submitted to the TDA. The trust had forecast it would have a 17.5m deficit at year end, before fixed asset impairments, and at the end of month 8 it was 4.2m adverse against this forecast. 7.1.2 There were three elements which contributed to the current position: - income was 1,529k adverse largely due to private patients ( 0.9m) and elective activity being behind plan in the previous 3 months - elective activity being behind plan in the previous 3 months - Clinical supplies were 737k adverse and other non pay was 1,562k adverse partly due to under delivery on CIPs and slippage in recovery trajectory in Estates. Page 11 of 12

7.1.3 Rakesh Patel stated he was concerned the trust could no longer meet its control total and the implications this would have on cash. Discussions were ongoing with the TDA. Block year end contracts had been agreed with Sutton CCG and he was also in discussion with Surrey Downs CCG. 7.1.4 Rakesh Patel stated that discussions would continue in the next meeting to agree how non-pay spends could be reduced. 8. Minutes from sub-committees 8.1 Operational management Group 8.1.1 The Committee approved the minutes from meeting held on 16 th October 2015. 8.2 Patient First Steering Group 8.2.1 The Committee approved the minutes from the meeting held on 16 th September 2015. 9. Any Other Business 9.1 There was no other business to conduct. 10. Date of the Next Meeting 10.1. 1 The next meeting of the Committee would be held on Wednesday 20 th January 2016 in the Conference Room 1, Postgraduate Centre, Epsom Hospital from 9:00am to 10:00am. Page 12 of 12