Agenda item: 5 EAST AND NORTH HERTFORDSHIRE NHS TRUST Minutes of the Trust Board meeting held in public on Wednesday 28 th September 2011 at 2.00 pm in Meeting Rooms 2 and 3 at Hertford County Hospital Present: Mr Ian Morfett Vice Chairman Mr Nick Carver Chief Executive Mrs Alison Bexfield Non-Executive Director Ms Dyan Crowther Non-Executive Director Mr Neil Dardis Director of Operations Mr Julian Nicholls Non-Executive Director Mr James Quinn Medical Director Mr Douglas Smallwood Non-Executive Director Ms Angela Thompson Director of Nursing & Patient Experience Mr Paul Traynor Director of Finance In attendance: From the Trust: Mr Stephen Posey Director of Strategic Development Ms Alex O Grady Interim Director of HR Ms Jude Archer Company Secretary Mrs Victoria Fisher Trust Secretary Mr John Fitzmaurice Divisional Director, Women s & Children s Services Ms Sandra Hibbert Practice Standards Matron, Women s Services Ms Chris Nixon Head of Midwifery Mr Manu Shah Project Manager, Maternity Project Ms Mandy Shoben Assistant Project Manager, Maternity Project Ms Jane Speed Clinical Reconfiguration Co-ordinator External: Ms Sara Howlett Provider Development Manager,NHS East of England Ms Wanda Kerr Finance Manager, NHS East of England Mr and Mrs D Allaker East Herts NHS Retirement Fellowship Mr Santo Mann LINks representative 11/207 CHAIRMAN S OPENING REMARKS ACTION 11/207.1 The Vice Chairman, as Acting Chairman, welcomed everyone to the meeting and extended a particular welcome to Ms Angela Thompson, who had recently joined the Trust from Cambridge University Hospitals NHS Foundation Trust, as Director of Nursing and Patient Experience 11/207.2 This was the last Board meeting to be attended by Ms Alex O Grady in her role as Interim Director of HR and OD. On behalf of the Board, the Vice Chairman expressed his thanks to her for all that she had done in the past 18 months, particularly in setting up the Trust s cultural change (ARC) programme: this was a considerable legacy. 11/207.3 The Trust had enjoyed a busy and successful summer, and this was an appropriate venue in which to record the fact that the Care Quality Commission (CQC) had carried out an unannounced inspection at Hertford County Hospital in July, following a desktop review in December 2010, and that the subsequent report had been extremely positive: it demonstrated that the hospital was fully compliant with all 16 essential standards of quality and safety. 11/207.4 In August, the Trust had received a visit from the Secretary of 1
State for Health, who had announced the approval of the outline business case (OBC) for Phase 4 of the Our Changing Hospitals programme, which would effectively set the Trust s agenda for the next three years; and in September, both Phase 1 and Phase 3 of the programme had come to fruition, with the opening of the Surgicentre and the multi-storey car park. Both would make a real difference to patients and the opening of the Surgicentre allowed the Trust to improve the configuration of its remaining surgical services. 11/207.5 Finally, September had also seen planning permission granted to the PCT for the new QEII Hospital. 11/208 DECLARATION OF INTERESTS There were no declarations of interest relevant to the agenda. 11/209 QUESTIONS FROM THE PUBLIC There were no questions from members of the public. 11/210 APOLOGIES FOR ABSENCE Apologies were received from Mr Richard Beazley, Chairman. 11/211 MINUTES OF THE PREVIOUS MEETING The Board approved the minutes as an accurate record of the meeting of 27 th July 2011. 11/212 MATTERS ARISING The Board reviewed the actions log and was satisfied that all actions were either completed or on track for completion, with the exception of the following: 11/94.3 Meaningful workforce cultural indicators on the floodlight scorecard had yet to be established but, after abortive discussions with the Gallup organisation, the Chief Executive explained that the Trust was now working with Aston Business School who had undertaken research in this area. Eleven of the findings from the national staff survey were found to correlate with better outcomes, and the Chief Executive proposed that these should be used from October to populate the scorecard, recognising that initially the data would be historical. Meanwhile, the Trust would be working with Aston Business School to establish its own staff surveys in order to obtain current data. Director of Workforce 11/213 CHIEF EXECUTIVE S REPORT 11/213.1 The Board reviewed the Chief Executive s monthly report, which captured the major themes of the past month and gave an overview of the issues that had concerned the Executive, as well as an update on recent developments. 11/213.2 Since the paper had been written, the Chief Executive was able to report that the Trust s application for foundation status had now been supported by NHS East of England and forwarded to the Department of Health. The tripartite agreement, signed some 2
months previously, confirming the Trust s obligation to achieve foundation status by April 2014, had been published on the website but would now need to be updated in terms of the risks as a result of the changed circumstances. The Director of Provider Development for the NHS, one of the signatories to the agreement, had been invited to visit the Trust. 11/213.3 Some 200 people had attended the Trust s AGM at Onslow St Audrey s School in Hatfield on 15 th September and, although the meeting had been plagued with problems with the sound system, the feedback overall had been positive, and the clinical presentations particularly well received. Mr Smallwood agreed that these had been excellent but asked if in future some patients could be involved in the presentations. The Chief Executive agreed that ways of involving patients would be explored. 11/213.4 The Chief Executive highlighted the second series of ARC sessions held in September: these had focused on two more of the Trust s values. As part of the ARC programme, the Trust s staff recognition schemes had also been relaunched under a new annual awards scheme entitled Celebration of Excellence. The awards evening would be held on 3 rd November and it was hoped that as many Board members as possible would be able to attend. Nominations had been invited for a wide range of categories, including volunteers and a new category for public nominations. 11/213.5 Noting that some 500 line managers had attended their second ARC sessions, Mrs Bexfield queried whether there were any who had failed to attend at all. The Chief Executive said that a very small number appeared to have slipped through the net but contact details for all line managers were now held centrally and the final few were being followed up. 11/213.6 Mr Nicholls commended the ARC programme but challenged the Chief Executive as to what outcome measures would allow the Board to assess its effectiveness. The Chief Executive explained that this would be measured through the eleven indicators that would in future be reflected on the floodlight scorecard. While initially these would be populated with historical data, they would reflect the findings of the Trust s own staff surveys once these were established, and could be benchmarked. Pressed as to when such surveys would begin, the Chief Executive said that he would be able to outline a timetable at the next Board meeting, following discussions with Aston Business School. Chief Executive 11/213.7 Finally, the Chief Executive stressed that the Trust was moving into a period of substantial change, altering dramatically the way in which care was provided to local people over the next few years. Within that period, the two key points were the final consolidation of services in 2014 and the reconfiguration of services over the next two to three months. Many of the changes would be described in greater detail under the following agenda items. 11/214 SURGICAL SERVICES RECONFIGURATION 11/214.1 The Board considered a paper that provided an update on the implementation of the Trust s plans to reconfigure its surgical services as a direct result of the Surgicentre becoming operational. The plans had been agreed by the Board in October 2010. 3
11/214.2 The Director of Operations explained that the reconfiguration plans had been designed to mitigate the impact of the transfer of part of the Trust s elective workload to the Surgicentre, by reducing the fragmentation of services, accelerating a number of quality improvements and ensuring the most effective use of the accommodation available. To that end, remaining elective orthopaedic and fracture neck of femur work would be centralised in Prince s Wing at the QEII, emergency general surgery and orthopaedic trauma surgery would be centralised at the Lister, and all remaining day surgery would be centralised in Queen s Wing at the QEII. The Director of Operations took the Board through the changes in some detail, focusing particularly on the impact on four key areas beds, theatres, pre-operative assessment and the fracture neck of femur service. Configuring surgical services as described was expected to have a significant and positive effect on the quality of patient care and on outcomes, and the full benefits realisation would be monitored through the Executive Committee. 11/214.3 The Vice Chairman said that the Risk and Quality Committee (RAQC) had received a presentation on the fracture neck of femur service and had been impressed by the planned improvements. It would monitor the outcomes closely. 11/215 ACCESS TO EMERGENCY SERVICES 11/215.1 The Board considered a paper that provided a detailed briefing on the issues relating to the proposed changes to emergency services across the Trust s sites. The paper, together with a full presentation, had been considered by the RAQC. 11/215.2 The Board recognised that the proposals were fully in line with Delivering Quality Healthcare for Hertfordshire and formed an integral part of Our Changing Hospitals, under which emergency services would eventually be consolidated on the Lister site, supported by a local A&E at the QEII. Following the centralisation of emergency surgery, maternity, cardiology and stroke services on the Lister site, a phased approach to consolidating emergency services was proposed, providing safer and better quality care for patients. The Director of Operations took the Board through the changes, which would affect night-time emergency services for adults at the QEII Hospital, where the majority of patients ie those with non life-threatening injuries or illnesses would continue to be seen but all ambulance cases would be taken to the Lister between 8.00pm and 8.00am. Patients who self-presented at the QEII with potentially life-threatening injuries or illnesses would be stabilised there before being transferred to the Lister. For children, the current arrangements at the QEII overnight would continue, with 24-hour specialist paediatric care provided through Lister s dedicated children s emergency service. 11/215.3 The proposals were clinically led through the Women s and Children s and Medical Divisions and had the support of GP colleagues. They would result in a number of service improvements and a resolution to the issue of paediatric junior doctor staffing. An extensive staff consultation had been launched on 1 st September 2011. 11/215.4 Recognising that the Trust was committed to working to avoid 4
clinical redundancies wherever possible, Mrs Bexfield challenged the extent to which it was possible to retrain staff. The Director of Operations explained that this was the benefit of a 90-day consultation, since it provided time to work through the options with staff and to establish training opportunities. 11/215.5 The Vice Chairman noted that a presentation on the changes had been given to the Involvement Committee and had been well received. He sought assurance that the Ambulance Trust was fully supportive of the changes, since this was vital to their success. The Director of Operations said that the Trust enjoyed good operational relationships with the ambulance service, which had been linked into the project from the start. The Trust had not yet received formal feedback but this was being pursued at chief executive level. 11/216 WOMEN S & CHILDREN S SERVICES RECONFIGURATION 11/216.1 The Director of Strategic Development introduced a presentation on the final commissioning phase of the new Maternity Unit, as the reconfiguration of Maternity services (Phase 2 of Our Changing Hospitals) entered its final stages. The Board welcomed the Divisional Director of Women s and Children s Services, together with several members of the project team, to give the presentation. 11/216.2 The presentation covered the historical position, the changes made to Maternity, Neonatal and Gynaecology services, the commissioning process for the consolidation phase, the commissioning period, communications, the project management structure, the risks and mitigations during consolidation, the project costs, the forecast shortfall in delivery of the financial savings, the detailed steps to full consolidation, project arrangements in the short term and, in the longer term, the issues, risks and opportunities that would impact upon the future development of the service. The aim was to provide a service that was exceptional, giving mothers much greater choice over the mode of delivery of their babies. 11/216.3 The Board agreed that the presentation gave an insight into the rigour of the planning process as well as assurance that the risks inherent in a service change of this scale had been identified and that mitigations had been put in place. 11/216.4 In terms of costs, the forecast overspend of 0.068m was largely due to the adverse effect of the increase in VAT: without this, the costs would have come in below budget. The shortfall in recurrent savings was largely due to the Trust s failure to secure a reduction in its Clinical Negligence Scheme for Trusts (CNST) premium by achieving only Level 1 in January 2011, but the consolidation of the service would make the higher levels achievable. These savings would therefore be delivered later than anticipated in the full business case (FBC). Mrs Bexfield challenged the team as to what actions were being taken to make up the shortfall from elsewhere. The Director of Operations explained that a number of mitigating actions had been identified already and the figures outlined represented the net result of those mitigations. The Director of Strategic Development confirmed that any member of the Board who wished to do so could view the detail outside the meeting: this had been scrutinised by the Executive Committee. 5
11/216.5 Noting that a renewed focus on Band 7 accountability and a Band 7 development programme were among the initiatives aimed at inculcating the right culture in the new unit, to ensure the adoption of new and better practices, Mrs Crowther asked when this would be put in place. The Head of Midwifery assured her that the programme would begin as quickly as possible after consolidation, in mid to late November. 11/216.6 The Director of Nursing sought assurance on the extent of engagement throughout all staff groups. The Clinical Reconfiguration Co-ordinator explained that staff were engaged from the beginning on mapping the pathways and every opportunity to engage was taken, through a number of initiatives. The Divisional Director added that staff were encouraged to express their views about issues affecting the service. 11.216.7 Mr Smallwood asked what measures would allow the Division to evaluate the success of these initiatives. The Head of Midwifery said that the Division would look at staff surveys, the sickness rate, the maternity dashboard, and any other relevant indicator. 11/216.8 The Board commended the team on its approach. 11/217 OUR CHANGING HOSPITALS PROGRESS REPORT 11/217.1 The Board received a progress report on the various elements of the Our Changing Hospitals (OCH) programme, together with a copy of the master programme showing key milestones and interdependencies. The report had been discussed in detail by the Finance and Performance Committee (FPC). 11/217.2 The Director of Strategic Development said that the past two months had been eventful and successful, with the completion of the multi-storey car park, the imminent completion of the Maternity project, the signing of the Combined Heat and Power plant (CHP) contract, the completion of Ward 11A, and the completion of the first phase of the cardiac catheter laboratory project all on schedule. In addition, the Surgicentre had now opened and approval had been given for the Phase 4 OBC. There was one emerging issue with the new generator, part of the site infrastructure project, but the Trust was confident that this would be resolved and an update would be given to the FPC in October. 11/217.3 The OCH Programme Board had now changed its format and membership, with project directors for the individual projects now attending the Board. This extended the excellent clinical leadership and engagement that characterised all projects. 11/218 REPORT FROM FOUNDATION TRUST COMMITTEE (FTC) 11/218.1 The Board noted the issues highlighted by the FTC. 11/218.2 The Committee had reviewed the Trust s Integrated Business Plan (IBP) and the Long Term Financial Model (LTFM) in detail, and after deciding upon a number of changes had approved them for submission to the SHA, as the key components of the Trust s application for foundation status. The documents had been duly submitted on 12 th September 2011. 6
11/219 FLOODLIGHT SCORECARD 2011/12 11/219.1 The Board reviewed the Floodlight Scorecard for month 5, which provided an overview of performance against the key indicators agreed by the Board at the start of the year. Detailed information on monthly trends and on quality indicators was attached, together with a summary of the technical changes in the indicators. The scorecard had been discussed in detail by both the FPC and the Risk and Quality Committee (RAQC). 11/219.2 An exception report was provided for the red indicators, all of which were familiar to the Board and had been discussed extensively by the committees. 11/219.3 Mr Nicholls, as Chair of the FPC, expressed the concern felt by the FPC that a scorecard of this type allowed an indicator to be green even if, for example, one component of the indicator was red particularly in view of the Trust s aspirations to be amongst the best. The FPC had agreed, however, to let the indicators run in their current format for a period before reassessing the situation. 11/219.4 Mr Nicholls raised the issue of the HSE (Health and Safety Executive) improvement notice which was reported elsewhere on the agenda: he felt that this should constitute a never event. The Vice Chairman said that the notice had been discussed fully at the RAQC and flagged up in the Committee s report to the Board. The Director of Nursing explained that the notice had been issued, not as a result of the original incident (a needlestick injury) but following the HSE s review of the Trust s policies and further discussion. The Trust had considered an appeal but had concluded that there was learning to be derived in that the relevant policies were not cross referenced: it had therefore drawn up an action plan to meet the recommendations in full by the required deadline of 6 th December. The RAQC had supported this approach. 11/219.5 The Chief Executive agreed that the Trust could consider classifying an improvement notice as a never event for its own purposes, although it was not formally classified as such. The Medical Director suggested that it could be classified alongside clinical alerts. 11/219.6 Mr Nicholls said that the Audit Committee had been concerned at some of the issues raised in a recent internal audit report on health and safety, such as failure to complete RIDDOR reports in a timely manner. Mrs Bexfield, as Chair of the Audit Committee, said that this was highlighted in the Committee s report to the Board. While the Committee recognised that reports on health and safety were submitted to the RAQC, it recommended that the Board should consider requiring periodic summary reports, in view of directors responsibilities in this area. The Company Secretary added that the last report to the Board had been considered in March 2011; since then, the RAQC had instigated work to raise the profile of health and safety and to improve reporting. Once this work was complete, it would ensure that appropriate reports were presented to the Board. 7
11/220 INFECTION PREVENTION & CONTROL REPORT 11/220.1 The Board considered a paper outlining the Trust s performance to the end of August 2011 in relation to MRSA, C.difficile and other areas of infection prevention and control. Infection control performance had been discussed in detail by the Executive Committee and the RAQC. 11/220.2 The Director of Nursing said that the Trust continued to be the best performer in the East of England for C.difficile, with only four cases to date in 2011/12 against a ceiling of 65. The Trust was not complacent, however, and was awaiting the results of an audit to provide assurance that it was not under-reporting. Mrs Crowther commended the Trust on its excellent performance but suggested that there might be merit in dialogue with the worst performing trusts as a means of ensuring that the Trust was alert to early warning signs and would avoid complacency. The Director of Nursing assured her that learning was shared across the region on an ongoing basis, although the themes from any investigations were almost always lack of adherence to antibiotic policies or lack of compliance with care bundles. The Director of Operations added that the recent round of Divisional performance reviews had shown particularly strong performance in care bundle compliance within the Trust. 11/220.3 As far as MRSA was concerned, the Trust had reached its ceiling of three for the year and the Director of Nursing assured the Board that this was being taken very seriously. Two cases were thought to have resulted from contaminated blood cultures, so that the patients themselves were not infected but could have had unnecessary treatments. An external review of all three cases had been commissioned and the Trust awaited the report. In the meantime, however, it had moved swiftly to address key issues such as training of the staff taking blood cultures and the equipment used. The third case was thought to have resulted from contaminated blood platelets and was being investigated by the national blood transfusion service: depending upon its findings, the Trust might be in a position to appeal. 11/220.4 Given that contaminated blood cultures were less serious for the patients concerned, since they were not infected, the Vice Chairman posed the question as to whether the Trust should start to categorise the cases in terms of their impact as well as numbers, to inform discussion internally. The Director of Nursing said that the Trust would continue to follow national guidance on reporting although recognition could be given to the nature of the cases where appropriate to do so. The Medical Director added that each case represented a failing and a reputational risk even where the patient was not infected. It was therefore important to maintain the clear message to staff that all cases were unacceptable, although it was not inappropriate to explain the circumstances of the cases externally. 11/221 PERFORMANCE REPORT 11/221.1 The Board considered a report demonstrating progress against the Trust s performance framework standards, including Monitor s Compliance Framework/SHA Governance Risk Rating, NHS Operating Framework standards, contract standards and local 8
standards. Exception reports were provided for MRSA, high risk transient ischaemic attacks (TIAs) scanned and treated within 24 hours, and the 18-week target in Oral Surgery, Ophthalmology and Orthopaedics. An update on the bed reduction programme was also attached. The whole report had been discussed in detail by both the FPC and the RAQC. 11/221.2 The Director of Operations explained that the Trust s governance risk rating now stood at green/amber, as a result of the three MRSA cases and the A&E indicators. However, good progress had been made on these and the Trust was currently delivering four out of the five new targets. The 18-week target for all specialties was an internal stretch target and the reasons for breaching were well understood but would be carefully monitored with the transfer of part of the Trust s workload to the Surgicentre, resulting in a changed case mix. 11/221.3 The update on the bed reduction programme provided context to the recommendation to measure occupied bed days as a key performance indicator alongside average length of stay. The FPC and the Board had previously requested that the indicators used to monitor the Trust s bed efficiency be reviewed. Progress on bed reduction had been impressive, with 74 beds removed and a further 59 to remove by the end of 2011/12, but there was a limit to the efficiencies that the Trust could achieve on its own and both the FPC and the RAQC had been clear on the need to focus on working with partners to achieve the required level. Mr Smallwood said that it was important to have an understanding of the level of risk to the Trust s ability to achieve its objectives posed by dependence upon other organisations. The Vice Chairman suggested that this be addressed through further length of stay improvement schemes as they are brought forward. 11/221.4 The Chair of the FPC confirmed that the FPC had discussed and approved the new indicator. 11/222 FINANCE AND PERFORMANCE COMMITTEE (FPC) REPORT 11/222.1 The Board reviewed the issues escalated by the FPC. 11/222.2 Mr Nicholls, as Chair of the FPC, said that the key issues of concern had been the Month 5 variances on income and expenditure combined with slippage in cost improvement programmes (CIPs), and the financial impact of the late opening of the Surgicentre. In relation to the latter, the FPC had requested that a bridge chart be included in the Finance Report prior to submission to the Board. In relation to the former, the FPC felt that further analysis was required from service line reports. 11/222.3 The FPC had discussed the Workforce Report in some detail, focusing particularly on the rising trend in long term sickness and its financial impact, together with the role of Occupational Health in the management of sickness. The FPC had stressed that that this role should be reviewed. It had also been concerned by the rise in bank and agency use in month. 11/223 FINANCE REPORT AT MONTH 5 11/223.1 The Board considered a report setting out the financial position of 9
the Trust at the end of August 2011. The paper had been discussed in detail by the FPC. 11/223.2 The Board noted that although the Trust had delivered a surplus in August, it had an adverse variance against plan of approximately 460k: this was the first time that it had been under target in 2011/12. Although August had a high number of working days, the holiday period for both staff and patients had had an impact on the level of activity undertaken. Nevertheless, the Trust s Financial Risk Rating had been maintained at 3. 11/223.3 The Director of Finance explained that more detail on variances had been included in the report at the request of the FPC. Delivery of CIPs stood at 89% for the year to date but there had been a marked slippage in August and all Divisions who were below target had a recovery plan in place, with a robust process for performance management through the PMO process. Some of the slippage resulted from delays to reconfiguration caused by the delay in the opening of the Surgicentre. The income variance against plan was relatively modest but further detail had been provided to the FPC on the new financial penalty faced by acute trusts for readmissions, outlining the process being followed by the Trust and the PCT to establish criteria. 11/223.4 Mrs Bexfield welcomed the extra detail and noted that part of the Surgical Division s overspend related to unfunded charges from other NHS trusts for visiting consultants, some going back to the previous year. She questioned what controls were being put in place to address this and what the Trust s overall exposure might be. The Director of Finance assured her that the Trust took a robust line and was investigating the charges. Surgery was on budget for the year to date but had experienced significant slippage in Month 5. Mrs Bexfield stressed that, to understand this, it was important to see actual income and actual expenditure. 11/223.5 Recognising that the delayed opening of the Surgicentre was one factor outside the Trust s control, the Chair of the FPC said that there were a range of variances within the 879k overspend in Month 5 - some due to external pressures but some not - and the Trust should be looking to control costs tightly where it was able to do so. The Director of Finance agreed: this was a key focus for Divisions and a narrative on this would be developed for future reports. The Board supported the approach and asked that the additional detail be presented to the FPC. Director of Finance 11/224 WORKFORCE REPORT 11/224.1 The Board considered a report outlining the latest information and trends in relation to workforce indicators. The paper had been discussed in detail by the FPC. 11/224.2 In relation to a query raised at the last Board meeting on the rise in disciplinary cases since the Capsticks service had been launched, the Interim Director of HR explained that the numbers included enquiries as well as actual cases. The Chair of the FPC said that it was important to know the closure rate as well, as previously requested. The Interim Director of HR said that this would be included in the next report. Director of Workforce 10
11/224.3 The FPC had been concerned about the rise in agency use in August and, although it was known that the bulk of this was for medical locum staff, the interim Director of HR agreed that future reports should give a breakdown between medical and nonmedical agency use, together with the actions being taken to reduce those costs. Director of Workforce 11/224.4 Long term sickness had increased and was now a considerable focus for Divisional HR Managers: a more detailed analysis would be included in the next report to the FPC. The Divisional Director for Clinical Support Services was undertaking a detailed review of the Occupational Health service and, again, further detail would be given in the next report. 11/224.5 Turning to mandatory training, the Interim Director of HR explained that the compliance rate was likely to be considerably higher than the figure quoted but this was all that could be evidenced at present. Some areas had not yet put records on the system and the recording of doctors training had been incorrect. Nevertheless, it was imperative to have the evidence on the system and this was a priority. The Chair of the FPC said that it was essential to have monthly targets for mandatory training in order to measure progress, as previously agreed. 11/224.6 The Board welcomed the section on hard to recruit posts and asked that this be maintained as a routine feature of the report. Director of Workforce Director of Workforce 11/224.7 In conclusion, the Interim Director of HR said that she would be continuing to work with the Trust on a number of projects, including staff engagement. The Board thanked her for all that she had done over the last 18 months and for developing workforce reporting significantly. 11/225 REPORT FROM AUDIT COMMITTEE 11/225.1 The Board considered the issues escalated by the Audit Committee from its meeting of 16 th September 2011. 11/225.2 Mrs Bexfield, as Chair of the Audit Committee, said that the Committee had been concerned to receive an amber/red rated internal audit report on health and safety, as already discussed. It had also received an amber/red rated report on clinical audit, and although this was concerning, it was important to be clear that additional days had been allocated to this because the Committee felt that it was an area that would benefit from such a review. It would not necessarily affect the Statement on Internal Control at the end of the year and it was clear that, in the experience of the auditors, the Trust was not out of line with other trusts. The Audit Committee recognised that reports on clinical audit were taken by the RAQC but its own concern related to the process involved particularly the process for ensuring delivery of the annual plan for clinical audit. It had therefore decided to ask the Medical Director to attend the next meeting to provide assurance. The Medical Director said that there had been an issue with the completion of audits but all the recommendations in the internal audit report had been addressed, except one that required the authorisation of the RAQC. The Vice Chairman, as Chair of the RAQC, said that the RAQC had begun to focus on clinical audit approximately a year to eighteen months ago and it felt that in that time there had been a 11
significant improvement under the leadership of the Medical Director. There was much to be gained from effective clinical audit and the RAQC would continue to focus on this. 11/225.3 The Audit Committee had returned to its discussion on compliance (as flagged up at a previous Board meeting) and had considered a paper from the Executive on performance management mechanisms. While these provided a short term solution to the issue, the Committee welcomed the ARC programme as a more sustainable solution, by ensuring that appropriate behaviours were embedded. Appraisal was a key part of this and the Committee would be looking at the scope of planned internal audit work in this area, which would consider the quality of the process. 11/225.4 The Committee had reviewed the registers of gifts/hospitality and interests, and had found the former to be surprisingly short: it was clear that there must be some specialties where declarations were not being completed. To encourage compliance and in the interests of transparency, the Committee recommended that the register should be published on the website on a quarterly basis, following a new awareness campaign. The Board unanimously agreed. 11/225.5 The Committee had considered its terms of reference in the light of the new Audit Committee Handbook and had debated them also in the context of the RAQC s duties. It had concluded that the Chair of the RAQC should be asked to confirm whether he was content with the distinction between the two. The Vice Chairman, as Chair of the RAQC, said he felt that the distinction was not necessarily reflected by the wording used in the terms of reference. Accordingly, the Chair of the Audit Committee proposed that further discussion should take place between the Chairs of the two committees before bringing back the terms of reference for approval. In addition, the Audit Committee would be taking advice from the external auditors as to how the distinction was handled elsewhere. Chair of Audit Committee / Chair of RAQC 11/225.6 Finally, the tender process for the internal audit service had now been completed and the Committee had decided to appoint PricewaterhouseCoopers (PwC) from October 2011. 11/226 AUDIT COMMITTEE ANNUAL REPORT 2010/11 11/226.1 The Board reviewed the Audit Committee s annual report for 2010/11. 11/227 RISK & QUALITY COMMITTEE (RAQC) REPORT 11/227.1 The Board reviewed the issues escalated by the RAQC from its meeting of 23 rd September 2011. 11/227.2 The Chair of the RAQC reported that the Committee had reviewed the red rated internal audit report on Facilities referred to it by the Audit Committee, together with an action plan presented by the Head of Estates and Facilities. It had been impressed by the approach being taken and was assured that the quality issues were being addressed; however, it had decided to review progress in three months. 12
11/228 ANY OTHER BUSINESS There being no further business, the Vice Chairman proposed that the Board move into private session at 4.30 pm. 11/229 DATE OF NEXT MEETING The next meeting would be held on Wednesday 30 th 2011 at 2.00 pm in the Lister Education Centre. November Ian Morfett Vice Chairman 13