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Agenda and minutes

Venue: Board Rooms, Trust HQ, Great Western Hospital, Swindon. View directions

Contact: Carole Nicholl  01793 605171

Items
No. Item

354.

Apologies for Absence and Chairman's Welcome

Minutes:

Apologies for absence were received from Roger Hill and Julie Soutter.

 

In the absence of the Chairman and the Deputy Chair, Steve Nowell, the Senior Independent Director chaired the meeting.

 

SN welcomed Paul Lewis to the meeting as an observer.

355.

Declarations of Interest

Members are reminded of their obligation to declare any interest they may have in any issue arising at the meeting, which might conflict with the business of the Trust.

Minutes:

There were no declarations of interest.

356.

Questions from the public to the Board relating to the work of the Trust

Minutes:

There were no questions from members of the public.

357.

Minutes pdf icon PDF 318 KB

Roger Hill, Chairman

·        1 February 2018 (public and summary of private minutes)

Minutes:

The minutes of the meeting of the Board held on 1 February 2018 were adopted and signed as a correct record, subject to the following amendments: -

 

Minute 336/17 Quality Report – the deletion of the words “The Trust was broadly within Clostridium difficile levels and the majority of cases were not avoidable or attributable to the Trust” and the substitution thereof with the words “The Trust was broadly within Clostridium difficile levels and the majority of cases were not hospital acquired”.

 

Minute 337/17 Operational Performance Report – the deletion of the words “rising fencing” in the ninth paragraph and the substitution thereof with the words “ring fencing”, plus the deletion of the word “targets” in the fourteenth paragraph and the substitution thereof with the word “targeted”.

358.

Outstanding actions of the Board (public) pdf icon PDF 364 KB

Minutes:

The Board received and considered the outstanding actions list.  The Board noted progress against the actions and agreed that completed actions be removed.

359.

Chairman's Report, Feedback from the Council of Governors

Roger Hill, Chairman

Minutes:

SN gave a verbal report on behalf of the Chairman as follows: -

 

Paul Lewis appointed as Non-Executive Director

 

SN was pleased to report that Paul Lewis had been appointed as a Non-Executive Director for a three year term commencing on 1 April 2018.  Paul brought specific knowledge and expertise to the Board around customer services, change management, staff and customer engagement as well as behaviour, values and cultural change.

 

SN was joined by all Directors in welcoming Paul onto the Board.

 

Council of Governors

 

The Council of Governors had met in February to consider reports on finance, operational performance and quality.  As the detail on these matters was considered through the governor working groups, Governors had asked for only the Executive Director summaries to be presented to the full Council in future.  Governors had no issues of concern to draw to the attention of the Board.

 

RESOLVED

 

that the report of the Chairman be received.

360.

Chief Executive's Report pdf icon PDF 192 KB

Nerissa Vaughan, Chief Executive

Minutes:

The Board received and considered a report from GR on behalf of the Chief Executive covering the following issues: -

 

·         Business as usual following Carillion collapse

·         Postponement of routine operations and appointments

·         New temporary ward opens

·         Trust was best in south west for preventing falls

·         New provider for GP out-of-hours service

·         Improving outcomes for premature babies

·         Anaesthetist given professional body’s highest honour

 

GR thanked everyone involved in ensuring the continuation of services following the collapse of Carillion. 

 

GR highlighted that the Trust had achieved fantastic results around processes in place for the assessment of risk around falls.  In response to a question from AC it was noted that the Trust was performing well around the assessments to minimise the risks of falling.  NLB commented that it was well known that fewer falls would occur if the underlying processes around assessment and prevention were good. 

 

GR explained that a quality improvement (QI) approach had been adopted around improving care of premature babies.  It was noted that more than 90% of babies born before 32 weeks now benefited from a procedure called “delayed core clamping” which dramatically reduced the risk of a premature baby developing a serious brain bleed or gut complication.

 

It was flagged that the Royal College of Anaesthetists had presented its highest honour to one of the Trust’s Leading doctors, Dr Michael Natarjan.  AC commented that this was an amazing achievement and all members of the Board commended Dr Natarjan and GR undertook to advise him of this after the meeting.

 

It was noted that a new ward had opened providing extra capacity for the remainder of the winter. JM questioned whether Dorcan Ward was working in the way it was intended.  JO responded that Dorcan was supporting the flow of patients in the hospital but that there was more work to do around Dorcan’s use which included a review of the criteria of patients who should go to Dorcan. 

 

RESOLVED

 

that the report of the Chief Executive be received.

361.

Finance Report pdf icon PDF 120 KB

Karen Johnson, Director of Finance

Additional documents:

Minutes:

The Board received and considered a report on finance for month 10, together with a presentation as follows: -

 

Actual Operating costs

The report did not contain any data relating to Sustainability & Transformation Funding (S&TF) and represented the Trust Control Total only.

In month deficit of £1,622k. Year to date (YTD) deficit of £9,184k compared to target deficit of £3,625k.

NHS Clinical Income

£22.7m in month and £224.7m YTD (£0.3m above plan YTD)

Total Income

£28.2m in month and £275.3m YTD (£2.5m below plan YTD)

Income Activity highlights for the month (based on estimated activity)

·         Elective inpatients below plan

·         Day case activity above plan

·         Non-elective above plan

·         Outpatient appointments above plan

·         A&E below plan

Total Operating Expenditure

 

£27.9m in month and £265.2m YTD (£2.7m above plan YTD)

Expenditure highlights in month:

·         Drugs £0.66m above plan (£2.57m above plan YTD)

·         Pay £1.46m above plan (£6.57m above plan YTD)

·         Supplies £0.21m above plan (£1.07m above plan YTD)

·         Other Costs £0.75m below plan (£7.53m below plan YTD)

EBITDA

3.7% YTD against a plan of 5.5%

Cost Improvement Plans (CIPs)

Savings

Savings plan of £14.052m of which £12.885m identified

£0.849m CIPS delivered in month against a plan of £1.384m.

£9.030m delivered against a plan of £11.271m YTD (£2.241m below plan)

Forecast

Forecast had not changed in month and was a £11.416m deficit which was £6.456m below the plan deficit of £4.96m.

Debtors

£35.8m debtors and stock

£5.5m above plan

Creditors

£53.6m creditors and borrowings

£3.4m below plan

Cash

£1.4m

£0.3 below plan

Loan

Loan of £3.339m received in month

Finance Risk Ratings

YTD Use of Resources (UoR) 4 (Rating 1 was now top and 4 was bottom).

 

The Board discussed the report and comments were made as follows: -

 

NHS National Position

KJ gave a brief overview of the national picture for the NHS at quarter 3 in terms of activity levels and the overall financial position.  In summary there had been a 4.7% increase in A&E attendances and there were 139 of 234 providers reporting a deficit year to date, of which 107 of 136 were acute providers.  68 providers had pushed out on their control total and there was £931m deficit across the NHS at quarter 3 which would move out even more at quarter 4.

 

 

Trust Financial overview

It was noted that there was £9,184k deficit year to date against a planned deficit of £3,625k.  One area of concern was the expenditure flow with ID medical. The Trust had recently received a bill relating to June. It was explained that the unit cost had been incorrect.  OF advised that there were 16 variables for a unit cost and that the processes around this needed to be reviewed.

 

Activity

GR commented that the Trust had seen an additional 600 emergency patients compared to this time last year.  There were financial pressures associated with this which were not included in the forecast, but there was also a material upside.

 

KJ explained that the negotiations with the clinical commissioning groups around  ...  view the full minutes text for item 361.

362.

Chair of Finance, Investment & Performance Committee Overview pdf icon PDF 160 KB

Liam Coleman, Non-Executive Director

Minutes:

The Board received and considered the report of the Chair of the Finance & Investment Committee which summarised the key issues considered at meetings of that Committee held on 22 January and 19 February 2018 covering the following: -

·         Overall financial position

·         Cost improvement programme

·         Agency reduction

·         Draft operational plan

·         Draft budget

·         CQUIN

·         Procurement transformation plan.

 

SN advised that the Committee had considered the detail of the above issues as set out in the report, much of which was included in the Finance Report considered earlier in the meeting.

 

RESOLVED

 

that the report be received.

363.

Chair of Audit, Risk & Assurance Committee Overview pdf icon PDF 177 KB

Julie Soutter, Non-Executive Director

Minutes:

The Board received and considered the report of the Chair of the Audit, Risk and Assurance Committee which summarised the key issues considered at a meeting of that Committee held on 18 January 2018 covering the following: -

 

·         Divisional risk register

·         15+ risk register / management of risk

·         External audit progress report and technical update / external audit plan

·         Internal audit progress report 2017/18 / follow up report

·         BDO internal audit strategic and operational plan 201819

·         Counter fraud

·         Combined costs collection

·         Fixed asset register update

·         Contract extensions and waivers

·         Losses and compensation.

 

It was noted that JS had provided a detailed briefing at the last meeting and there were no additional items to flag.

 

RESOLVED

 

that the report be received.

364.

Quality Report pdf icon PDF 112 KB

Hilary Walker, Chief Nurse

Additional documents:

Minutes:

The Board received and considered a report which provided commentary and progress on activity associated with key safety and quality indicators. The key points to note for January were as follows: -

 

·         The rolling 12 month Hospital Standard Mortality Rate (HSMR) for November 2016 to October 2017 was 99.56

·         3 cases of Clostridium difficile were reported during January 2018, the CDI rate year to date was 10.98 per 100,000 bed days against a target of 9.4 per 100,000 bed days

·         4 Serious Incidents were reported during January 2018

·         3 Freedom to Speak Up alerts were received during January 2018

 

Hospital Standard Mortality Rate (HSMR)

The rate remained below 100 and was therefore within accepted levels.  However, there were a number of planned initiatives to improve the position.

 

Clinical audits

GR reported that there had been a significant amount of work to progress clinical audits. GR explained that the Trust was unable to participate in the National Diabetes (Core) Audit due to internal processes for the capture of data.  The Trust needed to consider a system to capture the data to ensure that the Trust could take part in the audit going forward.  AC expressed his thanks to staff for their efforts around clinical audits which showed an improved position.

 

Infection, prevention and control

GR flagged that there had been 3 cases of Clostridium difficile in January.  GR was aware of further cases in February which meant that the Trust had now breached the annual maximum level.  However, given the increase in activity the number of cases was reasonable and overall infection, prevention and control was very good.

 

GR flagged that there had been 1 case of Ecoli bacteraemia attributed to community services during January.  An action plan was in place to improve processes.

 

GR referred to the number of influenza cases totalling 270 in January.  Staff were commended for their efforts around preventing infection spread and the work of the flu team to provide additional on call support to manage cases had been excellent.

 

Quality

HW referred to the operational pressures which impacted on the ability to sustain high quality care but noted that teams were making the best judgements to sustain quality.  HW commented that there were many patients needing close support, but that it was not always possible to provide this due to difficulties in securing staff. HW advised that staff were doing a very good job and that they escalated issues to ensure senior support around decisions making.

 

Clinical incidents

HW advised that further to a report to the last meeting which had flagged a serious incident relating to a category IV pressure ulcer in the community, there was now an improvement plan in place.

 

It was noted that there remained a number of overdue serious incident investigations.  HW reported that the Clinical Risk Team had been asked to further review processes to ensure learning in a timely way.

 

NLB advised that the Quality and Governance Committee had discussed presentation of data on overdue clinical incidents  ...  view the full minutes text for item 364.

365.

Chair of Quality & Governance Committee Overview pdf icon PDF 231 KB

Nick Bishop, Non-Executive Director

Minutes:

The Board received and considered the report of the Chair of the Quality and Governance Committee which summarised the key issues considered at meetings of that Committee held on 18 January and 15 February 2018 covering the following: -

 

·         Quality Report

·         Emergency Department Dashboard

·         Clinical Audit & Effectiveness

·         Ophthalmology Hold File Management progress report

·         Guardian of Safe Working – 6 monthly update

·         Safer Staffing Monthly Exception Report

·         Board Assurance Framework – Strategic risks aligned to this Committee

·         Co-Regulation & Self-Assessment

·         Corporate Governance Report

·         Committee Effectiveness Review 2017

·         Powers Reserved to the Board / Scheme of Delegation

·         Terms of Reference Refresh

 

NLB highlighted that the fractured neck of femur pathway score for x-ray within 30 minutes had deteriorated due to site pressures; however work was underway to improve this.

 

It was flagged that the Committee had discussed the management of the Ophthalmology hold file and planned actions were noted.  Progress was slow due to operational pressures, but work was continuing. 

 

The Committee had received a detailed report about Care Quality Commission (CQC) co-regulation and self-assessment and noted the work underway to support a sustainable systematic approach to compliance.  It was noted that whilst the “must” and “should do” actions arising out of the latest CQC inspection report had yet to be delivered, many underpinning milestone actions had been completed.   OF referred to the must do actions relating to mandatory training advising that the Executive Committee had approved a plan which aimed to achieve 80% compliance by the end of July.

 

CN advised that earlier in the week, Executive Directors had met with the CQC.  The CQC had commended the work underway to support self-assessment and co-regulation. There was a strong focus on risk management, noting that there was now a risk based approach to inspections.

 

RESOLVED

 

that the report be received.

 

366.

Operational Performance Report pdf icon PDF 273 KB

Jim O’Connell, Chief Operating Officer

Additional documents:

Minutes:

The Board considered the operational performance report which provided an update on performance against key national and local performance standards in addition to progress against key work streams and remedial recovery plans with headlines as follows:-

 

ED 4 hour standard (95%)

84.8% January

Not achieved

Referral to Treatment standard (92%)

89.08% January

Not achieved

6 week diagnostic wait (99%)

93.17% November

Not achieved

Cancer targets

2 week waits (93%)

2 week waits breast (93%)

31 day treatment (96%)

62 day treatment (85%)

December

97.3%

90.6%

99.2%

85.4%

 

Achieved

Not achieved

Achieved

Achieved

 

JO reported that a letter had been received from Jeremy Hunt, the Minister for Health congratulating the Trust on its improvement in cancer performance. 

 

Emergency Department (ED) 4 hour access target

JO reported that there were continued operational pressures and achieving the ED 4 hour performance standard continued to be challenging.  There had been days when performance was satisfactory and other days where the volume of patients had led to overcrowding and a drop in performance.  Also the number of patients with flu was a contributory factor impacting on performance, although staff had worked hard to isolate those patients. JO reported that there had been cases of flu and norovirus and Woodpecker Ward had been closed.  JO advised that there were significant pressures for acute medicine. 

 

In response to a question from AC around length of stay, it was noted that work was continuing with a focus on resolving medically fit for discharge delays.  January had seen an increase in the length of stay which correlated with the operational pressures.

 

KJ advised that the Trust had been asked to turn around a capital bid to NHSI within 4 hours for national money which the Trust would be required to commit to by 31 March.  The value was unknown, but the funding was directed at ED performance.  JM commented that the time scales for submission of bids was unreasonable in terms of ability to prepare robust applications and supporting governance to approve.  NV commented that the Trust was getting better at preparing bids in advance ready for funding opportunities.  NV advised that in her view a tranche of additional money for the NHS might materialise in April.

 

Referral to Treatment Times (RTT)

JO reported that from mid-February the Trust had started recovery of the Referral to Treatment standard.  However, there had been some cancelled operations mid-month because of flu and norovirus.  There had been few last minute cancelled operations as staff were able to plan ahead and inform patients earlier than on the day of treatment.

 

In response to a query raised, JO undertook to ensure that waiting list data was included in the Operational Report.  JO confirmed that numbers on the waiting list were increasing.

 

Stroke performance

JO advised that there was work to do to improve stroke performance which included review of the patient pathway and agreement of new processes.  JO reassured the Board that actions would progress which would be reported through the Performance, People and  ...  view the full minutes text for item 366.

367.

Chair of Performance, People & Place Committee Overview pdf icon PDF 169 KB

Peter Hill, Non-Executive Director

Minutes:

The Committee received a report from the Chair of the Performance, People & Place Committee which summarised key issues considered by that Committee at its meetings held on 29 November and 20 December 2017 covering the following: -

 

·         Emergency Department Performance

·         Referral to Treatment Times (RTT)

·         Theatre activity and utilisation performance

·         Cancer performance

·         Diagnostic Tests

·         Swindon Community Services

·         IT Performance and strategy update

·         Stroke performance

·         Informatics

·         Workforce

 

PH referred to DM01 diagnostic testing within 6 weeks, advising that whilst this was not a priority for the Trust, the Chief Operating Officer was undertaking work to look at capacity to ensure the resources around DM01 were being utilised efficiently and effectively.  

 

PH summarised the discussion held around stroke performance.  The Committee had welcomed a stronger emphasis on driving forward improvement, notably to the patient pathway.  PH referred to the presentation given on the actions proposed and it was noted that going forward there would be thought given to the most appropriate person to update the Committee and the focus of that reporting.  

 

NLB commented that the main area of concern around stroke was not just about CT scanning but also radiology.  JO responded that there were a number of other issues to consider, such as therapies. 

 

RESOLVED

 

that the report be received and it be noted that the Performance, People & Place Committee will continue to scrutinise and challenge the delivery of actions to drive improvements.

368.

Safer Staffing Bi-Monthly Exception Report pdf icon PDF 377 KB

Hilary Walker, Chief Nurse

Additional documents:

Minutes:

The Board received and considered the safer staffing bi-monthly exception report and noted that the actual versus planned nursing hours (fill rate) was as follows: -

 

December

Dayshift

Registered Nurses

87.8%

Care Staff

103.6%

Night shift

Registered Nurses

95.9%

Care Staff

110.5%

 

January

Dayshift

Registered Nurses

91%

Care Staff

107.5%

Night shift

Registered Nurses

97.9%

Care Staff

112.3%

 

OF reported that Bank staff had worked well to ensure shifts were filled.

 

RESOLVED

 

that the report be received.

 

 

369.

Research & Innovation Progress Report pdf icon PDF 113 KB

Oonagh Fitzgerald, Director of Human Resources

Dr Liz Price, Clinical Lead for Research & Innovation and Catherine Lewis-Clark, Research & Innovation Manager to present (11.30am)

Additional documents:

Minutes:

The Board received and considered a presentation from Dr Elizabeth Price (EP) covering the following: -

 

·         Team structure

·         Current trials

·         Open trails by speciality

·         Trials opened

·         Total recruitment

·         2017/18 successes

·         Contribution to the Trust

·         Opportunities

                                               

In making the presentation EP emphasised that undertaking research had an impact on culture and it was known that better care was delivered when research was undertaken. Research was an integral part of NHS activity and was essential for finding new and better ways of preventing, diagnosing and treating illness.

 

The Trust had moved to a model of generic research teams, with support from Allied Health Professionals and Practitioners.

 

It was noted that the Trust took part in a wide range of trials and that there was a mix commercial and non-commercial trails. The number of current trials was reported and it was noted that the long term follow up of patients following trial closure, created a burden for the Trust which was unfunded for non-commercial trials.

 

EP outlined the opportunities for research going forward which included increasing commercial and non-commercial studies; engaging with all consultants so that they understand use of research and innovation to attract other consultants and clinical staff; and in the longer term establishing a dedicated area for trials which would generate more income.  EP explained that more space was needed in pharmacy and manufacturing. PH commented that clinical trials and their importance were often not understood and he welcomed the work underway.  

 

The Board thank Dr Price for the presentation and noted that she was standing down as clinical lead from 1 May as she had been appointed Medical President of the British Sjogren’s Syndrome Association.  Directors congratulated her on this appointment and thanked her for work undertaking around research and innovation.

 

RESOLVED

 

that the presentation be received and further development of Research and Innovation across the organisation be supported.

370.

Ratification of Decisions made via Board Circular/Board Workshop

Carole Nicholl, Company Secretary & Head of Corporate Governance

Minutes:

Terms of Reference of Board Committees were approved (see minute 372/17 below).

371.

Membership of Committees pdf icon PDF 99 KB

Carole Nicholl, Director of Governance & Assurance

Additional documents:

Minutes:

The Board considered an amendment to the membership of Board Committees.

 

RESOLVED

 

that the membership of Board Committees be approved from 1 April 2018 as set out in the appendix to the report.

372.

Terms of Reference of Committees / Powers Reserved to the Board / Scheme of Delegation pdf icon PDF 206 KB

Carole Nicholl, Director of Governance & Assurance

Minutes:

The Board considered a report that invited Directors to refresh the Terms of Reference of the Board Committees as circulated via Board circular.  Minor amendments only had been made to reflect feedback received.

 

The Board was reminded that there was a fundamental review of the Board Committees implemented from January 2017.  Since that time, each main Committee had undertaken an effectiveness review and there were no issues or concerns to draw to the attention of the Board about the effectiveness of the committee structure.  In addition, the Board recalled that a Board workshop was held in May 2017 to discuss challenge, scrutiny and support of Non-Executive Directors as well as the interaction between the Board Committees and the Board, focussing on the added value provided.

 

In addition, the Board was asked to approve the Powers Reserved to the Board and the Scheme of Delegation also circulated via Board circular.  These had been considered through the Executive Committee and the Finance and Investment Committee.

 

RESOLVED

 

(a)   that it be agreed that there are no changes proposed to the Board Committee structure set out in this report;

 

(b)   that the Terms of Reference for each Committee as circulated via Board circular dated 23 February 2018 be approved;

 

(c)   that the Powers Reserved to the Board and the Scheme of Delegation as circulated via Board circular dated 23 February 2018 be approved.

373.

Register of Interests and Declaration of Interests at Meetings pdf icon PDF 165 KB

Carole Nicholl, Director of Governance & Assurance

Additional documents:

Minutes:

The Board considered a report that provided an annual reminder to Directors of their obligation to register any relevant and material interests as soon as they arise or within 7 clear days of becoming aware of the existence of the interest and to also make amendments to their registered interests as appropriate. 

 

The report also reminded of the requirement to declare interests at meetings when matters in which there was an interest were being considered and the requirement to withdraw from the meeting during their consideration.

 

Furthermore, the report asked the Board to receive a copy of the Register of Interests of the Board of Directors for review, which best practice suggested, should be undertaken on at least an annual basis.

 

RESOLVED

 

(a)      that the requirement of directors to register their relevant and material interests as they arise or within 7 clear days of becoming aware of the existence of an interest be noted;

 

(b)      that the requirement to keep the register up to date by making amendments to any registered interests as appropriate be noted;

 

(c)      that the requirement to declare the existence of registered interests or any other relevant and material interests at meetings be noted including the requirement to leave the meeting room whilst the matter is discussed; and

 

(d)      that the Director’s Register of Interests be received and it be agreed that the Board is assured that the requirements of the Constitution to maintain a register of interest of Board Directors are being met.

374.

Postgraduate Medical Education Progress Report pdf icon PDF 228 KB

Oonagh Fitzgerald, Director of Human Resources

Miss Sue Chalstrey, Director of Medical Education to present (12.30pm)

Minutes:

The Board received and considered a paper which highlighted risks and put forward an action plan to support improvements in post graduate medical education for the benefit of the trainees and the organisation. It was explained that the Trust had agreed a ward based under graduate guardian programme.

 

In response to a question from AC around risk, it was noted that immediate risks had been addressed; however concerns remained around the quality of induction and lack of support for junior doctors, particularly at night.

 

RESOLVED

 

(a)   that the risks to the experience and learning of junior doctors and the Trust’s reputation as an organisation that supports a good learning culture be noted; and

 

(b)   that the action plan be noted and supported.

375.

Urgent Public Business (if any)

To consider any business which the Chairman has agreed should be considered as an item of urgent business and to note the reasons for the urgency.

Minutes:

None.

376.

Date and Time of next meeting

Date: 5 April 2018

Time: 9:30am

Venue: Trust Management Boardrooms, Trust HQ, 2nd Floor, Great Western Hospital

Minutes:

It was noted that the next meeting of the Board would be held on Thursday 5 April 2018 at 9.30am in the Boardrooms, Great Western Hospital, Swindon.

377.

Exclusion of the Public and Press

The Board is asked to resolve:-

that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest” .

Minutes:

RESOLVED

 

that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity of which would be prejudicial to the public interest.