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Council of Governors Wednesday, 20 June 2018

10am – 12:30pm

James de Lostock Room

St Catherine’s Hospice

St Catherine’s Park, Lostock Lane

Lostock Hall, Preston, PR5 5XU

Council of

Governors

Nomination Remuneration

Committee (Nom Rem)

Governance Working Group

(GWG)

Membership and

Engagement Committee

(MEC)

Quality and Assurance Committee

(QAC)

Council of Governors

Meeting Council of Governors Meeting

Location James de Lostock, St Catherine’s Hospice, Lostock Lane, Preston, PR5 5XU

Date 20 June 2018

Time 10:00am – 10:30am Governors Pre-Meet

10.30am – 12:30pm Council of Governors Meeting

FORMAL

Reference Item Lead Action Enc.

PROCEDURAL ITEMS

COG 04718 Welcome and opening comments Trust Chair Verbal

COG 048/18 Apologies for absence and confirmation of quoracy

Trust Chair Verbal

COG 049/18 Declarations of Interest Trust Chair Verbal

COG 050/18 Minutes of the previous meeting held on 16 May 2018

Trust Chair Decision Paper

COG 051/18 Action Tracker Trust Chair Decision Paper

CHAIRS’ REPORTS

COG 052/18 Chair’s Report Trust Chair Noting Paper

GOVERNANCE AND ASSURANCE

COG 053/18 Chief Executives Report Chief Finance

Officer Noting Paper

COG 054/18 CQC Report Interim Director of Nursing / Deputy

Director of Nursing Noting

Paper/

Pres

COG 055/18 Quality & Assurance Committee

Chairs Report Phil Curwen Noting Paper

COG 056/18 Nomination Remuneration

Committee Chairs Report Trust Chair Decision Verbal

COG 057/18 Changes to the Constitution Trust Chair Decision To

Follow

COG 058/18 Fit and Proper Person Declaration Trust Chair Noting Paper

DEVELOPMENT

COG 059/18 Accountability Presentation Trust Chair Noting Pres

COG 060/18 Date and Time of Next Meeting Tuesday 14 August 2018 9.15am Governors pre-meet 10.00am Council of Governors

Trust Chair Noting Verbal

UNCONFIRMED

COUNCIL OF GOVERNORS Minutes of the Formal Meeting of the Council of Governors

held on Wednesday, 16 May 2018 The Garden Room at St Catherine’s Hospice, St Catherine’s Park,

Lostock Lane, Lostock Hall, Preston, PR5 5XU

In Attendance Steve Jameson, Property Services Director Sarah Wright, Deputy Head of Operations for Children and Young People Elizabeth Crabtree, Clinical Director for Children and Young People Lisa Moorhouse, Head of Operations for Mental Health Tanya Hibbert, Head of Operations for Community and Wellbeing

17 Apr

16 May

20 June

14 Aug

18 Sept

16 Oct

14 Nov

19 Dec

19 Feb

19 Mar

David Eva - Trust Chair

Isla Wilson - NED Apol

Gwynne Furlong - NED

David Curtis - NED x x

Julia Possener - NED x x

Louise Dickinson - NED x x

Joanne Alker - Company Secretary Apol

Viv Prentice - Dep Company Secretary

Katie Sharples - Corporate Gov Support

Alan Ravenscroft - Public Governor Apol

Chris Johnson - Public Governor Apol

Paul Graham - Public Governor

Keith Holt - Public Governor Apol Apol

Lorena Dumitrache - Public Governor

Phil Curwen - Public Governor

Christine Cartwright - Public Governor

Ken Lowe - Public Governor

Michael Helm - Public Governor

John Walden - Public Governor Apol

Bernadette Ashton - Public Governor x x

Mary Jackson - Public Governor

Katharine Wykes - Public Governor Apol

Julia Kay Horn - Public Governor Apol Apol

Pauline Walsh - Public Governor Apol

Chris Burgess - Public Governor Apol

Adnan Gharib-Omar - Staff Governor

Sallyann Walker - Staff Governor

Yvonne Guilfoyle - Staff Governor Apol

Helen Scott - Staff Governor

Judy Laing - Staff Governor Apol

Emma Allen - Staff Governor

Geraldine Gasson - Staff Governor Apol Apol

Debbie Wisby - UCLan

Teresa Jennings - NCompass

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UNCONFIRMED

COG 036/18 WELCOME & OPENING COMMENTS The Chair welcomed everyone to the meeting and introductions were made by all attendees.

COG 037/18 APOLOGIES FOR ABSENSE & CONFIRMATION OF QUORACY Apologies were received from Non-Executive Director, Isla Wilson, Public Governors: Alan Ravenscroft, Chris Johnson, Keith Holt, John Walden, Katharine Wykes, Julia Kay Horn and Staff Governors: Judy Laing and Geraldine Gasson.

Confirmation of quoracy was provided.

Liz Crabtree and Sarah Wright joined the meeting.

COG 038/18 DECLARATIONS OF INTEREST There were no declarations of interest.

COG 039/18 MINUTES OF THE PREVIOUS MEETING The minutes of the previous meeting held on the 17 April 2018 were approved as a true and accurate record subject to noting the attendance of Nominated Governor, Teresa Jennings.

COG 040/18 ACTION TRACKER The action tracker was reviewed and the closed actions noted. In respect of the open action relating to Lancashire Constabulary’s attendance at a Council of Governor meeting, it was agreed that further contact would be made with Steve Sansbury and if no response was received the action would be closed. Public Governor, Phil Curwen also agreed to raise this with him informally. ACTION

COG 041/18 CHAIR’S REPORT The Chair presented his report which provided an update following recent Board of Director meetings together with an overview of the activities undertaken by the Chair and Non-Executive Directors. The report also provided an overview of the activities of the governors and detailed upcoming opportunities.

COG 042/18 NED PRESENTATION Non-Executive Director, Gwynne Furlong introduced Healthcare Support & Infrastructure Services (HSIS) Property Director, Steve Jameson who was in attendance to provide the governors with information in respect of the newly established company, HSIS.

The Non-Executive Director set the context for the presentation and confirmed that the new company had been formed following the dis-establishment of Red Rose Corporate Services which had been a formal joint venture between Ryhurst and the Trust that had responsibility for the estates portfolio. The new company was a 100% subsidiary of the Trust that would operate on a much more commercial basis.

The Property Director outlined the previous successes of the joint venture which included the ‘Grow Your Own’ project at Guild Lodge, £8m CIP delivery and hard and soft FM savings of £1m+.

An overview of the transition to HSIS was provided which had involved staff consultations and engagement events, the TUPE of staff from Red Rose Corporate Services and the establishment of the new company by the 01 April 2018. In addition, a Shadow Board had been formed with the first formal Board meeting due to take place on the 29 May.

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UNCONFIRMED

Non-Executive Director, Gwynne Furlong discussed the 6 month plan HSIS had in place and outlined the structure of the company, highlighting in particular the role of the Specialist Fire Officer that would report directly to Steve Jameson in recognition of the importance of this role. The Property Director confirmed that the 6 month plan could be circulated if required.

Staff Governor, Yvonne Guilfoyle was very complimentary of the new structure, in particular the new Hard FM process for maintenance.

Public Governor, Chris Burgess complimented the presentation and requested a copy of the 6 month plan. ACTION

Following a question from a Public Governor in respect of the number of buildings the Trust has, the Property Director confirmed that the number of buildings had been reduced significantly and that the use of LIFT buildings was optimised.

A Public Governor referred to the Willow House project and questioned if this could be used for accommodation. The Property Director confirmed that the estates strategy was currently being updated and assured the governors that discussions take place before any estate is disposed of to ascertain if there is an alternative use for the premises.

Steve Jameson left the meeting

COG 043/18 NETWORK BUSINESS PLANS Children and Young People Network The Clinical Director opened the presentation by introducing herself and Deputy Head of Operations. The Clinical Director summarised the structure of the network together with the network’s portfolio of services.

The Clinical Director confirmed that quality and safety underpinned all business plans and that a network meeting is held each month to discuss quality and safety which is fed up into the organisational governance structure.

In relation to people and leadership and ensuring that staff consider their own wellbeing, the Clinical Director confirmed that staff are involved in both the NHS70 parkrun and the Blackpool 10k. The network is also heavily involved via Twitter to promote staff wellbeing.

In relation to performance, the network had experienced challenges in the Early Intervention Service (EIS) in meeting the Referral to Treatment (RTT) target. However, a lot of work had been undertaken to ensure compliance by quarter four. In addition, there had been improvement in both CAMHS and psychology waiting times.

The Clinical Director explained that since October there had been a request from the CCGs to look at CAMHS across the STP and how children’s mental health services could be provided more coherently. The network had therefore been involved with other providers across the STP to provide an inclusive model which would be implemented in April 2019 for children up to the age of 18.

The Clinical Director provided insight into the inpatient unit at The Cove which had co-located from the Platform and the Junction to create 18 beds for young people. Unfortunately the network had experienced challenges in respect of staff retention and as a result a decision had been made in January, in conjunction with NHS England, to reduce the beds to 10 to allow recruitment and retention to take place and to ensure practice was embedded. The Clinical Director was pleased to inform the governors that

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UNCONFIRMED

the number of beds had this week been increased to 12 and that the Trust was working with NHS England to further increase bed numbers over the next six months.

The Deputy Head of Operations referred to the 0-19 tender and confirmed that whilst the Trust was still awaiting the outcome of the court case, the network was still very much engaged in running the service.

The Deputy Head of Operations confirmed that the Eating Disorder Service, as an early adopter, was identifying the benefits of EPR.

Following a question from a staff governor regarding the age range for the EIS service, the Deputy Head of Operations confirmed that the service accepts referrals up to the age of 65. Following a further question from a public governor regarding the success rates, the Deputy Head of Operations confirmed that the benefit for service user trajectory into mental health services was enormous. However, the Head of Operations for the Mental Health Network would be in attendance today and would be able to provide an update into the work targeted at suicide prevention.

A staff governor suggested that teaching people how to manage life stresses would be a proactive way of prevention. A public governor reflected on his own experience at university and asked what was in place today for young people. The Deputy Head of Operations reassured the governors that the Trust has strong connections with the universities and attempt to see patients within 2-3 days of referral.

A staff governor with particular interest in equality and diversity asked how the network engages with BAME minorities, particularly in respect of EIS intervention. The Deputy Head of Operations confirmed that the network have good relationships with local mosques and had reached out to a number of people.

The Chair recognised the difficulties in getting young people involved and requested that if governors had any recommendation on how the network could try and involve young people then this could be passed on to Company Secretary, Joanne Alker who would liaise with Clinical Director, Elizabeth Crabtree.

The Chair voiced his concern regarding the number of young people that commit suicide that are not known to services and was therefore interested to know what work was being done with schools and colleges in this respect. The Clinical Director referred to a Green Paper that was currently being discussed in Parliament and confirmed that both herself and the Deputy Head of Operations would be happy to return to a future Council of Governor meeting to discuss the outcome of this.

The Clinical Director and Deputy Head of Operations for the Children and Young People Network left the meeting The Head of Operations for the Community and Welling Network joined the meeting

Community and Wellbeing Network The Head of Operations introduced herself and outlined the structure of the network together with the portfolio of services which included supported living, dental, community LD and the Southport and Formby services which were acquired in 2017. This had involved integrating staff from an acute trust background into community and whilst this had been challenging at times, feedback had highlighted that overall this had been a positive experience.

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UNCONFIRMED

The Head of Operations confirmed that there had been lots of tendering opportunity within the network and highlighted the recently awarded IMSK tender. This is a brand new service which will be launched in August and will involve taking referrals from GPs for people in pain. Following a question from a staff governor on whether the impact of mental health was part of the remit of the team, the Head of Operations confirmed that they was an aspect of mental health in the programme and psychology teams had also been involved in the pain management offer.

The work around neighbourhood developments within the STPs was outlined. Under the 5YFV this had moved to the next level and would involve integrating social care into the model.

The Trust Chair referred to TCS and highlighted that there was little evidence of integrated physical and mental health. The Head of Operations agreed that this had not moved at pace and that the neighbourhood offering was the vehicle that would provide the right interest and opportunity. It was acknowledged that whilst there was still work to be done, the geographic spread of LCFT was a logistical challenge. However, both the Community and Wellbeing Network and Mental Health Network were working collaboratively in this regard.

The Head of Operations for the Community and Welling Network left the meeting The Head of Operations for the Mental Health Network joined the meeting

MENTAL HEALTH NETWORK The Head of Operations introduced herself and confirmed that the Mental Health Network was proportionally the largest of the networks with a budget of £140m and approximately 3000 members of staff. The services provided include inpatient units, community services, secure services and dementia services. There is also a very strong focus on older adults.

A number of service developments were outlined which included two new crisis houses in Burnley and Chorley.

The Head of Operations referred to staffing issues and confirmed that consideration was being given to roles and training to attract new people. A staff governor voiced concern how a lack of sleep can cause some mental health problems and that part of preventative thinking must be around sleep. A public governor raised a question about the process of triaging mental health patients. The Head of Operations explained that the Trust has a Mental Health Decision Unit (MHDU) on site at A&E but emphasised that this was an LCT service that other trusts may not provide. A staff governor drew attention to the fact that having the time and privacy to undertake a full mental health assessment as opposed to the environment of A&E was extremely positive.

Following a question from a public governor regarding the education given to parents or carers of young people or adults with mental health problems, the Head of Operations confirmed that the network has a relationship with NCompass who undertake carer’s assessments and discuss carer’s requirements. In addition, part of the care plan would involve inviting families to care planning meetings.

A public governor raised a question regarding how LCFT are performing on 136 suites following the reduction in the detention period. The Head of Operations confirmed that the network was working collaboratively with police colleagues to understand why the use of 136 suites was so high.

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UNCONFIRMED

The Head of Operations for the Mental Health Network left the meeting

COG 044/18 LEAD GOVERNOR REPORT The Deputy Lead Governor presented the Lead Governor Report which provided an overview of the activity undertaken by the governors during the period January – April 2018.

Following review, it was further noted that Staff Governor, Helen Scott had attended the CQC Focus Group, Staff Governor, Emma Allen had attended the Staff Awards and Nominated Governor, Teresa Jennings had attended the North West Governor Forum.

COG 045/18 ACCOUNTABILITY It was agreed that this would be deferred to the June meeting.

COG 046/18 DATE AND TIME OF NEXT MEETING Wednesday, 20 June 2018

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Agenda Item COG 052/18 Date: 20/06/2018

Report Title Chair’s Report

FOIA Exemption No Exemption Not Applicable

Prepared by Katie Sharples, Corporate Governance Support

Presented by David Eva, Trust Chair

Action required Noting

Supporting Executive Director

Chief Executive

PURPOSE OF THE REPORT:

Report purpose The purpose of the report is to provide the Governors with an overview of the activity undertaken by Non-Executive Directors in addition to Board meetings. An overview is also provided on the activity of Governors.

1.0 BOARD OF DIRECTORS MEETINGS

Since the last CoG Chairs Report the following Board of Directors meeting has taken place:

Board of Directors – 07 June 2018 Standard Reports

The Board received the standard reports including the performance report, quality reportand finance report.

Health Informatics PlanThe Board received an update on developments related to the Board Development Sessionwhich had focused on Digitally Enabled Care and received an update on progress with theimplementationof the health informatics plan.

CQC Action PlansThe Board received the final inspection report from the CQC and an update on the plans todevelop the CQC actionplan and the impact on tye next iteration of the Quality Plan.

Quality Committee ReportThe Board received the Quality Committee Chair’s Report following the meeting held on15 May and approved the revised Terms of Reference for 2018/19.

Staff/Service StoryThe Podiatry Clinical Lead was in attendance and provided an overview of the podiatryservice in Southport & Formby which included the improvements the team are driving anddelivering.

In addition to the above, a Board Development Session was held to provide the Board with further assurance around the responsibilities of the Hospital Manager.

2.0 NON-EXECUTIVE DIRECTOR ACTIVITY

The Non-Executive Directors have been attending the Board Committee meetings of which they are a member (including the Financial Recovery Group) and apologies have been given where they were unable to attend.

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In addition to the usual Board business, Non-Executive Directors (NEDs) have been involved in their areas of special interest during the period of 10 May 2018 – 08 June 2018:

Gwynne Furlong

Attended NED discussion re CQC report Attended Quality Committee 1-1 with Project Director, Alistair Rose Attended the Council of Governor Meeting Attended Board 360 feedback Attended Trust Board Year End Sign off Attended Board of Directors Nomination Remuneration Committee

Louise Dickinson

Attended Audit Committee Board Assurance Framework Session Chaired multiple Audit Committee meetings Attended Quality Improvement Conference Attended Trust Board Year End Sign Off Attended Board of Directors Nomination Remuneration Committee Attended ICP Development Session Attended Board of Directors Meeting Meet with Alan Yates re HMP Liverpool

Julia Possener

Attended Pennine Lancashire Healthy Hearts Partnership Meeting 1-1 with Trust Chair, David Eva Attended NED discussion re CQC report Attended Quality Committee Attended Quality and Assurance Sub-Committee Attended Audit Committee Board Assurance Framework Session Attended multiple Audit Committee meetings Attended meeting with Phil Bardzil re Board 360 Feedback Attended Quality Improvement Conference Attended Trust Board Year End Sign Off Attended Board of Directors Nomination Remuneration Committee Attended HSIS Board Meeting Phone call with Helen Lowey from Healthy Hearts Attended Board of Directors Meeting

David Curtis

Chaired Serious Incident Panel Attended NED discussion re CQC report Chaired Quality Committee Attended Board Assurance Framework Meeting Session Attended multiple Audit Committee meetings Attended Quality Improvement Conference Attended Trust Board Year End Sign off Attended Board of Directors Nomination Remuneration Committee Attended Board of Directors Meeting Meet with Alan Yates re HMP Liverpool

Isla Wilson Chaired Finance and Performance Committee Attended a meeting regarding Board 360 Feedback Attended NED discussion re CQC Attended Quality Committee Attended Quality Improvement Conference

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Attended Trust Board Year End Sign off Attended Board of Directors Nomination Remuneration Committee Attended Intergrated Care System Board Attended Board of Directors meeting

3.0 CHAIRS ACTIVITY

1-1 with Non-Executive Director, Julia Possener Chaired Council of Governor meeting Attended Board 360 Feedback with Impact Consultating Attendd Accountable Health and Care Partnership Leaders Forum 1-1 with Acting Director of Nursing Attended meeting to discuss outputs from Board Session (Strategy) 1-1 with Chief Executive, Heather Tierney-Moore 1-1 with Director of HR, Damain Gallagher Attended Trust Board Year End Sign off Attended Board of Directors Nomination Remuneration Committee Attended Accountable Health and Care Partnership Leaders Forum Attended ICP Development Session with Governing Bodies Attended Board of Directors meeting 2-1 with Chief Executive, Heather Tierney Moore and Chief Finance Officer, Bil Gregory Several calls with Alan Yates re HMP Liverpool

4.0 GOVERNORS ACTIVITY

In addition to attending the Council of Governors meetings and the sub-committee meetings, governors have individually been involved in additional activities as below:

Public Governors, Phil Curwen and Chris Burgess attended the Quality Committee meeting. Public Governor, Paul Graham attended the Board of Directors meeting Public Governor, Lorena Dumitrache attended the Governor Focus Conference.

5.0 FUTURE INVOLVEMENT

Opportunities available to Governors over the next few months can be seen at Appendix One.

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APPENDIX ONE

Governor Training Opportunities

External Events

Programme/Event Date(s)

GovernWell Training Programmes with NHS Providers

Core skills

This one day course is designed for all types of governors in the first year of their first term of office, and for those governors who would like a refresher. The core training builds on a trust’s induction programme to help governors learn in more detail and discuss issues from a position of insight and initial experience in the role. At the end of the course you will have:

an understanding of the structure of the NHS and the governor's role within this context

knowledge of the statutory role and associated duties an understanding of public accountability and local ownership an understanding of NHS finance the skills to hold the board to account.

Upcoming courses

13 June 2018 – Taunton 19 July 2018 - London

Recruitment, The Governor Role in Non-Executive Appointments

This one day course will help governors to understand the process and procedures for the appointment of non-executive directors and the Chair. It offers practical "how to" advice, includes an update on relevant legislation and provides an opportunity to practise formulating interview questions and participate in a "mock" interview. The course is aimed at governors serving on nominations committees and/or sitting on selection panels. At the end of the course you will have:

familiarity with the overall recruitment process awareness of good practice in relation to recruitment

had an opportunity to practise recruitment skills.

Upcoming courses

28 June 2018 - London

Finance & Business Skills

This one-day course will help governors learn more about the detail of a provider's finances and their business operations, through a range of interactive learning methods and shared experience. At the end of the course you will have:

a better understanding of financial flows in the NHS and the financial context in which foundation trusts operate

an improved appreciation of income / expenditure, cost improvement plans, and possible strategies to support organisation health

an understanding of the NHS as a "business" and considered the role of competition

a better understanding of the governor role in mergers and acquisitions.

Upcoming courses

05 July 2018 - Leeds

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Accountability

This one day course will help governors build a dynamic and effective accountability relationship with their board of directors. Using a range of interactive learning methods, we will look at how governors can be effective in holding their non-executive directors to account for board performance. At the end of the day participants will:

understand the need for good ground rules in promoting good relationships

have an understanding of a risk based approach to assessing information needs and be able to use this approach to assess whether they have enough information

understand the main elements of a performance report be confident in make appropriate challenge.

Upcoming courses

11 July 2018 - London

Effective Questioning and Challenge

This one day course will help governors work confidently and effectively with their directors in posing effective questions to hold the board to account. Using a range of interactive learning methods, we will look at listening skills, questioning styles, and how to frame effective questions, specifically within the context of the governor role. At the end of the day participants will have:

honed their communication skills to be more effective and confident in their role

received practical hints and tips to help them communicate with their trust

had an opportunity to self-reflect on their style of listening and questioning and considered how they might want to change it.

Upcoming Courses

17 July 2018 - Newcastle

Member and Public Engagement

Governors have an important role in making a NHS foundation trusts publicly accountable for the services it provides. They bring valuable perspectives and contributions to its activities. Importantly, it is the duty of the council of governors to represent the interests of NHS foundation trust members and the public. This half day training explores what it means to represent the interests of members and the public and reflects on ways to build effective relationships in order to present their views to the board. You will also share good practice with your peers and reflect on how you can support engagement activities within your trust. At the end of the day participants will:

be clear on the governor and board duties in this area as laid out in the Health & Social Care Act 2012

understand the reasons behind why trusts have members and need to engage

explore examples of good practice recognise the challenges to member/patient engagement reflect on the importance of good relationships and what you as

governors can do to support engagement activities.

Upcoming Courses

12 September 2018 -

London

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Agenda Item CG 053/18 Date: 20/06/2018

Report Title Chief Executive Assurance Report


Prepared by Viv Prentice, Deputy Company Secretary

Presented by Bill Gregory, Chief Finance Officer


Supporting Executive Director Chief Executive


Report purpose The purpose of this report is to provide Governors with an overall summary of the Trust position and highlight areas for further discussion.

Strategic Objective(s) this work supports To provide high quality services

CQC domain Well-led

Introduction This report aims to give Governors an overview of the activity undertaken since the last formal Council of Governors meeting, both within the Trust and externally.

Outlined below is a brief snapshot of the ‘highlights’ and ‘areas for attention’ from the reporting period. More detail on these issues is provided in the main body of the report.

Highlights any Areas for Attention

Financial position - The Trust exceeded plan by £0.3m and attracted additional Sustainability & Transformation Funding (STF) taking us to an overall surplus position

The Annual Report and Accounts were submitted within the required deadline along with the Quality Account and both received clean audit opinions

! Performance - all NHS Improvement targets for Month 1 were achieved with the exception of performance against the Early Intervention in Psychosis two week target

! The Trust received a revised CQC rating of requires improvement

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QUALITY AND SAFETY

Care Quality Commission (CQC) Narrative: The CQC published their inspection reports of the Trust on 23 May 2018.

Action Taken/Board Assurance: Board members met on 15 May 2018 to agree the communications approach and the Quality Committee received a report on 15 May 2018 setting out the planned approach to developing and implementing the improvement action plan. An item has been added to the CoG agenda for further discussion.

During April 2018, the CQC also undertook Mental Health Act Monitoring Visits to Stockbeck Ward, Scarisbrick Ward, Elmridge Ward and Calder Ward. A governance process is in place for these visits, overseen by the Mental Health Law Sub-committee, to ensure action plans are returned to the CQC and that themes and trends from these regular visits are identified.

International Nurses Day: 11 May 2018 Narrative: The Trust celebrated International Nurses Day at Preston North End. Attended by over 300 Nurses the event was a huge success. Innovative presentations from services across the Trust provided an insight into the Past, Present and Future of Nursing.

Board Assurance: There were also presentations from by the Chief Executive and the Trainee Nursing Associates. Feedback on the day was extremely positive and attendees will soon receive an attendance certificate and an opportunity to feedback more formally.

Serious Incidents Narrative: Serious Incidents during the period:

Feb 2018 - 07 Mar 2018 - 12 Apr 2018 - 03

Action Taken: In all cases, a formal investigation is now underway and the incidents have been reported to commissioners, NHS England and regulators as required under the NHS Serious Incident Framework.

Board Assurance: Each month the Board is appraised of the serious incidents that have occurred and is informed whether a formal investigation is underway and whether the incidents have been reported to commissioners, NHS England and regulators as required under the NHS Serious Incident Framework. The Board also receives assurance from the Quality Committee Chair’s report which outlines the discussions held on the Serious Incidents Bi-Annual Report.

Raising Concerns Narrative: Raising Concerns during the period, reported through various mechanisms including Dear David:

Feb 2018 - 12 Mar 2018 - 07 Apr 2018 - 04

Action Taken/Board Assurance: In all cases a review of proportionate scale has been commissioned. The findings from each review are individually fed back to the person raising the concern if they have provided their name. The findings from every concern is summarised in the Quality Matters bulletin.

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Governors are sighted on themes of the concerns raised through Dear David via his monthly Chairs Report.

Freedom to Speak Up: Guidance for NHS FT Boards Narrative: NHS Improvement and the National Freedom to Speak Up Guardian published guidance and a self-review tool for Boards in May 2018 that sets out expectations of boards in relation to Freedom to Speak Up (FTSU). The Care Quality Commission (CQC) assesses a Trust’s speaking up culture during inspections under a key line of enquiry as part of the well-led domain. The guidance is aligned with the good practice set out in the well-led framework.

Action Taken/Board Assurance: The Quality Committee, as the delegated committee for quality and people, agreed at its meeting on 15 May 2018 to complete the self-review tool contained with the guidance, as part of its schedule development session at the next meeting in July 2018. The session will be facilitated by the Trust’s Freedom to Speak Up Guardian. Governors will be aware that the Trust already has routes for raising concerns in place (Dear David, Whistleblowing) and that these arrangements are reported to the Audit Committee.

FINANCE AND PERFORMANCE

Financial Position Narrative: As highlighted earlier, the Trust delivered a year-end position £0.3m in excess of its planned surplus of £2.2m. This attracted an STF bonus of £2.5m. After adjusting for impairments of £1.5m the surplus for the year is a £4.8m, against a planned year end surplus of £2.2m. The underlying position continues to be driven by staffing pressures in ward and prison areas which is also impacting on delivery against planned cost improvement programmes, particularly ward staffing. In addition, expenditure has exceeded funding on OAPs resulting in current pressures, with OAPS now ahead of expectations. Secure ward staffing has again deteriorated by £0.1m.

In month 1, the Trust delivered a position £0.3m in excess of its planned deficit of £0.6m, which assumes we receive STF money of £0.1m. At this early stage some elements of the CIP are in development and others are still to be transacted so month 1 is a prudent assessment, but at this stage the slippage is offset by underspends in both Children & Young Peoples and Community & Wellbeing Networks. Mental health, excluding OAPs is £0.6m overspent, but this is without the application of staffing reserves pending implementation of the nurse staffing actions agreed as part of the plan which would see it nearing balance. Agency is £608k vs plan of £595k which is a slight adverse variance.

Board Assurance: The Finance Recovery Group which was established in August 2016 continues to provide the opportunity to scrutinise the financial data and the recovery plan in more detail. The meeting is chaired by Non-Exec, Isla Wilson. Other members of this Group include Non-Execs Louise Dickinson, Gwynne Furlong and David Curtis and the Executive Directors.

Final Operational Plan 2018/19 Narrative: At the April Council meeting, Governors received a presentation on the work being undertaken to refresh the Trust’s Operational Plan in line with guidance issued by NHS Improvement and were given the opportunity to feedback. The Board received the draft Operational Plan at a session which took place on 20 April. The comments and feedback from that session have been incorporated into the final version.

Action Taken: The final Operational Plan was submitted to NHS England and NHS Improvement on 30 April and has been circulated to Governors outside of the meeting.

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Cyber Security Requirements Narrative: The Department of Health and Social Care, NHS England and NHS Improvement has published a set of 10 data and cyber security standards called the 2017/18 data security protection requirements (DSPR) that all providers of health and care must comply with.

Action Taken/Board Assurance: The Board reviewed and approved the organisation’s response to the requirements.

Quality and Performance Report Narrative: As outlined earlier, all NHS Improvement targets for month 1 were achieved with the exception of performance against the Early Intervention in Psychosis two week target.

For 2018/19, the target to be achieved has increased from 50% to 53%. The predominant reason for patients not being treated within the 14 day window is a delay in referral to the EIP team. This is often because the presenting condition of the patient within the mental health single point of access service is not clearly identifiable as first episode psychosis.

Action Taken/Board Assurance: In addition, the network are now focussing on actions to deliver a sustainable position for 18/19 alongside delivery of the target for quarter 1 in the first instance. This is being supported by the Transformation Advisory Service and is a DTS programme of work.

PEOPLE AND LEADERSHIP

Accommodation for Clinicians Narrative: The Trust has approved the progression of a project being led by Dr Khaled Mostafa and Dr Richard Morgan to establish accommodation solutions for recruiting international doctors. The project aims to enable the Trust to overcome some of the hurdles faced when recruiting international doctors and clinical staff into permanent positions within the Trust. The Trust will now move to secure a number of units within a new, luxury student accommodation development in Central Preston as an interim solution to helping overseas clinicians to re-locate. The Trust has considered the risks and technical detail of securing a five year arrangement with the developer for 12 units as part of a cost benefits case, recognising that a longer term and more permanent solution will continue to be explored. The intention is for the rental costs to be covered by the staff occupying the units.

NHS Improvement “Just Culture” Guidance Narrative: NHS Improvement have published a guide which encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way to support a culture of fairness, openness and learning in the NHS. The guide is suggested to be used as part of certain patient safety investigations. It aims to promote cultural change and move away from a ‘blame culture’ by making staff feel confident to speak up when things go wrong, rather than fearing blame and support staff to be open about mistakes to allow valuable lessons to be learnt and avoid repeated errors.

Action Taken/Board Assurance: A Board Development Session will be held in July 2018 focusing on just culture and human factors.

Student Experience Narrative: Whilst Lancashire Care continues to look at the recruitment and retention of current staff, we are also conscious of the need to plan for the future. The Practice Education Facilitators (PEFs) work with local education providers to ensure that healthcare students enjoy and learn as much as possible whilst on placements with us and it is likely that the recruitment of student nurses will form part of a future overarching plan for nursing which will be led through the Senior Nurse Leaders Group.

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In order to assess the efficacy of placements, the Practice Assessment Record and Evaluation (PARE) system has been rolled out across all Universities within the North West. Whilst evaluating placements is not compulsory for students, as the system has now been in place for almost two years, an increasing number of assessments are being completed. PARE reports are produced quarterly and contain information and commentary about placement experiences, they also highlight any practice areas which received less than 80% positive feedback for the quarter.

Board Assurance: The latest report shows that out of 169 placements only 1 placement fell under 80% positive feedback and that eighteen teams across the Trust consistently received 100% positive feedback for both the last 2 quarters.

Lancashire Care’s positive student feedback is now slightly higher than the regional average, scoring 97.52%. This is a significant achievement, particularly given the current climate and challenges and is testament to the clinical staff providing support to learners. It is important that the organisation continues to provide positive experiences to students as they will form part of the future LCFT workforce.

NHS England and NHS Improvement Closer Working Narrative: The first public Board meeting in common for NHS England and NHS Improvement took place on 24 May 2018. The meeting considered a number of proposals about how they will start to work closer together as system leaders for the health service. Those proposals included integrated regional teams, alignment of national functions and joint governance and accountability arrangements.

BUSINESS DEVELOPMENT

0-19 Universal ServicesNarrative: On 28 November 2017, the Trust received notification that it had been unsuccessful in securing the universal tender to deliver 0-19 services across Lancashire and together with Blackpool Teaching Hospitals put a legal challenge forward. The Court Trial concluded on the 1 May 2018 and the Trust awaits the ruling.

Board Assurance: The Board has continued to be updated on the matter as has progressed and Governors will be informed of the Court decision once it is received.

HMP Liverpool Demobilisation Narrative: The Trust demobilised and handed over the healthcare services provided at HMP Liverpool. A Demobilisation Group was established to managed the demobilisation process and provide assurance to the Trust and external stakeholders that all legal and financial obligations were met.

Board Assurance: The Board received an assurance report at its April meeting that confirmed the only outstanding actions related to Serious Incidents that were still in the process of concluding.

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Report Title Care Quality Commission (CQC) – Inspection Report and Action Planning Process


Prepared by Matthew Joyes, Assoc Dir of Safety & Quality Governance

Presented by Julie Seed, Deputy Director of Nursing & Quality

Paul Lumsdon, Interim Director of Nursing & Quality


Supporting Executive Director Executive Director of Nursing & Quality


Report purpose To provide the Council of Governors with the finalinspection report from the CQC and to update on the plans to develop the CQC action plan and the impact on the next iteration of the Quality Plan

Strategic Objective(s) this work supports

To provide high quality services

Board Assurance Framework risk

1.1 The Trust does not protect service users from avoidable harm and fails to comply with the CQC standards for the quality and safety of services.

CQC domain Well-led

1.0 INTRODUCTION

1.1 The Care Quality Commission (CQC) inspected the Trust in January and February 2018; which was preceded by the annual provider information request in the summer of 2017. The Trust received the daft reports in April 2018 with publication in May 2018. The Trust submitted factual accuracy challenges which resulted in minor changes.

1.2 The ratings for the Trust are included at appendix 1.

1.3 The Head of Communications and Associate Director of Safety and Quality Governance have enacted the communications and engagement plan agreed by Board including briefings for staff, commissioners and stakeholders.

1.4 For context, the CQC inspected five “core services” (their mechanism for grouping services) as part of their continual inspection process. Where services did not receive an inspection, the previous ratings remain in effect.

• acute wards for adults of working age and psychiatric intensive care units• forensic inpatient / secure wards• child and adolescent mental health wards

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• mental health crisis services and health based places of safety• community health inpatient services

The Trust provides the following 10 core services which the CQC did not inspect:

• community-based mental health services for adults of working age• wards for older people with mental health problems• community-based mental health services for older people• specialist community mental health services for children and young people• community mental health services for people with a learning disability or autism• community health services for adults• community health (sexual services)• community health services for children, young people and families• learning disability supported living• community dental services

In addition, the Trust at the time provided offender healthcare services.

2.0 DEVELOPMENT AND DELIVERY OF THE ACTION PLAN

2.1 As agreed at the Senior Leadership Team, the Associate Director of Safety and Quality Governance will lead the development of the action plan and the associated assurance mechanism to ensure delivery of the actions. The following arrangements for action plan development form part of that that overall process:

The Quality Governance Department will identify, from all reports, the Must Doand Should Do requirements identified by the CQC and will further identify allpossible improvement opportunities mentioned throughout the reports.

Each requirement or improvement opportunity will have an identified outcomemeasure, centrally developed by the Quality Governance Department that meetsthe intention of the CQC. The outcome measure will be set taking into accountthe anticipated next inspection date.

The appropriate Networks and Support Services will develop actions to meet therequirement/improvement and outcome measure. Each action will includemilestones where the action has a long delivery timeframe. Action developmentwill be supported by the Quality Governance Department who will coordinatecross- Network/Support Service actions.

Where an action links to existing work (such as an existing quality improvementproject or transformation project) then the link can be made to avoid duplicationof effort however the CQC action plan will include details of the actions,milestones and action owner to meet the full requirements and improvementsidentified by the CQC.

Each action will have an action owner and an executive lead – the action ownerwill be at least Clinical Director/Head of Operations/Associate Director/Head Oflevel.

The actions put forward will scrutinised by the Quality Governance Department.The final action plan will then be presented to the Executive Directors Group forapproval and then reported to the Trust Board.

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3.0 MONITORING OF THE ACTION PLAN

3.1 As agreed at the Senior Leadership Team, the Associate Director of Safety and Quality Governance will lead the development of the action plan and the associated assurance mechanism to ensure delivery of the actions. The following arrangements for action plan monitoring form part of that that overall process:

All actions will be added to the Datix action tracking function. The system will bere-designed to accommodate the approach set-out.

Live dashboards will be available to monitor progress sin real-time.

Action completion will involve the action owner submitting evidence, to bevalidated by the Quality Governance Department and approved by the executivelead.

Monthly reporting will be in place to the Quality and Safety Sub-committee,Business Development and Delivery Sub-committee and People Sub-committee,with bi-monthly reporting to the Quality Committee (and through that reporting toTrust Board).

The Effectiveness and Experience Delivery group, chaired by the AssociateDirector of Safety and Quality Governance, will oversee on a monthly basis andin detail the delivery of the action plan.

3.2 Any actions moving “overdue” or identified as “at risk” of delivery will trigger a summit meeting with the Executive Director of Nursing and Quality, Deputy Director of Nursing and Associate Director of Safety and Quality Governance along with the action owner and executive lead. The outcome will be reported through the framework mentioned above to the appropriate sub-committee with immediate escalation to the Executive Director Group if needed.

3.3 The CQC will be kept informed of progress through monthly engagement meetings attended by the CQC local inspection team, Executive Director of Nursing and Quality and Associate Director of Safety and Quality Governance (using the same report that is presented to the Quality and Safety Sub-committee).

3.4 It is being proposed that commissioners and other stakeholders will be kept informed of progress through a specially convened quality improvement board (using the same report that is presented to the Quality Committee). Discussion is underway with NHS Improvement to enact this.

4.0 NEXT ITERATION OF THE QUALITY PLAN

4.1 The Quality Plan for 2017/18 was developed to meet the requirements of the CQC inspection in 2016 using a quality improvement approach to the issues identified. As such, a decision was taken not to have a specific CQC action plan. It is planned that, following this inspection, a CQC plan is developed (which references other work where appropriate) and that the Quality Plan be refreshed into a three year plan looking at longer term quality improvements (linked to Trust development and transformation plans). A refreshed plan will be developed during quarter one for review by the Quality Committee.

5.0 CONCLUSION AND RECOMMENDATIONS

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5.1 The Council of Governors is asked to note this report.

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APPENDIX 1 – CQC Ratings

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Council of Governor’s Quality & Assurance Committee Chairs Report

Date 20 June 2018

Chair Phil Curwen, Deputy Lead Governor

Member(s) in attendance Yvonne Guilfoyle, Staff Governor

Helen Scott, Staff Governor

Paul Graham – Public Governor

Christine Cartwright – Public Governor

Mary Jackson, Public Governor

Ken Lowe, Public Governor

NED(s) / Other attendance Viv Prentice, Deputy Company Secretary

Katie Sharples, Corporate Governance Support

Ian Cheung, Head of Performance

Julia Possener, Non-Executive Director

SUMMARY

The Head of Performance was in attendance to provide the Committee with a summary of the key quality and performance indicators for the end of Q4 2017/18. Key highlights from the report were outlined which included the achievement of all NHSI metrics, this was despite the challenges experienced with the EIS service.

In terms of people and leadership, the Committee noted that there would be an increased focus on agency spend, sickness absence and PDRs. Following the staff survey, the Committee noted that further work would be undertaken in respect of PDRs including the need for meaningful conversations to take place. In addition, the importance of having protected time for PDRs was noted.

A discussion was held regarding the use of 136 suites, funding and the need for collaborative working with the police.

Non-Executive Director, Julia Possener provided an overview of the activity undertaken by the Board’s Committees during the previous quarter.

The Clinical Director from the Community and Wellbeing Network was in attendance to provide an update in respect of patient activation and confirmed that the idea of people self-caring and self-managing their conditions is something that is really important. As many of the services within the Network provide care to people with long term conditions, the patient activation measure is something the Trust is looking to adopt across the whole of the organisation, both in mental and physical health.

The revised terms of Reference for 2018/19 that had been updated following the appointment of the newly elected governors were approved.

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Report Title Changes to the Constitution


Prepared by Jo Alker, Company Secretary



Supporting Executive Director Chief Executive PURPOSE OF THE REPORT: Report purpose The purpose of this report is to provide Governors with

proposed changes to both the Constitution and the Board of Directors Standing Orders as a result of the changes amongst the Executive team.

Strategic Objective(s) this work supports To provide high quality services

CQC domain Well-led 1.0 INTRODUCTION

The current composition of the LCFT Board of Directors is one Non-Executive Chair, five Non-Executive Directors, and five Executive Directors. Other Directors attend the Board on a regular basis but are non-voting. A separate communication has been sent out to Governors detailing the changes to the Executive team and this paper describes the changes that are required to the Constitution as a result of this.

In line with the Health & Social Care Act 2012, changes to the Constitution require approval by the Board of Directors and the Council of Governors to be enacted.

2.0 PROPOSED CHANGES

Communication has gone out to staff and governors about changes amongst the Executive team to further strengthen our capacity, particularly responding to the outcome of the recent CQC inspection and staff survey.

The current role of the Trust’s Chief Operating Officer (COO) spans both operational and service development. The changes will see the role split with Sue Moore (our current COO), maintaining responsibility for service development but will see a strengthened focus on leading new models of care developments, external partnerships and new business. A new appointment will be made to the position of Director of Operations who will have responsibility for the operational delivery and management of the networks.

The Board also recognises the importance and focus needed on the Trust’s workforce and will be making the Director of HR a voting position on the Board (currently non-voting).

These changes mean a move from five Executive Directors to seven and this requires a change to the Trust’s Constitution. To maintain parity on the Board, this also means an increase in Non-Executive Directors from five to six, however the Constitution already allows for this increase.

Governors will note that the changes result in an equal number of Non-Executive Directors (including the Chair) and Executive Directors. In the event of a vote at the Board, the Chair will have the second and casting vote. This has been specified in the standing orders that are appended to the Trust’s Constitution.

Extracted at appendix one are the proposed changes to both the Constitution and the Board of Directors Standing Orders.

3.0 COUNCIL OF GOVERNORS ACTION

The Council is asked to approve the changes proposed at appendix one.

APPENDIX ONE

Extract from the Trust’s Constitution

1. Board of Directors - composition

1.1 The trust is to have a Board of Directors to manage the business of the trust and to exercise all powers of the trust (subject to any contrary provisions in the 2006 Act and/or this constitution), which shall comprise both executive and non-executive directors.

1.2 The Board of Directors is to comprise:

1.2.1 a non-executive Chair;

1.2.2 a minimum of five (5) , but no more than six (6) other non-executive directors; and

1.2.3 a minimum of five (5), but no more than six (6) seven (7) executive directors.

1.3 In the event of a vote, the Chair shall have the casting vote.

1.4 One of the executive directors shall be the Chief Executive

1.5 The Chief Executive shall be the Accounting Officer.

1.6 One of the executive directors shall be the finance director.

1.7 One of the executive directors is to be a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984).

1.8 One of the executive directors is to be a registered nurse or a registered midwife.

Extract from Board of Directors Standing Orders

1.1. Voting

1.1.1. Save as otherwise specified in this Constitution, decisions at meetings shall

be determined by a majority of the votes of the Directors present and voting.

In the case of any equality of votes, and as the composi t ion of the

Board detai led in th is Const i tut ion provides for par i ty between

execut ive and non-executive directors, the Chair, or, in his absence,

the person appointed to preside in accordance with 4.5 shall have a second

and casting vote. No resolution of the Board of Directors shall be passed if it

is opposed by all of the Non-Executive Directors present or by all of the

Executive Directors present.

1.1.2. All decisions put to the vote shall, at the discretion of the Chair of the meeting, be

determined by oral expression or by a show of hands. A paper ballot may also

be used if a majority of the Directors present so request or if the Chair so directs.

1.1.3. If at least one-third of the Directors present so request, the voting (other

than by paper ballot) on any question may be recorded to show how each

Director present voted or abstained.

1.1.4. If a Director so requests, her vote shall be recorded by name upon any vote

(other than by paper ballot).

1.1.5. In no circumstances may an absent Director vote by proxy.

Subject to paragraph 4.14.4, absence is defined as being absent at the time of the

vote.

1.1.6. An officer who has been appointed formally by the Board of Directors to act

up for an Executive Director during a period of incapacity or temporarily to fill

an Executive Director vacancy, shall be entitled to exercise the voting rights of

the Executive Director. An Officer attending the Board of Directors to represent

an Executive Director during a period of incapacity or temporary absence

without formal acting up status may not exercise the voting rights of the

Executive Director. An Officer’s status when attending a meeting shall be

recorded in the minutes.



Report Title Fit and Proper Person Declaration


Prepared by Viv Prentice, Deputy Company Secretary



Supporting Executive Director Chief Executive


Report purpose To note the Fit and Proper Persons declaration for Governors

Strategic Objective(s) this work supports

To provide high quality services

CQC domain Well-led

1. INTRODUCTIONThe Trust’s Provider Licence requires all Governors to be fit and proper in order to hold a publicoffice. Governors are therefore required to complete a declaration on an annual basis in line withthe practice undertaken by the Board of Directors. Governors have provided their completeddeclarations and the current position is highlighted for noting below.

The central register is held centrally in the Trust’s HR department.

It should be noted that should a governor become aware at any point in the year that they havebecome an ‘unfit person’, this must be declared to the Trust at the earliest opportunity. Thegovernor would then have to permanently vacate their office.

2. RECOMMENDATIONThe Council of Governors is asked to note the Fit and Proper Declaration for Governors.

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Name Constituency FPP Completed

Public Governors

Alan Ravenscroft Pennine Lancashire Yes

Christopher Johnson Pennine Lancashire Yes

Paul Graham Pennine Lancashire Yes

Keith Holt Fylde Coast Yes

Katharine Wykes Fylde Coast Yes

Julia Kay Horn Out of Area Yes

Lorena Dumitrache Central Lancashire Yes

Bernadette Ashton Central Lancashire Pending

Phil Curwen Central Lancashire Yes

Christine Cartwright Central Lancashire Yes

Chris Burgess West Lancashire Yes

Ken Lowe West Lancashire Yes

Michael Helm North Lancashire & South Cumbria Yes

Mary Jackson North Lancashire & South Cumbria Yes

John Walden North Lancashire & South Cumbria Yes

Staff Governors

Emma Allen Staff - Corporate Yes

Adnan Gharib-Omar Staff - Medical Yes

Yvonne Guilfoyle Staff - Nursing Yes

Judy Laing Staff - Nursing Yes

Helen Scott Staff - Nursing Yes

Sallyann Walker Staff - Other clinical and social care professionals Yes

Geraldine Gasson Staff - Administrative and Clinical Yes

Appointed Governors

Teresa Jennings N Compass Yes

Debbie Wisby UCLaN Yes

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