Agenda Council of Governors 26.02.15 Page 1 of 2
MEETING OF THE COUNCIL OF GOVERNORS
A Meeting to be held in public on Thursday 26 February 2015 at the Wigan Investment Centre, Waterside Drive, Wigan, WN3 5BA
Commencing at 1.30pm
There will be a get together for Governors to meet prior to the meeting between 1pm and 1.30pm where tea, coffee and sandwiches will be served,
with the Council of Governors meeting commencing at 1.30pm
A G E N D A
Item No
Agenda Item
Time
Duration Enclosure
15/01
Apologies for Absence & Welcome
1.30
5 min
Verbal
15/02 Declaration of Interest in Agenda items (Bernard Pilkington, Chairman)
1.35 2 mins Verbal
15/03 Register of Interests (Chairman)
1.37 5 mins Verbal
15/04 Minutes of Council of Governors meeting held on 18 November 2014
(Chairman) 1.42 5 mins
15/05 Matrix Action Log (Chairman)
1.47 5 mins
15/06 Chairman’s Report To include Governor Elections Update
(Chairman)
1.52 10mins
Quality and Performance:
15/07 Business Report and Questions (Simon Barber, Chief Executive)
2.02 20 mins
Papers and Decisions Required
15/08
Minutes from the Governor’s Assurance Committee meeting held on 2 September 2014and verbal update of the meeting held on 15 December 2014
(Alan Griffiths Committee Chair)
2.22 10mins
15/09
Minutes from the Membership and Communications Committee meeting held on 9 September 2014 and a verbal update from the meeting held on 8 December 2014, to include Terms of Reference Review
(Chris Whittle Committee Chair)
2.32
10 mins
Agenda Council of Governors 26.02.15 Page 2 of 2
15/10 Election of Lead Governor BREAK Presentations & Discussions:
(Chairman)
2.42 2.52
10 mins
10 mins
Verbal
15/11
15/12
Annual Plan Quality Account Audit 2014/15 and Quality Priorities 2015/16
(Donna Sandiford) Assistant Director of Strategy and Performance) (Tracy Hill, Director of People and Integrated Governance & Pat Drohan, Complaints and Litigation Lead, Integrated Governance)
3.05 3.25
20 mins 30 mins
Presentation
Paper, Presentation &
discussion
Meeting Close 4.00
Date of next meeting 20 May 2015 The Foundry Lugsdale Road Widnes WA8 6DA
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 1 of 8
Minutes of the Council of Governors’ Meeting held on Tuesday 18 November 2014 at
The World of Glass, Chalon Way East, St Helens, Merseyside, WA10 1BX
Commencing at 1.30pm
NAME DESCRIPTION PRESENT APOLOGIES
Peter Ashley Warrington Constituency
Sarah Hall Warrington Constituency James Leicester Warrington Constituency
Michael Mackenzie Warrington Constituency
Christine Molyneux Warrington Constituency
John Chiocchi Halton Constituency
Bill Jackson Halton Constituency
Joan Jackson Halton Constituency Jacqui McGloin Halton Constituency Bill Bradbury St Helens Constituency
Alan Griffiths St Helens Constituency
Jeff Hext St Helens Constituency
John Richards St Helens Constituency
Ron Rotheram Knowsley Constituency
Mandy Strode Knowsley Constituency
Chris Whittle Knowsley Constituency
Oliver Parke Wigan Constituency
Norman Bradbury Wigan Constituency
John Brennan Wigan Constituency
Frank Jones Wigan Constituency
Jean Garlick Wigan Constituency
Sheila Ratcliffe Wigan Constituency Sue Rimmer Wigan Constituency Alan Slater Wigan Constituency Denis McFarland Other Constituency
Kathryn Critchley Staff – Supporting Services
Donna Hargreaves Staff – Supporting Services
Charlie Leonard Staff – Supporting Services
Wendy Mitchell Staff – Supporting Services
Neil Powell Staff – Managers
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 2 of 8
NAME DESCRIPTION PRESENT APOLOGIES
Neil Callan Staff – Nursing
Gary Lamph Staff – Nursing
Adrianne Roberts Staff – Nursing Sandeep Ranote Staff – Medical
Cecelia Barber Staff – Allied Professions
Kaye Cunliffe Staff – Allied Professions Cllr Marie Wright Appointed – Halton Council Cllr Norman Hogg Appointed – Knowsley Borough
Council
Cllr Joe Pearson Appointed - St Helens Council
Cllr Susan Loudon Appointed - Wigan Borough Council
Cllr Pat Wright Appointed - Warrington Borough Council
Ann Cunliffe Appointed - Staff Side Representative
Vacant Appointed - St Helens Clinical Commissioning Group
Dr Andy Pryce Appointed - Knowsley Clinical Commissioning Group
Dr Mike Dennis Appointed - Warrington Clinical Commissioning Group
Dr Tony Ellis Appointed – Wigan Clinical Commissioning Group
IN ATTENDANCE
Bernard Pilkington Chairman
Sam Proffitt Chief Finance Officer
Derek Taylor Non Executive Director
Steve Hull Assistant Director for Nursing and Safeguarding
Lesley Pennington Assistant Company Secretary
Gemma Currall Membership Manager
NO MINUTES ACTION
1.
1.
2.
3.
14/56 Apologies for Absence As above. Mr Pilkington welcomed the new Governors, in attendance at the meeting, following the recent election; Mr Alan Slater and Mrs Sue Rimmer, public constituency of Wigan, Mr Denis McFarland, ‘Other’ public constituency, Ms Wendy Mitchell, Staff Supporting Services and Ms Kaye Cunliffe, Allied Health Professionals.
2.
14/57 Declaration of Interest in Agenda Items
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 3 of 8
4. None were declared.
3.
5.
6.
14/58 Register of Interests Mr Bernard Pilkington, Chairman, reminded Governors of the requirement to complete the 2014/15 Register of Interests Form and return completed forms to the Company Secretary’s Office. Additional copies of the Register of Interests forms were available at the meeting.
4.
7.
14/59 Minutes of Council of Governors meeting held on 15 September 2014 The minutes of the previous meeting held on 15 September 2014 were accepted as a true and accurate record of the meeting.
5.
8.
9.
10.
14/60 Matrix Action Log Mr Pilkington reminded Governors that they were welcome to attend and observe the Trust Board meetings. All Governors had previously been invited to attend at least one Trust Board meeting during 2014. Mr Pilkington requested that Governors wishing to attend the last meeting of 2014 contact Mrs Pennington, Assistant Company Secretary, to confirm their attendance. Mr Pilkington also advised the Council of Governors that a list of 2015 Trust Board dates would be issued in December and requested that Governors contact the Company Secretary’s Office to confirm which meeting they wished to attend in 2015. All actions with a due date of 18 November 2014 were complete.
Action: Council of Governors
7.
11.
12.
13.
14.
15.
14/61 Chairman’s Report The Chairman had included a written report with the papers and referred to the following: Local Authority Stakeholder meetings were taking place with Council representatives on a regular basis. Mr Pilkington explained that these meetings had been very positive and demonstrated strong partnership working and had led to closer working relationships with Local Authority colleagues. Mr Pilkington provided an update on the recent Elections to the Council of Governors that had taken place. In addition to the new Governors who were in attendance at today’s meeting, Mr Pilkington also welcomed Ms Jacqui McGloin, public Governor for Halton and Mr Frank Jones, who had successfully been re-elected as a public Governor for Wigan. Mr Pilkington passed on his thanks to Mr Steven Darbyshire, public
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 4 of 8
16.
17.
constituency of Wigan, Mrs Susan Bradfield-Smith, public constituency of Halton and Ms Diane French, Staff Supporting Services, who had decided not to stand again for the role of Governor at the end of their tenure. The Chairman advised the Council of Governors that there would be a larger end of tenure election which would take place in early 2015 and that nominations would open on 10 December 2014 for nominations in the five public constituencies of Halton, Knowsley, St Helens, Warrington and Wigan and the staff classifications of Manager (above Band 8), Medical, Nursing and Supporting Services. Mr Pilkington explained to the Governors that a wide variety of communication tools would be used to promote the Election to all staff and public members and that further information and nomination forms would be available on the Trust’s website from December. Mr Pilkington agreed to provide an update on the forthcoming Election at the February 2015 Council of Governors’ meeting.
Action: Chairman
8.
18.
19.
20.
21.
22.
23.
14/62 Business Report and Questions Ms Sam Proffitt, the Chief Financial Officer, presented the Business report. Financial Dashboard The Trust was forecasting a surplus of £4m at Year End, which would facilitate future capital investment projects. There was a slight variance at month six and Ms Proffitt explained that some pressures had emerged, however these were being managed and the Trust was forecasting to meet the surplus at Year End. Capital Expenditure Ms Proffitt advised the Council of Governors that following Monitor’s request to review the Trust’s plans for the Leigh New Build, that there had been a slight slip in terms of expenditure owing to this delay. Monitor’s work on the project was now complete and land improvement works had commenced. Cash Flow The Trust was slightly below profile against surplus, but expected to meet the forecast by the end of the year. Cost Improvement Programme (CIP) Ms Proffitt advised Governors that all NHS Trusts had a challenging savings plan and explained that the Trust was looking at how we could continue to deliver these savings over the next five years through transformational ideas and exploring new opportunities. Ms Proffitt reminded the Council that all Trust CIP programmes are clinically assessed to ensure that quality of service is not impacted and that services continue to be delivered safely. Monitor Continuity of Service Risk Raking, Debt Service Cover Rating and Liquidity Rating
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 5 of 8
24.
25.
26.
27.
28.
29.
30.
31.
The Trust had achieved a maximum score of 4 for Debt Service Cover Rating and Continuity of Service Risk Rating and a high score of 3 for Liquidity Rating. Ms Proffitt explained that the Liquidity Rating score was expected to return to a score of 4 by Year End. Ms Proffitt also advised the Council of Governors that these scores may change in the future should debt need to be raised in relation to the new build in Leigh. Quality Measures – Compliance Framework All indicators were reporting green, except meeting commitment to serve new psychosis cases by early intervention teams. Ms Proffitt advised the Council that in Quarter 2 the Trust was slightly under target for this measure but that the intervention teams were working hard to identify new cases against this target. Ms Proffitt also explained that the Delayed Discharge measure, although on target, was being monitored closely by the Trust, as work continued with other agencies to achieve this target. Care Quality Commission/Objectives/CQUINS The majority of Strategic Objectives were currently showing green with two showing as amber. Ms Proffitt explained that one of the objectives showing as amber was in relation to the implementation of the new clinical information system which was still slightly behind schedule and that extra resources had been allocated to this project, which was still on schedule to deliver, but there had been a small slippage in delivery timescales. The majority of the Commissioning for Quality and Innovation (CQUINS) indicators were currently on track and showing as green. The two amber indicators reflected where there had been some slippage in achieving the Falls indicator and that the team was working hard to address this. A number of questions were raised and answered at the meeting regarding the Business Report: A question was asked by the Governors in relation to the large increase in Capital Expenditure between P5 & P6. Ms Proffitt, confirmed that this rise was due to the purchase of the land for the Leigh New Build, which was in line with planned expenditure. Governors asked for more information on the Delayed discharge CQUIN target as to whether it was a problem in specific boroughs, and had this issue been raised with our Commissioners? Ms Proffitt explained that the Trust continued to work with the Local Authority and Clinical Commissioning Groups (CCG) to look at solutions in the boroughs where this was an issue. A question was also asked in relation to the use of agency staff within the Trust. Ms Proffitt explained that the Trust does use some bank staff for intensive support on the wards and advised the Council that the use of Locums is quite low as there is a high level of substantive posts
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 6 of 8
32.
33.
within the Trust. Governors requested further information on the Transformational schemes that the Trust was currently undertaking. Ms Proffitt explained that the Trust, like other NHS Trusts, was tasked with delivering continued efficiency savings. The Trust had set out its vision for how the Corporate Service Teams could better support the Operational Teams, through the use of better technology, to help deliver an improved service to patients, service users and carers. Ms Proffitt advised the Governors that the Trust had undertaken a review of the Corporate Services function; had conducted an engagement exercise with staff and was currently consulting with staff on this matter. A Governor also asked a question in relation to how the voluntary sector could work with the Trust to help keep people from being admitted into hospital, as part of a transformational project. Ms Proffitt advised the Governors that the Trust was looking at opportunities for collaborative work and had recently tendered for an Improving Access to Psychological Therapies (IAPT) service bid with the Voluntary Sector.
10.
34.
35.
36.
37.
38.
14/63 Nominations and Remuneration Committee Mr Bill Bradbury, public Governor for St Helens and member of the Nominations and Remuneration Committee, gave a verbal update from the Committee meeting held on 11 November 2014. In his update, Mr Bradbury informed the Council of Governors that the current Vice Chair, Dr Colin Dale, Non Executive Director, had indicated that he wished to step down from this role. At the meeting, the Committee had considered the appointment of a new Vice Chair from two Non Executive Directors who had both expressed an interest in the role. The Committee members had reviewed information presented by the Chairman, Mr Pilkington, in relation to clauses in the Trust’s Constitution, Monitor’s Code of Governance and details of the Terms of Office for both Non Executive Directors. Mr Bradbury advised the Council of Governors that following a detailed discussion against appointment criteria, the Committee agreed that both Non Executive Directors were worthy candidates, but recommended that Mrs Helen Bellairs, Non Executive Director, should be appointed to the role. The Council of Governors unanimously approved the recommendation from the Nominations and Remuneration Committee that Mrs Helen Bellairs, Non Executive Director, be appointed to the role of Vice Chair.
13.
39.
14/64 Progress Against Quality Priorities 2014/15 Mr Steve Hull, Assistant Director for Nursing and Safeguarding,
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 7 of 8
40.
41.
42.
provided a presentation to the Council on the progress against the 2014/15 Quality Priorities. Mr Hull provided background information on the wide range of engagement exercises that had been undertaken by the Trust to establish the priorities and explained that the three selected quality priorities would demonstrate improvement within the domains of safety, experience and effectiveness of Trust services. Progress against each of the three priorities was explained in detail; Quality Priority for Safety – Reduction in harm in relation to falls, violence, aggression and self harm; Quality Priority for Effectiveness; Care plans are person centred and involve service users and carers as appropriate; and Quality Priority for Experience – to communicate and implement our Culture of Care based on the 6Cs. Governors commented that it was important to involve carers in Care Plans. Mr Hull provided an update on a wide range of activities that had been undertaken by the Trust against each priority to date and Governors asked if further information regarding the achievement of the targets could be provided. It was agreed that this would be presented to Governors as part of the Year End review of 2014/15 Quality Priorities.
Action: Governance
Team
14.
43.
44.
45.
46.
14/65 Culture of Care Strategy Mr Hull provided a presentation to the Council of Governors on the Trust’s Culture of Care Strategy and explained how this linked to the Trust’s High Level Objectives. Mr Hull reminded the Council of the Trust’s Quality Definition and explained the principles and values of the Culture of Care. He also gave details of how the Trust was embedding the culture into the Trust, and building a portfolio of evidence of how 5BP is living the Culture of Care across the organisation. Details of how the Trust was introducing the Cultural Barometer, the Friends and Family Test and the 100 Care Makers was also provided to the Council of Governors. Governors discussed the presentation and asked a range of questions regarding the support offered to carers in embedding the Culture of Care Strategy across the Trust; the role of the Care Makers and how the Trust was ensuring that paperwork and procedures do not detract from the implementation of the Care Strategy. Mr Hull responded to each question and provided examples of Trust Culture of Care activity.
15.
47.
48.
14/66 Suicide Prevention Strategy Mr Hull gave a presentation on the Trust’s Suicide Prevention Strategy to the Council of Governors. Mr Hull provided background information on the formulation of the Suicide Prevention Strategy and the key actions against Year One of
Agenda Item CoG/15/04
15/04 Minutes of the Council of Governors meeting held on 18 November 2014 Page 8 of 8
49.
50.
51.
the Strategy which included the implementation of a specific Suicide Assessment Tool. Governors were advised that a Pilot Scheme for the Assessment Tool had been trialled with the Wigan Assessment Team. The Pilot had commenced in September 2014 and following positive feedback and evaluation of the Assessment Tool in October 2014, it was being rolled out in the other boroughs. Mr Hull provided information on the next steps in the implementation of the Suicide Prevention Strategy, including details of online training for staff. The Governors thanked Mr Hull for his three very informative presentations which had engendered a wide range of discussion throughout the meeting.
16.
52.
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55.
Date of next meeting: 26 February 2015 Wigan Investment Centre Waterside Drive Wigan WN3 5BA (Tea, coffee and sandwiches will be served from 1pm) A full schedule of 2015 Council of Governor and Committee meetings will be provided to Governors.
Assistant Company Secretary
Agenda Item COG/15/05
15/05 Matrix Action Log 26 February 2015
COUNCIL OF GOVERNORS’ MEETING MATRIX ACTION LOG
Ref: COUNCIL OF GOVERNORS 2014/15 DATE: 26 February 2015 Meeting Date:
Item/subject: Decision taken and/or Action required:
Product:
Responsible Person:
Deadline:
Complete
18 Nov 2014
Trust Board dates Governors to confirm the date of the 2015 Trust Board meeting they wish to attend
Matrix attendance schedule
CoG February 2015
On Agenda
18 Nov 2014
Council of Governor Elections To provide an update on the Council of Governor Election at the February 2015 Council of Governors’ meeting.
Report Chairman February 2015
On Agenda
18 Nov 2014
Quality Priorities 2014/15 Provide a presentation on the achievement of targets as part of the Year End review of 2014/15 Quality Priorities
Presentation Governance Team
May 2015 Not Due
18 Nov 2014
2015 Governor Meetings Provide a full schedule of 2015 Council of Governor and Committee meetings to Governors
Meeting List Assistant Company Secretary
December 2014
Yes
15 Sept 2014
Business Report – Quality Measures Governors Assurance Committee to consider quality measures reporting to Council of Governors
Business Report Quality Measures Report
Governors Assurance Committee
March 2015
Not Due
15 Sept 2014
Effectiveness Review To provide feedback to Council of Governors on recommendations from Effectiveness Review
Item at Council of Governors Meeting
JTH/JF March 2014
Not Due
Agenda Item COG/15/05
15/05 Matrix Action Log 26 February 2015
COUNCIL OF GOVERNORS MEETING MATRIX ACTION LOG
ARCHIVE Ref: COUNCIL OF GOVERNORS 2014/15 DATE: 26 February 2015
Meeting Date:
Item/subject: Decision taken and/or Action required:
Product:
Responsible Person:
Deadline:
Complete
15 Sept 2014
Governors Assurance Committee To provide a copy of the Assurance presentation to Governors with 15.09.14 meeting minutes
Presentation slides LP November 2014
Complete
12May 2014
Trust Board dates Governors to confirm the date of the 2014 Trust Board meeting they wish to attend
Matrix attendance schedule
CoG December 2014
Complete
12May 2014
Culture of Care Presentation Invite the Director of Nursing and Quality to make a presentation at Council of Governors Meeting
Presentation LP November 2014
Complete
15 Sept 2014
Question Time To pass on Council of Governors thanks to staff at Taylor Ward
Letter LP November 2014
Complete
12 May 2014
2004/15 Register of Interests Form Governors to complete and return Register of Interests 2014/15
Register of Interests 2004/15
CoG December 2014
Complete
12May 2014
Governor Training Day 21 May 2014 Governors to confirm their attendance at the Governor Training Day on 21/05/14 with Company Secretary Office
Attendance List CoG May 2014 Complete
12May 2014
Staff Recognition Awards Governors to confirm their attendance at the Trust’s Staff Recognition Awards on 19/06/14 with Company Secretary Office
Attendance List CoG June 2014 Complete
12 May 2014
New Code of Conduct to be completed Governors to complete and return Code of Conduct 2014/15
Code of Conduct 2014/15
CoG May 2014 Complete
Agenda Item COG/15/05
15/05 Matrix Action Log 26 February 2015
12May 2014
Membership Stand at DAD Day Governors to contact Company Secretary Office if available to staff membership stand on 13/07/14
Membership Stand CoG July 2014 Complete
12May 2014
Insight Magazine Invite Gold Members to join editorial panel for Insight Magazine
MACC Committee Agenda Item
MACC September 2014
Complete
18 March 2014
Trust Board dates Member Councillors to confirm the date of the 2014 Trust Board meeting they wish to attend
Matrix attendance schedule
ALL September 14
Complete
18 March 2014
Changes to Constitution Company Secretary to send new Constitution to Monitor
Constitution JTH May 14 Complete
18 March 2014
Attendance at Council of Members meetings
Chairman to write to Member Councillors with low attendance at Council of Member meetings
Letter BP May 2014 Complete
18 March 2014
Code of Conduct/Register of Interests Copies of 2004/15 forms to be sent to Member Councillors not in attendance at 18.03.14 Council of Members meeting
Forms issued LP May 2014 Complete
18 March 2014
New Code of Conduct to be completed Member Councillors to complete and return Code of Conduct 2014/15
Code of Conduct 2014/15
ALL May 2014 Complete
18 March 2014
New Register of Interests to be completed
Member Councillors to complete and return Register of Interests 2014/15
Register of Interests 2004/15
ALL May 2014 Complete
11Feb 2014
Trust Board dates Member Councillors to confirm the date of the 2014 Trust Board meeting they wish to attend
Matrix attendance schedule
ALL April 2014 Complete
11Feb 2014
Quorum at Council of Members Meetings
Chairman and Senior Council Member to write to all Member Councillors regarding attendance at Council of Member meetings
Letter CP/CW February 2014
Complete
11Feb 2014
Add deferred Items from 11 February Meeting to next meeting agenda
14/09 Update from the Nominations and Remuneration Committee 14/12 Change to Constitution 14/13 Election to the Council of Members
Agenda Item LP May 2014 Complete
Agenda Item N
o.
COG (15/06)
15/06 Chairman’s Report – Council of Governors 26 February 2015 Page 1 of 4
COUNCIL OF GOVERNORS REPORT
_________________________________________________________________ DATE OF MEETING
26 February 2015
TITLE OF REPORT
Chairman’s Report
AGENDA ITEM NUMBER
COG/15/06
REPORT PRESENTED BY
Bernard Pilkington, Chairman
PURPOSE OF REPORT
To give the Council of Governors an overview of meetings attended by the Chairman since the Council of Governors meeting held on 18 November 2014 and an update on the current election to the Council of Governors
RECOMMENDATION TO THE COUNCIL OF GOVERNORS
The Council of Governors notes the contents of this report
Agenda Item N
o.
COG (15/06)
15/06 Chairman’s Report – Council of Governors 26 February 2015 Page 2 of 4
Chairman’s Report
1. MEETINGS ATTENDED / INFORMATION
Adult Mental Health Services – Service User Carer Forum On the 1 December 2014, I attended the Adult Service User Carer Forum at the Orford Jubilee Hub, Warrington Chairman’s Chat On the 3 December 2014, I held a Chairman’s chat with members of the Council of Governors. The meeting was well attended and provided a good opportunity to discuss matters of mutual interest in an informal way with Governors.
Knowsley Recovery Team Promotional Event On the 8 December 2014, I visited the Knowsley Recovery Team at the Huyton Core & Cluster Rehab Centre, Yew Trees Centre, Huyton. Later Life and Memory Services – Service User and Carer Forum On 11 December 2014, I attended the Later Life and Memory Services Forum at the Old Schoolhouse, St John's Road, Huyton. Staff Study Achievement Awards On the 12 December 2014, I presented Staff Study Achievement Awards to 22 of the Trust’s staff who have qualified with accredited study within the last six months. Chairman’s Christmas Visits Throughout December 2014, I held my Christmas visits to staff within some of the 5 Boroughs Operational Teams and accompanied by Allan Chan and Derek Taylor, Non Executive Directors, on visits to St Chad’s Clinic and the Later Life and Memory Service, I met our staff based at:
Huyton Core & Cluster Rehab Centre, Yew Trees Centre, Huyton
A & E Liaison, Whiston Hospital
St Chad’s Clinic (Walk-In Centre), Kirkby
Later Life and Memory Service, Wigan
Wigan Child and Family Helping Hands Centre, Wigan
Wigan RAID Team, Royal Albert Edward Infirmary, Wigan The Non Executive Directors and I were very impressed by the staff we met during the visits. They were very experienced and demonstrated a great deal of commitment and dedication to our patients and service users.
Agenda Item N
o.
COG (15/06)
15/06 Chairman’s Report – Council of Governors 26 February 2015 Page 3 of 4
Prospective Governor Event On 7 January 2015, I attended a meeting for prospective Governors held in the Education Centre at Hollins Park. Presentations were given to members interested in finding out more about the Trust and the role of the Governors in relation to the Council of Governors’ Elections. Wigan Borough Council Stakeholder meeting On the 21 January 2015, I attended the above meeting at Wigan Town Hall. The meeting was held as part of the schedule of regular stakeholder meetings that I attend with Mr Simon Barber, Chief Executive. The meeting was very positive. Adult Mental Health Services – Service User and Carer Forum On the 2 February 2015, I attended the Adult Service User Carer Forum at Hollins Park, Winwick St Helens Clinical Commissioning Group On the 11 February 2015, I met with Mr Geoffrey Appleton, the new Lay Chair of the St Helens Clinical Commissioning Group (CCG) and invited him to meet with our staff and tour the facilities of the Peasley Cross Hospital, St Helens. As part of this meeting, Mr Appleton met with Managers, Team Leaders, staff and patients across a range of Trust services at the Hospital and he was extremely impressed with the professionalism demonstrated by our staff. Advancing Quality Alliance (AQuA) Faculty visit On the 12 February 2015, myself and members of the Board attended a quality and safety session with Mr David Fillingham, AQuA’s Chief Executive and Mr Jamie Orlikoff, an International Patient Safety and Quality expert to review our AQuA Plan and discuss how the Plan could be developed. Learning Disability Services – Service User and Carer Forum On 16 February 2015, I attended the Learning Disability Services Forum at Hollins Park, Winwick.
2. ELECTION TO COUNCIL OF GOVERNORS
The Trust, through Electoral Reform Services, (appointed as the Trust’s independent election company), is holding elections for Council of Governors of the 5 Boroughs Partnership NHS Foundation Trust.
Agenda Item N
o.
COG (15/06)
15/06 Chairman’s Report – Council of Governors 26 February 2015 Page 4 of 4
Nominations opened on 10 December 2014 and the closing date deadline for nominations was 16 January 2015. The following members have been elected to the Council of Governors: 2.1 Unopposed Governor Nominations: Halton Bill Jackson Knowsley Chris Whittle Warrington Michael Ashley Peter Ashley
Christian Hugo Michael Mackenzie
Wigan Trevor Barton John Brennan Sheila Ratcliffe Staff: Managers (Above Band 8) Jackie Hughes Staff: Medical Dr Marian Catalan Staff: Supporting Services Brian Cross 2.2 Public Governor Election: Seven nominations were received for the two St Helens public Governor vacancies and an election is currently underway in this constituency. The closing date for the St Helens election is Thursday 26 February 2015. Bernard Pilkington Chairman
Council of Members Meeting
Date: 15 March 2011
Chairman’s Report
Presented by: Bernard Pilkington
Date: 15 March 2011
Business Report and Questions
Presented by: Simon Barber, Chief Executive
26 February 2015
Financial Dashboard
Financial Dashboard Monitor Risk Ratings
Annual Month 10 Month12
Accounts Actual Forecast
2013/14 2014/15 2014/15
% Score Score Score
Debt Service Cover Rating 50 4 4 4
Liquidity Rating 50 4 4 4
Continuity of Service Risk Rating 100 4 4 4
WeightFinancial Criteria
Quality Measures – Compliance Framework
Qtr 1 Qtr 2 Oct-14 Nov-14 Dec-14 Qtr 3 Jan-15 3 Month Trend Arrow
a) % Seen within 4 Hours 95% 99.91% 99.89% 100.00% 99.86% 99.88% 99.91% 99.97%
96.1% 97.3% 95.4% 97.0% 94.0% 95.5% 94.7%
(546/568) (571/587) (188/197) (196/202) (173/184) (557/583) (178/188)
(b) having formal review within 12 months Snapshot position - Oct 13 onwards Quarterly 95% 99.9% 99.8% 99.9% 99.9% 100.0% 100.0% 100.0%
Monitor RAF Guidance Quarterly <7.5% 1.0 5.3% 5.5% 6.9% 5.1% 10.1% 7.3% 9.3%
Care Quality Commission Periodic Review Quarterly 95% 1.0 100.0% 99.8% 96.5% 98.9% 97.2% 97.6% 98.1%
Department of Health Quarterly Omnibus
SurveyQuarterly
95%*
(143 cases)0.5 101.8% 83.9% 87.1% 99.7% 99.2% 99.2% 97.4%
Quarterly 99% 0.5 99.9% 99.9% 99.9% 99.8% 99.8% 99.8% 99.8% ↔a) % open patients on CPA with a valid
employment statusSnapshot position - Oct 13 onwards Quarterly 87.0% 89.6% 89.2% 90.0% 90.8% 90.8% 90.8%
b) % open patients on CPA with a valid
accommodation statusSnapshot position - Oct 13 onwards Quarterly 99.5% 99.4% 99.4% 99.5% 99.4% 99.4% 99.4%
c) % open patients on CPA having HoNOS
assessment in past 12 monthsQuarterly 71.9% 73.4% 72.1% 73.0% 72.9% 72.9% 74.3%
Care Quality Commission Periodic Review Annual n/a 0.5 COMPLIANT COMPLIANT COMPLIANT COMPLIANT COMPLIANT COMPLIANT COMPLIANT
i) Referral to Treatment Times - AHP Lead in the
Community
a) % of Patients on an AHP Pathway with a
valid start date
b) % of Patients on an AHP Pathway with a
valid end date
c) % of Patients on an AHP Pathway with a
valid status
no threshold not applicable not applicable not applicable not applicable not applicable not applicable not applicable
ii) Community Treatment Activity - Referrals
a) % of Referrals logged within PARIS with a
valid priority code
b) % of Referrals logged within PARIS with a
valid reason for referral code
c) % of Closed Referrals within PARIS with a
date of closure completed
no threshold 63.2% 63.2% 62.5% 62.0% 61.7% 62.3% 65.0%
iii) Community treatment activity – care contact
activity
a) % of face to face contacts with a valid
location type
b) % of face to face contacts with a valid care
professional staff group
no threshold 99.9% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% ↔
Weighting
Admissions to inpatient services had access to crisis resolution home
treatment teams
Indicators Data SourceReporting
FrequencyThresholds
A&E 1.0
Care Programme
Approach (CPA) patients
Either of the following
indicators
1.0
Department of Health Quarterly Omnibus
SurveyQuarterly
(a) receiving follow-up contact within seven days
of discharge OR95%
Minimising delayed transfers of care
New Risk Assessment Framework Guidance
Data completeness:
Community Care Activity50% 1.0
Meeting commitment to serve new psychosis cases by early
intervention teams
Data completeness: identifiers
Data completeness:
outcomes50% 0.5
Self-certification against compliance with requirements regarding
access to healthcare for people with a learning disability
Care Quality Commission / Objectives / CQUIN
CQC QRP Rating- Self Declaration
high red
low red
high
amber
Worse than
expected
low amber
Tending towards
worse than
expected
high
yelloe
Similar to
expected
low yellow
Tending towards
better than
expected
high
green
Better than
expected
low greenMuch better than
expected
Much worse than
expected
Strategic Objectives CQUIN
Agenda Item No CoG 15/08
15/08 Minutes from Compliance with Authorisation Committee meeting 02.09.14 Page 1 of 3
COMPLIANCE WITH AUTHORISATION COMMITTEE
Notes of the Meeting held on 2 Sept 2014 Hollins Park Hospital, 14.00-16.00
Items
Action for
1. Present Alan Griffiths (Chair), Governor Gail Briers, Director of Nursing & Quality Chris Whittle, Governor Jane Taylor-Holmes, Company Secretary Adrienne Roberts, Staff Governor, Matron Frank Jones, Governor Jean Garlick, Governor Donna Hargreaves, Staff Governor James Leicester, Governor Sheila Ratcliffe, Governor Chloe Mckeown (notes) Apologies for Absence: Peter Ashley, Governor Lesley Pennington, Assistant Company Secretary Brian Marshall, Non-Executive Director Jeff Hext, Governor Sheila Ratcliffe was introduced as a new governor member for Leigh.
2. Previous Minutes: The previous minutes were read through for accuracy and agreed.
3. Action Matrix: All current open actions on September agenda.
4.
Monitoring Effectiveness – Jane Taylor-Holmes
Presentation given out & discussed, on the remit of the group, including Friends and Family Test, Safer Staffing, Complaints, Compliments, involvement of all members in the Annual Plan process.
Performance papers – Group does like to see prior to the Council of Governors meeting – to demonstrate assurance, responsibility and scrutiny.
Discussed groups role in the production of the Quality Accounts – responsibility of all governors to sign off, not just this group.
JTH welcomed any further suggestions on the remit to herself.
ToR to be approved at the next Council meeting on 15/9.
Workplan to be approved – agreed. Terms of Reference;
Name change officially agreed subject to approval at the Council of Governors meeting on 15/9/14.
Duties revised and agreed. Workplan;
To ensure an even spread of assurance and timelines across the year.
Add external inspections by exception.
Workplan agreed.
Agenda Item No CoG 15/08
15/08 Minutes from Compliance with Authorisation Committee meeting 02.09.14 Page 2 of 3
5. Trust Board Committees and structures – Gail Briers;
Have revised governance processes and team meeting structures. Presented for information.
Assurance links between the Audit Committee and the Quality Committee and the Trust Board defined, and the associated scrutiny meetings/business stream meetings.
Discussed management and leadership governance structure. Briefly touched on changes to the D.o.N’s portfolio to include clinical operations from December 2014.
Role of the divisional director in performance/CLG/CIP areas and future structure with corporate review changes imminent. Potential to change integrated working and strengthen relationships (e.g. St Helens/MIND).
Committee Handbook – to include all meeting ToRs, accountability and reporting mechanisms – in progress.
6. KPMG report on internal assurance – Chair;
Provided for information. KPMG are reporting Significant Assurance. No further comments raised.
7.
8.
Performance Data – Gail Briers – Highlights; (Performance summary sheets circulated in advance with the agenda)
CQC – All green, no issues.
CQUIN –Q1 all green to achieve against plan. Warrington highlighted separately as they have a single contract specific to them.
Finance – No issues to note. Question noted; “What does “private beds” mean in narrative?
SUI’s up in last 2 months. Summary report enclosed with details.
Monitor – all ok, re; delayed discharges transfer of care. Quality Account Update – Gail Briers;
Paper provided from August Quality Committee with full update position. No further comments raised at this time.
9. 10.
Serious Incidents summaries - Gail Briers;
As attached summary paper circulated with the agenda.
High number commissioned in July. Has been discussed and reported by the Quality Committee and Quality & Safety Committees. Focus on substance mis-use and risks.
15 more staff have undergone SI training.
No further questions or comments raised. Quality Committee summary – Gail Briers;
Summary papers were circulated with the agenda in advance, and no further questions or comments raised at the meeting.
Group would appreciate presentations on our services occasionally when agenda permits. Suggestions welcomed.
Staff uniforms – on-going discussions – operational issue (not QC remit).
Agenda Item No CoG 15/08
15/08 Minutes from Compliance with Authorisation Committee meeting 02.09.14 Page 3 of 3
11. 12. 13.
Audit Committee summary – Alan Griffiths (for Brian Marshall);
RiO project
Governance and compliance
Strategic objectives
Risk management updates
Financial/deb/salary overpayments.
Any Other Business:
December’s meeting date moved forward to 15 December due to apologies on 23
rd Dec.
Chris Whittle – St Helens/Young People/Self-harm radio feature. Health & Wellbeing boards aware re CAMHS services. Concerns have been raised and on-going talks happening in Knowsley Healthwatch, schools etc – for information.
Date of Next Meeting : 15 December 2014 – 1-3 pm, Rosetti Room, Hollins Park Hospital. Teas & coffees will be provided. Please send apologies to Chloe Mckeown Hard copy papers will be sent to all external members home addresses (as well as emailed) except where apologies have been given. Please bring these to the meeting.
Agenda Item No CoG 15/09
15/09 Minutes of Membership & Communications Meeting held on 9 September 2014 Page 1 of 4
Minutes of the Membership & Communications Committee held on Monday 9 September 2014
at Bronte Meeting Room, Hollins Park Main Hospital, Hollins Lane, Warrington, WA2 8WA
Commencing at 2.00pm
NAME DESCRIPTION PRESENT APOLOGIES
Cecelia Barber Staff – Allied Professions
Chris Whittle Knowsley Constituency
Donna Hargreaves Staff – Supporting Services
James Leicester Warrington Constituency
John Brennan Wigan Constituency
Mike Mackenzie Warrington Constituency
Peter Ashley Warrington Constituency Sheila Ratcliffe Wigan Constituency
IN ATTENDANCE
Dave Thompson Assistant Director of Inclusion & Partnerships
Derek Taylor Non Executive Director Gemma Currall Membership Manager Jane Taylor-Holmes Company Secretary Lesley Pennington Assistant Company Secretary Sophie Ellis Communications Officer Bernie Fitzpatrick Involvement Scheme Co-ordinator
NO MINUTES ACTION
14/28
1.
Apologies for Absence Apologies as above.
14/29
2.
Election of Committee Chair This item was deferred from the June meeting. Nominations were invited from members of the committee. The current Chair Chris Whittle put himself forward to stand again for the role. There were no other nominations. Mr Whittle’s nomination was seconded by the other members of the committee and Chris was unanimously elected as Chair of the committee for a further 12 months.
14/30
3.
Minutes of meeting held on 9 June 2014 The minutes were accepted as a true record of the meeting.
14/31
4.
Matrix Action Log
The committee reviewed the matrix action log. The expenses policy was
Agenda Item No CoG 15/09
15/09 Minutes of Membership & Communications Meeting held on 9 September 2014 Page 2 of 4
therefore complete and will be an agenda item at the Council of Governors meeting on 15 September.
14/32
5.
6.
7.
8.
9.
Governor Elections Mrs Pennington explained that ERS (Electoral Reform Services) have been appointed to run our forthcoming election. There are currently six public vacancies in the constituencies of Halton (1), Knowsley (1), Wigan (3) and Other (1) and two staff vacancies for Allied Health Professional and Supporting Staff. Mrs Pennington thanked staff Governors and members of the committee Cecelia Barber and Donna Hargreaves for their help in promoting the vacancies with other members of staff regarding the election. An Open Afternoon – ‘What it means to become a Governor’ was held on 4 September. Members were invited to come along to find out more about becoming a Governor. Simon Barber, Chief Executive, and Jane Taylor-Holmes, Company Secretary, gave presentations at the meeting on the Trust and the role of the Governor which was attended by public members, staff members and a number of current Governors. Mrs Pennington confirmed that the deadline for applications is 22 September and will give more information at the Council of Governors meeting on 15 September. Mrs Pennington to send ERS documents to Mrs Fitzpatrick to share the election details and process with other groups.
LP
14/33
10.
11.
Membership & Engagement Strategy The membership and engagement strategy will be an agenda item for the Council of Governors meeting on 15 September. Mrs Pennington and Chris Whittle will give a Membership Strategy presentation at the meeting which will include a member engagement discussion amongst Governors.
14/34
12.
13.
14.
Communications Update Miss Ellis, Communications Officer, confirmed that the quarterly Council of Governors update is due to go out at the end of the month and welcomed any suggestions or ideas for features to be included. It was suggested that the Culture of Care ‘Care Makers’ story that recently featured in the staff newsletter would be interesting for Governors. Miss Ellis explained the role of a Care Maker to the committee and the possibility of Dr Sandeep Ranote (Medical Staff Governor and Care Maker) featuring. Miss Ellis to follow this suggestion up. Values based recruitment was also discussed – Mrs Fitzpatrick,
SE
Agenda Item No CoG 15/09
15/09 Minutes of Membership & Communications Meeting held on 9 September 2014 Page 3 of 4
15.
16.
17.
Involvement Scheme Co-ordinator, suggested Shannon Whitworth and Justin Forrest who are both involvement scheme members to get a perspective from both sides. The forthcoming Governor elections will also feature. Mrs Fitzpatrick will speak to Anne Kiney regarding the closing date for Art in the Park competition entries – this could also feature in the update. Miss Ellis also spoke about the yearly staff flu jab campaign which will be starting again shortly. Last year’s uptake was below target so fresh ideas to promote the campaign are being explored.
14/35
18.
19.
20
21.
22..
Insight Magazine – November Content As discussed at previous meetings, an Editorial Group for Insight will be arranged for the next issue. Public gold members are to be invited to join a working group to look at content for the Autumn/Winter issue of the magazine. The draft terms of reference for the editorial group were shared at the meeting. The editorial group will comprise of Foundation Trust Governors, Foundation Trust Members, Communications Manager/Assistant, Membership Manager and Assistant Company Secretary. It was discussed whether the invitations should be sent to all gold members or just those who have supplied us with an email address. It was decided that the invite should be extended to all gold members. As there are 904 current gold members, it was agreed that the invitation needs to be specific and worded correctly as although we would like members to take up the opportunity of joining the working group, we do not want to be inundated with too many attendees. Miss Currall is to arrange an editorial group meeting for early October with the invitation to all gold members to be sent out following the confirmation of the meeting date.
GC
14/36
23.
24.
25.
26.
Members Engagement Group Feedback Mrs Fitzpatrick provided the update in the absence of Mr Thompson. Mrs Fitzpatrick explained that we have permission to get on site at Atherleigh Way. There will be extra engagement groups arranged to look at the planning and design of the external aspects of the building. The next planned main engagement group meeting will be 20 November 2014 with the extra groups going ahead between that time. It was discussed how great it is that the local community are very positive about the whole thing with no negative comments being raised.
Agenda Item No CoG 15/09
15/09 Minutes of Membership & Communications Meeting held on 9 September 2014 Page 4 of 4
14/37
27.
28.
29.
30.
Review of Annual Members’ Meeting 2014 Mrs Pennington asked the committee for their feedback on this year’s Annual Members’ Meeting which was held on 15 July at the Orford Jubilee Neighbourhood Hub in Warrington. It was felt by all that the venue was a very good facility, very accessible with plenty of car parking. It was also noted that disability parking was very good. It was agreed that the market place exhibitors were a good mix of Trust and third sector organisation stalls and looked pleasing to the eye with plenty of space. It was suggested that for future meetings, if a vote is required then an auto voting kit could be used. Mrs Fitzpatrick confirmed that the Trust do have the kit available and would check how many we have in total.
BF
14/38
31.
Items to go to future COG Meeting None raised.
14/40
32.
33.
34.
Membership Figures As at 9 September 2014, there are 9,719 Members. 6,106 of these are public members and 3,613 are staff members. Miss Currall explained that the update of staff starters and leavers is now due and that she will shortly be working on updating the member database.
GC
14/41
35.
36. .
Any Other Business Skills training for Governors was discussed. It was agreed that all Governors should be encouraged to take part in presentation / communication/listening skills training. It was also mentioned that the Trust website needs to be updated in terms of dates and times of forums. Mrs Fitzpatrick confirmed that these updates are currently underway.
Date of next meeting The next meeting will be held on 8 December 2014 – 2.00pm-4.00pm Rossetti Meeting Room (Ground Floor) Hollins Park Hospital Winwick, Warrington WA2 8WA
15/09 Membership and Communications Committee Terms of Reference Page 1 of 4
Agenda Item No CoG 15/09
COUNCIL OFGOVERNORS REPORT
_________________________________________________________________
DATE OF MEETING
26 February 2015 Council of Governors
TITLE OF MEETING AGENDA ITEM NUMBER
COG 15/09
REPORT PRESENTED BY
Chris Whittle, Chairman, Membership and Communication Committee
PURPOSE OF THE REPORT
To revise the Terms of Reference for the Membership & Communications Committee. Proposed changes are highlighted within the Terms of Reference.
ACTION REQUIRED AT THIS MEETING
Discuss and approve the revised Terms of Reference.
RECOMMENDATION TO THE COUNCIL OF GOVERNORS
Approve the revised Terms of Reference for the Membership and Communications Committee.
15/09 Membership and Communications Committee Terms of Reference Page 2 of 4
Membership and Communications Committee
TERMS OF REFERENCE
1. Constitution The Council of Governors hereby resolves to establish a Committee known as the ‘Membership and Communications Committee’.
2. Duties The Committee will be responsible for:
• Overseeing the implementation of the Membership Strategy
• Reviewing communication with members
• Reviewing plans for member engagement
• Raising the profile of Governors with members of the Trust and the
public
• The ongoing development of the membership
The ongoing monitoring of the membership
• Involvement in planning of the Annual Members’ Meeting
• Involvement in Trust communication campaigns as appropriate
• Establishing reporting and communication links between this group and other involvement groups already established within the Trust, voluntary sector and external groups
3. Membership
The standing membership of the Committee will be:
A minimum of eight Governors, preferably with one representative for each of the five Boroughs and two staff representatives. The Committee will be supported by representatives from the Trust.
a) Quorum
A quorum will be a minimum of four Governors.
15/09 Membership and Communications Committee Terms of Reference Page 3 of 4
b) Attendance by Members
Committee members that miss three meetings in a row, without sending apologies, will be contacted regarding their attendance. Attendance of this Committee is reported in the Annual Report.
c) Attendance by Officers
The Committee will be supported by appropriate officers from the Trust and a Non Executive Director.
The Trust will take minutes of the meeting.
d) Chair
The Membership and Communications Committee will be chaired by a Governor, who is elected annually.
e) Voting Only members of the group have the right to attend meetings and each member will have one vote, with the Chairman having an additional casting vote if required. In the event that a vote is necessary, a decision will be determined by a simple majority vote. 4. Accountability and Reporting Arrangements The Committee will be accountable to the Council of Governors. The minutes of the meetings of the Committee will be submitted to the Council of Governors and the Chairman shall report on its proceedings. The Committee shall report on its activities in the Annual Report. 5. Frequency of Meetings
The Committee will meet a minimum four times per year.
6. Authority
The Committee will have the authority to address the issues outlined in these Terms of Reference and in accordance with the function of the Council of Governors. The Committee will be allowed to make emergency decisions between meetings e.g. via e-mail in order to progress implementation of policies and work programmes already approved by the Council of Governors.
15/09 Membership and Communications Committee Terms of Reference Page 4 of 4
7. Monitoring Effectiveness
The Committee will undertake an annual review of its performance against these Terms of Reference. The Committee will also produce its own report annually to show key objectives, results and achievements.
8. Confidentiality All members of the group are required to observe the strictest confidence regarding the information presented to the Committee and must not disclose any confidential information. 9. Review These Terms of Reference will be reviewed annually 10. Recommendation That the Council of Governors:
Approve the Terms of Reference for the Membership and Communications Committee.
Agenda Item N
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CoG (15/12)
CoG 15/12 Quality Account, Priorities and Audit Criteria 2015/16 Page 1 of 5
COUNCIL OFGOVERNORS REPORT
_________________________________________________________________ DATE OF MEETING
26 February 2014
TITLE OF REPORT
Quality Account Audit 2014/15 and Quality Priorities 2015/16
AGENDA ITEM NUMBER
CoG 15/12
REPORT PRESENTED BY
Tracy Hill Director of People and Integrated Governance
PURPOSE OF REPORT
To provide the Council of Governors with the outcomes from stakeholder engagement to decide and approve Quality Priorities for 2015/16. To inform the Council of Governors on their responsibilities in relation to the external audit of the Quality Account, and the indicator being audited. Tracy Hill will present the findings from this report and facilitate a workshop at the meeting to assist in identifying themes for Quality Priorities for 2015/16.
RECOMMENDATION TO THE COUNCIL OF GOVERNORS
To decide and approve the Quality Priorities for 2015/16, under the 3 domains of effectiveness, safety and experience. To note the indicator to be audited on behalf of the Governors by External Audit, and decide if a further indicator is to be audited.
Agenda Item N
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CoG (15/12)
CoG 15/12 Quality Account, Priorities and Audit Criteria 2015/16 Page 2 of 5
Report to Council of Governors 26 February 2014
Quality Account Audit 2014/15 and Quality Priorities 2015/16 1. BACKGROUND
The Council of Governors plays a key role in the Quality Account each year,
being responsible for; agreeing the forthcoming quality priorities, and
agreeing the indicator to be audited as part of the external audit of the
Quality Account, both these responsibilities are requirements of the Quality
Account Regulations.
Each year the Trust establishes its quality priorites for the year ahead; this is
done by consulting with our stakeholder organisations and asking for their
suggestions. The final agreement and approval for the Trust’s quality
priorites is undertaken by the Trust’s Council of Governors.
Each year the Quality Account content and indicators are audited by
external audit, the Council of Governors are responsible for identifying ‘their’
indicator for auditing, which they will receive the independent report ( Limited
Assurance Audit Report to the Council of Governors) with the findings of the
audit.
2. QUALITY PRIORITIES 2015/2016
2.1 Stakeholder engagement exercise
The Trust held a stakeholder event on 21st November at the Halliwell Jones
Stadium in Warrington and invited; Health watch, Local Authorities, Clinical
Commissioning Groups for all our boroughs and asked members of the
Governors Assurance Committee to attend.
The event provided the attendees with an update against the Quality
Priorities for 2014/15, and a workshop; an opportunity to talk and discuss
their suggestions for the Quality Priorities for 2015/16.
In addition, during December all the stakeholders were contacted, and
asked for any further suggestions, this process has now been completed.
2.2 Outcomes from the engagement exercise
Quality Priorities are under the 3 domain headings of, effectiveness, safety
and experience, the themes from the feedback received from the
engagement exercises has been collated, and provided in appendix A of this
report.
Agenda Item N
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CoG (15/12)
CoG 15/12 Quality Account, Priorities and Audit Criteria 2015/16 Page 3 of 5
2.3 Deciding and approving priorities
The Council of Governors are required to agree the Quality Priorites for each
of the 3 domains. By becoming a quality priority, a topic is given greater
visibility at the Trust, it is monitored closely by the Quality Committee and
updates are provided to our stakeholder organisations. Topic areas
suggested which have already commenced, but not chosen as quality
priorites will continue and be monitored as expected.
The Council of Governors is asked to note the above, and decide and
approve the Trust’s 2015/2016 Quality Priorities.
3. QUALITY ACCOUNT INDICATOR FOR AUDIT
3.1 Mandated local indicator
In accordance with Monitor guidance, the Trust’s Council of Governors
choose an indicator to be audited from the Quality Accounts. In 2012/13,
regulations changed, and imposed a mandated local indicator for inclusion in
the audit report for the Council of Governors. This mandated indicator
covered patient safety incidents which resulted in severe harm or death.
Both the Trust and our external auditors predict that this will continue to be a
mandated requirement for 2014/15, as guidance is only expected to be
released by Monitor in March 2014.
3.2 Additional local indicator
There is an opportunity for a further local indicator to be chosen by the
Council of Governors, and included in the report. Should an additional
indicator be chosen we have been informed that this will incur an additional
cost for the work undertaken by our external auditors.
The Council of Governors is asked to note the above, and decide if an
additional indicator is to be audited, and if so, what this would be.
4. RECOMMENDATIONS
The Council of Governors is asked to:
To decide and approve the Quality Priorities for 2015/16, under the 3 domains of effectiveness, safety and experience.
To note the indicator to be audited on behalf of the Governors by External Audit, and decide if a further indicator is to be audited.
Tracy Hill Director of People and Integrated Governance
Agenda Item N
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CoG (15/12)
CoG 15/12 Quality Account, Priorities and Audit Criteria 2015/16 Page 4 of 5
Appendix A – Outcomes from Stakeholder Quality Priority 2015/16 Engagement
SAFETY
MOST POPULAR - Falls Strategy continuation, Sign up to safety campaign DoH and 5BP identify target areas, self-harm de-escalation, physical health e.g. UTI and pressure sores. Identification, assessment and treatment of physical health problems in mental health population.
What is the expectation of ‘safety’? How can Trust support people where expectation may be very low.
Falls and Pressure Sores, especially learning from other organisations.
Incident reporting focus, decrease in LCW/No harm incidents, increase in near miss reporting. Serious Incident process to improve.
Patient perceptions of safety, expectations, articulation.
Accessibility - reviewing DNA themes analysis about why patients don’t attend assessment team.
Accessibility reviewing DNA themes analysis about why patients don’t attend routine appointments.
Access to services /SU in crisis.
EFFECTIVENESS MOST POPULAR - Better care planning and implementation of
care plans. How to make sure positive outcomes come to fruition and are
reported.
Carer training.
Better health and wellbeing for service user and carer.
Reduce reduction of readmissions.
The integration agenda, asking your organisation and its users and carers where 5BP can get involved with its partners ‘upstream’ to prevent later problems e.g. work with schools, police, homeless, etc.
Development of shared care process across CCGs
Communication across social care in relation to looked after children and children in need
Dual diagnosis
Mental Health in A&E
Ex-service men and women
Agenda Item N
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CoG 15/12 Quality Account, Priorities and Audit Criteria 2015/16 Page 5 of 5
EXPERIENCE MOST POPULAR - Create understanding of ‘culture of care’ and
all intended outcomes to the wider community, target setting for outcomes re culture of care.
Shared decision making-embed and evidence. Work Trust could do in enabling MH patients back to work as part of a multi-agency initiative Looking at social part of engagement not just health and cultural.
Better utilisation of any feedback collated, analysis and use of the information.
Development of IAPT proms
Supporting families including children of mental health service users
Out of area placements and bed management
Using feedback from friends and family test analysis/action
Integrated health services, acute/community/MH/LD
Integrated health and social care joint initiatives